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|
As Introduced
122nd General Assembly
Regular Session
1997-1998 | H. B. No. 374 |
REPRESENTATIVES VAN VYVEN-BRADING-CORBIN-GARCIA-HAINES-MOTTLEY-
NETZLEY-SCHURING-TAYLOR-TERWILLEGER-THOMAS-TIBERI
A BILL
To amend sections 1739.05, 1742.06, 1742.12, 1742.16, 1742.37, 1742.39,
1742.45, 3901.21, 3923.122, 3923.26, 3923.40, 3923.57,
3923.58, 3923.59,
3923.63, 3923.64, 3924.01, 3924.03, 3924.07 to 3924.11, 3924.111, 3924.12 to
3924.14, 3924.51, 3924.61 to 3924.64, 3924.66 to
3924.68, and 3924.73, to
enact new section 1742.13 and sections 1742.47, 3923.571,
3923.581, 3924.031,
3924.032, 3924.033, and 3924.27, and to repeal sections
1742.13 and 3941.53 of
the Revised Code relative to the
implementation of the federal Health Insurance Portability and
Accountability Act of 1996, and insurance coverage
of follow-up
care for a mother and newborn.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.05, 1742.06, 1742.12, 1742.16, 1742.37,
1742.39, 1742.45, 3901.21, 3923.122, 3923.26, 3923.40, 3923.57, 3923.58,
3923.59, 3923.63, 3923.64, 3924.01, 3924.03, 3924.07, 3924.08, 3924.09,
3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51,
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67,
3924.68, and 3924.73 be amended and new section 1742.13 and sections
1742.47, 3923.571, 3923.581, 3924.031, 3924.032, 3924.033, and 3924.27 of the
Revised Code be enacted
to read as follows:
Sec. 1739.05. (A) A multiple employer welfare arrangement
that is created pursuant to sections 1739.01 to 1739.22 of the
Revised Code and that operates a group self-insurance program may
be established only if any of the following applies:
(1) The arrangement has and maintains a minimum enrollment
of three hundred employees of two or more employers.
(2) The arrangement has and maintains a minimum enrollment
of three hundred self-employed individuals.
(3) The arrangement has and maintains a minimum enrollment
of three hundred employees or self-employed individuals in any
combination of divisions (A)(1) and (2) of this section.
(B) A multiple employer welfare arrangement that is
created pursuant to sections 1739.01 to 1739.22 of the Revised
Code and that operates a group self-insurance program shall
comply with all laws applicable to self-funded programs in this
state, including sections 3901.04, 3901.041, 3901.19 to 3901.26,
3901.38, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, 3923.30,
3923.301, and 3923.38, 3923.581, 3923.63,
3924.031, 3924.032, AND 3924.27 of the
Revised Code.
(C) A multiple employer welfare arrangement created
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall
solicit enrollments only through agents or solicitors licensed
pursuant to Chapter 3905. of the Revised Code to sell or solicit
sickness and accident insurance.
(D) A multiple employer welfare arrangement created
pursuant to sections 1739.01 to 1739.22 of the Revised Code shall
provide benefits only to individuals who are members, employees
of members, or the dependents of members or employees, or are
eligible for continuation of coverage under section 1742.34 or
3923.38 of the Revised Code or under Title X of the "Consolidated
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29
U.S.C.A. 1161, as amended.
Sec. 1742.06. Upon obtaining a certificate of authority as
required under this chapter, a health maintenance organization
may:
(A) Enroll individuals and their dependents in either of
the following circumstances:
(1) The individual resides OR LIVES in the approved service area.
(2) The individual's place of employment is located in the
approved service area and his place of
residence is in a county
contiguous to the approved service area.
(B) Contract with health care providers and facilities for
the services to which enrollees are entitled under the terms of
its health care contracts.
(C) Contract with insurance companies authorized to do
business in this state for insurance, indemnity, or reimbursement
against the cost of providing emergency and nonemergency health
care services for enrollees, subject to the provisions set forth
elsewhere in this chapter and the limitations set forth elsewhere
in the Revised Code;
(D) Contract with any persons for the provision of
authorized services including, but not limited to, managerial and
administrative, marketing and enrolling, data processing,
actuarial analysis, billing services, and any other services
authorized by the superintendent of insurance. If such contracts
are made with insurance companies, they must be authorized to
engage in business in this state.
(E) Accept from governmental agencies, private agencies,
corporations, associations, groups, individuals, or other persons
payments covering all or part of the costs of planning,
development, construction, and the provision of health care
services.
(F) Purchase, lease, construct, renovate, operate, or
maintain health care facilities, and their ancillary equipment,
and any property necessary in the transaction of the business of
the organization.
(G) IMPOSE AN
AFFILIATION PERIOD OF NOT MORE THAN SIXTY DAYS, WHICH PERIOD
BEGINS ON THE INDIVIDUAL'S DATE OF ENROLLMENT AND RUNS
CONCURRENTLY WITH ANY WAITING PERIOD IMPOSED UNDER THE COVERAGE.
FOR PURPOSES OF THIS DIVISION, "AFFILIATION PERIOD" MEANS A
PERIOD OF TIME WHICH, UNDER THE TERMS OF THE COVERAGE OFFERED,
MUST EXPIRE BEFORE THE COVERAGE BECOMES EFFECTIVE. NO HEALTH
CARE SERVICES OR BENEFITS NEED TO BE PROVIDED DURING AN
AFFILIATION PERIOD, AND NO PERIODIC PREPAYMENTS CAN BE CHARGED
FOR ANY COVERAGE DURING THAT PERIOD.
(H) IF A HEALTH
MAINTENANCE ORGANIZATION OFFERS COVERAGE IN THE SMALL GROUP
MARKET THROUGH A NETWORK PLAN, LIMIT OR DENY THE COVERAGE IN
ACCORDANCE WITH SECTION 3924.031 OF THE
REVISED
CODE.
(I) REFUSE TO ISSUE
COVERAGE IN THE SMALL GROUP MARKET PURSUANT TO SECTION 3924.032
OF THE REVISED
CODE.
(J) ESTABLISH
EMPLOYER CONTRIBUTION RULES OR GROUP PARTICIPATION RULES FOR THE
OFFERING OF COVERAGE IN CONNECTION WITH A GROUP CONTRACT IN THE
SMALL GROUP MARKET, AS PROVIDED IN DIVISION
(E)(1) OF SECTION 3924.03 OF
THE REVISED
CODE.
Nothing in this section shall be construed to limit the
authority of a health maintenance organization to perform those
functions not otherwise prohibited by law.
Sec. 1742.12. (A) After the health maintenance
organization has furnished, directly or indirectly, basic health
care services to enrollees for a period of twenty-four months and
if it currently meets the financial requirements set forth in
section 1742.171 of the Revised Code and had net income as
reported to the superintendent of insurance for at least one of
the preceding four calendar quarters, the organization shall hold
an open enrollment period of not less than thirty days at least
once during each calendar year.
(B) During the open enrollment period described in
division (A) of this section, the organization shall accept
enrollees in the order in which they apply for enrollment and in
accordance with any of the following:
(1) Up to its capacity, as determined by the organization
subject to review by the superintendent;
(2) If less than its capacity, one per cent of the
organization's total number of subscribers residing in this state
as of the immediately preceding thirty-first day of December.
(C)(1) An open enrollment period shall not be considered
to satisfy the requirements of this section unless the
organization provides adequate public notice in accordance with
division (C)(2) of this section.
(2) A public notice pursuant to division (C)(1) of this
section shall run in at least one newspaper of general
circulation in the health maintenance organization's service
area, at least once in each of the two weeks immediately
preceding the month in which the open enrollment is to occur and
in each week of that month. The notice shall be at least twice
the size commonly used by the newspaper for public legal notices,
provide an explanation of an open enrollment period, and state
the period of open enrollment.
(D) Where a health maintenance organization demonstrates
to the satisfaction of the superintendent that such open
enrollment would jeopardize its economic viability, the
superintendent may:
(1) Waive the requirement for open enrollment;
(2) Impose a limit on the number of new members that must
be enrolled;
(3) Authorize WITH RESPECT TO ENROLLEES WHO ARE NOT FEDERALLY
ELIGIBLE INDIVIDUALS, AUTHORIZE the organization to impose such
underwriting
restrictions upon open enrollment as are necessary to:
(a) Preserve its financial stability;
(b) Prevent excessive adverse selection by prospective
enrollees;
(c) Avoid unreasonably high or unmarketable charges for
enrollee coverage of health services.
(E) The actions of the superintendent under division (D)
of this section shall be effective for a period of not more than
one year. At the expiration of such time, a new showing of need
for such waiver, limitation, or authorization by the organization
shall be made before a new waiver, limitation, or authorization
is issued or imposed.
(F) A health maintenance organization shall not be
required to enroll individuals who are confined to a health care
facility because of chronic illness, permanent injury, or other
infirmity that would cause economic impairment to the health
maintenance organization if such individuals were enrolled or to
make the effective date of benefits for individuals enrolled
under this section earlier than ninety days after the date of
enrollment. THIS DIVISION APPLIES ONLY WITH RESPECT TO INDIVIDUALS WHO
ARE NOT FEDERALLY ELIGIBLE INDIVIDUALS.
(G)(1) A health maintenance organization shall not be
required to cover the fees or costs, or both, for any basic
health care service or contract for supplemental health care
services related to a transplant of a body organ if the
transplant occurred within one year after the effective date of
an individual's coverage under this section.
(2) The limitation on coverage set forth in division
(G)(1) of this section does not apply to a newly born child who
meets the requirements for coverage under section 1742.39 of the
Revised Code.
(3) DIVISION
(G) OF THIS SECTION APPLIES
ONLY WITH RESPECT TO INDIVIDUALS WHO ARE NOT FEDERALLY ELIGIBLE
INDIVIDUALS.
(H)(1) A HEALTH
MAINTENANCE ORGANIZATION MAY DENY COVERAGE UNDER THIS SECTION TO A FEDERALLY
ELIGIBLE
INDIVIDUAL IF THE ORGANIZATION DEMONSTRATES BOTH OF THE
FOLLOWING TO THE SUPERINTENDENT:
(a) THE ORGANIZATION DOES NOT HAVE THE
FINANCIAL RESERVES NECESSARY TO UNDERWRITE ADDITIONAL
COVERAGE.
(b) THE ORGANIZATION IS APPLYING DIVISION
(H)(1) OF THIS SECTION
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THE INDIVIDUAL MARKET IN
THIS
STATE CONSISTENT WITH APPLICABLE LAWS AND RULES OF THIS STATE
AND WITHOUT REGARD TO ANY HEALTH STATUS-RELATED FACTOR OF SUCH
INDIVIDUALS OR WHETHER THE INDIVIDUALS ARE FEDERALLY ELIGIBLE
INDIVIDUALS.
(2) AN ORGANIZATION THAT, PURSUANT TO
DIVISION (H)(1) OF THIS
SECTION, REFUSES TO ISSUE COVERAGE IN A SERVICE AREA, SHALL NOT
OFFER SUCH COVERAGE IN THE INDIVIDUAL MARKET WITHIN THAT SERVICE
AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE THE
COVERAGE IS DENIED OR UNTIL THE ORGANIZATION HAS DEMONSTRATED TO
THE SUPERINTENDENT THAT THE ORGANIZATION HAS SUFFICIENT
FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE, WHICHEVER
IS LATER.
(3) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF
DIVISION (H) OF THIS SECTION ON
A SERVICE-AREA-SPECIFIC BASIS.
(I)(1) WITH
RESPECT TO INDIVIDUALS WHO ARE FEDERALLY ELIGIBLE INDIVIDUALS, A
HEALTH MAINTENANCE ORGANIZATION MAY DO BOTH OF THE FOLLOWING:
(a) LIMIT THE INDIVIDUALS WHO MAY BE
ENROLLED UNDER SUCH COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE
IN THE SERVICE AREA;
(b) DENY THE COVERAGE TO SUCH
INDIVIDUALS WITHIN THE SERVICE AREA, IF THE
ORGANIZATION HAS DEMONSTRATED BOTH OF THE FOLLOWING TO THE
SUPERINTENDENT:
(i) THE ORGANIZATION WILL NOT HAVE THE CAPACITY TO
DELIVER SERVICES ADEQUATELY TO ADDITIONAL INDIVIDUAL ENROLLEES
BECAUSE OF THE ORGANIZATION'S OBLIGATIONS TO EXISTING GROUP
CONTRACT HOLDERS AND ENROLLEES AND INDIVIDUAL ENROLLEES.
(ii) THE ORGANIZATION IS APPLYING DIVISION
(I)(1)(b)OF THIS SECTION UNIFORMLY TO INDIVIDUALS WITHOUT REGARD TO ANY
HEALTH STATUS-RELATED FACTOR RELATING TO SUCH INDIVIDUALS AND
WITHOUT REGARD TO WHETHER THE INDIVIDUALS ARE FEDERALLY ELIGIBLE
INDIVIDUALS.
(2) AN ORGANIZATION THAT, PURSUANT TO DIVISION
(I)(1)(b)OF THIS SECTION, DENIES COVERAGE IN A SERVICE AREA, SHALL NOT
OFFER COVERAGE IN THE INDIVIDUAL MARKET WITHIN THAT SERVICE AREA
FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE THE COVERAGE
IS DENIED.
(J) A HEALTH
MAINTENANCE ORGANIZATION MAY REINSURE COVERAGE OF ANY FEDERALLY ELIGIBLE
INDIVIDUAL ACQUIRED UNDER THIS SECTION WITH THE OPEN ENROLLMENT
REINSURANCE PROGRAM IN ACCORDANCE WITH DIVISION
(G) OF SECTION 3924.11 OF THE
REVISED
CODE. FIXED PERIODIC PREPAYMENT RATES CHARGED
FOR COVERAGE REINSURED BY THE PROGRAM SHALL BE ESTABLISHED IN
ACCORDANCE WITH SECTION 3924.12 OF THE
REVISED
CODE.
(K) AS USED IN THIS
SECTION:
(1) "FEDERALLY ELIGIBLE INDIVIDUAL" HAS THE SAME MEANING AS IN
SECTION 2741(b)OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996," PUB. L. NO. 104-191, 110
STAT. 1955, 42
U.S.C.A.
300gg-41(b), AS
AMENDED.
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE
FOLLOWING:
(a) HEALTH STATUS;
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND
MENTAL ILLNESSES;
(c) CLAIMS EXPERIENCE;
(d) RECEIPT OF HEALTH CARE;
(e) MEDICAL HISTORY;
(f) GENETIC INFORMATION;
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS
ARISING OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY.
Sec. 1742.13. (A) EVERY GROUP CONTRACT ISSUED BY A HEALTH
MAINTENANCE ORGANIZATION SHALL PROVIDE AN OPTION FOR CONVERSION TO A DIRECT
PAYMENT BASIS TO ANY SUBSCRIBER COVERED BY THE GROUP CONTRACT WHO
TERMINATES EMPLOYMENT OR MEMBERSHIP IN THE GROUP UNLESS:
(1) TERMINATION OF THE CONVERSION OPTION OR CONTRACT IS
BASED UPON NONPAYMENT OF PREMIUM AFTER REASONABLE NOTICE IN
WRITING;
(2) THE SUBSCRIBER IS, OR IS ELIGIBLE TO BE, COVERED FOR
BENEFITS AT LEAST COMPARABLE TO THE GROUP POLICY UNDER:
(a) TITLE XVIII OF THE SOCIAL SECURITY
ACT, AS AMENDED
OR
SUPERSEDED;
(b) ANY ACT OF CONGRESS OR LAW UNDER THIS OR ANY OTHER
STATE OF THE UNITED STATES WHICH PROVIDES COVERAGE AT LEAST
COMPARABLE TO THE BENEFITS OFFERED UNDER DIVISION
(A)(2)(a)OF THIS SECTION;
(c) ANY POLICY OF INSURANCE OR HOSPITALIZATION PLAN
PROVIDING COVERAGE AT LEAST COMPARABLE TO THE BENEFITS UNDER
DIVISION (A)(2)(a)OF THIS SECTION.
(B) THE DIRECT PAYMENT CONTRACT OFFERED BY THE HEALTH
MAINTENANCE ORGANIZATION, PURSUANT TO DIVISION (A) OF THIS SECTION,
SHALL PROVIDE A BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF
DIRECTORS OF THE OHIO HEALTH
REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY SIMILAR TO THE BASIC
AND STANDARD PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED
SERVICES. FOR PURPOSES OF THIS DIVISION, THE SUPERINTENDENT OF
INSURANCE SHALL DETERMINE WHETHER A PLAN IS SUBSTANTIALLY
SIMILAR TO THE BASIC OR STANDARD PLAN IN BENEFIT DESIGN AND
SCOPE OF COVERED SERVICES. CONTRACTUAL PERIODIC PREPAYMENTS MAY
NOT EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT OF THE
STANDARD RATE CHARGED ANY OTHER INDIVIDUAL OF A GROUP TO WHICH
THE ORGANIZATION IS CURRENTLY ACCEPTING NEW BUSINESS AND FOR
WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED.
THE CONTRACT MAY INCLUDE A COORDINATION OF
BENEFITS PROVISION AS APPROVED BY THE SUPERINTENDENT.
(C) THE OPTION FOR CONVERSION SHALL BE AVAILABLE:
(1) UPON THE DEATH OF THE EMPLOYEE OR MEMBER, TO THE
SURVIVING SPOUSE WITH RESPECT TO SUCH OF THE SPOUSE AND
DEPENDENTS AS ARE THEN COVERED BY THE GROUP CONTRACT;
(2) TO A CHILD SOLELY WITH RESPECT TO HIMSELF OR HERSELF UPON
ATTAINING THE LIMITING AGE OF COVERAGE UNDER THE GROUP CONTRACT
WHILE COVERED AS A DEPENDENT THEREUNDER;
(3) UPON THE DIVORCE, DISSOLUTION, OR ANNULMENT OF THE
MARRIAGE OF THE EMPLOYEE OR MEMBER, TO THE DIVORCED SPOUSE, OR
FORMER SPOUSE IN THE EVENT OF ANNULMENT, OF SUCH EMPLOYEE OR
MEMBER.
(D) NO HEALTH MAINTENANCE ORGANIZATION SHALL USE AGE AS THE BASIS
FOR REFUSING TO RENEW A CONVERTED CONTRACT.
(E) WRITTEN NOTICE OF THE CONVERSION OPTION PROVIDED BY
DIVISIONS (B) AND (C) OF THIS SECTION SHALL BE GIVEN TO THE
SUBSCRIBER BY THE HEALTH MAINTENANCE ORGANIZATION BY MAIL TO THE
SUBSCRIBER'S ADDRESS IN THE RECORDS OF THE EMPLOYER UPON RECEIPT
OF NOTICE FROM THE EMPLOYER OF THE EVENT GIVING RISE TO THE
CONVERSION OPTION. IF THE EMPLOYEE OR SUBSCRIBER HAS NOT
RECEIVED NOTICE OF THE CONVERSION PRIVILEGE AT LEAST FIFTEEN DAYS
PRIOR TO THE EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD, THEN
THE EMPLOYEE OR SUBSCRIBER HAS AN ADDITIONAL PERIOD WITHIN WHICH
TO EXERCISE THE PRIVILEGE. THIS ADDITIONAL PERIOD SHALL EXPIRE
FIFTEEN DAYS AFTER THE EMPLOYEE OR SUBSCRIBER RECEIVES NOTICE,
BUT IN NO EVENT SHALL THE PERIOD EXTEND BEYOND SIXTY DAYS AFTER
THE EXPIRATION OF THE THIRTY-DAY CONVERSION PERIOD.
Sec. 1742.16. No health maintenance organization, or
representative thereof, may cause or knowingly permit the use of
any advertisement, solicitation document, or activity which is
untrue, misleading, or deceptive.
No health maintenance organization may cancel or fail to
renew the coverage of a subscriber because of his
ANY health status
or his STATUS-RELATED FACTOR IN RELATION TO THE SUBSCRIBER, THE
SUBSCRIBER'S requirements for health care services, or
for any other
reason designated under rules promulgated by the superintendent
of insurance.
Unless otherwise required by state or federal law, no
health maintenance organization, or any health care facility or
provider through which it has made arrangements to provide health
care services under its health care plan or plans, shall
discriminate against any individual with regard to enrollment,
disenrollment, or the quality of health care services rendered to
enrollees, on the basis of such individual's race, color, sex,
age, religion, state of health, or status as a recipient of
medicare or medical assistance under Title XVIII or XIX of the
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 301, as
amended, OR ANY HEALTH STATUS-RELATED FACTOR IN RELATION TO THE
INDIVIDUAL; provided, however, an organization shall not be required
to accept a recipient of medicare or medical assistance, if an
agreement has not been reached on appropriate payment mechanisms
between the organization and the governmental agency
administering such programs, and provided further, however,
except during a period of open enrollment under section 1742.12
of the Revised Code, a health maintenance organization may reject
an application for non-group NONGROUP enrollment on the basis of
the state
of ANY health of STATUS-RELATED FACTOR IN RELATION TO
the applicant.
No health maintenance organization may, unless licensed to
transact the business of insurance in this state, in referring to
or describing itself, use in its name or contracts any of the
words "insurance," "casualty," "surety," "mutual," or any other
words descriptive of the insurance, casualty, or surety business
or deceptively similar to the name or description of any
insurance or surety corporation doing business in this state.
AS USED IN THIS SECTION, "HEALTH
STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING:
(A) HEALTH
STATUS;
(B) MEDICAL
CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL ILLNESSES;
(C) CLAIMS
EXPERIENCE;
(D) RECEIPT OF HEALTH
CARE;
(E) MEDICAL
HISTORY;
(F) GENETIC
INFORMATION;
(G) EVIDENCE OF
INSURABILITY, INCLUDING CONDITIONS ARISING OUT OF ACTS OF
DOMESTIC VIOLENCE;
(H) DISABILITY.
Sec. 1742.37. No individual or group health maintenance organization contract
providing THAT MAKES family coverage AVAILABLE may be
delivered, issued for delivery, or renewed in
this state on or after January 1, 1989, unless the contract covers adopted
children of the subscriber on the same basis as other dependents.
The coverage required by this section is subject to the
requirements and restrictions set forth in section 3924.51 of the Revised
Code.
Sec. 1742.39. (A) Each individual or group evidence of
coverage that is delivered, issued for delivery, or renewed by a
health maintenance organization in this state on or after January
1, 1992, and that provides MAKES coverage AVAILABLE for
family members of a
subscriber also shall provide that coverage applicable to
children is payable from the moment of birth with respect to a
newly born child of the subscriber or subscriber's spouse.
(B) Coverage for a newly born child is effective for a
period of thirty-one days from the date of birth.
(C) To continue coverage for a newly born child beyond the
thirty-one-day period described in division (B) of this section,
the subscriber shall notify the organization within that period.
(D) If payment of a specific fixed periodic prepayment is
required to provide coverage under this section for an additional
child, the evidence of coverage may require the subscriber to
make this payment to the organization within the thirty-one-day
period described in division (B) of this section in order to
continue the coverage beyond that period.
Sec. 1742.45. (A) Notwithstanding section 3901.71
of the Revised Code, each individual or
group health maintenance organization contract delivered, issued
for delivery, or renewed in this state that provides maternity
benefits shall provide coverage of inpatient care and follow-up care for a
mother and her newborn as follows:
(1) The contract shall cover a minimum of forty-eight
hours of inpatient care following a normal vaginal delivery and a minimum of
ninety-six
hours of inpatient care
following a cesarean delivery. Services covered as inpatient
care shall include medical, educational, and any other services that are
consistent with the inpatient care recommended in the protocols and guidelines
developed by national organizations that represent pediatric, obstetric, and
nursing professionals.
(2) The contract shall cover a physician-directed source of follow-up
care. Services covered as follow-up care shall include
physical assessment of the mother and newborn, parent education,
assistance and training in breast or bottle feeding, assessment
of the home support system, performance of any medically
necessary and appropriate clinical tests, and any other services
that are consistent with the follow-up care recommended in the
protocols and guidelines developed by national organizations
that represent pediatric, obstetric, and nursing
professionals. The coverage shall apply to services provided in a medical
setting or through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who conducts the
visit is knowledgeable and experienced in maternity and newborn care.
When a decision is made in accordance with division (B) of this
section to discharge a mother or newborn prior to the expiration of the
applicable number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to all follow-up care that is provided
within forty-eight SEVENTY-TWO hours after discharge. When a
mother or newborn receives
at least the number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to follow-up care that is determined to
be medically necessary by the health care professionals responsible for
discharging the mother or newborn.
(B) Any decision to
shorten the length of inpatient stay to less than that specified
under division (A)(1) of this
section shall be made by the physician attending the mother or
newborn, except that if a nurse-midwife is attending the mother
in collaboration with a physician, the decision may be made by
the nurse-midwife. Decisions regarding early discharge shall be
made only after conferring with the mother or a person
responsible for the mother or newborn. For purposes of this
division, a person responsible for the mother or newborn may
include a parent, guardian, or any other person with authority
to make medical decisions for the mother or newborn.
(C)(1) No health
maintenance organization may do either of the following:
(a) Terminate the participation of a health
care professional or health care facility as a provider under an
individual or group health maintenance organization contract
solely for making recommendations for inpatient or follow-up
care for a particular mother or newborn that are consistent with
the care required to be covered by this section;
(b) Establish or offer monetary or other
financial incentives for the purpose of encouraging a person to
decline the inpatient or follow-up care required to be covered
by this section.
(2) Whoever violates division
(C)(1)(a)
or (b) of this section has 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.
(D) This section does
not do any of the following:
(1) Require a contract to
cover inpatient or follow-up care that is not received in accordance with the
contract's terms pertaining to the health care professionals and
facilities from which an individual is authorized to receive
health care services.
(2) Require a mother or newborn to stay in a hospital
or other inpatient setting for a fixed period of time following
delivery;
(3) Require a child to be delivered in a hospital or
other inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the
authority to practice nurse-midwifery in accordance with
Chapter 4723. of the
Revised
Code;
(5) Establish minimum standards of medical diagnosis,
care, or treatment for inpatient or follow-up care for a mother
or newborn. A deviation from the care required to be covered
under this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those
terms are defined in section 2305.11 of the
Revised
Code.
Sec. 1742.47. THE FOLLOWING CONDITIONS APPLY TO ALL
INDIVIDUAL HEALTH MAINTENANCE ORGANIZATION CONTRACTS AND ALL
GROUP HEALTH MAINTENANCE ORGANIZATION CONTRACTS THAT ARE NOT
SUBJECT TO SECTION 3924.03 OF THE
REVISED
CODE:
(A) EXCEPT AS PROVIDED IN SECTION 2742(b)
TO (e) OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF1996,"
PUB.
L.
NO. 104-191, 110
STAT. 1955, 42
U.S.C.A.
300gg-42, AS AMENDED, A HEALTH
MAINTENANCE ORGANIZATION THAT PROVIDES INDIVIDUAL COVERAGE TO AN
INDIVIDUAL SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT THE
OPTION OF THE INDIVIDUAL.
(B) EXCEPT AS
PROVIDED IN SECTION2712(b)TO
(e) OF THE "HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF1996,"IF A
HEALTH MAINTENANCE ORGANIZATION OFFERS COVERAGE IN THE SMALL OR
LARGE GROUP MARKET IN CONNECTION WITH A GROUP CONTRACT, THE
ORGANIZATION SHALL RENEW OR CONTINUE IN FORCE SUCH COVERAGE AT
THE OPTION OF THE CONTRACT HOLDER.
(C) SUCH GROUP CONTRACTS ARE SUBJECT TO DIVISIONS
(A) AND (E)(1) OF SECTION 3924.03 AND
SECTIONS 3924.033 AND 3924.27 OF THE
REVISED
CODE.
Sec. 3901.21. The following are hereby defined as unfair
and deceptive acts or practices in the business of insurance:
(A) Making, issuing, circulating, or causing or permitting
to be made, issued, or circulated, or preparing with intent to so
use, any estimate, illustration, circular, or statement
misrepresenting the terms of any policy issued or to be issued or
the benefits or advantages promised thereby or the dividends or
share of the surplus to be received thereon, or making any false
or misleading statements as to the dividends or share of surplus
previously paid on similar policies, or making any misleading
representation or any misrepresentation as to the financial
condition of any insurer as shown by the last preceding verified
statement made by it to the insurance department of this state,
or as to the legal reserve system upon which any life insurer
operates, or using any name or title of any policy or class of
policies misrepresenting the true nature thereof, or making any
misrepresentation or incomplete comparison to any person for the
purpose of inducing or tending to induce such person to purchase,
amend, lapse, forfeit, change, or surrender insurance.
Any written statement concerning the premiums for a policy
which refers to the net cost after credit for an assumed
dividend, without an accurate written statement of the gross
premiums, cash values, and dividends based on the insurer's
current dividend scale, which are used to compute the net cost
for such policy, and a prominent warning that the rate of
dividend is not guaranteed, is a misrepresentation for the
purposes of this division.
(B) Making, publishing, disseminating, circulating, or
placing before the public or causing, directly or indirectly, to
be made, published, disseminated, circulated, or placed before
the public, in a newspaper, magazine, or other publication, or in
the form of a notice, circular, pamphlet, letter, or poster, or
over any radio station, or in any other way, or preparing with
intent to so use, an advertisement, announcement, or statement
containing any assertion, representation, or statement, with
respect to the business of insurance or with respect to any
person in the conduct of his THE PERSON'S insurance business,
which is untrue, deceptive, or misleading.
(C) Making, publishing, disseminating, or circulating,
directly or indirectly, or aiding, abetting, or encouraging the
making, publishing, disseminating, or circulating, or preparing
with intent to so use, any statement, pamphlet, circular,
article, or literature, which is false as to the financial
condition of an insurer and which is calculated to injure any
person engaged in the business of insurance.
(D) Filing with any supervisory or other public official,
or making, publishing, disseminating, circulating, or delivering
to any person, or placing before the public, or causing directly
or indirectly to be made, published, disseminated, circulated,
delivered to any person, or placed before the public, any false
statement of financial condition of an insurer.
Making any false entry in any book, report, or statement of
any insurer with intent to deceive any agent or examiner lawfully
appointed to examine into its condition or into any of its
affairs, or any public official to whom such insurer is required
by law to report, or who has authority by law to examine into its
condition or into any of its affairs, or, with like intent,
willfully omitting to make a true entry of any material fact
pertaining to the business of such insurer in any book, report,
or statement of such insurer, or mutilating, destroying,
suppressing, withholding, or concealing any of its records.
(E) Issuing or delivering or permitting agents, officers,
or employees to issue or deliver agency company stock or other
capital stock or benefit certificates or shares in any common-law
corporation or securities or any special or advisory board
contracts or other contracts of any kind promising returns and
profits as an inducement to insurance.
(F) Making or permitting any unfair discrimination among
individuals of the same class and equal expectation of life in
the rates charged for any contract of life insurance or of life
annuity or in the dividends or other benefits payable thereon, or
in any other of the terms and conditions of such contract.
(G)(1) Except as otherwise expressly provided by law,
knowingly permitting or offering to make or making any contract
of life insurance, life annuity or accident and health insurance,
or agreement as to such contract other than as plainly expressed
in the contract issued thereon, or paying or allowing, or giving
or offering to pay, allow, or give, directly or indirectly, as
inducement to such insurance, or annuity, any rebate of premiums
payable on the contract, or any special favor or advantage in the
dividends or other benefits thereon, or any valuable
consideration or inducement whatever not specified in the
contract; or giving, or selling, or purchasing, or offering to
give, sell, or purchase, as inducement to such insurance or
annuity or in connection therewith, any stocks, bonds, or other
securities, or other obligations of any insurance company or
other corporation, association, or partnership, or any dividends
or profits accrued thereon, or anything of value whatsoever not
specified in the contract.
(2) Nothing in division (F) or division (G)(1) of this
section shall be construed as prohibiting any of the following
practices: (a) in the case of any contract of life insurance or
life annuity, paying bonuses to policyholders or otherwise
abating their premiums in whole or in part out of surplus
accumulated from nonparticipating insurance, provided that any
such bonuses or abatement of premiums shall be fair and equitable
to policyholders and for the best interests of the company and
its policyholders; (b) in the case of life insurance policies
issued on the industrial debit plan, making allowance to
policyholders who have continuously for a specified period made
premium payments directly to an office of the insurer in an
amount which fairly represents the saving in collection expenses;
(c) readjustment of the rate of premium for a group insurance
policy based on the loss or expense experience thereunder, at the
end of the first or any subsequent policy year of insurance
thereunder, which may be made retroactive only for such policy
year.
(H) Making, issuing, circulating, or causing or permitting
to be made, issued, or circulated, or preparing with intent to so
use, any statement to the effect that a policy of life insurance
is, is the equivalent of, or represents shares of capital stock
or any rights or options to subscribe for or otherwise acquire
any such shares in the life insurance company issuing that policy
or any other company.
(I) Making, issuing, circulating, or causing or permitting
to be made, issued or circulated, or preparing with intent to so
issue, any statement to the effect that payments to a
policyholder of the principal amounts of a pure endowment are
other than payments of a specific benefit for which specific
premiums have been paid.
(J) Making, issuing, circulating, or causing or permitting
to be made, issued, or circulated, or preparing with intent to so
use, any statement to the effect that any insurance company was
required to change a policy form or related material to comply
with Title XXXIX of the Revised Code or any regulation of the
superintendent of insurance, for the purpose of inducing or
intending to induce any policyholder or prospective policyholder
to purchase, amend, lapse, forfeit, change, or surrender
insurance.
(K) Aiding or abetting another to violate this section.
(L) Refusing to issue any policy of insurance, or
canceling or declining to renew such policy because of the sex or
marital status of the applicant, prospective insured, insured, or
policyholder.
(M) Making or permitting any unfair discrimination between
individuals of the same class and of essentially the same hazard
in the amount of premium, policy fees, or rates charged for any
policy or contract of insurance, other than life insurance, or in
the benefits payable thereunder, or in underwriting standards and
practices or eligibility requirements, or in any of the terms or
conditions of such contract, or in any other manner whatever.
(N) Refusing to make available disability income insurance
solely because the applicant's principal occupation is that of
managing a household.
(O) Refusing, when offering maternity benefits under any
individual or group sickness and accident insurance policy, to
make maternity benefits available to the policyholder for the
individual or individuals to be covered under any comparable
policy to be issued for delivery in this state, including family
members if the policy otherwise provides coverage for family
members. Nothing in this division shall be construed to prohibit
an insurer from imposing a reasonable waiting period for such
benefits UNDER AN INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE POLICY,
but in no event shall such waiting period exceed two
hundred seventy days.
(P) Using, or permitting to be used, a pattern settlement
as the basis of any offer of settlement. As used in this
division, "pattern settlement" means a method by which liability
is routinely imputed to a claimant without an investigation of
the particular occurrence upon which the claim is based and by
using a predetermined formula for the assignment of liability
arising out of occurrences of a similar nature. Nothing in this
division shall be construed to prohibit an insurer from
determining a claimant's liability by applying formulas or
guidelines to the facts and circumstances disclosed by the
insurer's investigation of the particular occurrence upon which a
claim is based.
(Q) Refusing to insure, or refusing to continue to insure,
or limiting the amount, extent, or kind of life or sickness and
accident insurance or annuity coverage available to an
individual, or charging an individual a different rate for the
same coverage solely because of blindness or partial blindness.
With respect to all other conditions, including the underlying
cause of blindness or partial blindness, persons who are blind or
partially blind shall be subject to the same standards of sound
actuarial principles or actual or reasonably anticipated
actuarial experience as are sighted persons. Refusal to insure
includes, but is not limited to, denial by an insurer of
disability insurance coverage on the grounds that the policy
defines "disability" as being presumed in the event that the
eyesight of the insured is lost. However, an insurer may exclude
from coverage disabilities consisting solely of blindness or
partial blindness when such conditions existed at the time the
policy was issued. To the extent that the provisions of this
division may appear to conflict with any provision of section
3999.16 of the Revised Code, this division applies.
(R)(1) Directly or indirectly offering to sell, selling,
or delivering, issuing for delivery, renewing, or using or
otherwise marketing any policy of insurance or insurance product
in connection with or in any way related to the grant of a
student loan guaranteed in whole or in part by an agency or
commission of this state or the United States, except insurance
that is required under federal or state law as a condition for
obtaining such a loan and the premium for which is included in
the fees and charges applicable to the loan; or, in the case of
an insurer or insurance agent, knowingly permitting any lender
making such loans to engage in such acts or practices in
connection with the insurer's or agent's insurance business.
(2) Except in the case of a violation of division (G) of
this section, division (R)(1) of this section does not apply to
either of the following:
(a) Acts or practices of an insurer, its agents,
representatives, or employees in connection with the grant of a
guaranteed student loan to its insured or the insured's spouse or
dependent children where such acts or practices take place more
than ninety days after the effective date of the insurance;
(b) Acts or practices of an insurer, its agents,
representatives, or employees in connection with the
solicitation, processing, or issuance of an insurance policy or
product covering the student loan borrower or his THE BORROWER'S
spouse or dependent children, where such acts or practices take place more
than one hundred eighty days after the date on which the borrower is notified
that the student loan was approved.
(S) Denying coverage, under any health insurance or health
care policy, contract, or plan providing family coverage, to any
natural or adopted child of the named insured or subscriber
solely on the basis that the child does not reside in the
household of the named insured or subscriber.
(T)(1) Using any underwriting standard or engaging in any other act or
practice that, directly or indirectly, due solely to the actual or
expected ANY
health condition of STATUS-RELATED FACTOR IN RELATION TO one or
more individuals, does either of the following:
(a) Terminates or fails to renew an existing individual policy, contract, or
plan of health benefits, or a health benefit plan issued to a small
AN employer as those terms are defined in section 3924.01 of the
Revised Code, for which an individual would otherwise be eligible;
(b) With respect to a health benefit plan issued to a small AN
employer, as those terms are defined in section 3924.01 of the Revised
Code,
excludes or causes the exclusion of an individual from coverage under an
existing employer-provided policy, contract, or plan of health benefits,
except that an insurer may exclude, on the basis of health
status, a late
enrollee as defined in section 3924.01 of the Revised Code.
(2) The superintendent of insurance may adopt rules in accordance with
Chapter 119. of the Revised Code for purposes of implementing division (T)(1)
of this section.
(3) FOR PURPOSES OF
DIVISION (T)(1) OF THIS
SECTION, "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE
FOLLOWING:
(a) HEALTH STATUS;
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL
AND MENTAL ILLNESSES;
(c) CLAIMS EXPERIENCE;
(d) RECEIPT OF HEALTH CARE;
(e) MEDICAL HISTORY;
(f) GENETIC INFORMATION;
(g) EVIDENCE OF INSURABILITY, INCLUDING
CONDITIONS ARISING OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY.
(U) With respect to a health benefit plan issued to a small employer, as
those terms are defined in section 3924.01 of the Revised Code, negligently or
willfully placing coverage for adverse risks with a certain carrier, as
defined in section 3924.01 of the Revised Code.
(V) Using any program, scheme, device, or other unfair act
or practice that, directly or indirectly, causes or results in
the placing of coverage for adverse risks with another carrier,
as defined in section 3924.01 of the Revised Code.
(W) Failing to comply with section 3923.23, 3923.231,
3923.232, 3923.233, or 3923.234 of the Revised Code by engaging
in any unfair, discriminatory reimbursement practice.
(X) Intentionally establishing an unfair premium for, or
misrepresenting the cost of, any insurance policy financed under
a premium finance agreement of an insurance premium finance
company.
With respect to private passenger automobile insurance, no
insurer shall charge different premium rates to persons residing
within the limits of any municipal corporation based solely on
the location of the residence of the insured within those limits.
The enumeration in sections 3901.19 to 3901.26 of the
Revised Code of specific unfair or deceptive acts or practices in
the business of insurance is not exclusive or restrictive or
intended to limit the powers of the superintendent of insurance
to adopt rules to implement this section, or to take action under
other sections of the Revised Code.
This section does not prohibit the sale of shares of any
investment company registered under the "Investment Company Act
of 1940," 54 Stat. 789, 15 U.S.C.A. 80a-1, as amended, or any
policies, annuities, or other contracts described in section
3907.15 of the Revised Code.
As used in this section, "estimate," "statement,"
"representation," "misrepresentation," "advertisement," or
"announcement" includes oral or written occurrences.
Sec. 3923.122. (A) Every policy of group sickness and
accident insurance providing hospital, surgical, or medical
expense coverage for other than specific diseases or accidents
only, and delivered, issued for delivery, or renewed in this
state on or after January 1, 1976, shall include a provision
giving each insured the option to convert to any of the
individual policies of hospital, surgical, or medical expense
insurance then being issued by the insurer with benefit limits
not to exceed those in effect under the group policy A BASIC OR
STANDARD PLAN ESTABLISHED BY THE BOARD OF
DIRECTORS OF THE OHIO HEALTH
REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY SIMILAR TO THE BASIC
AND STANDARD PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED
SERVICES. FOR PURPOSES OF THIS DIVISION, THE
SUPERINTENDENT OF INSURANCE SHALL DETERMINE WHETHER A PLAN IS
SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN BENEFIT
DESIGN AND SCOPE OF COVERED SERVICES.
(B) An option for conversion to an individual policy shall
be available without evidence of insurability to every insured,
including any person eligible under division (D) of this section,
who terminates his employment or membership in the group holding
the policy after having been continuously insured thereunder for
at least one year.
Upon receipt of the insured's written application and upon
payment of at least the first quarterly premium not later than
thirty-one days after the termination of coverage under the group
policy, the insurer shall issue a converted policy on a form then
available for conversion. The premium shall be in accordance
with the insurer's table of premium rates in effect on the later
of the following dates:
(1) The effective date of the converted policy;
(2) The date of application therefor; and shall be applicable to the class of
risk to which each person
covered belongs and to the form and amount of the policy at his THE
PERSON'S
then attained age. HOWEVER, PREMIUMS MAY NOT EXCEED AN AMOUNT THAT IS TWO
TIMES THE MIDPOINT OF THE STANDARD RATE CHARGED ANY OTHER
INDIVIDUAL OF A GROUP TO WHICH THE INSURER IS CURRENTLY
ACCEPTING NEW BUSINESS AND FOR WHICH SIMILAR COPAYMENTS AND
DEDUCTIBLES ARE APPLIED.
At the election of the insurer, a separate converted policy
may be issued to cover any dependent of an employee or member of
the group.
Except as provided in division (H) of this section, any
converted policy shall become effective as of the day following
the date of termination of insurance under the group policy.
Any probationary or waiting period set forth in the
converted policy is deemed to commence on the effective date of
the insured's coverage under the group policy.
(C) No insurer shall be required to issue a converted
policy to any person who is, or is eligible to be, covered for
benefits at least comparable to the group policy under:
(1) Title XVIII of the Social Security Act, as amended or
superseded;
(2) Any act of congress or law under this or any other
state of the United States that duplicates coverage offered under
division (C)(1) of this section;
(3) Any policy that duplicates coverage offered under
division (C)(1) of this section;
(4) Any other group sickness and accident insurance
providing hospital, surgical, or medical expense coverage for
other than specific diseases or accidents only.
(D) The option for conversion shall be available:
(1) Upon the death of the employee or member, to the
surviving spouse with respect to such of the spouse and
dependents as are then covered by the group policy;
(2) To a child solely with respect to himself OR HERSELF upon
his
attaining the limiting age of coverage under the group policy
while covered as a dependent thereunder;
(3) Upon the divorce, dissolution, or annulment of the
marriage of the employee or member, to the divorced spouse, or
former spouse in the event of annulment, of such employee or
member, or upon the legal separation of the spouse from such
employee or member, to the spouse.
Persons possessing the option for conversion pursuant to
this division shall be considered members for the purposes of
division (H) of this section.
(E) If coverage is continued under a group policy on an
employee following his retirement prior to the time he THE
EMPLOYEE is, or is
eligible to be, covered by Title XVIII of the Social Security
Act, he THE EMPLOYEE may elect, in lieu of the continuance of
group insurance,
to have the same conversion rights as would apply had his THE
EMPLOYEE'S
insurance terminated at retirement by reason of termination of
employment.
(F) If the insurer and the group policyholder agree upon
one or more additional plans of benefits to be available for
converted policies, the applicant for the converted policy may
elect such a plan in lieu of a converted policy.
(G) The converted policy may contain provisions for
avoiding duplication of benefits provided pursuant to divisions
(C)(1), (2), (3), and (4) of this section or provided under any
other insured or noninsured plan or program.
(H) If an employee or member becomes entitled to obtain a
converted policy pursuant to this section, and if the employee or
member has not received notice of the conversion privilege at
least fifteen days prior to the expiration of the thirty-one-day
conversion period provided in division (B) of this section, then
the employee or member has an additional period within which to
exercise the privilege. This additional period shall expire
fifteen days after the employee or member receives notice, but in
no event shall the period extend beyond sixty days after the
expiration of the thirty-one-day conversion period.
Written notice presented to the employee or member, or
mailed by the policyholder to the last known address of the
employee or member as indicated on its records, constitutes
notice for the purpose of this division. In the case of a person
who is eligible for a converted policy under division (D) (2) or
(D)(3) of this section, a policyholder shall not be responsible
for presenting or mailing such notice, unless such policyholder
has actual knowledge of the person's eligibility for a converted
policy.
If an additional period is allowed by an employee or member
for the exercise of a conversion privilege, and if written
application for the converted policy, accompanied by at least the
first quarterly premium, is made after the expiration of the
thirty-one-day conversion period, but within the additional
period allowed an employee or member in accordance with this
division, the effective date of the converted policy shall be the
date of application.
(I) The converted policy may provide:
(1) That any hospital, surgical, or medical expense
benefits otherwise payable with respect to any person may be
reduced by the amount of any such benefits payable under the
group policy for the same loss after termination of coverage;
(2) For termination of coverage on any person who is, or
is eligible to be, covered pursuant to division (C) of this
section;
(3) That the insurer may request information in advance of
any premium due date of the policy as to whether the insured is,
or is eligible to be, covered pursuant to division (C) of this
section. If the insured is, or is eligible to be, covered, and
he THE INSURED fails to furnish the details of his THE
INSURED'S coverage or eligibility to
the insurer within thirty-one days after the date of the request,
the benefits payable under the converted policy may be based on
the hospital, surgical, or medical expenses actually incurred
after excluding expenses to the extent of the amount of benefits
for which the insured is, or is eligible to be, covered pursuant
to division (C) of this section.
(J) The converted policy may contain:
(1) Any exclusion, reduction, or limitation contained in
the group policy or customarily used in individual policies
issued by the insurer;
(2) Any provision permitted in this section;
(3) Any other provision not prohibited by law.
Any provision required or permitted in this section may be
made a part of any converted policy by means of an endorsement or
rider.
(K) The time limit specified in a converted policy for
certain defenses with respect to any person who was covered by a
group policy shall commence on the effective date of such
person's coverage under the group policy.
(L) No insurer shall use deterioration of health as the
basis for refusing to renew a converted policy.
(M) No insurer shall use age as the basis for refusing to
renew a converted policy.
(N) A converted policy made available pursuant to this
section shall, if delivery of the policy is to be made in this
state, comply with this section. If delivery of a converted
policy is to be made in another state, it may be on a form
offered by the insurer in the jurisdiction where the delivery is
to be made and which provides benefits substantially in
compliance with those required in a policy delivered in this
state.
Sec. 3923.26. Every certificate furnished by an insurer in
connection with, or pursuant to any provision of, any group
sickness and accident insurance policy providing coverage on an
expense incurred basis, and every individual sickness and
accident insurance policy which provides coverage on an expense
incurred basis, either of which provides MAKES coverage
AVAILABLE for family
members of the insured, shall, as to such family members'
coverage, also provide that any sickness and accident insurance
benefits applicable for children shall be payable with respect to
a newly born child of the insured from the moment of birth.
The coverage for newly born children shall consist of
coverage of injury or sickness, including the necessary care and
treatment of medically diagnosed congenital defects and birth
abnormalities.
If payment of a specific premium is required to provide
coverage for an additional child, the certificate or policy may
require that notification of birth of a newly born child and
payment of the required premium must be furnished to the insurer
within thirty-one days after the date of birth in order to have
the coverage continue beyond such period.
The requirements of this section apply to all such
individual or group sickness and accident insurance policies
delivered or issued for delivery in this state on or after
January 1, 1975, and all such individual or group sickness and
accident insurance policies renewed in this state on or after
January 1, 1978.
Sec. 3923.40. No individual or group policy of sickness and accident
insurance providing THAT MAKES family coverage AVAILABLE
may be delivered, issued for delivery, or
renewed in this state on or after January 1, 1989, unless the policy covers
adopted children of the insured on the same basis as other dependents.
The coverage required by this section is subject to the
requirements and restrictions set forth in section 3924.51 of the Revised
Code.
Sec. 3923.57. Notwithstanding any provision of this
chapter, every individual policy of sickness and accident
insurance that is delivered, issued for delivery, or renewed in
this state is subject to the following conditions, as applicable:
(A) Pre-existing conditions provisions shall not exclude
or limit coverage for a period beyond twelve months following the
policyholder's effective date of coverage and may only relate to
conditions during the six months immediately preceding the
effective date of coverage.
(B) In determining whether a pre-existing conditions
provision applies to a policyholder or dependent, each policy
shall credit the time the policyholder or dependent was covered
under a previous policy, contract, or plan
if the previous
coverage was continuous to a date not more than thirty
days prior
to the effective date of the new coverage, exclusive of any
applicable service waiting period under the policy.
(C) Any such policy shall be renewable with respect to the
policyholder, or dependents of the policyholder, at the option of
the policyholder, except for any of the following reasons:
(1) Nonpayment of the required premiums by the
policyholder;
(2) Fraud or misrepresentation of the policyholder;
(3) When the insurer ceases to do the business of
individual sickness and accident insurance in this state,
provided that all of the following conditions are met:
(a) Notice of the decision to cease doing the business of
individual sickness and accident insurance is provided to the
department of insurance and the policyholder.
(b) An individual policy shall not be canceled by the
insurer for ninety days after the date of the
notice required
under division (C)(3)(a) of this section unless the business has
been sold to another insurer.
(c) An insurer that ceases to do the business of
individual sickness and accident insurance in this state shall
not resume such business in this state for a period of five years
from the date of the notice required under division (C)(3)(a) of
this section (1) EXCEPT AS OTHERWISE PROVIDED IN
DIVISION (C) OF THIS SECTION,
AN INSURER THAT PROVIDES AN INDIVIDUAL SICKNESS AND ACCIDENT
INSURANCE POLICY TO AN INDIVIDUAL SHALL RENEW OR CONTINUE IN
FORCE SUCH COVERAGE AT THE OPTION OF THE INDIVIDUAL.
(2) AN INSURER MAY NONRENEW OR DISCONTINUE COVERAGE OF
AN INDIVIDUAL IN THE INDIVIDUAL MARKET BASED ONLY ON ONE OR MORE
OF THE FOLLOWING REASONS:
(a) THE INDIVIDUAL FAILED TO PAY PREMIUMS OR
CONTRIBUTIONS IN ACCORDANCE WITH THE TERMS OF THE POLICY OR THE
INSURER HAS NOT RECEIVED TIMELY PREMIUM PAYMENTS.
(b) THE INDIVIDUAL PERFORMED AN ACT OR PRACTICE
THAT CONSTITUTES FRAUD OR MADE AN INTENTIONAL MISREPRESENTATION
OF MATERIAL FACT UNDER THE TERMS OF THE POLICY.
(c) THE INSURER IS CEASING TO OFFER COVERAGE IN
THE INDIVIDUAL MARKET IN ACCORDANCE WITH DIVISION
(D) OF THIS SECTION AND THE
APPLICABLE LAWS OF THIS STATE.
(d) IF THE INSURER OFFERS COVERAGE IN THE
MARKET THROUGH A NETWORK PLAN, THE INDIVIDUAL NO LONGER RESIDES,
LIVES, OR WORKS IN THE SERVICE AREA, OR IN AN AREA FOR WHICH THE
INSURER IS AUTHORIZED TO DO BUSINESS; PROVIDED, HOWEVER, THAT
SUCH COVERAGE IS TERMINATED UNIFORMLY WITHOUT REGARD TO ANY
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(e)IF THE COVERAGE IS MADE AVAILABLE IN THE
INDIVIDUAL MARKET ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MEMBERSHIP OF THE INDIVIDUAL IN THE
ASSOCIATION, ON THE BASIS OF WHICH THE COVERAGE IS PROVIDED,
CEASES; PROVIDED, HOWEVER, THAT SUCH COVERAGE IS TERMINATED
UNDER DIVISION
(C)(2)(e)OF THIS SECTION UNIFORMLY WITHOUT REGARD TO ANY HEALTH
STATUS-RELATED FACTOR OF COVERED INDIVIDUALS.
(D)(1) IF AN INSURER DECIDES TO
DISCONTINUE OFFERING A PARTICULAR TYPE OF HEALTH INSURANCE
COVERAGE OFFERED IN THE INDIVIDUAL MARKET, COVERAGE OF SUCH TYPE
MAY BE DISCONTINUED BY THE INSURER IF THE INSURER DOES ALL OF
THE FOLLOWING:
(a) PROVIDES NOTICE TO EACH INDIVIDUAL PROVIDED
COVERAGE OF THIS TYPE IN SUCH MARKET OF THE DISCONTINUATION AT
LEAST NINETY DAYS PRIOR TO THE DATE OF THE DISCONTINUATION OF
THE COVERAGE;
(b) OFFERS TO EACH INDIVIDUAL PROVIDED COVERAGE
OF THIS TYPE IN SUCH MARKET, THE OPTION TO PURCHASE ANY OTHER
INDIVIDUAL HEALTH INSURANCE COVERAGE CURRENTLY BEING OFFERED BY
THE INSURER FOR INDIVIDUALS IN THAT MARKET;
(c) IN EXERCISING THE OPTION TO DISCONTINUE
COVERAGE OF THIS TYPE AND IN OFFERING THE OPTION OF COVERAGE
UNDER DIVISION
(D)(1)(b)
OF THIS SECTION, ACTS UNIFORMLY WITHOUT REGARD TO ANY
HEALTH STATUS-RELATED FACTOR OF COVERED INDIVIDUALS OR OF
INDIVIDUALS WHO MAY BECOME ELIGIBLE FOR SUCH COVERAGE.
(2) IF AN INSURER ELECTS TO DISCONTINUE OFFERING ALL
HEALTH INSURANCE COVERAGE IN THE INDIVIDUAL MARKET IN THIS
STATE, HEALTH INSURANCE COVERAGE MAY BE DISCONTINUED BY THE
INSURER ONLY IF BOTH OF THE FOLLOWING APPLY:
(a) THE INSURER PROVIDES NOTICE TO THE
DEPARTMENT OF INSURANCE AND TO EACH INDIVIDUAL OF THE
DISCONTINUATION AT LEAST ONE HUNDRED EIGHTY DAYS PRIOR TO THE
DATE OF THE EXPIRATION OF THE COVERAGE.
(b) ALL HEALTH INSURANCE DELIVERED OR ISSUED
FOR DELIVERY IN THIS STATE IN SUCH MARKET IS DISCONTINUED AND
COVERAGE UNDER THAT HEALTH INSURANCE IN THAT MARKET IS NOT
RENEWED.
(3) IN THE EVENT OF A DISCONTINUATION UNDER DIVISION
(D)(2) OF THIS SECTION IN THE
INDIVIDUAL MARKET, THE INSURER SHALL NOT PROVIDE FOR THE
ISSUANCE OF ANY HEALTH INSURANCE COVERAGE IN THE MARKET AND THIS
STATE DURING THE FIVE-YEAR PERIOD BEGINNING ON THE DATE OF THE
DISCONTINUATION OF THE LAST HEALTH INSURANCE COVERAGE NOT SO
RENEWED.
(E) Notwithstanding division DIVISIONS (C)
AND (D) of this section, both of the following apply:
(1) The benefit structure of any such policy may
be changed by the insurer to make it consistent with the benefit
structure contained in individual policies being marketed to new
individual insureds.
(2) Any such policy may be rescinded for fraud, material
misrepresentation, or concealment by an applicant, policyholder,
or dependent
AN INSURER MAY, AT THE TIME OF COVERAGE RENEWAL, MODIFY
THE HEALTH INSURANCE COVERAGE FOR A POLICY FORM OFFERED TO
INDIVIDUALS IN THE INDIVIDUAL MARKET IF THE MODIFICATION IS
CONSISTENT WITH THE LAW OF THIS STATE AND EFFECTIVE ON A UNIFORM
BASIS AMONG ALL INDIVIDUALS WITH THAT POLICY FORM.
IN APPLYING DIVISIONS
(C) TO
(E) OF THIS SECTION WITH
RESPECT TO HEALTH INSURANCE COVERAGE THAT IS MADE AVAILABLE BY
AN INSURER IN THE INDIVIDUAL MARKET TO INDIVIDUALS ONLY THROUGH
ONE OR MORE ASSOCIATIONS, THE TERM "INDIVIDUAL" INCLUDES THE
ASSOCIATION OF WHICH THE INDIVIDUAL IS A MEMBER.
AS USED IN THIS SECTION, "BONA FIDE ASSOCIATION" HAS
THE SAME MEANING AS IN SECTION 3924.03 OF THE
REVISED
CODE, AND "HEALTH-STATUS
RELATED FACTOR" AND "NETWORK PLAN" HAVE THE SAME MEANINGS AS IN
SECTION 3924.031 OF THE REVISED
CODE.
This section does not apply to any policy that provides
coverage for specific diseases or accidents only, or to any
hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer
than six months, or other policy that offers only supplemental
benefits.
Sec. 3923.571. THE FOLLOWING CONDITIONS APPLY TO ALL
GROUP POLICIES OF SICKNESS AND ACCIDENT INSURANCE THAT ARE NOT
SUBJECT TO SECTION 3924.03 OF THE
REVISED
CODE:
(A) ANY SUCH POLICY SHALL COMPLY WITH THE REQUIREMENTS OF
DIVISION
(A) OF SECTION 3924.03 OF THE
REVISED
CODE.
(B) EXCEPT AS
PROVIDED IN SECTION 2712(b)TO
(e) OF THE "HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996,"
PUB.
L.
NO. 104-191, 110
STAT. 1955, 42
U.S.C.A.300gg-12,AS AMENDED, IF AN INSURER OFFERS
COVERAGE IN THE SMALL OR LARGE GROUP MARKET IN CONNECTION WITH A
GROUP POLICY, THE INSURER SHALL RENEW OR CONTINUE IN FORCE SUCH
COVERAGE AT THE OPTION OF THE POLICYHOLDER.
(C)(1) NO GROUP
POLICY, OR INSURER OFFERING HEALTH INSURANCE COVERAGE IN
CONNECTION WITH A GROUP POLICY, SHALL REQUIRE ANY INDIVIDUAL, AS
A CONDITION OF COVERAGE OR CONTINUED COVERAGE UNDER THE POLICY,
TO PAY A PREMIUM OR CONTRIBUTION THAT IS GREATER THAN THE
PREMIUM OR CONTRIBUTION FOR A SIMILARLY SITUATED INDIVIDUAL
COVERED UNDER THE POLICY ON THE BASIS OF ANY HEALTH
STATUS-RELATED FACTOR IN RELATION TO THE INDIVIDUAL OR TO AN
INDIVIDUAL COVERED UNDER THE PLAN AS A DEPENDENT OF THE
INDIVIDUAL.
(2) NOTHING IN DIVISION
(C)(1) OF THIS SECTION SHALL BE
CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY BE CHARGED
FOR COVERAGE UNDER A GROUP POLICY, OR TO PREVENT A GROUP POLICY,
AND AN INSURER OFFERING GROUP HEALTH INSURANCE COVERAGE, FROM
ESTABLISHING PREMIUM DISCOUNTS OR REBATES OR MODIFYING OTHERWISE
APPLICABLE COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO
PROGRAMS OF HEALTH PROMOTION AND DISEASE PREVENTION.
(D) SUCH POLICIES
SHALL PROVIDE FOR THE SPECIAL ENROLLMENT PERIODS DESCRIBED IN
SECTION2701(f)OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996."
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59
of the Revised Code:
(1) "Case characteristics," "eligible employee," "health HEALTH
benefit plan," "late enrollee," AND
"MEWA,"
and "pre-existing conditions provision" have the same meanings as in
section
3924.01 of the Revised Code.
(2) "Insurer" means any sickness and accident insurance
company authorized to issue health benefit plans DO BUSINESS in
this state,
or MEWA authorized to issue insured health benefit plans in this
state. "Insurer" does not include any health maintenance
organization that is owned or operated by an insurer.
(3) "Small employer" means any person, firm, corporation,
or partnership actively engaged in business whose total employed
work force, on at least fifty per cent of its working days during
the preceding year, consisted of at least two unrelated eligible
employees but no more than twenty-five eligible employees, the
majority of whom were employed within this state. In determining
the number of eligible employees, companies that are affiliated
companies or that are eligible to file a combined tax return for
purposes of state taxation shall be considered one employer. In
determining whether the members of an association are small
employers, each member of the association shall be considered as
a separate person, firm, corporation, or partnership PRE-EXISTING
CONDITIONS PROVISION" MEANS A POLICY
PROVISION THAT EXCLUDES OR LIMITS COVERAGE FOR CHARGES OR
EXPENSES INCURRED DURING A SPECIFIED PERIOD FOLLOWING THE
INSURED'S EFFECTIVE DATE OF COVERAGE AS TO A CONDITION WHICH,
DURING A SPECIFIED PERIOD IMMEDIATELY PRECEDING THE EFFECTIVE
DATE OF COVERAGE, HAD MANIFESTED ITSELF IN SUCH A MANNER AS
WOULD CAUSE AN ORDINARILY PRUDENT PERSON TO SEEK MEDICAL ADVICE,
DIAGNOSIS, CARE, OR TREATMENT OR FOR WHICH MEDICAL ADVICE,
DIAGNOSIS, CARE, OR TREATMENT WAS RECOMMENDED OR RECEIVED, OR A
PREGNANCY EXISTING ON THE EFFECTIVE DATE OF COVERAGE.
(4) "Small employer group" means any group consisting of
all of the eligible employees of a small employer, except those
employees who are covered, or are eligible for coverage, under
any other private or public health benefits arrangement,
including the medicare program established under Title XVIII of
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301,
as amended, or any other act of congress or law of this or any
other state of the United States that provides benefits
comparable to the benefits provided under this section.
(B) Beginning in January of each year, insurers
IN THE BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS
AND ACCIDENT INSURANCE AS CONTEMPLATED BY SECTION 3923.021 OF
THE REVISED
CODE, EXCEPT INDIVIDUAL
POLICIES ISSUED PURSUANT TO SECTION 3923.122 OF THE
REVISED
CODE,
shall
accept applicants for open enrollment coverage, as set forth in
divisions (B)(1) and (2) of this
section DIVISION, in the order in which
they apply for coverage and subject to the limitation set forth
in division (G) of this section:.
(1) Insurers in the business of issuing health benefit
plans to small employer groups shall accept small employer groups
for which coverage is not otherwise available and for whom
coverage had not been terminated by the employer or by an insurer
or health maintenance organization during the preceding
twelve-month period;
(2) Insurers in the business of issuing individual
policies of sickness and accident insurance as contemplated by
section 3923.021 of the Revised Code, except individual policies
issued pursuant to section 3923.122 of the Revised Code, shall
either accept individuals pursuant to the open enrollment
requirements of section 3941.53 of the Revised Code, if subject
to that section, or accept for coverage pursuant to this
section
individuals to whom both of the following conditions apply:
(a)(1) The individual is not applying for coverage as an
employee of an employer, as a member of an association, or as a
member of any other group.
(b)(2) The individual is not covered, and is not eligible for
coverage, under any other private or public health benefits
arrangement, including the medicare program established under
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, or any other act of congress or law of
this or any other state of the United States that provides
benefits comparable to the benefits provided under this section,
any medicare supplement policy, or any conversion or continuation
of coverage policy under state or federal law.
(C) An insurer shall offer to any individual or small employer group
accepted
under this section the small employer health care plan established by the
board of directors of the Ohio small employer health reinsurance
program under
division (A) of section 3924.10 of the Revised Code or a health benefit plan
that is substantially similar to the small employer health care plan in
benefit plan design and scope of covered services.
An insurer may offer other health benefit plans in addition to, but not in
lieu of, the plan required to be offered under this division. These
additional health benefit plans shall provide, at a minimum, the coverage
provided by the small employer health care plan or any health benefit plan
that is substantially similar to the small employer health care plan in
benefit plan design and scope of covered services.
For purposes of this division, the superintendent of insurance shall
determine whether a health benefit plan is substantially similar to the small
employer health care plan in benefit plan design and scope of covered
services.
(D) Health benefit plans issued under
this section may
establish pre-existing conditions provisions that exclude or
limit coverage for a period of up to twelve months following the
individual's effective date of coverage and that may relate only
to conditions during the six months immediately preceding the
effective date of coverage. However, an insurer may exclude a
late enrollee for a period of up to eighteen months following the
individual's date of application for coverage.
(E) Premiums charged to groups or individuals under this
section may not exceed an amount that is two and one-half times
the highest rate charged any other group with similar case
characteristics or any other individual to which the insurer is
currently accepting new business, and for which similar
copayments and deductibles are applied.
(F) In offering health benefit plans under this section,
an insurer may require the purchase of health benefit plans that
condition the reimbursement of health services upon the use of a
specific network of providers.
(G)(1) In no event shall
an insurer be
required to accept
annually under this section either individuals or small employer
groups that WHO, in the aggregate, would cause the insurer to have
a
total number of new insureds that is more than one-half per cent
of its total number of insured individuals in this state per
year, as contemplated by section 3923.021 of the Revised Code,
and small group certificate holders of health benefit plans in this state
per
year,
calculated as of the immediately preceding thirty-first day of
December and excluding the insurer's medicare supplement policies
and
conversion or continuation of coverage policies under state or
federal law and any policies described in division
(N)(M) of this section. If an insurer is subject
to, and elects to operate
under, the individual open enrollment requirements of section
3941.53 of the Revised Code, in no event shall the insurer be
required to accept annually under this section small employer
groups that would cause the insurer to have a total number of new
insureds that is more than one-half per cent of its total number
of small group certificate holders calculated as set forth in
division (G)(1) of this section.
(2) An officer of the insurer shall certify to the
department of insurance when it has met the enrollment limit set
forth in division (G)(1) of this section. Upon providing such
certification, the insurer shall be relieved of its open
enrollment requirement under this section for the remainder of
the calendar year.
(H) An insurer shall not be required to accept under this
section applicants who, at the time of enrollment, are confined
to a health care facility because of chronic illness, permanent
injury, or other infirmity that would cause economic impairment
to the insurer if the applicants were accepted, or to make the
effective date of benefits for individuals or groups accepted
under this section earlier than ninety days after the date of
acceptance.
(I) The requirements of this section do not apply to any
insurer that is currently in a state of supervision, insolvency,
or liquidation. If an insurer demonstrates to the satisfaction
of the superintendent that the requirements of this
section would place the insurer in a state of supervision,
insolvency, or liquidation, the superintendent may waive or
modify the requirements of division (B) or (G) of this section. The actions
of the superintendent under this division shall be
effective for a period of not more than one year. At the
expiration of such time, a new showing of need for a waiver or
modification by the insurer shall be made before a new waiver or
modification is issued or imposed.
(J) No hospital, health care facility, or health care practitioner, and no
person who employs any health care practitioner, shall balance bill any
individual or dependent of an individual or any eligible employee or
dependent
of an
employee for any health care supplies or services provided to the
individual or dependent or the eligible employee or dependent,
who is insured under a policy or enrolled under a
health benefit plan issued under this section. The hospital,
health care
facility, or health care practitioner, or any person that employs
the health care practitioner, shall accept payments made to it by
the insurer under the terms of the policy or
contract insuring or
covering such individual as payment in full for such health care
supplies or services.
As used in this division, "hospital" has the same meaning
as in section 3727.01 of the Revised Code; "health care
practitioner" has the same meaning as in section 4769.01 of the
Revised Code; and "balance bill" means charging or collecting an
amount in excess of the amount reimbursable or payable under the
policy or health care service contract issued to an individual or
group under this section for such health care supply or service.
"Balance bill" does not include charging for or collecting
copayments or deductibles required by the policy or contract.
(K) An insurer shall pay an agent a commission in the amount of five per cent
of the premium charged for initial placement or for otherwise securing the
issuance of a policy or contract issued to an individual or small employer
group under this section, and four per cent of the premium charged for the
renewal of such a policy or contract. The superintendent may adopt, in
accordance with Chapter 119. of the Revised Code, such rules as are necessary
to enforce this division.
(L) Except as otherwise provided in this section, sections
3924.01 to 3924.06 of the Revised Code apply to all health
benefit plans issued under this section.
(M) Individuals accepted for coverage under this section
may be issued contracts and certificates subject to the
requirements of section 3923.12 of the Revised Code. The
coverage issued to such individuals is not subject to the
requirements of section 3923.021 of the Revised Code.
(N)(M) This section does not apply to any policy that
provides coverage for specific diseases or accidents only, or
to any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no
longer than six months, or other policy that offers only
supplemental benefits.
Sec. 3923.581. (A) AS USED IN THIS SECTION:
(1) "FEDERALLY ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS
DEFINED IN SECTION 2741(b)OF THE "HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT OF 1996," PUB. L. NO. 104-191, 110
STAT. 1955, 42 U.S.C.A. 300gg-41, AS AMENDED.
(2) "HEALTH BENEFIT PLAN," "MEWA," AND "PRE-EXISTING CONDITIONS
PROVISION" HAVE THE SAME MEANINGS AS IN SECTION 3924.01 of the Revised Code.
(3) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE FOLLOWING:
(a) HEALTH STATUS;
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL
ILLNESSES;
(c) CLAIMS EXPERIENCE;
(d) RECEIPT OF HEALTH CARE;
(e) MEDICAL HISTORY;
(f) GENETIC INFORMATION;
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING OUT OF
ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY.
(4) "INSURER" MEANS ANY SICKNESS AND ACCIDENT INSURANCE COMPANY OR
MEWA AUTHORIZED TO DO BUSINESS IN THIS STATE. "INSURER" DOES NOT
INCLUDE ANY HEALTH MAINTENANCE ORGANIZATION THAT IS OWNED OR OPERATED BY AN
INSURER.
(5) "MIDPOINT RATE" MEANS, FOR INDIVIDUALS WITH SIMILAR CASE
CHARACTERISTICS AND PLAN DESIGNS AND AS DETERMINED BY THE APPLICABLE INSURER
FOR A RATING PERIOD, THE ARITHMETIC AVERAGE OF THE APPLICABLE BASE PREMIUM
RATE AND THE CORRESPONDING HIGHEST PREMIUM RATE.
(6) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF AN INSURER UNDER WHICH
THE FINANCING AND DELIVERY OF MEDICAL CARE, INCLUDING ITEMS AND SERVICES PAID
FOR AS MEDICAL CARE, ARE PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET
OF PROVIDERS UNDER CONTRACT WITH THE INSURER.
(B) BEGINNING IN JANUARY OF EACH YEAR, INSURERS IN THE
BUSINESS OF ISSUING INDIVIDUAL POLICIES OF SICKNESS AND ACCIDENT INSURANCE AS
CONTEMPLATED BY SECTION 3923.021 of the Revised Code, EXCEPT INDIVIDUAL POLICIES ISSUED
PURSUANT TO SECTION 3923.122 of the Revised Code, SHALL ACCEPT FEDERALLY ELIGIBLE INDIVIDUALS
FOR OPEN ENROLLMENT COVERAGE, AS PROVIDED IN THIS SECTION, IN THE ORDER IN
WHICH THEY APPLY FOR COVERAGE AND SUBJECT TO THE LIMITATION SET FORTH IN
DIVISION (J) OF THIS SECTION.
(C) NO INSURER SHALL DO EITHER OF THE FOLLOWING:
(1) DECLINE TO OFFER SUCH COVERAGE TO, OR DENY ENROLLMENT OF, SUCH
INDIVIDUALS;
(2) APPLY ANY PRE-EXISTING CONDITIONS PROVISION TO SUCH COVERAGE.
(D) AN INSURER SHALL OFFER TO FEDERALLY ELIGIBLE INDIVIDUALS THE
BASIC AND STANDARD PLAN ESTABLISHED BY THE BOARD OF DIRECTORS OF THE
OHIO HEALTH REINSURANCE PROGRAM OR PLANS SUBSTANTIALLY SIMILAR TO THE
BASIC AND STANDARD PLAN IN BENEFIT DESIGN AND SCOPE OF COVERED SERVICES. FOR
PURPOSES OF THIS DIVISION, THE SUPERINTENDENT OF INSURANCE SHALL DETERMINE
WHETHER A PLAN IS SUBSTANTIALLY SIMILAR TO THE BASIC OR STANDARD PLAN IN
BENEFIT DESIGN AND SCOPE OF COVERED SERVICES.
(E) PREMIUMS CHARGED TO INDIVIDUALS UNDER THIS SECTION MAY NOT
EXCEED AN AMOUNT THAT IS TWO TIMES THE MIDPOINT RATE CHARGED ANY OTHER
INDIVIDUAL TO WHICH THE INSURER IS CURRENTLY ACCEPTING NEW BUSINESS, AND FOR
WHICH SIMILAR COPAYMENTS AND DEDUCTIBLES ARE APPLIED.
(F) IF AN INSURER OFFERS A HEALTH BENEFIT PLAN IN THE INDIVIDUAL
MARKET THROUGH A NETWORK PLAN, THE INSURER MAY DO BOTH OF THE FOLLOWING:
(1) LIMIT THE FEDERALLY ELIGIBLE INDIVIDUALS THAT MAY APPLY FOR SUCH
COVERAGE TO THOSE WHO LIVE, WORK, OR RESIDE IN THE SERVICE AREA OF THE NETWORK
PLAN;
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE COVERAGE TO
FEDERALLY ELIGIBLE INDIVIDUALS IF THE INSURER HAS DEMONSTRATED BOTH OF THE
FOLLOWING TO THE SUPERINTENDENT:
(a) THE INSURER WILL NOT HAVE THE CAPACITY TO DELIVER SERVICES
ADEQUATELY TO ANY ADDITIONAL INDIVIDUALS BECAUSE OF THE INSURER'S OBLIGATIONS
TO EXISTING GROUP CONTRACT HOLDERS AND INDIVIDUALS.
(b) THE INSURER IS APPLYING DIVISION (F)(2) OF THIS
SECTION UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS WITHOUT REGARD TO ANY
HEALTH STATUS-RELATED FACTOR OF THOSE INDIVIDUALS.
(G) AN INSURER THAT, PURSUANT TO DIVISION (F)(2) OF THIS
SECTION, DENIES COVERAGE TO AN INDIVIDUAL IN THE SERVICE AREA OF A NETWORK
PLAN, SHALL NOT OFFER COVERAGE IN THE INDIVIDUAL MARKET WITHIN THAT SERVICE
AREA FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE THE COVERAGE IS
DENIED.
(H) AN INSURER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS TO
FEDERALLY ELIGIBLE INDIVIDUALS IF THE INSURER HAS DEMONSTRATED BOTH OF THE
FOLLOWING TO THE SUPERINTENDENT:
(1) THE INSURER DOES NOT HAVE THE FINANCIAL RESERVES NECESSARY TO
UNDERWRITE ADDITIONAL COVERAGE.
(2) THE INSURER IS APPLYING DIVISION (H) OF THIS SECTION
UNIFORMLY TO ALL FEDERALLY ELIGIBLE INDIVIDUALS IN THIS STATE CONSISTENT WITH
THE APPLICABLE LAWS AND RULES OF THIS STATE AND WITHOUT REGARD TO ANY HEALTH
STATUS-RELATED FACTOR RELATING TO THOSE INDIVIDUALS.
(I) AN INSURER THAT, PURSUANT TO DIVISION (H) OF THIS
SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS TO FEDERALLY ELIGIBLE
INDIVIDUALS, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE INDIVIDUAL MARKET IN
THIS STATE FOR AT LEAST ONE HUNDRED EIGHTY DAYS AFTER THE DATE THE COVERAGE IS
DENIED OR UNTIL THE INSURER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE
INSURER HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL COVERAGE,
WHICHEVER IS LATER.
(J)(1) EXCEPT AS PROVIDED IN DIVISION
(J)(2) OF THIS SECTION, AN INSURER SHALL NOT BE
REQUIRED TO ACCEPT
ANNUALLY UNDER THIS SECTION FEDERALLY ELIGIBLE INDIVIDUALS
WHO, IN THE AGGREGATE, WOULD CAUSE THE INSURER TO HAVE
A TOTAL NUMBER OF NEW INSUREDS THAT IS MORE THAN ONE-HALF PER CENT
OF ITS TOTAL NUMBER OF INSURED INDIVIDUALS IN THIS STATE PER
YEAR, AS CONTEMPLATED BY SECTION 3923.021 of the Revised Code,
CALCULATED AS OF THE IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF
DECEMBER AND EXCLUDING THE INSURER'S MEDICARE SUPPLEMENT POLICIES
AND
CONVERSION OR CONTINUATION OF COVERAGE POLICIES UNDER STATE OR
FEDERAL LAW AND ANY POLICIES DESCRIBED IN DIVISION
(M) OF SECTION 3923.58 of the Revised Code.
(2) AN OFFICER OF THE INSURER SHALL CERTIFY TO THE
DEPARTMENT OF INSURANCE WHEN IT HAS MET THE ENROLLMENT LIMIT SET
FORTH IN DIVISION (J)(1) OF THIS SECTION. UPON PROVIDING SUCH
CERTIFICATION, THE INSURER SHALL BE RELIEVED OF ITS OPEN
ENROLLMENT REQUIREMENT UNDER THIS SECTION FOR THE REMAINDER OF
THE CALENDAR YEAR
UNLESS, PRIOR TO THE END OF THE CALENDAR YEAR, ALL THE
INSURERS SUBJECT TO THIS SECTION HAVE INDIVIDUALLY MET THE
ENROLLMENT LIMIT SET FORTH IN DIVISION
(J)(1) OF THIS SECTION. IN
THAT EVENT, INSURERS SHALL AGAIN ACCEPT APPLICANTS FOR OPEN
ENROLLMENT COVERAGE PURSUANT TO THIS SECTION, SUBJECT TO THE
ENROLLMENT LIMIT SET FORTH IN DIVISION
(J)(1) OF THIS SECTION.
(K) THE SUPERINTENDENT MAY PROVIDE FOR THE APPLICATION OF THIS
SECTION ON A SERVICE-AREA-SPECIFIC BASIS.
(L) THE REQUIREMENT OF THIS SECTION SHALL NOT APPLY TO ANY HEALTH
BENEFIT PLAN DESCRIBED IN DIVISION (M) OF SECTION 3923.58 of the Revised Code.
Sec. 3923.59. Any insurer may reinsure coverage of any individual, small
employer group, or member of that group acquired under section 3923.58
OR 3923.581 of the
Revised Code with the Ohio small employer health OPEN ENROLLMENT
reinsurance program in
accordance with division (G) of section 3924.11 of the Revised Code. Premium
rates charged for coverage reinsured by the program shall be established in
accordance with section 3924.12 of the Revised Code.
Sec. 3923.63. (A) Notwithstanding section 3901.71 of the Revised Code, each
individual or group policy
of sickness and accident insurance delivered, issued for delivery, or renewed
in this state that provides maternity benefits shall provide coverage of
inpatient care and follow-up care for a mother and her newborn as follows:
(1) The policy shall cover a
minimum of forty-eight hours of inpatient care following a normal vaginal
delivery and a minimum of
ninety-six hours of inpatient care following a cesarean delivery.
Services covered as inpatient care shall include medical,
educational, and any other services that are consistent with the inpatient
care recommended in the protocols and guidelines developed by national
organizations that represent pediatric, obstetric, and nursing
professionals.
(2) The policy shall cover a physician-directed source of follow-up care.
Services covered as follow-up care shall include physical
assessment of the mother and newborn, parent education,
assistance and training in breast or bottle feeding, assessment
of the home support system, performance of any medically
necessary and appropriate clinical tests, and any other services
that are consistent with the follow-up care recommended in the
protocols and guidelines developed by national organizations
that represent pediatric, obstetric, and nursing
professionals. The coverage shall apply to services provided in a medical
setting or through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who conducts the
visit is knowledgeable and experienced in maternity and newborn care.
When a decision is made in accordance with division (B) of this
section to discharge a mother or newborn prior to the expiration of the
applicable number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to all follow-up care that is provided
within forty-eight SEVENTY-TWO hours after discharge. When a
mother or newborn receives
at least the number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to follow-up care that is determined to
be medically necessary by the health care professionals responsible for
discharging the mother or newborn.
(B) Any decision to
shorten the length of inpatient stay to less than that specified
under division (A)(1) of this
section shall be made by the physician attending the mother or
newborn, except that if a nurse-midwife is attending the mother
in collaboration with a physician, the decision may be made by
the nurse-midwife. Decisions regarding early discharge shall be
made only after conferring with the mother or a person
responsible for the mother or newborn. For purposes of this
division, a person responsible for the mother or newborn may
include a parent, guardian, or any other person with authority
to make medical decisions for the mother or newborn.
(C)(1) No sickness
and accident insurer may do either of the following:
(a) Terminate the participation of a health
care professional or health care facility as a provider under a
sickness and accident insurance policy solely for making
recommendations for inpatient or follow-up care for a particular
mother or newborn that are consistent with the care required to
be covered by this section;
(b) Establish or offer monetary or other
financial incentives for the purpose of encouraging a person to
decline the inpatient or follow-up care required to be covered
by this section.
(2) Whoever violates division
(C)(1)(a)
or (b) of this section has 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.
(D) This section does
not do any of the following:
(1) Require a policy to
cover inpatient or follow-up care that is not received in accordance with the
policy's terms pertaining to the health care professionals and
facilities from which an individual is authorized to receive
health care services.;
(2) Require a mother or newborn to stay in a hospital
or other inpatient setting for a fixed period of time following
delivery;
(3) Require a child to be delivered in a hospital or
other inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the
authority to practice nurse-midwifery in accordance with
Chapter 4723. of the
Revised
Code;
(5) Establish minimum standards of medical diagnosis,
care or treatment for inpatient or follow-up care for a mother
or newborn. A deviation from the care required to be covered
under this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those
terms are defined in section 2305.11 of the
Revised
Code.
Sec. 3923.64. (A) Notwithstanding section 3901.71 of the Revised Code, each
public employee benefit
plan established or modified in this state that provides maternity benefits
shall
provide coverage of inpatient care and follow-up care for a mother and her
newborn as follows:
(1) The plan shall cover a minimum of forty-eight hours of inpatient care
following a normal vaginal
delivery and a minimum of ninety-six hours of inpatient care following a
cesarean delivery.
Services covered as inpatient care shall include medical,
educational, and any other services that are consistent with the inpatient
care recommended in the protocols and guidelines developed by national
organizations that represent pediatric, obstetric, and nursing professionals.
(2) The plan shall cover a physician-directed source of follow-up care.
Services covered as follow-up care shall include physical
assessment of the mother and newborn, parent education,
assistance and training in breast or bottle feeding, assessment
of the home support system, performance of any medically
necessary and appropriate clinical tests, and any other services
that are consistent with the follow-up care recommended in the
protocols and guidelines developed by national organizations
that represent pediatric, obstetric, and nursing
professionals. The coverage shall apply to services provided in a medical
setting or through home health care visits. The coverage shall apply to a
home health care visit only if the health care professional who conducts the
visit is knowledgeable and experienced in maternity and newborn care.
When a decision is made in accordance with division (B) of this
section to discharge a mother or newborn prior to the expiration of the
applicable number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to all follow-up care that is provided
within forty-eight SEVENTY-TWO hours after discharge. When a
mother or newborn receives
at least the number of hours of inpatient care required to be covered, the
coverage of follow-up care shall apply to follow-up care that is determined to
be medically necessary by the health care professionals responsible for
discharging the mother or newborn.
(B) Any decision to
shorten the length of inpatient stay to less than that specified
under division (A)(1) of this
section shall be made by the physician attending the mother or
newborn, except that if a nurse-midwife is attending the mother
in collaboration with a physician, the decision may be made by
the nurse-midwife. Decisions regarding early discharge shall be
made only after conferring with the mother or a person
responsible for the mother or newborn. For purposes of this
division, a person responsible for the mother or newborn may
include a parent, guardian, or any other person with authority
to make medical decisions for the mother or newborn.
(C)(1) No public
employer who offers an employee benefit plan may do either of
the following:
(a) Terminate the participation of a health
care professional or health care facility as a provider under
the plan solely for making recommendations for inpatient or
follow-up care for a particular mother or newborn that are
consistent with the care required to be covered by this
section;
(b) Establish or offer monetary or other
financial incentives for the purpose of encouraging a person to
decline the inpatient or follow-up care required to be covered
by this section.
(2) Whoever violates division
(C)(1)(a)
or (b) of this section has 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.
(D) This section does
not do any of the following:
(1) Require a plan to
cover inpatient or follow-up care that is not received in accordance with the
plan's terms pertaining to the health care professionals and
facilities from which an individual is authorized to receive
health care services.;
(2) Require a mother or newborn to stay in a hospital
or other inpatient setting for a fixed period of time following
delivery;
(3) Require a child to be delivered in a hospital or
other inpatient setting;
(4) Authorize a nurse-midwife to practice beyond the
authority to practice nurse-midwifery in accordance with
Chapter 4723. of the
Revised
Code;
(5) Establish minimum standards of medical diagnosis,
care, or treatment for inpatient or follow-up care for a mother
or newborn. A deviation from the care required to be covered
under this section shall not, solely on the basis of this section, give
rise to a medical claim or derivative medical claim, as those
terms are defined in section 2305.11 of the
Revised
Code.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of
the Revised Code:
(A) "Actuarial certification" means a written statement
prepared by a member of the American academy of actuaries, or by
any other person acceptable to the superintendent of insurance,
that states that, based upon the person's examination, a carrier
offering health benefit plans to small employers is in compliance
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial
certification" shall include a review of the appropriate records
of, and the actuarial assumptions and methods used by, the
carrier relative to establishing premium rates for the health
benefit plans.
(B) "Adjusted average market premium price" means the average
market premium price as
determined by the board of directors of the Ohio small employer
health reinsurance program either on the basis of the
arithmetic mean of all carriers'
premium rates for an SEHC plan sold to groups with similar case
characteristics by all carriers selling SEHC plans in the
state, or on any other equitable basis determined by the board.
(C) "Base premium rate" means, as to any health benefit
plan that is issued by a carrier and that covers at least two but no more than
fifty
employees of a small employer, the lowest premium rate for a new
or existing business prescribed by the carrier for the same or
similar coverage under a plan or arrangement covering any small
employer with similar case characteristics.
(D) "Carrier" means any sickness and accident insurance
company or health maintenance organization authorized to issue
health benefit plans in this state or a MEWA. A
sickness and
accident insurance company that owns or operates a health
maintenance organization, either as a separate corporation or as
a line of business, shall be considered as a separate carrier
from that health maintenance organization for purposes of
sections 3924.01 to 3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small
employer, the geographic area in which the employees work; the
age and sex of the individual employees and their dependents; the
appropriate industry classification as determined by the carrier;
the number of employees and dependents; and such other objective
criteria as may be established by the carrier. "Case
characteristics" does not include claims experience, health
status, or duration of coverage from the date of issue.
(F) "Dependent" means the spouse or child of an eligible
employee, subject to applicable terms of the health benefits plan
covering the employee.
(G) "Eligible employee" means an employee who works a
normal work week of twenty-five or more hours. "Eligible
employee"
does not include a temporary or substitute employee, or
a seasonal employee who works only part of the calendar year on
the basis of natural or suitable times or circumstances.
(H) "Financially impaired" means a program member that,
after
April 14, 1993, is not insolvent
but is determined by the superintendent
to be potentially unable to fulfill its contractual
obligations, or is placed under an order of rehabilitation
or conservation by a court of competent jurisdiction or
under an order of supervision by the superintendent.
(I) "Health benefit plan" means any hospital or medical
expense policy or certificate or any health
plan provided by a
carrier, that is delivered, issued for delivery,
renewed, or used in this state on or after the date occurring six
months after the effective date of this amendment
NOVEMBER 24, 1995. "Health benefit plan" does not
include policies covering only accident, credit, dental, disability income,
long-term care, hospital indemnity, medicare supplement,
specified disease, or vision care; coverage under a
one-time-limited-duration policy of no longer than six
months; coverage issued by a health care corporation;
coverage issued by
a prepaid dental plan organization solely or in conjunction with
a carrier; coverage issued as a supplement to liability
insurance; insurance arising out of a workers' compensation or
similar law; automobile medical-payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any
liability insurance policy or equivalent self-insurance.
(J) "Initial enrollment period" means the thirty-day
period immediately following any service waiting period
established by an employer.
(K)(I) "Late enrollee" means an eligible employee or
dependent who requests enrollment ENROLLS in a small employer's
health benefit plan following OTHER THAN DURING the initial
enrollment FIRST period provided
under the terms of the first plan for IN which the employee or
dependent was IS eligible through the small employer, unless
any of the following apply:
(1) The individual:
(a) Was covered under another health
benefit plan at the time the individual was eligible to enroll;
(b) States, at the time of the initial eligibility, that
coverage under another health benefit plan was
the
reason for declining enrollment;
(c) Has lost coverage under another health
benefit plan as a result of the termination of employment, a
reduction of hours worked per week, the
termination of the other plan's coverage, death of a spouse, or
divorce; and
(d) Requests enrollment within thirty days after the
termination of coverage under another health benefit plan.
(2) The individual is employed by an employer who offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period.
(3) A court has ordered coverage to be provided for a
spouse or minor child under a covered employee's plan and a
request for enrollment is made within thirty days after issuance
of the court order TO ENROLL UNDER THE PLAN OR DURING A SPECIAL
ENROLLMENT PERIOD DESCRIBED IN SECTION
2701(f)OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996,"
PUB.
L.
NO. 104-191, 110
STAT. 1955, 42
U.S.C.A.
300gg, AS AMENDED.
(L)(J) "MEWA" means any "multiple employer
welfare
arrangement" as defined in section 3 of the "Federal Employee
Retirement Income Security Act of 1974," 88 Stat. 832, 29
U.S.C.A. 1001, as amended, except for any arrangement which is
fully insured as defined in division (b)(6)(D) of section 514 of
that act.
(M)(K) "Midpoint rate" means, for small employers with
similar case characteristics and plan designs and as determined
by the applicable carrier for a rating period, the arithmetic
average of the applicable base premium rate and the corresponding
highest premium rate.
(N)(L) "Pre-existing conditions provision" means a
policy provision that
excludes or limits coverage for charges or
expenses incurred during a specified period following the
insured's effective ENROLLMENT date of coverage as to a
condition which,
during a specified period immediately preceding the effective
date of coverage, had manifested itself in such a manner as would
cause an ordinarily prudent person to seek medical advice,
diagnosis, care, or treatment or for which medical advice,
diagnosis, care, or treatment was recommended or received, or
DURING a
pregnancy existing on SPECIFIED PERIOD IMMEDIATELY PRECEDING the
effective ENROLLMENT date of coverage. GENETIC
INFORMATION SHALL NOT BE TREATED AS SUCH A CONDITION IN THE ABSENCE
OF A DIAGNOSIS OF THE CONDITION RELATED TO SUCH INFORMATION.
FOR PURPOSES OF THIS DIVISION, "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN
INDIVIDUAL
COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE OF
ENROLLMENT OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE
FIRST DAY OF THE WAITING PERIOD FOR SUCH ENROLLMENT.
(O)(M) "Service waiting period" means the period of
time after employment begins before an eligible employee may enroll
in IS ELIGIBLE TO BE COVERED FOR BENEFITS UNDER THE TERMS OF any
applicable health benefit plan offered by the small employer.
(P)(N)(1) "Small employer"
means any person, firm, corporation, partnership, or association
actively engaged in business whose total, IN CONNECTION WITH A
GROUP HEALTH
BENEFIT PLAN AND WITH RESPECT TO A CALENDAR YEAR AND A PLAN
YEAR, AN EMPLOYER WHO employed work force
consisted of, on at least fifty per cent of its working days
during the preceding year, AN AVERAGE OF at least two but no more
than fifty eligible employees, the majority of whom were employed within
the
state ON BUSINESS DAYS DURING THE PRECEDING CALENDAR YEAR AND
WHO EMPLOYS AT LEAST TWO EMPLOYEES ON THE FIRST DAY OF THE PLAN
YEAR.
(2) In determining the number of eligible employees for FOR
purposes of division (P)(N)(1) of this section,
companies which are affiliated companies or which are eligible to file a
combined tax
return for purposes of state taxation ALL PERSONS TREATED AS A SINGLE
EMPLOYER UNDER
SUBSECTION (b), (c), (m),
OR (o) OF SECTION 414 OF THE
"INTERNAL
REVENUE
CODE OF 1986," 100
STAT. 2085, 26
U.S.C.
1, AS AMENDED, shall be considered one
employer. IN THE CASE OF AN EMPLOYER THAT WAS NOT IN EXISTENCE
THROUGHOUT THE PRECEDING CALENDAR YEAR, THE DETERMINATION OF
WHETHER THE EMPLOYER IS A SMALL OR LARGE EMPLOYER SHALL BE BASED
ON THE AVERAGE NUMBER OF ELIGIBLE EMPLOYEES THAT IT IS
REASONABLY EXPECTED THE EMPLOYER WILL EMPLOY ON BUSINESS DAYS IN
THE CURRENT CALENDAR YEAR. ANY REFERENCE IN DIVISION
(N) OF THIS SECTION TO AN
"EMPLOYER" INCLUDES ANY PREDECESSOR OF THE
EMPLOYER. Except as otherwise specifically provided, provisions
of sections 3924.01 to 3924.14 of the Revised Code that apply to
a small employer that has a health benefit plan shall continue to
apply until the plan anniversary following the date the employer
no longer meets the requirements of this division.
(Q)(O) "SEHC plan" means an Ohio small
employer health care plan, which is a health benefit plan for INDIVIDUALS
AND small employers
established by the board in accordance with section 3924.10 of
the Revised Code.
Sec. 3924.03. Health benefit plans covering small
employers are subject to the following conditions, as applicable:
(A)(1) Pre-existing conditions provisions shall not exclude
or limit coverage for a period beyond twelve months, OR EIGHTEEN
MONTHS IN THE CASE OF A LATE ENROLLEE, following the individual's
effective ENROLLMENT date of coverage and may only relate
to conditions during A PHYSICAL OR MENTAL CONDITION, REGARDLESS OF
THE CAUSE OF
THE CONDITION, FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR
TREATMENT WAS RECOMMENDED OR RECEIVED WITHIN the six months immediately
preceding the
effective ENROLLMENT date of coverage.
DIVISION (A)(1) OF
THIS SECTION IS SUBJECT TO THE EXCEPTIONS SET FORTH IN
SECTION 2701(d) AND SECTION 2721 OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996,"
PUB.
L.
NO. 104-191, 110
STAT. 1955, 42
U.S.C.A.
300gg AND 300gg-21, AS AMENDED.
(2) THE PERIOD OF ANY SUCH PRE-EXISTING CONDITION
EXCLUSION SHALL BE REDUCED BY THE AGGREGATE OF THE PERIODS OF
CREDITABLE COVERAGE, IF ANY, APPLICABLE TO THE EMPLOYEE OR
DEPENDENT AS OF THE ENROLLMENT DATE.
(3) A PERIOD OF CREDITABLE COVERAGE SHALL NOT BE
COUNTED, WITH RESPECT TO ENROLLMENT OF AN INDIVIDUAL UNDER A
GROUP HEALTH BENEFIT PLAN, IF, AFTER THAT PERIOD AND BEFORE THE
ENROLLMENT DATE, THERE WAS A SIXTY-THREE-DAY PERIOD DURING ALL
OF WHICH THE INDIVIDUAL WAS NOT COVERED UNDER ANY CREDITABLE
COVERAGE. SUBSECTIONS(c)(2) TO (4)
AND (e) OF SECTION 2701 OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996" APPLY WITH RESPECT
TO CREDITING PREVIOUS COVERAGE.
(4) AS USED IN DIVISION
(A) OF THIS SECTION:
(a) "CREDITABLE COVERAGE" HAS THE
SAME MEANING AS IN SECTION 2701(c)(1) OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996."
(b) "ENROLLMENT DATE" MEANS, WITH RESPECT TO AN
INDIVIDUAL COVERED UNDER A GROUP HEALTH BENEFIT PLAN, THE DATE
OF ENROLLMENT OF THE INDIVIDUAL IN THE PLAN OR, IF EARLIER, THE
FIRST DAY OF THE WAITING PERIOD FOR SUCH ENROLLMENT.
(B) In determining whether a pre-existing conditions
provision applies to an eligible employee or dependent, all
health benefit plans shall credit the time the person was covered
under a previous employer-based health benefit plan provided by a
carrier if the previous
coverage was continuous to a date not
more than thirty days prior to the effective date of
the new
coverage, exclusive of any applicable service waiting period
under the plan.
(C) Any such health benefit plan shall be renewable with
respect to all eligible employees or dependents at the option of
the policyholder, contract holder, or small employer, except for
any of the following reasons:
(1) Nonpayment of the required premiums by the
policyholder, contract holder, or employer;
(2) Fraud or misrepresentation of the policyholder,
contract holder, or employer or, with respect to coverage of
individual insureds, the insureds or their representatives
;
(3) When the total number of insured individuals covered
under all of the health benefit plans of any one employer is less
than the total number of individuals or percentage of individuals
required by participation requirements under any specific health
benefit plan of that employer;
(4) Noncompliance with any plan provision that has been
approved by the superintendent of insurance;
(5) When the carrier ceases doing business in the small
employer market, provided that all of the following conditions
are met:
(a) Notice of the decision to cease to do business in the
small employer market is provided to the department of insurance,
the board of directors of the Ohio small employer health
reinsurance program, the policyholder or contract holder, and the
employer.
(b) Health benefit plans subject to sections 3924.01 to
3924.14 of the Revised Code shall not be canceled by the carrier
for ninety days after the date of the notice
required under
division (C)(5)(a) of this section unless the business has been
sold to another carrier or the cancellations are approved by the
superintendent.
(c) A carrier that ceases to do business in the small
employer marketplace is prohibited from re-entering the small
employer marketplace for a period of five years from the date of
the notice required under division (C)(5)(a) of this section.
(D) Notwithstanding division (C) of this section, any such
health benefit plan or any coverage provided to an individual
under such a plan may be rescinded for fraud, material
misrepresentation, or concealment by an applicant, employee,
dependent, or small employer.
(E) Every carrier doing business in the small employer
market may underwrite and rate small employer groups, as
permitted by sections 3924.01 to 3924.14 of the Revised Code,
using accepted underwriting and actuarial practices.
(F) A carrier shall not exclude any eligible employee or
dependent, who would otherwise be covered under a health benefit
plan, on the basis of any actual or expected health
condition of the employee or dependent. However, a carrier may
exclude a late enrollee for a period of up to twenty-four months
or may, in the discretion of the carrier, extend coverage to the late enrollee
at any time during that period. A carrier also may
medically underwrite a late enrollee EXCEPT AS PROVIDED IN SECTION
2712(b)
TO (e) OF THE
"HEALTH
INSURANCE
PORTABILITY AND
ACCOUNTABILITY
ACT OF 1996," IF A CARRIER
OFFERS COVERAGE IN THE SMALL EMPLOYER MARKET IN CONNECTION WITH
A GROUP HEALTH BENEFIT PLAN, THE CARRIER SHALL RENEW OR CONTINUE
IN FORCE SUCH COVERAGE AT THE OPTION OF THE PLAN SPONSOR OF THE
PLAN.
(C) If, prior to the effective date of this amendment
NOVEMBER 24, 1995, a carrier
excluded an eligible employee or dependent, other than a late
enrollee, on the basis of an actual or expected health condition,
the carrier shall, upon the initial renewal of the coverage on or
after that date, extend coverage to the employee or dependent if
all other eligibility requirements are met.
(G)(D) No health benefit plan issued by a carrier
shall limit or exclude, by use of a rider or amendment applicable to a
specific
individual, coverage by type of illness, treatment, medical
condition, or accident, except for pre-existing conditions as
permitted under division (A) of this section. If a health
benefit
plan that is delivered or issued for delivery prior to
April 14, 1993, contains such limitations
or exclusions, by use of a rider or amendment applicable to a
specific individual, the plan shall eliminate the use of such
riders or amendments within eighteen months after April 14,
1993.
(H)(E)(1) EXCEPT AS PROVIDED
IN SECTIONS 3924.031 AND 3924.032 OF THE
REVISED
CODE, AND SUBJECT TO SUCH RULES
AS MAY BE ADOPTED BY THE SUPERINTENDENT IN ACCORDANCE WITH
CHAPTER 119. OF THE
REVISED
CODE, A
CARRIER SHALL ISSUE A HEALTH BENEFIT PLAN TO EVERY SMALL
EMPLOYER THAT APPLIES TO THE CARRIER FOR SUCH COVERAGE.
DIVISION (E)(1) OF
THIS SECTION DOES NOT APPLY TO A HEALTH BENEFIT PLAN THAT A CARRIER MAKES
AVAILABLE IN THE SMALL EMPLOYER MARKET ONLY
THROUGH ONE OR MORE BONA FIDE ASSOCIATIONS.
DIVISION (E)(1) OF
THIS SECTION SHALL NOT BE CONSTRUED TO PRECLUDE A CARRIER FROM
ESTABLISHING EMPLOYER CONTRIBUTION RULES OR GROUP PARTICIPATION
RULES FOR THE OFFERING OF COVERAGE IN CONNECTION WITH A GROUP
HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER MARKET, AS ALLOWED
UNDER THE LAW OF THIS STATE. AS USED IN DIVISION
(E)(1) OF THIS SECTION,
"EMPLOYER CONTRIBUTION RULE" MEANS A REQUIREMENT RELATING TO THE
MINIMUM LEVEL OR AMOUNT OF EMPLOYER CONTRIBUTION TOWARD THE
PREMIUM FOR ENROLLMENT OF EMPLOYEES AND DEPENDENTS AND "GROUP
PARTICIPATION RULE" MEANS A REQUIREMENT RELATING TO THE MINIMUM
NUMBER OF EMPLOYEES OR DEPENDENTS THAT MUST BE ENROLLED IN
RELATION TO A SPECIFIED PERCENTAGE OR NUMBER OF ELIGIBLE
INDIVIDUALS OR EMPLOYEES OF AN EMPLOYER.
(2) Each health benefit plan, at the time of initial group
enrollment, shall make coverage available to all the eligible
employees of a small employer without a service waiting period.
The decision of
whether to impose a service waiting period shall be made by the
small employer. Such waiting periods shall not be greater than
ninety days.
(I)(F) The benefit structure of any health benefit
plan may, AT THE
TIME OF COVERAGE RENEWAL,
be changed by the carrier to make it consistent with the benefit
structure contained in health benefit plans being marketed to new
small employer groups. IF THE HEALTH BENEFIT PLAN IS AVAILABLE IN THE
SMALL
EMPLOYER MARKET OTHER THAN ONLY THROUGH ONE OR MORE BONA FIDE
ASSOCIATIONS, THE MODIFICATION MUST BE CONSISTENT WITH THE LAW
OF THIS STATE AND EFFECTIVE ON A UNIFORM BASIS AMONG SMALL
EMPLOYER GROUP PLANS.
(J)(G) A carrier may obtain any facts and information
necessary to apply this section, or supply those facts and
information to any other third-party payer, without the consent
of the beneficiary. Each person claiming benefits under a health
benefit plan shall provide any facts and information necessary to
apply this section.
FOR PURPOSES OF THIS SECTION, "BONA
FIDE ASSOCIATION" MEANS AN ASSOCIATION THAT HAS BEEN ACTIVELY IN
EXISTENCE FOR AT LEAST FIVE YEARS; HAS BEEN FORMED AND
MAINTAINED IN GOOD FAITH FOR PURPOSES OTHER THAN OBTAINING
INSURANCE; DOES NOT CONDITION MEMBERSHIP IN THE ASSOCIATION ON
ANY HEALTH STATUS-RELATED FACTOR, AS DEFINED IN SECTION 3924.031
OF THE REVISED
CODE, RELATING TO AN
INDIVIDUAL, INCLUDING AN EMPLOYEE OR DEPENDENT; MAKES HEALTH
INSURANCE COVERAGE OFFERED THROUGH THE ASSOCIATION AVAILABLE TO
ALL MEMBERS REGARDLESS OF ANY HEALTH STATUS-RELATED FACTOR, AS
DEFINED IN SECTION 3924.031 OF THE
REVISED
CODE, RELATING TO SUCH MEMBERS
OR TO INDIVIDUALS ELIGIBLE FOR COVERAGE THROUGH A MEMBER; DOES
NOT MAKE HEALTH INSURANCE COVERAGE OFFERED THROUGH THE
ASSOCIATION AVAILABLE OTHER THAN IN CONNECTION WITH A MEMBER OF
THE ASSOCIATION; AND MEETS ANY OTHER REQUIREMENT IMPOSED BY THE
SUPERINTENDENT.
Sec. 3924.031. (A) AS
USED IN THIS SECTION AND SECTION 3924.032 OF THE
REVISED
CODE:
(1) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE
FOLLOWING:
(a) HEALTH STATUS;
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND
MENTAL ILLNESSES;
(c) CLAIMS EXPERIENCE;
(d) RECEIPT OF HEALTH CARE;
(e) MEDICAL HISTORY;
(f) GENETIC INFORMATION;
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS
ARISING OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY.
(2) "NETWORK PLAN" MEANS A HEALTH BENEFIT PLAN OF A
CARRIER UNDER WHICH THE FINANCING AND DELIVERY OF MEDICAL CARE,
INCLUDING ITEMS AND SERVICES PAID FOR AS MEDICAL CARE, ARE
PROVIDED, IN WHOLE OR IN PART, THROUGH A DEFINED SET OF
PROVIDERS UNDER CONTRACT WITH THE CARRIER.
(B) IF A CARRIER OFFERS
A HEALTH BENEFIT PLAN IN THE SMALL EMPLOYER MARKET THROUGH A
NETWORK PLAN, THE CARRIER MAY DO BOTH OF THE FOLLOWING:
(1) LIMIT THE SMALL EMPLOYERS THAT MAY APPLY FOR SUCH
COVERAGE TO THOSE WITH ELIGIBLE EMPLOYEES WHO LIVE, WORK, OR
RESIDE IN THE SERVICE AREA OF THE NETWORK PLAN;
(2) WITHIN THE SERVICE AREA OF THE NETWORK PLAN, DENY THE
COVERAGE TO SMALL EMPLOYERS IF THE CARRIER HAS DEMONSTRATED BOTH
OF THE FOLLOWING TO THE SUPERINTENDENT OF INSURANCE:
(a) THE CARRIER WILL NOT HAVE THE CAPACITY TO
DELIVER SERVICES ADEQUATELY TO THE MEMBERS OF ANY ADDITIONAL
GROUPS BECAUSE OF THE CARRIER'S OBLIGATIONS TO EXISTING GROUP
CONTRACT HOLDERS AND MEMBERS.
(b) THE CARRIER IS APPLYING DIVISION
(B)(2) OF THIS SECTION
UNIFORMLY TO ALL SMALL EMPLOYERS WITHOUT REGARD TO THE CLAIMS
EXPERIENCE OF THOSE EMPLOYERS AND THEIR ELIGIBLE EMPLOYEES AND
DEPENDENTS OR TO ANY HEALTH STATUS-RELATED FACTOR RELATING TO
SUCH EMPLOYEES AND DEPENDENTS.
(C) A CARRIER THAT,
PURSUANT TO DIVISION (B)(2) OF
THIS SECTION, DENIES COVERAGE TO A SMALL EMPLOYER IN THE SERVICE
AREA OF A NETWORK PLAN, SHALL NOT OFFER COVERAGE IN THE SMALL
EMPLOYER MARKET WITHIN THAT SERVICE AREA FOR AT LEAST ONE
HUNDRED EIGHTY DAYS AFTER THE DATE THE COVERAGE IS
DENIED.
Sec. 3924.032. (A) A
CARRIER MAY REFUSE TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET IF THE CARRIER HAS DEMONSTRATED BOTH OF THE
FOLLOWING TO THE SUPERINTENDENT OF INSURANCE:
(1) THE CARRIER DOES NOT HAVE THE FINANCIAL RESERVES
NECESSARY TO UNDERWRITE ADDITIONAL COVERAGE.
(2) THE CARRIER IS APPLYING DIVISION
(A) OF THIS SECTION UNIFORMLY
TO ALL EMPLOYERS IN THE SMALL EMPLOYER MARKET IN THIS STATE
CONSISTENT WITH THE APPLICABLE LAWS AND RULES OF THIS STATE AND
WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE EMPLOYERS AND
THEIR EMPLOYEES AND DEPENDENTS OR TO ANY HEALTH STATUS-RELATED
FACTOR RELATING TO SUCH EMPLOYEES AND DEPENDENTS.
(B) A CARRIER THAT,
PURSUANT TO DIVISION (A) OF
THIS SECTION, REFUSES TO ISSUE HEALTH BENEFIT PLANS IN THE SMALL
EMPLOYER MARKET, SHALL NOT OFFER HEALTH BENEFIT PLANS IN THE
SMALL EMPLOYER MARKET IN THIS STATE FOR AT LEAST ONE HUNDRED
EIGHTY DAYS AFTER THE DATE THE COVERAGE IS DENIED OR UNTIL THE
CARRIER HAS DEMONSTRATED TO THE SUPERINTENDENT THAT THE CARRIER
HAS SUFFICIENT FINANCIAL RESERVES TO UNDERWRITE ADDITIONAL
COVERAGE, WHICHEVER IS LATER.
(C) THE SUPERINTENDENT
MAY PROVIDE FOR THE APPLICATION OF THIS SECTION ON A
SERVICE-AREA-SPECIFIC BASIS.
Sec. 3924.033. (A) EACH CARRIER,
IN CONNECTION WITH THE OFFERING OF A HEALTH BENEFIT PLAN TO A
SMALL EMPLOYER, SHALL DISCLOSE TO THE EMPLOYER, AS PART OF ITS
SOLICITATION AND SALES MATERIALS, THAT THE INFORMATION DESCRIBED
IN DIVISION (B) OF THIS SECTION
IS AVAILABLE UPON REQUEST.
(B) A CARRIER SHALL
PROVIDE THE FOLLOWING INFORMATION TO A SMALL EMPLOYER UPON
REQUEST:
(1) THE PROVISIONS OF THE PLAN CONCERNING THE
CARRIER'S RIGHT TO CHANGE PREMIUM RATES AND THE FACTORS THAT MAY
AFFECT CHANGES IN PREMIUM RATES;
(2) THE PROVISIONS OF THE PLAN RELATING TO
RENEWABILITY OF COVERAGE;
(3) THE PROVISIONS OF THE PLAN RELATING TO ANY
PRE-EXISTING CONDITION EXCLUSION;
(4) THE BENEFITS AND PREMIUMS AVAILABLE UNDER ALL
HEALTH BENEFIT PLANS FOR WHICH THE EMPLOYER IS QUALIFIED.
(C) THE INFORMATION
DESCRIBED IN DIVISION (B) OF
THIS SECTION SHALL BE PROVIDED IN A MANNER DETERMINED TO BE
UNDERSTANDABLE BY THE AVERAGE SMALL EMPLOYER, AND IN A MANNER
SUFFICIENT TO REASONABLY INFORM A SMALL EMPLOYER REGARDING THE
EMPLOYER'S RIGHTS AND OBLIGATIONS UNDER THE HEALTH BENEFIT
PLAN.
(D) NOTHING IN THIS
SECTION REQUIRES A CARRIER TO DISCLOSE ANY INFORMATION THAT IS BY LAW
PROPRIETARY AND TRADE SECRET INFORMATION.
Sec. 3924.07. (A) There is hereby established a nonprofit
entity to be known as the "Ohio small employer health
reinsurance program." Any carrier issuing health
benefit plans in this state on or after April 14, 1993, may
be a member of the program.
(B) A carrier may elect to be a member of the program by
filing a written intention to participate with the
superintendent of insurance at least thirty days prior to the implementation
of the program. Any carrier that does not file a written
intention to participate within that time period may not
participate for three years after April 14, 1993, and may file
an
intention to participate only at that time or on any subsequent
three-year anniversary date. However, the superintendent may
permit a carrier to participate in the program at other
intervals for reasons based on financial solvency.
(C) THE BOARD OF DIRECTORS OF THE PROGRAM MAY PERMIT A CARRIER TO
PARTICIPATE IN THE PROGRAM AT ANY TIME FOR GOOD CAUSE SHOWN. THE BOARD SHALL
ESTABLISH AN APPLICATION PROCESS FOR CARRIERS SEEKING TO CHANGE THEIR STATUS
UNDER THIS DIVISION.
Sec. 3924.08. (A) The board of directors of the Ohio
small employer health reinsurance program shall consist of nine
appointed members who shall serve staggered terms as determined
by the initial board for its members and by the plan of operation
of the program for members of subsequent boards. Within thirty
days after April 14, 1993, the members of the board shall be appointed, as
follows:
(1) The chairperson of the senate committee having
jurisdiction over insurance shall appoint the following members:
(a) Two member carriers that are small employer carriers;
(b) One member carrier that is a health maintenance
organization predominantly in the small employer market;
(c) One representative of providers of health care.
(2) The chairperson of the committee in the house of
representatives having jurisdiction over insurance shall appoint
the following members:
(a) One member carrier that is a small employer carrier;
(b) One member carrier whose principal health insurance
business is in the large employer market;
(c) One representative of an employer with fifty or fewer
employees;
(d) One representative of consumers in this state.
(3) The superintendent OF INSURANCE shall appoint a representative of
a
member carrier operating in the small employer market who is a
fellow of the society of actuaries.
The superintendent, a member of the house of
representatives appointed by the speaker of the house of
representatives, and a member of the senate appointed by the
president of the senate, shall be ex-officio members of the
board. The membership of all boards subsequent to the initial
board shall reflect the distribution described in division (A)
of this section.
The chairperson of the initial board and each subsequent
board shall represent a small employer member carrier and shall
be elected by a majority of the voting members of the board. Each chairperson
shall serve for the maximum duration established
in the plan of operation.
(B) Within one hundred eighty days after the appointment
of the initial board, the board shall establish a plan of
operation and, thereafter, any amendments to the plan that are
necessary or suitable, to assure the fair, reasonable, and
equitable administration of the program. The board shall,
immediately upon adoption, provide to the superintendent copies
of the plan of operation and all subsequent amendments to it.
(C) The plan of operation shall establish rules,
conditions, and procedures for all of the following:
(1) The handling and accounting of assets and moneys of
the program and for an annual fiscal reporting to the
superintendent;
(2) Filling vacancies on the board;
(3) Selecting an administering insurer, which shall be a
carrier as defined in section 3924.01 of the Revised Code, and
setting forth the powers and duties of the administering insurer;
(4) Reinsuring risks in accordance with sections 3924.07
to 3924.14 of the Revised Code;
(5) Collecting assessments subject to section 3924.13 of
the Revised Code from all members to provide for claims reinsured
by the program and for administrative expenses incurred or
estimated to be incurred during the period for which the
assessment is made;
(6) Providing protection for carriers from the financial
risk associated with small employers that present poor credit
risks;
(7) Establishing standards for the coverage of small
employers that have a high turnover of employees;
(8) Establishing an appeals process for carriers to seek
relief when a carrier has experienced an unfair share of
administrative and credit risks;
(9) Establishing the adjusted average market premium
prices for use by the SEHC plan for groups of two to twenty-five
employees and for groups of twenty-six to fifty employees that
are offered in the state;
(10) Establishing participation standards at issue and
renewal for reinsured cases;
(11) Reinsuring risks and collecting assessments in
accordance with division (G) of section 3924.11 of the Revised
Code;
(12) Any additional matters as determined by the board.
Sec. 3924.09. The Ohio small employer health reinsurance
program shall have the general powers and authority granted under
the laws of the state to insurance companies licensed to transact
sickness and accident insurance, except the power to issue
insurance. The board of directors of the program also shall have
the specific authority to do all of the following:
(A) Enter into contracts as are necessary or proper to
carry out the provisions and purposes of sections 3924.07 to
3924.14 of the Revised Code, including the authority to enter
into contracts with similar programs of other states for the
joint performance of common functions, or with persons or other
organizations for the performance of administrative functions;
(B) Sue or be sued, including taking any legal actions
necessary or proper for recovery of any assessments for, on
behalf of, or against any program or board member;
(C) Take such legal action as is necessary to avoid the
payment of improper claims against the program;
(D) Design the SEHC plan which, when offered by a carrier,
is eligible for reinsurance and issue reinsurance policies in
accordance with the requirements of sections 3924.07 to 3924.14
of the Revised Code;
(E) Establish rules, conditions, and procedures pertaining
to the reinsurance of members' risks by the program;
(F) Establish appropriate rates, rate schedules, rate
adjustments, rate classifications, and any other actuarial
functions appropriate to the operation of the program;
(G) Assess members in accordance with division (G)
of section 3924.11 and the provisions of
section 3924.13 of the Revised Code, and make such advance
interim assessments as may be reasonable and necessary for
organizational and interim operating expenses. Any interim
assessments shall be credited as offsets against any regular
assessments due following the close of the calendar year.
(H) Appoint members to appropriate legal, actuarial, and
other committees if necessary to provide technical assistance
with respect to the operation of the program, policy and other
contract design, and any other function within the authority of
the program;
(I) Borrow money to effect the purposes of the program.
Any notes or other evidence of indebtedness of the program not in
default shall be legal investments for carriers and may be
carried as admitted assets.
(J) Reinsure risks, collect assessments, and otherwise
carry out its duties under division (G) of section 3924.11 of the
Revised Code.;
(K) Study the operation of the Ohio small
employer health reinsurance program and the open enrollment
reinsurance program and, based on its findings, make legislative
recommendations to the general assembly for improvements in the
effectiveness, operation, and integrity of the programs;
(L) DESIGN A BASIC AND STANDARD PLAN FOR PURPOSES OF SECTIONS
1742.13, 3923.122, AND 3923.581 of the Revised Code.
Sec. 3924.10. (A) The board of directors of the Ohio small
employer 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 small employer
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 1742., 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
maintenance organizations shall be consistent with the basic
method of operation of such organizations.
(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.
(F) A carrier shall not be required to renew coverage
where the superintendent finds that renewal of coverage would
place the carrier in a financially impaired condition. The
superintendent shall determine when the carrier is no longer
financially impaired and is, therefore, subject to the guaranteed
renewability requirements.
Sec. 3924.11. Any member of the Ohio small employer health
reinsurance program may reinsure small employer groups or
individuals in accordance with the following conditions and
limitations:
(A) With respect to eligible employees and their
dependents who are hired subsequent to the commencement of the
employer's coverage by a carrier and who are not late enrollees,
and with respect to employees of an employer who are otherwise
eligible for insurance but were excluded by the carrier's
underwriting and who are not late enrollees, coverage may be
reinsured in either of the following ways:
(1) Except in the case of late enrollees, within sixty
days after the commencement of their coverage under the plan;
(2) In the case of late enrollees, eighteen months after
the date the late enrollee becomes a member of the small
employer's plan.
(B)(1) The carrier may reinsure either the entire
eligible
group or any eligible individual, in accordance with the
premium
rates established in section 3924.12 of the Revised Code,
upon commencement of the coverage.
(2) The carrier may reinsure an eligible employee,
or the dependents of an eligible employee, who were previously
excluded from group coverage for medical reasons, and shall
reinsure such employees or dependents within sixty days after the
carrier is required to include them in the group coverage.
(C) With respect to an SEHC plan, the program
shall reinsure the level of coverage provided.
(D) With respect to other plans issued to small employers, the
program shall reinsure the level of coverage provided up to, but
not exceeding, the level of coverage provided in an SEHC
plan. In the coverage provided to small employers, carriers
shall be required to use high-cost care management, hospital
precertification techniques, and other cost containment
mechanisms established by the program.
(E) A carrier may not reinsure existing business, except
pursuant to division (A) of this section.
(F) If an employer group is covered under a plan other than an
SEHC plan and the carrier chooses to reinsure the group
subsequent to the initial coverage period, or if a new individual
joins the group and the carrier wants to reinsure that
individual, the carrier shall not force the employer to change
to an SEHC plan. The carrier shall allow the employer
to maintain the same benefit plan and reinsure only that portion
of the plan that is consistent with an SEHC plan.
(G) With respect to coverage provided to a small employer
group or AN individual acquired under section 3923.58 OR A
FEDERALLY ELIGIBLE INDIVIDUAL ACQUIRED UNDER SECTION 1742.12 OR
3923.581 of the Revised Code, the following conditions and
limitations apply:
(1) Within sixty days after the commencement of
the
initial coverage, any carrier may reinsure coverage of an entire
small employer group, or of eligible employees or dependents of
such group, or any SUCH AN individual acquired under section
3923.58 of
the Revised Code with the OPEN ENROLLMENT REINSURANCE program IN
ACCORDANCE WITH DIVISION (G) OF THIS SECTION. A carrier may
reinsure,
within sixty days after the effective date of
coverage, an
employee eligible for coverage under section 3923.58 of the
Revised Code. Premium rates charged for coverage reinsured by
the program shall be established in accordance with section
3924.12 of the Revised Code.
(2) The board of directors of the OHIO HEALTH
REINSURANCE program shall establish
the open enrollment reinsurance fund for coverage provided under
section 3923.58 of the Revised Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE
INDIVIDUALS, COVERAGE PROVIDED UNDER SECTIONS 1742.12 AND 3923.581 of the Revised Code.
The fund shall
be
maintained separately from any reinsurance fund established for
small employer health care plans issued pursuant to sections
3924.07 to 3924.14 of the Revised Code. The board shall
calculate, on a retrospective basis, the amount needed for
maintenance of the open enrollment reinsurance fund and, on the
basis of that calculation, shall determine the amount to be
assessed each carrier that is required to provide open enrollment
coverage.
Assessments shall be apportioned by the board among all
carriers participating in the open enrollment reinsurance program
in proportion to their respective shares of the total premiums,
net of reinsurance premiums paid by a carrier for open enrollment
coverage and net of reinsurance premiums paid by the carrier for
all other small group and individual health benefit plans, earned
in this state from all health benefit plans covering small
employers and individuals that are issued by all such carriers
during the calendar year coinciding with or ending during the
fiscal year of the open enrollment program, or on any other
equitable basis reflecting coverage of small employers and
individuals in this state as may be provided in the plan of
operation adopted by the board. In no event shall the assessment
of any carrier under this section exceed, on an annual
basis, three per cent of its Ohio premiums for health
benefit plans covering small employers and individuals
as reported on its most recent annual statement filed with the superintendent
of insurance.
The board shall submit its determination of the amount of
the assessment to the superintendent for review of
the accuracy of the calculation of the assessment. Upon approval
by the superintendent, each carrier shall, within thirty days
after receipt of the notice of assessment, submit the assessment
to the board for purposes of the open enrollment reinsurance
fund.
(3) If the assessments made and collected pursuant to
division (G)(2) of this section are not sufficient to pay the
claims reinsured under division (G) of this section and the
allocated administrative expenses, incurred or estimated to be
incurred during the period for which the assessment was made, the
secretary of the board shall immediately notify the
superintendent, and the superintendent shall suspend the
operation of open enrollment under section 3923.58 of the Revised
Code AND, WITH RESPECT TO FEDERALLY ELIGIBLE INDIVIDUALS, UNDER SECTIONS
1742.12 AND 3923.581 of the Revised Code until the board has collected in subsequent
years through assessments made pursuant to division (G)(2) of this section an
amount sufficient to pay such claims and administrative expenses.
(4)(a) Any carrier that is subject to open enrollment
under section 3923.58 of the Revised Code may elect
not to
participate in the open enrollment reinsurance program under
division (G) of this section by filing an application with the
superintendent and obtaining the superintendent's approval. In
determining whether to approve an application, the superintendent
shall consider whether the carrier meets all of the following
standards:
(i) Demonstration by the carrier of a substantial and
established market presence;
(ii) Demonstrated experience in the small employer group
INDIVIDUAL market and history of rating and underwriting small
employer
groups INDIVIDUAL PLANS;
(iii) Commitment to comply with the requirements of
section 3923.58 of the Revised Code;
(iv) Financial ability to assume and manage the risk of
enrolling open enrollment groups and individuals without the need
for, or protection of, reinsurance.
(b) A carrier whose application for nonparticipation has
been rejected by the superintendent may appeal the decision in
accordance with Chapter 119. of the Revised Code. A carrier that
has received approval of the superintendent not to participate in
the open enrollment reinsurance program shall, on or before the
first day of December, annually certify to the superintendent
that it continues to meet the standards described in division
(G)(4)(a) of this section.
(c) In any year subsequent to the year in which its
application not to participate has been approved, a carrier may
elect to participate in the open enrollment reinsurance program
by giving notice to the superintendent and board on or before the
thirty-first day of December. If, after a period of
nonparticipation, a carrier elects to participate in the open
enrollment reinsurance program, the carrier retains the risks it
assumed during the period when it was not participating.
(d) The superintendent may, at any time, authorize a
carrier to modify an election not to participate if the risk from
the carrier's open enrollment business jeopardizes the financial
condition of the carrier. If the superintendent authorizes the
carrier to again participate in the open enrollment reinsurance
program, the carrier shall retain the risks it assumed during the
period of nonparticipation.
(5) At the time of acquiring a small employer group, a
carrier shall determine whether to reinsure the entire group or
any individual pursuant to section 3924.12 of the Revised Code.
(6)(a) The open enrollment reinsurance program shall
be operated separately from the Ohio small employer
health reinsurance program.
(b) A carrier's election to participate in the open
enrollment reinsurance program under division (G) of
this section shall not be construed as an election to participate
in the Ohio small employer health reinsurance program
under section 3924.07 of the Revised Code.
Sec. 3924.111. (A) The Ohio small
employer health reinsurance program shall not provide reinsurance
for any individual reinsured under the program until five
thousand dollars in benefit payments have been made by a member
of the program for services provided to that individual during a
calendar year, which payments would have been reimbursed through
the program but for the five-thousand-dollar deductible. The
member shall retain ten per cent of the next fifty thousand
dollars of benefit payments made during that calendar year, and
the program shall reinsure the remainder. However, a member's
maximum liability under this section with respect to any one
individual reinsured under the program shall not exceed ten
thousand dollars in any one calendar year.
(B) The board of directors of the Ohio
small employer health reinsurance program shall periodically
review the deductible amount and the maximum liability amount set
forth in division (A) of this section and, considering
the rate of inflation, adjust each amount as the board considers
necessary.
Sec. 3924.12. (A) Except as provided in division (B) of
this section, premium rates charged for coverage reinsured by the
Ohio small employer health reinsurance program shall be
established as follows:
(1) For whole group reinsurance coverage, one and one-half
times the adjusted average market premium price established by
the program for that classification or group with similar
characteristics and coverage, with respect to the eligible
employees of a small employer and their dependents, all of whose
coverage is reinsured with the program, minus a ceding expense
factor determined by the board of directors of the program;
(2) For individual reinsurance coverage, five times the
adjusted average market premium price established by the program
for an individual in that classification or group with similar
characteristics and coverage, with respect to an eligible
employee or his dependents, minus a ceding expense factor
determined by the board.
(B) Premium rates charged for reinsurance by the program
to a health maintenance organization that is approved by the
secretary of health and human services as a federally qualified
health maintenance organization pursuant to the "Social Security
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and as
such is subject to requirements that limit the amount of risk
that may be ceded to the program, may be modified to reflect the
portion of risk that may be ceded to the program.
Sec. 3924.13. (A) Following the close of each calendar year,
the administering insurer of the Ohio small employer health
reinsurance program shall determine the net premiums, the program
expenses for administration, and the incurred losses, if any, for
the year, taking into account investment income and other
appropriate gains and losses. For purposes of this section, health
benefit plan premiums earned by MEWAs shall be established
by adding paid claim losses and administrative expenses of the
MEWA. Health benefit plan premiums and benefits paid by
a carrier that are less than an amount determined by the board
of directors of the program to justify the cost of collection
shall not be considered for purposes of determining assessments.
For purposes of this division, "net premiums" means health
benefit plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by
assessments of carriers in accordance with this division.
Assessments shall be apportioned by the board among all carriers
participating in the program in proportion to their respective
shares of the total premiums, net of reinsurance premiums paid
for coverage under this program earned in the state from health
benefit plans covering small employers that are issued by
participating members during the calendar year coinciding with or
ending during the fiscal year of the program, or on any other
equitable basis reflecting coverage of small employers as may be
provided in the plan of operation. An assessment shall be made
pursuant to this division against a health maintenance
organization that is approved by the secretary of health and
human services as a federally qualified health maintenance
organization pursuant to the "Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended, subject to an assessment
adjustment formula adopted by the board for such health
maintenance organizations that recognizes the restrictions
imposed on the organizations by federal law. The adjustment
formula shall be adopted by the board prior to the first
anniversary of the program's operation. In no event shall the
assessment made pursuant to this division exceed, on an
annual basis, one per cent
of the carrier's Ohio small employer
group premium as reported on its most recent annual statement
filed with the superintendent of insurance. If an excess is
actuarially projected, the superintendent may take any action necessary to
lower the assessment to the maximum level of one per cent.
(C) If assessments exceed actual losses and administrative
expenses of the program, the excess shall be held at interest and
used by the board to offset future losses or to reduce program
premiums. As used in this division, "future losses" includes
reserves for incurred but not reported claims.
(D) Each carrier's proportion of participation in the
program shall be determined annually by the board based on
annual statements and other reports deemed necessary by the
board and filed by the carrier with the board. MEWAs
shall report to the board claims payments made and administrative
expenses incurred in this state on an annual basis
on a form prescribed by the superintendent.
(E) Provision shall be made in the plan of operation for
the imposition of an interest penalty for late payment of
assessments.
(F) A carrier may seek from the superintendent a
deferment, in whole or in part, from any assessment issued by the
board. The superintendent may defer, in whole or in part, the
assessment of a carrier if, in the opinion of the superintendent,
payment of the assessment would endanger the carrier's ability to
fulfill its contractual obligations.
(G) In the event an assessment against a carrier is
deferred in whole or in part, the amount by which the assessment
is deferred may be assessed against the other carriers in a
manner consistent with the basis for assessments set forth in
this section. In such event, the other carriers assessed shall
have a claim in the amount of the assessment against the carrier
receiving the deferment. The carrier receiving the deferment
shall remain liable to the program for the amount deferred. The
superintendent may attach appropriate conditions to any
deferment.
Sec. 3924.14. Neither the participation as members of the Ohio small
employer health reinsurance program or as members of the board of
directors of the
program, the establishment of rates, forms, or procedures for coverage issued
by the program, nor any other joint or collective action required by sections
3924.01 to 3924.14 of the Revised Code, shall be the basis of any legal action
or any criminal or civil liability or penalty against the program, the board,
or any of its members either jointly or separately.
Sec. 3924.27. (A) AS
USED IN THIS SECTION:
(1) "CARRIER," "DEPENDENT," AND "HEALTH BENEFIT PLAN" HAVE THE SAME
MEANINGS AS IN SECTION 3924.01 of the Revised Code.
(2) "HEALTH STATUS-RELATED FACTOR" MEANS ANY OF THE
FOLLOWING:
(a) HEALTH STATUS;
(b) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND
MENTAL ILLNESSES;
(c) CLAIMS EXPERIENCE;
(d) RECEIPT OF HEALTH CARE;
(e) MEDICAL HISTORY;
(f) GENETIC INFORMATION;
(g) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS
ARISING OUT OF ACTS OF DOMESTIC VIOLENCE;
(h) DISABILITY.
(B) NO GROUP HEALTH BENEFIT PLAN, OR CARRIER OFFERING HEALTH
INSURANCE COVERAGE IN CONNECTION WITH A GROUP HEALTH BENEFIT
PLAN, SHALL REQUIRE ANY INDIVIDUAL, AS A CONDITION OF ENROLLMENT
OR CONTINUED ENROLLMENT UNDER THE PLAN, TO PAY A PREMIUM OR
CONTRIBUTION THAT IS GREATER THAN THE PREMIUM OR CONTRIBUTION
FOR A SIMILARLY SITUATED INDIVIDUAL ENROLLED IN THE PLAN ON THE
BASIS OF ANY HEALTH STATUS-RELATED FACTOR IN RELATION TO THE
INDIVIDUAL OR TO AN INDIVIDUAL ENROLLED UNDER THE PLAN AS A
DEPENDENT OF THE INDIVIDUAL.
(C) NOTHING IN
DIVISION (B) OF THIS SECTION
SHALL BE CONSTRUED TO RESTRICT THE AMOUNT THAT AN EMPLOYER MAY
BE CHARGED FOR COVERAGE UNDER A GROUP HEALTH BENEFIT PLAN, OR TO
PREVENT A GROUP HEALTH BENEFIT PLAN, AND A CARRIER OFFERING
GROUP HEALTH INSURANCE COVERAGE, FROM ESTABLISHING PREMIUM
DISCOUNTS OR REBATES OR MODIFYING OTHERWISE APPLICABLE
COPAYMENTS OR DEDUCTIBLES IN RETURN FOR ADHERENCE TO PROGRAMS OF
HEALTH PROMOTION AND DISEASE PREVENTION.
Sec. 3924.51. (A) As used in this section:
(1) "Child" means, in connection with any adoption or
placement for adoption of the child, an individual who has not
attained age eighteen as of the date of the adoption or placement
for adoption.
(2) "Health insurer" has the same meaning as in section 3924.41
of the Revised Code.
(3) "Placement for adoption" means the assumption and
retention by a person of a legal obligation for total or partial
support of a child in anticipation of the adoption of the child.
The child's placement with a person terminates upon the
termination of that legal obligation.
(B) If an individual or group health plan of a health
insurer provides MAKES coverage AVAILABLE for dependent
children of participants or beneficiaries, the plan shall provide
benefits to dependent children placed with participants or
beneficiaries for adoption under the same terms and conditions as
apply to the natural, dependent children of the participants and
beneficiaries, irrespective of whether the adoption has become
final.
(C) A health plan described in division (B) of this
section shall not restrict coverage under
the plan of any dependent child adopted by a participant or
beneficiary, or placed with a participant or beneficiary for
adoption, solely on the basis of a pre-existing condition of the
child at the time that the child would otherwise become eligible
for coverage under the plan, if the adoption or placement for
adoption occurs while the participant or beneficiary is eligible
for coverage under the plan.
Sec. 3924.61. As used in sections 3924.61 to 3924.74 of the
Revised Code:
(A) "Account holder" means the
natural person who opens a medical savings account or on whose behalf a
medical savings account is opened.
(B) "Eligible medical expense" means any
expense for a service rendered by a licensed health care
provider or a christian science CHRISTIAN
SCIENCE practitioner, or for an article, device, or
drug prescribed by a licensed health care provider or provided by a
christian science CHRISTIAN SCIENCE
practitioner, when intended for use in the
mitigation, treatment, or prevention of disease; ANY AMOUNT PAID FOR
TRANSPORTATION TO THE LOCATION AT WHICH SUCH A SERVICE IS RENDERED; ANY AMOUNT
PAID FOR LODGING NECESSITATED BY THE RECEIPT OF CARE AT A NONLOCAL
HOSPITAL; or premiums paid for
comprehensive sickness and accident insurance,
coverage under a health care plan of a health maintenance
organization organized under Chapter 1742. of the Revised
Code, long-term care insurance as defined in section 3923.41 of the
Revised Code, Medicare supplemental coverage as defined in section 3923.33 of
the Revised Code, or payments made pursuant
to cost sharing agreements under comprehensive sickness and
accident plans. An "eligible medical
expense" does not include expenses otherwise paid or reimbursed, including
medical expenses paid or reimbursed under an automobile or motor vehicle
insurance policy, a workers' compensation insurance policy or plan, or an
employer-sponsored health coverage policy, plan, or contract.
(C) "Qualified dependent" means a
child of an account holder when any of the following applies:
(1) The child is under nineteen years of age, or is
under twenty-three years of age and a full-time student at an
accredited college or university;
(2) The child is not self-sufficient due to physical or
mental disorders or impairments;
(3) The child is legally entitled to the provision of
proper or necessary subsistence, education, medical care, or
other care necessary for the child's health, guidance, or
well-being and is not otherwise emancipated, self-supporting,
married, or a member of the armed forces of the United
States DEPENDENT" HAS THE SAME MEANING AS IN SECTION 152 OF THE
"INTERNAL REVENUE CODE OF 1986," 100 STAT.
2085, 26 U.S.C.A. 1, AS AMENDED.
Sec. 3924.62. (A) A medical savings account may be opened
by or on behalf of any natural person, to pay the person's eligible medical
expenses and the eligible medical expenses of that person's spouse or
qualified dependent. A medical savings account may be opened by or on
behalf
of a person only if
that person participates in a sickness or accident insurance plan,
a plan offered by a health maintenance organization organized under
Chapter 1742. of the Revised Code, or a
self-funded, employer-sponsored health benefit plan
established pursuant to the "Employee Retirement
Income Security Act of 1974," 88 Stat.
832, 29 U.S.C.A.
1001, as amended. While the medical savings account is open,
the account holder shall continue to participate in such a plan.
(B) A person who refuses
to participate in a policy, plan, or contract of health coverage
that is funded by the person's employer, and who receives
additional monetary compensation by virtue of refusing that
coverage, may not open a medical savings account unless the
medical savings account also is sponsored by the person's
employer.
Sec. 3924.63. The owners of interest in
a medical savings account are the account holder, AND the
account holder's spouse,
and qualified dependents. No medical savings account shall be subject
to
garnishment or attachment.
Sec. 3924.64. (A) At the time a medical
savings account is opened, an administrator for the account shall
be designated. If an employer opens an account for an employee,
the employer may designate the administrator. If an account is
opened by any person other than an employer, or if an employer
chooses not to designate an administrator for an account opened
for an employee, the account holder shall designate the
administrator. The administrator shall manage the account in a
fiduciary capacity for the benefit of the account holder.
(B) Medical savings accounts shall be
administered by one of the following:
(1) A federally or state-chartered bank, savings and
loan association, savings bank, or credit union;
(2) A trust company authorized to act as a fiduciary;
(3) An insurer authorized under Title
XXXIX of the Revised Code to engage in
the business of sickness and accident insurance;
(4) A dealer or salesperson licensed under Chapter
1707. of the Revised Code;
(5) An administrator licensed under Chapter
3959. of the Revised Code;
(6) A certified public accountant;
(7) An employer that administers an employee benefit
plan subject to regulation under the "Employee
Retirement Income Security Act of
1974," 88 Stat. 829, 29
U.S.C.A. 1001, as amended, or
that maintains medical savings accounts for its employees;
(8) Health maintenance organizations organized under Chapter
1742. of the Revised Code.
(C) Each administrator shall send to the
account holder, at least annually, a statement setting forth the
balance remaining in the account holder's account and detailing
the activity in the account since the last statement was
issued. Upon an administrator's receipt of a written request
from an account holder for a current statement, the administrator
shall promptly send the statement to the account holder.
(D) When an account holder documents to the
administrator of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the account
holder, OR
the account holder's spouse, or qualified
dependents, the administrator shall reimburse the account holder
for, or shall pay for, the eligible medical expense with funds from the
account holder's account, if sufficient funds are available in
the account holder's account. If there are not
sufficient funds in the account to fully reimburse the account
holder or pay the expenses, the administrator shall reimburse
the account holder or pay the expenses using whatever funds are
in the account. The reimbursement or payment shall
be made within thirty days of the administrator's receipt of the
documentation. At the time of making the reimbursement or payment, the
administrator shall notify the account holder if the medical
expense does not count toward meeting the deductible or other
obligation for the receipt of benefits that is required by the
insurer or other third-party payer providing health coverage to
the account holder. The administrator shall keep a record of the
amounts disbursed from the account for documented eligible medical
expenses and of the dates on which the expenses were
incurred. This record shall be made available to any sickness
and accident insurer or other third-party payer providing health
coverage to the account holder, for use by the insurer or
third-party payer in determining whether the account holder has
met the deductible or other obligation required for the receipt
of benefits from the insurer or third-party payer.
(E) When an account is opened, the
administrator shall give written notice to the account holder of
the date of the last business day of the administrator's business
year.
Sec. 3924.66. (A) In determining Ohio adjusted gross
income under Chapter 5747. of the Revised Code, an account holder may deduct
an amount
equaling the total of the deposits that the account holder, the account
holder's spouse, or the account holder's employer made to the account during
the taxable year, to the extent that the funds for the deposits have not
otherwise been deducted or excluded in determining the account holder's
federal adjusted gross
income. The amount deducted by an account holder for a taxable year shall not
exceed three thousand dollars. If two married persons each have an account,
each
spouse may claim the deduction described in this section, and
the amount deducted by each spouse shall not exceed three
thousand dollars, whether the spouses file returns jointly or
separately.
(B) The maximum deduction allowed under division (A) of
this section shall be adjusted annually by the department of taxation to
reflect increases in the consumer price index for all items for all urban
consumers for the north central region, as published by the United
States bureau of labor statistics.
(C) In determining Ohio adjusted gross income under
Chapter 5747. of the Revised Code, an account holder may deduct the investment
earnings of a medical savings account from the account holder's federal
adjusted gross income, to the extent that these earnings have been included in
the account holder's federal adjusted gross income.
(D) In determining Ohio adjusted gross income under
Chapter 5747. of the Revised Code, an account holder shall add to the account
holder's federal adjusted gross income an amount equal to the sum of
the amounts described in divisions
(D)(1) and (2) of this section
to the extent that those amounts were included in the account
holder's federal adjusted gross income and previously deducted
in determining the account holder's
Ohio adjusted gross income. In
determining the extent to which amounts withdrawn from the
account shall be included in the account holder's
Ohio adjusted gross income, the
tax commissioner shall be guided by the provisions of sections
72 and 408 of the Internal Revenue Code governing the
determination of the amount of withdrawals from an individual
retirement account to be included in federal gross income.
(1) Amounts withdrawn from the account during the
taxable year used
for any purpose other than to reimburse the account holder for, or to pay, the
eligible medical expenses of the account holder, OR the account
holder's spouse,
or qualified
dependents;
(2) Investment earnings during the taxable year on amounts withdrawn
from the account that are described in division (D)(1) of this
section.
(E) Amounts withdrawn from a medical savings account to reimburse
the account holder for, or to pay, the account holder's eligible medical
expenses, or the eligible medical expenses of the account holder's spouse or
qualified
dependents, shall not be included in the account holder's Ohio
adjusted gross income in determining taxes due under Chapter 5747.
of the Revised Code.
(F) If a qualified dependent of an account
holder becomes
ineligible to continue to participate in the
account holder's policy, plan, or contract of health coverage, the account
holder may withdraw funds from the account holder's account and use those
funds to pay the premium for the first year of a policy,
plan, or contract of health coverage for the qualified dependent and to
pay
any deductible for the first year of that policy, plan, or
contract. Funds withdrawn and used for that purpose shall not be included in
the account holder's Ohio adjusted gross income in
determining taxes due under Chapter 5747. of the
Revised Code.
Sec. 3924.67. An account holder may withdraw funds
from the account holder's account at any time, for any purpose. However, the
administrator of a medical savings account shall not disburse funds to an
account holder during
the year in which the funds were deposited, except to reimburse the
account holder for, or pay for, a documented eligible medical expense of the
account holder, OR the account holder's spouse, or a
qualified dependent.
Sec. 3924.68. (A) If an account holder,
whose medical savings account has been opened by the account holder's
employer,
later ceases to be employed by that employer, the account holder
may, within sixty days of the account holder's final date of employment,
request
in writing to the administrator of the account that the
administrator continue to administer the account.
(1) If the administrator agrees to continue to
administer the account, funds in the account may continue to be
used to pay the eligible medical expenses of the account holder,
AND the account
holder's spouse, and qualified dependents, pursuant to sections
3924.61 to
3924.74 of the Revised Code.
If the account holder later becomes employed by a new employer that opens a
new medical savings account on the account holder's behalf, the account holder
may
transfer any funds remaining in the account opened by the account holder's
former employer to
the account opened by the account holder's new employer. For purposes of
determining taxes due
under Chapter 5747. of the Revised Code, this transfer of funds shall not be
considered a withdrawal of funds from a medical savings account, nor shall it
be considered a deposit to a medical savings account.
(2) If the administrator does not agree to
continue to administer the account, or if the account holder
requests that the account be closed, the administrator shall
close the account and mail a check or other negotiable instrument
in the amount of the account balance as of that date to the
account holder. The amount distributed shall be included in the
account holder's Ohio adjusted gross income in
determining taxes due under Chapter 5747. of the
Revised Code.
(B) Within sixty days of the account holder's final date of
employment, the
account holder may transfer any funds remaining in the account opened by the
account holder's former employer to another medical savings account owned by
the account holder. For purposes of determining taxes due under
Chapter 5747,. of the Revised Code, this
transfer of funds shall not be considered a withdrawal of funds from a medical
savings account, nor shall it be considered a deposit to a medical savings
account.
(C) An administrator of an account opened by an employer shall
not close an account without the permission of the account holder until at
least sixty-one days after the account holder's final date of employment. The
employer shall notify the administrator of the employee's final date of
employment.
Sec. 3924.73. (A) As used in this section:
(1) "Health care insurer" means any person legally engaged in the business
of providing sickness and accident insurance contracts in this
state, a health maintenance organization organized under
Chapter 1742. of the Revised Code, or any legal
entity that
is self-insured and provides health care benefits to its
employees or members.
(2) "Small employer" has the same meaning as in division
(P) of section 3924.01 of the Revised Code.
(B)(1) Subject to division (B)(2) of this
section, nothing in sections 3924.61 to 3924.74 of the
Revised Code shall be construed to
limit the rights, privileges, or protections of employees or
small employers under sections 3924.01 to 3924.14 of the
Revised Code.
(2) If any account holder enrolls or applies to enroll in a
policy or contract offered by a health care insurer providing
sickness and accident coverage that is more comprehensive than,
and has a deductible amount that is less than, the coverage and
deductible amount of the policy under which the account holder
currently is enrolled, the health care insurer to which the
account holder applies may subject the account holder to the
same medical review, waiting periods, and underwriting
requirements to which the health care insurer generally subjects
other enrollees or applicants, unless the account holder enrolls
or applies to enroll during a designated period of open
enrollment.
Section 2. That existing sections 1739.05, 1742.06, 1742.12, 1742.16,
1742.37, 1742.39, 1742.45, 3901.21, 3923.122, 3923.26, 3923.40, 3923.57,
3923.58, 3923.59, 3923.63, 3923.64, 3924.01, 3924.03, 3924.07, 3924.08,
3924.09, 3924.10, 3924.11, 3924.111, 3924.12, 3924.13, 3924.14, 3924.51,
3924.61, 3924.62, 3924.63, 3924.64, 3924.66, 3924.67, 3924.68, and 3924.73 and
sections 1742.13 and 3941.53 of the Revised Code are hereby
repealed.
Section 3. The amendments to sections 1742.37, 1742.39, 3923.122,
3923.26, 3923.40, and 3924.51 of the Revised Code by this act
shall apply to contracts, evidences of coverage, policies, and
plans that are delivered, issued for delivery, renewed, or
established in this state on or after the effective date of this
section.
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