The online versions of legislation provided on this website are not official. Enrolled bills are the final version passed by the Ohio General Assembly and presented to the Governor for signature. The official version of acts signed by the Governor are available from the Secretary of State's Office in the Continental Plaza, 180 East Broad St., Columbus.
|
As Introduced
122nd General Assembly
Regular Session
1997-1998 | H. B. No. 698 |
REPRESENTATIVE VAN VYVEN
A BILL
To amend sections 1739.01, 1751.01, 1751.02, 1751.03, 1751.05, 1751.06,
1751.11, 1751.12, 1751.13, 1751.15, 1751.16, 1751.20,
1751.31, 1751.46, 1751.55, 1751.58, 1751.59,
1751.60, 1751.62,
1907.161, 2305.252, 3901.21, 3923.021,
3923.122, 3923.571, 3923.58, 3924.01,
3924.03, 3924.08, 3924.09,
3924.10, 3924.11, 3999.22, 5112.01, and 5112.08, to enact
sections 1751.141
and 1751.151 of
the Revised Code, and to amend Section 3 of Am. Sub.
S.B. 67 of the 122nd General Assembly, to conform
provisions in the Health Insuring Corporation Law and the
Sickness and Accident Insurance Law with the
Health Insurance
Portability and Accountability Act of 1996, to clarify other
provisions in these laws, to specify how health insuring
corporations are to bring their net worth into compliance with
the Health Insuring Corporation Law, and to
maintain the
provisions of this act on and after October 1, 1998, by amending
the versions of sections 1751.02, 1751.03, 1751.13, and 3924.10
of the Revised Code that take effect on that
date.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.01, 1751.01, 1751.02, 1751.03, 1751.05,
1751.06, 1751.11, 1751.12, 1751.13, 1751.15, 1751.16,
1751.20, 1751.31, 1751.46, 1751.55, 1751.58, 1751.59, 1751.60,
1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 3923.122, 3923.571, 3923.58,
3924.01, 3924.03, 3924.08,
3924.09, 3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 be amended and
sections 1751.141
and 1751.151 of the Revised Code be enacted to read as follows:
Sec. 1739.01. As used in sections 1739.01 to 1739.22 of
the Revised Code:
(A) "Agreement" means a written agreement executed by
members of a multiple employer welfare arrangement that
establishes an arrangement, provides for its operation, and
through which each member agrees to assume and discharge all
liability under sections 1739.01 to 1739.22 of the Revised Code
relating to or arising out of the operation of the arrangement in
proportion to the ratio of the total number of covered employees
employed by the member at the time the liability arose to the
total number of covered employees employed by all members of the
arrangement at the time the liability arose.
(B) "Excess insurance" or "stop-loss insurance" means an
insurance policy purchased by a multiple employer welfare
arrangement under which it receives reimbursement for benefits it
pays in excess of a preset deductible or limit.
(C) "Fully-insured FULLY INSURED program" means a program by
which
benefits are provided to members, employees of members, or the
dependents of such members or employees, through the purchase of
sickness and accident insurance from an insurance company
licensed to do business in this state or health services
purchased from a health maintenance organization INSURING
CORPORATION authorized to do
business in this state.
(D) "Group self-insurance program" means a program by
which benefits are provided to members, employees of members, or
the dependents of such members or employees, other than through
sickness and accident insurance purchased from an insurance
company licensed to do business in this state or health care
services purchased from a health maintenance organization INSURING
CORPORATION authorized to do business in this state.
(E) "Member" means an individual or an employer that is a
member of an organization sponsoring a multiple employer welfare
arrangement.
(F) "Multiple employer welfare arrangement" means an
employee welfare benefit plan, trust, or any other arrangement,
whether such plan, trust, or arrangement is subject to the
"Employee Retirement Income Security Act of 1974," 88 Stat. 829,
29 U.S.C.A. 1001, as amended, that is established or maintained
for the purpose of offering or providing, through group insurance
or group self-insurance programs, medical, surgical, or hospital
care or benefits, or benefits in the event of sickness, accident,
disability, or death, to the employees, and their dependents, of
two or more employers, or to two or more self-employed
individuals and their dependents.
(G) "Premium" means any type of consideration paid to a
multiple employer welfare arrangement by a member for coverage
under the arrangement.
(H) "Surplus" means the total assets of the multiple
employer welfare arrangement less its liabilities and reserves as
determined in accordance with the requirements of sections
1739.01 to 1739.21 of the Revised Code.
(I) "Third-party administrator" has the same meaning as
"administrator" in section 3959.01 of the Revised Code.
Sec. 1751.01. As used in this chapter:
(A) "Basic health care
services" means the following services when medically
necessary:
(1) Physician's services, except when such services are
supplemental under division (B)
of this section;
(2) Inpatient hospital services;
(3) Outpatient medical services;
(4) Emergency health services;
(5) Urgent care services;
(6) Diagnostic laboratory services and diagnostic and
therapeutic radiologic services;
(7) Preventive health care services, including, but not
limited to, voluntary family planning services, infertility
services, periodic physical examinations, prenatal obstetrical
care, and well-child care.
"Basic health care services" does not include experimental
procedures.
A health insuring corporation shall not offer coverage for
a health care service, defined as a basic health care service by
this division, unless it offers coverage for all listed basic
health care services. However,
this requirement does not apply to the coverage of beneficiaries
enrolled in Title XVIII of the "Social
Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, pursuant
to a medicare risk contract or medicare cost contract, or to the
coverage of beneficiaries enrolled in the federal employee
health benefits program pursuant to 5
U.S.C.A. 8905, or to the coverage of
beneficiaries enrolled in Title XIX of the
"Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended,
known as the medical assistance program or medicaid, provided by
the Ohio department of human services under
Chapter 5111. of the Revised Code, or to
the coverage of beneficiaries under any federal health care
program regulated by a federal regulatory body,OR TO THE COVERAGE
OF BENEFICIARIES UNDER ANY
CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS
BEEN ENTERED INTO BY THE DEPARTMENT OF
ADMINISTRATIVE SERVICES.
(B) "Supplemental health
care services" means any health care services other than basic
health care services that a health insuring corporation may
offer, alone or in combination with either basic health care services or other
supplemental health care services, and includes:
(1) Services of facilities for intermediate or long-term
care, or both;
(2) Dental care services;
(3) Vision care and optometric services including lenses
and frames;
(4) Podiatric care or foot care services;
(5) Mental health services including psychological
services;
(6) Short-term outpatient evaluative and
crisis-intervention mental health services;
(7) Medical or psychological treatment and referral
services for alcohol and drug abuse or addiction;
(8) Home health services;
(9) Prescription drug services;
(10) Nursing services;
(11) Services of a dietitian licensed under
Chapter 4759. of the Revised Code;
(12) Physical therapy services;
(13) Chiropractic services;
(14) Any other category of services approved by the
superintendent of insurance.
(C) "Specialty health care services" means one of the
supplemental health care services listed in division
(B)(1) to (13) of this section, when provided by a health
insuring corporation on an outpatient-only basis and not in
combination with other supplemental health care services.
(D) "Closed panel plan" means a health care plan that
requires enrollees to use participating providers.
(E) "Compensation" means remuneration for the
provision of health care services, determined on other than a
fee-for-service or discounted-fee-for-service basis.
(F) "Contractual
periodic prepayment" means the formula for
determining the premium rate for all subscribers of a health insuring
corporation.
(G) "Corporation" means
a corporation formed under Chapter 1701. or 1702. of the
Revised
Code or the similar laws of another state.
(H) "Emergency health
services" means those health care services that must be
available on a seven-days-per-week, twenty-four-hours-per-day
basis in order to prevent jeopardy to an enrollee's health
status that would occur if such services were not received as
soon as possible, and includes, where appropriate, provisions
for transportation and indemnity payments or service agreements
for out-of-area coverage.
(I) "Enrollee" means any
natural person who is entitled to receive health care benefits
provided by a health insuring corporation.
(J) "Evidence of
coverage" means any certificate, agreement, policy, or contract
issued to a subscriber that sets out the coverage and other
rights to which such person is entitled under a health care
plan.
(K) "Health care
facility" means any facility, except a health care
practitioner's office, that provides preventive, diagnostic,
therapeutic, acute convalescent, rehabilitation, mental health,
mental retardation, intermediate care, or skilled nursing
services.
(L) "Health care
services" means any BASIC, SUPPLEMENTAL, AND SPECIALTY HEALTH
CARE services involved in or incident to the
furnishing of preventive, diagnostic, therapeutic, or
rehabilitative care.
(M) "Health delivery
network" means any group of providers or health care facilities,
or both, or any representative thereof, that have entered into an agreement to
offer health
care services in a panel rather than on an individual
basis.
(N) "Health insuring
corporation" means a corporation, as defined in division (G) of this
section, that, pursuant to a policy, contract,
certificate, or agreement, pays for, reimburses, or provides,
delivers, arranges for, or otherwise makes available, basic
health care services, supplemental health care services, or
specialty health care services, or a combination of basic health
care services and either supplemental health care services or
specialty
health care services, through either an open panel plan or a closed panel
plan.
"Health insuring
corporation" does not include a limited liability company formed
pursuant to Chapter 1705. of
the Revised
Code,
AN INSURER LICENSED UNDER
TITLE
XXXIX OF THE
REVISED
CODE IF THAT INSURER OFFERS
ONLY OPEN PANEL PLANS UNDER WHICH ALL PROVIDERS AND HEALTH CARE
FACILITIES PARTICIPATING RECEIVE THEIR COMPENSATION DIRECTLY
FROM THE INSURER, a corporation formed by
or on behalf of a political subdivision or a department, office,
or institution of the state, or a public entity formed by or on behalf of
a board of county commissioners, a county
board of mental retardation and developmental disabilities,
an
alcohol and drug
addiction services board, a board of alcohol, drug addiction,
and mental health services, or a community mental health board,
as those terms are used in Chapters 340. and 5126. of the
Revised Code.
Except as provided by division (D)
of section 1751.02 of the
Revised
Code, or as
otherwise provided by law, no
board, commission,
agency, or other entity under the control of a political
subdivision may accept insurance risk in providing for health
care services. However, nothing in this division shall be
construed as prohibiting such entities from purchasing the
services of a health insuring corporation or a third-party
administrator licensed under Chapter 3959. of the Revised
Code.
(O) "Intermediary
organization" means a health delivery network or other entity
that contracts with licensed health insuring corporations or self-insured
employers, or both, to
provide health care services, and that enters into
contractual arrangements with other entities for the provision
of health care services for the purpose of fulfilling the terms
of its contracts with the health insuring corporations and self-insured
employers.
(P) "Intermediate care"
means residential care above the level of room and board for
patients who require personal assistance and health-related
services, but who do not require skilled nursing care.
(Q) "Medical record"
means the personal information that relates to an individual's
physical or mental condition, medical history, or medical
treatment.
(R)(1) "Open panel plan" means a health care plan that provides
incentives for enrollees to use participating providers and that also allows
enrollees to use providers that are not participating providers.
(2) No health insuring corporation may offer an open
panel plan, unless the health insuring corporation is also
licensed as an insurer under Title XXXIX of the
Revised Code, the health insuring corporation, on the
effective date of this section JUNE 4, 1997,
holds a certificate of authority or license to
operate under Chapter 1736. or 1740. of
the Revised Code, or an insurer licensed under
Title XXXIX of the Revised Code is
responsible for the out-of-network risk as evidenced by both an evidence of
coverage filing under section 1751.11
of the Revised Code and a policy and
certificate filing under section 3923.02 of the
Revised Code.
(S) "PANEL" MEANS A GROUP OF PROVIDERS OR HEALTH CARE
FACILITIES THAT HAVE JOINED TOGETHER TO DELIVER HEALTH CARE
SERVICES THROUGH A CONTRACTUAL ARRANGEMENT WITH A HEALTH
INSURING CORPORATION, EMPLOYER GROUP, OR OTHER PAYOR.
(T) "Person" has the same meaning as in section 1.59 of the
Revised Code, and, unless the context otherwise requires,
includes any insurance company holding a certificate of authority under
Title XXXIX of the Revised Code, any
subsidiary and affiliate of an insurance company, and any government
agency.
(T)(U) "Premium rate" means any set fee
regularly paid by a subscriber to a health insuring corporation. A "premium
rate" does not include a one-time membership fee, an annual
administrative fee, or a nominal access fee, paid to a managed
health care system under which the recipient of health care
services remains solely responsible for any charges accessed for
those services by the provider or health care facility.
(U)(V) "Primary care
provider" means a provider that is designated by a health
insuring corporation to supervise, coordinate, or provide
initial care or continuing care to an enrollee, and that may be
required by the health insuring corporation to initiate a
referral for specialty care and to maintain supervision of the
health care services rendered to the enrollee.
(V)(W) "Provider" means any
natural person or partnership of natural persons who are
licensed, certified, accredited, or otherwise authorized in this
state to furnish health care services, or any professional
association organized under Chapter 1785. of the Revised
Code, provided that nothing in
this chapter or other provisions of law shall be construed to
preclude a health insuring corporation, health care
practitioner, or organized health care group associated with a
health insuring corporation from employing nurse practitioners,
dietitians, physicians' assistants, dental assistants, dental
hygienists, optometric technicians, or other allied health
personnel who are licensed, certified, accredited, or otherwise
authorized in this state to furnish health care services.
(W)(X) "Provider sponsored
organization" means a corporation, as defined in division
(G) of this section, that is at least eighty per cent owned or
controlled
by one or more hospitals, as defined in section 3727.01 of the
Revised Code, or one or more physicians licensed
to practice medicine or surgery or osteopathic medicine and
surgery under Chapter 4731. of the Revised
Code, or any combination of such physicians and
hospitals. Such control is presumed to exist if at least eighty per cent
of the voting rights or governance rights of a provider
sponsored organization are directly or indirectly owned,
controlled, or otherwise held by any combination of the
physicians and hospitals described in this division.
(X)(Y) "Solicitation document" means the written materials
provided
to prospective subscribers or enrollees, or both, and used for advertising and
marketing to induce enrollment in the health care plans of a
health insuring corporation.
(Y)(Z) "Subscriber" means a
person who is responsible for making payments to a health
insuring corporation for participation in a health care plan, or
an enrollee whose employment or other status is the basis of
eligibility for enrollment in a health insuring corporation.
(Z)(AA) "Urgent care
services" means those health care services that are
appropriately provided for an unforeseen condition of a kind
that usually requires medical attention without delay but that
does not pose a threat to the life, limb, or permanent health of
the injured or ill person,
and may include such health care services provided
out of the health insuring corporation's approved service area
pursuant to indemnity payments or service agreements.
Sec. 1751.02. (A) Notwithstanding any law in this state to the
contrary, any
corporation, as defined in section 1751.01 of the
Revised Code, may apply to the
superintendent of insurance for a certificate of authority to
establish and operate a health insuring corporation. If the corporation
applying for a certificate of authority is a
foreign corporation domiciled in a state without laws
similar to those of this chapter,
the corporation must form a domestic corporation to apply for, obtain, and
maintain a certificate of authority under this chapter.
(B) No person shall
establish, operate, or perform the services of a health insuring corporation
in this state
without obtaining a certificate of authority under this
chapter.
(C) Except as provided by division (D) of this section,
no political subdivision or department, office, or
institution of this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of this state,
shall establish, operate, or perform the services of a health insuring
corporation.
Nothing in this
section shall be construed to preclude a board of county
commissioners, a county board of mental retardation and
developmental disabilities, an alcohol and drug addiction
services board, a board of alcohol, drug addiction, and mental
health services, or a community mental health board, or a public
entity formed by or on behalf of any of these boards, from using
managed care techniques in carrying out the board's or public
entity's duties pursuant to the requirements of
Chapters 307., 329., 340., and
5126. of the Revised
Code. However, no such board
or public entity may operate so as to compete in the private
sector with health insuring corporations holding certificates of
authority under this chapter.
(D) A corporation formed by or on behalf of a publicly owned,
operated, or funded hospital or health care facility may apply to the
superintendent for
a certificate of authority under division (A) of this section to
establish and operate a health insuring corporation.
(E) A health insuring
corporation shall operate in this state in compliance with this
chapter and with sections 3702.51 to 3702.62 of the
Revised
Code, and shall operate in
conformity with its filings with the superintendent under this
chapter, including filings made pursuant to sections 1751.03,
1751.11, 1751.12, and 1751.31 of the
Revised
Code.
(F) An insurer licensed under Title XXXIX of
the
Revised Code need not obtain a certificate of
authority as a health insuring corporation to offer an open
panel plan as long as the providers and health care facilities
participating in the open panel plan receive their compensation
directly from the insurer. If the providers and health care
facilities participating in the open panel plan receive their
compensation from any person other than the insurer, or if the
insurer offers a closed panel plan, the insurer must obtain a
certificate of authority as a health insuring corporation.
(G) An intermediary
organization need not obtain a certificate of authority as a
health insuring corporation, regardless of the method of reimbursement to the
intermediary organization,
as long as a health insuring
corporation or a self-insured employer maintains the ultimate responsibility
to assure delivery of all health care services required by the contract
between the health insuring corporation and the subscriber and
the laws of this state or between the self-insured employer and its
employees.
Nothing in this section shall be construed to require any
health care facility, provider, health delivery network, or
intermediary organization that contracts with a health insuring
corporation or self-insured employer, regardless of the method
of reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a
certificate of authority as a health insuring corporation under
this chapter, unless otherwise provided, in the case of
contracts with a self-insured employer, by operation of the
"Employee
Retirement
Income
Security
Act of 1974," 88
Stat. 829, 29
U.S.C.A.
1001, as amended.
(H) Any health delivery
network doing business in this state, INCLUDING ANY
HEALTH DELIVERY NETWORK THAT IS FUNCTIONING AS AN INTERMEDIARY ORGANIZATION
DOING BUSINESS IN THIS
STATE, that is not required to
obtain a certificate of authority under this chapter shall
certify to the superintendent annually, not later than the
first day of July, and shall
provide a statement signed by the highest ranking official which
includes the following information:
(1) The health delivery network's full name and the
address of its principal place of business;
(2) A statement that the health delivery network is not
required to obtain a certificate of authority under this chapter
to conduct its business.
(I) The superintendent
shall not issue a certificate of authority to a health insuring
corporation that is a provider sponsored organization unless all
health care plans to be offered by the health insuring
corporation provide basic health care services.
Substantially all of the physicians and hospitals with
ownership or control of the provider sponsored organization, as
defined in division (W)(X) of
section 1751.01 of the Revised
Code, shall also be
participating providers for the provision of basic health care
services for health care plans offered by the provider sponsored
organization. If a health insuring corporation that is a
provider sponsored organization offers health care plans that do
not provide basic health care services, the health insuring
corporation shall be deemed, for purposes of section 1751.35 of
the Revised Code, to have failed to substantially
comply with this chapter.
Except as specifically provided in this division and in division
(C) of section 1751.28 of the Revised Code,
the provisions of this chapter shall apply to all health insuring corporations
that are provider sponsored organizations in the same manner that these
provisions apply to all health insuring corporations that are not provider
sponsored organizations.
(J) Nothing in this section shall be construed to apply to any
multiple employer welfare arrangement operating pursuant to Chapter
1739. of the Revised Code.
(K) Any person who
violates division (B) of this
section, and any health delivery network that fails to comply
with division (H) of this
section, is subject to the penalties set forth in section
1751.45 of the Revised
Code.
(L) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER
1, 1998.
Sec. 1751.03. (A) Each
application for a certificate of authority under this chapter
shall be verified by an officer or authorized representative of
the applicant, shall be in a format prescribed by the
superintendent of insurance, and shall set forth or be
accompanied by the following:
(1) A certified copy of the applicant's articles of
incorporation and all amendments to the articles of
incorporation;
(2) A copy of any regulations adopted for the government
of the corporation, any bylaws, and any similar documents, and a
copy of all amendments to these regulations, bylaws, and
documents. The corporate secretary shall certify that these
regulations, bylaws, documents, and amendments have been
properly adopted or approved.
(3) A list of the names, addresses, and official
positions of the persons responsible for the conduct of the
applicant, including all members of the board, the principal
officers, and the person responsible for completing or filing
financial statements with the department of insurance,
accompanied by a completed original biographical affidavit and
release of information for each of these persons on forms
acceptable to the department;
(4) A full and complete disclosure of the extent and
nature of any contractual or other financial arrangement between
the applicant and any provider or a person listed in division
(A)(3) of this section,
including, but not limited to, a full and complete disclosure of
the financial interest held by any such provider or person in
any health care facility, provider, or insurer that has entered
into a financial relationship with the health insuring
corporation;
(5) A description of the applicant, its facilities, and
its personnel, including, but not limited to, the location,
hours of operation, and telephone numbers of all contracted
facilities;
(6) The applicant's projected annual enrollee population
over a three-year period;
(7) A clear and specific description of the health care
plan or plans to be used by the applicant, including a
description of the proposed providers, procedures for accessing
care, and the form of all proposed and existing contracts
relating to the administration, delivery, or financing of health
care services;
(8) A copy of each type of evidence of coverage and
identification card or similar document to be issued to
subscribers;
(9) A copy of each type of individual or group policy,
contract, or agreement to be used;
(10) The schedule of the proposed contractual periodic
prepayments or premium rates, or both, accompanied by appropriate supporting
data;
(11) A financial plan which provides a three-year
projection of operating results, including the projected
expenses, income, and sources of working capital;
(12) The enrollee complaint procedure to be utilized as
required under section 1751.19 of the
Revised
Code;
(13) A description of the procedures and programs to be implemented on an
ongoing basis to assure the quality of health care services delivered to
enrollees;
(14) A statement describing the geographic area or areas
to be served, by county;
(15) A copy of all solicitation documents;
(16) A balance sheet and other financial statements
showing the applicant's assets, liabilities, income, and other
sources of financial support;
(17) A description of the nature and extent of any
reinsurance program to be implemented, and a demonstration that
errors and omission insurance and, if appropriate, fidelity
insurance, will be in place upon the applicant's receipt of a
certificate of authority;
(18) Copies of all proposed or in force related-party or
intercompany agreements with an explanation of the financial
impact of these agreements on the applicant. If the applicant
intends to enter into a contract for managerial or
administrative services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed description
of the person to
provide these services. The description shall include that person's
experience in managing or administering health care plans, a
copy of that person's most recent audited financial statement,
and a completed biographical affidavit on a form acceptable to
the superintendent for each of that person's principal officers
and board members and for any additional employee to be directly
involved in providing managerial or administrative services to
the health insuring corporation. If the person to provide
managerial or administrative services is affiliated with the
health insuring corporation, the contract must provide for
payment for services based on actual costs.
(19) A statement from the applicant's board that the
admitted assets of the applicant have not been and will not be
pledged or hypothecated;
(20) A statement from the applicant's board that the
applicant will submit monthly financial statements during the
first year of operations;
(21) The name and address of the applicant's
Ohio statutory agent for
service of process, notice, or demand;
(22) Copies of all documents the applicant filed with the secretary of
state;
(23) The location of those books and records of the
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL BE
MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, AND
WHICH MAY BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF DOMICILE OR IN
OHIO IF THE APPLICANT IS A FOREIGN CORPORATION;
(24) The applicant's federal identification number,
corporate address, and mailing address;
(25) An internal and external organizational
chart;
(26) A list of the assets representing the initial net
worth of the applicant;
(27) If the applicant has a parent company, the parent
company's guaranty, on a form acceptable to the superintendent,
that the applicant will maintain
Ohio's minimum net worth. If
no parent company exists, a statement regarding the availability
of future funds if needed.
(28) The names and addresses of the applicant's actuary
and external auditors;
(29) If the applicant is a foreign corporation, a copy of the
most recent financial statements filed with the insurance
regulatory agency in the applicant's state of domicile;
(30) If the applicant is a foreign corporation, a statement
from the insurance regulatory agency of the applicant's state of
domicile stating that the regulatory agency has no objection to
the applicant applying for an Ohio license and that the
applicant is in good standing in the applicant's state of
domicile;
(31) Any other information that the superintendent may
require.
(B)(1) A health insuring
corporation, unless otherwise provided for in this chapter
OR IN SECTION 3901.321 of the Revised Code, shall file a timely notice with the
superintendent describing
any change to the corporation's articles of incorporation or
regulations, or any major modification to its operations as set
out in the information required by division
(A) of this section that
affects any of the following:
(a) The solvency of the
health insuring corporation;
(b) The health insuring
corporation's continued provision of services that it has
contracted to provide;
(c) The manner in which
the health insuring corporation conducts its business.
(2) If the change or modification is to be the result of an action
to be taken by the health insuring corporation, the notice shall
be filed with the superintendent prior to the health insuring corporation
taking
the action. The action shall be deemed approved if the
superintendent does not disapprove it within sixty days of
filing.
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION
(B)(1) OR (2) OF THIS SECTION
SHALL ALSO SERVE AS THE SUBMISSION OF A NOTICE WHEN REQUIRED FOR
THE SUPERINTENDENT'S REVIEW FOR PURPOSES OF SECTION 3901.341 OF
THE REVISED
CODE, IF THE NOTICE CONTAINS
ALL OF THE INFORMATION
THAT SECTION 3901.341 OF THE
REVISED
CODE REQUIRES FOR SUCH
SUBMISSIONS AND A COPY OF ANY WRITTEN AGREEMENT. THE FILING OF SUCH A NOTICE,
FOR THE PURPOSE OF SATISFYING THIS
DIVISION AND SECTION 3901.341 OF THE
REVISED
CODE, SHALL BE SUBJECT TO THE
SIXTY-DAY REVIEW PERIOD OF DIVISION
(B)(2) OF THIS SECTION.
(C)(1) No health
insuring corporation shall expand its approved service area
until a copy of the request for expansion, accompanied by
documentation of the network of providers,
FORMS OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS
RELATING TO THE DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF
PROPOSED CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR
GROUP CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING
DATA, enrollment
projections, plan of operation, and any other changes have been
filed with the superintendent.
(2) Within ten calendar days after receipt of a complete
filing under division (C)(1) of
this section, the superintendent shall refer the appropriate
jurisdictional issues to the director of health pursuant to
section 1751.04 of the Revised
Code.
(3) Within seventy-five days after the superintendent's receipt
of a complete filing under division
(C)(1) of this section, the
superintendent shall determine whether the plan for expansion is
lawful, fair, and reasonable. The superintendent may not make a
determination until the superintendent has received the
director's certification of compliance, which the director shall
furnish within forty-five days after referral under division
(C)(2) of this section. The
director shall not certify that the requirements of section
1751.04 of the Revised
Code are not met, unless the
applicant has been given an opportunity for a hearing as
provided in division (D) of
section 1751.04 of the Revised
Code. The forty-five-day and
seventy-five-day review periods provided for in division
(C)(3) of this section shall
cease to run as of the date on which the notice of the
applicant's right to request a hearing is mailed and shall
remain suspended until the director issues a final
certification.
(4) If the superintendent has not approved or disapproved
all or a portion of a service area expansion within the
seventy-five-day period provided for in division
(C)(3) of this section, the
filing shall be deemed approved.
(5) Disapproval of all or a portion of the filing shall
be effected by written notice, which shall state the grounds for
the order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code.
(D) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER
1, 1998.
Sec. 1751.05. (A) The
superintendent of insurance shall issue or deny a certificate of
authority to establish or operate a health insuring corporation
to any corporation filing an application pursuant to section
1751.03 of the Revised
Code within forty-five days of the
superintendent's receipt of the certification from the director
of health under division (C) of section 1751.04 of
the Revised Code. A certificate of authority shall be
issued upon payment of the application fee prescribed in section 1751.44 of
the Revised Code if the superintendent is
satisfied that the following conditions are met:
(1) The persons responsible for the conduct of the
affairs of the applicant are competent, trustworthy, and possess
good reputations.
(2) The director certifies, in accordance with division (C)
of section 1751.04 of the Revised Code, that the
organization's proposed plan of operation meets the requirements
of division (B) of that section and sections 3702.51 to
3702.62 of the Revised Code. If, after the
director has certified compliance, the application is amended in
a manner that affects its approval under section 1751.04 of the
Revised Code, the superintendent shall request the
director to review and recertify the amended plan of operation.
Within forty-five days of receipt of the amended plan from the
superintendent, the director shall certify to the
superintendent, pursuant to section 1751.04 of the
Revised Code, whether or not the amended plan
meets the requirements of section 1751.04 of the Revised
Code. The superintendent's forty-five-day review period
shall cease to run as of the date on which the amended plan is
transmitted to the director and shall remain suspended until the
superintendent receives a new certification from the director.
(3) The applicant constitutes an appropriate mechanism to
effectively provide or arrange for the provision of the basic health
care services, supplemental health care services, or specialty health care
services to be provided to enrollees.
(4) The applicant is financially responsible, complies
with section 1751.28 of the Revised
Code, and may reasonably be expected to meet its obligations to
enrollees and prospective
enrollees. In making this determination, the superintendent may
consider:
(a) The financial soundness of the applicant's arrangements for
health care services, including the applicant's proposed contractual
periodic prepayments or premiums and the use of copayments or
deductibles;
(b) The adequacy of working capital;
(c) Any agreement with
an insurer, a government, or any other person for insuring the
payment of the cost of health care services or providing for
automatic applicability of an alternative coverage in the event
of discontinuance of the health insuring corporation's
operations;
(d) Any agreement with providers or health care facilities for
the provision of health care services;
(e) Any deposit of
securities submitted in accordance with section 1751.27 of the
Revised Code as a guarantee that the obligations will be
performed.
(5) The applicant has submitted documentation of an
arrangement to provide health care services to its enrollees
until the expiration of the enrollees' contracts with the
applicant if a health care plan or the operations of the health
insuring corporation are discontinued prior to the expiration of
the enrollees' contracts. An arrangement to provide health care
services may be made by using any one, or any combination, of
the following methods:
(a) The maintenance of insolvency insurance;
(b) A provision in
contracts with providers and health care facilities, but no health insuring
corporation shall rely solely on such a
provision for more than thirty days;
(c) An agreement with
other health insuring corporations or insurers, providing
enrollees with automatic conversion rights upon the
discontinuation of a health care plan or the health insuring
corporation's operations;
(d) Such other methods as approved by the superintendent.
(6) Nothing in the applicant's proposed method of
operation, as shown by the information submitted pursuant to
section 1751.03 of the Revised
Code or by independent
investigation, will cause harm to an enrollee or to the public
at large, as determined by the superintendent.
(7) Any deficiencies certified by the director have been
corrected.
(8) The applicant has deposited securities as set forth
in section 1751.27 of the Revised Code.
(B) If an applicant
elects to fulfill the requirements of division
(A)(5) of this section through
an agreement with other health insuring corporations or
insurers, the agreement shall require those health insuring
corporations or insurers to give thirty days' notice to the
superintendent prior to cancellation or discontinuation of the
agreement for any reason.
(C) A certificate of
authority shall be denied only after compliance with the
requirements of section 1751.36 of the Revised Code.
Sec. 1751.06. Upon obtaining a certificate of authority as
required under this chapter, a health insuring corporation may
do all of the following:
(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.
(B) Contract with providers and health care facilities for the health care
services to which enrollees are entitled under the terms of the health
insuring corporation's 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 in this chapter
and the limitations set forth in the
Revised Code;
(D) Contract with any person pursuant to the requirements of division (A)(18)
of section 1751.03 of the Revised Code for managerial or
administrative services, or for data processing,
actuarial analysis, billing services, or any other services
authorized by the superintendent of insurance. However, a
health insuring corporation shall not enter into a contract for
any of the services listed in this division with an insurance
company that is not authorized to engage in the business of
insurance 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 health insuring corporation;
(G) In the employer group market, impose an
affiliation period of not more than sixty days, OR FOR LATE ENROLLEES AN
AFFILIATION PERIOD OF NOT MORE THAN NINETY 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
insuring corporation offers coverage in the small employer 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 employer 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 employer group market, as provided in division
(E)(1) of section 3924.03 of
the Revised
Code.
Nothing in this section shall be construed as prohibiting a health insuring
corporation without other commercial enrollment from contracting solely with
federal health care programs regulated by federal regulatory bodies.
Nothing in this section shall be construed to limit the
authority of a health insuring corporation to perform those
functions not otherwise prohibited by law.
Sec. 1751.11. (A) Every
subscriber of a health insuring corporation is entitled to an
evidence of coverage for the health care plan under which
health care benefits are
provided.
(B) Every subscriber of a health insuring corporation that offers
basic health care services is entitled to an identification card or similar
document that specifies the health insuring corporation's name as stated in
its articles of incorporation, and any trade or fictitious names
used by the health insuring corporation. The identification
card or document shall list at least one telephone number that
provides the subscriber with access to health care
on a twenty-four-hour-per-day TWENTY-FOUR-HOURS-PER-DAY,
seven-day-per-week SEVEN-DAYS-PER-WEEK basis.
(C) No evidence of coverage, or amendment to the evidence of
coverage, shall be delivered, issued for delivery, renewed, or used, until the
form of the evidence of coverage or amendment has been filed by the
health insuring corporation with the superintendent of
insurance. If the superintendent does not disapprove the
evidence of coverage or amendment within sixty days after it is
filed it shall be deemed approved, unless the superintendent
sooner gives approval for the evidence of coverage or amendment.
With respect to an amendment to an approved evidence of
coverage, the superintendent only may disapprove provisions
amended or added to the evidence of coverage. If the
superintendent determines within the sixty-day period that any
evidence of coverage or amendment fails to meet the requirements
of this section, the superintendent shall so notify the health
insuring corporation and it shall be unlawful for the health
insuring corporation to use such evidence of coverage or
amendment. At any time, the superintendent, upon at least
thirty days' written notice to a health insuring corporation,
may withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this
section. Such disapproval shall be effected by a written order,
which shall state the grounds for disapproval and shall be
issued in accordance with
Chapter 119. of the
Revised Code.
(D) No evidence of coverage or amendment shall be delivered,
issued for delivery, renewed, or used:
(1) If it contains provisions or statements that are
inequitable, untrue, misleading, or deceptive;
(2) Unless it contains a clear, concise, and complete
statement of the following:
(a) The health care
services and insurance or other benefits, if any, to which the
enrollee is entitled under the health care plan;
(b) Any exclusions or
limitations on the health care services, type of health care
services, benefits, or type of benefits to be provided,
including copayments or deductibles;
(c) The enrollee's personal financial obligation for noncovered
services;
(d) Where and in what
manner general information and information as to how services
may be obtained is available, including the telephone
number;
(e) The premium rate with respect to individual and
conversion contracts, and relevant copayment provisions with
respect to all contracts. The statement of the premium rate, however, may be
contained in a separate insert.
(f) The method utilized
by the health insuring corporation for resolving enrollee
complaints.
(3) Unless it provides for the continuation of an
enrollee's coverage, in the event that the enrollee's coverage
under the policy, contract, certificate, or agreement terminates
while the enrollee is receiving inpatient care in a hospital.
This continuation of coverage shall terminate at the earliest
occurrence of any of the following:
(a) The enrollee's discharge from the hospital;
(b) The determination by the enrollee's attending physician that
inpatient care is no longer medically indicated for the enrollee;
(c) The enrollee's reaching the limit for contractual
benefits;
(d) THE EFFECTIVE DATE OF ANY NEW
COVERAGE.
(4) Unless it contains a provision that states, in
substance, that the health insuring corporation is not a member
of any guaranty fund, and that in the event of the health
insuring corporation's insolvency, the enrollee is protected
only to the extent that the hold harmless provision required by
section 1751.13 of the Revised
Code applies to the health care
services rendered;
(5) Unless it contains a provision that states, in
substance, that in the event of the insolvency of the health
insuring corporation, the enrollee may be financially
responsible for health care services rendered by a provider or
health care facility that is not under contract to the health
insuring corporation, whether or not the health insuring
corporation authorized the use of the provider or health care
facility.
(E) Notwithstanding
division (D) of this section, a
health insuring corporation may use an evidence of coverage that
provides for the coverage of beneficiaries enrolled in
Title XVIII of the "Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, pursuant to a
medicare risk contract or
medicare cost contract, or an evidence of coverage that provides
for the coverage of beneficiaries enrolled in the federal
employees health benefits program pursuant to 5
U.S.C.A.
8905, or an evidence of coverage that provides for the coverage
of beneficiaries enrolled in
Title XIX of the "Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, known as the
medical assistance program or medicaid, provided
by the Ohio department of human services under Chapter 5111.
of the Revised Code, or an evidence of coverage that
provides for the coverage of beneficiaries under any other federal health care
program regulated by a federal regulatory body,
OR AN EVIDENCE OF COVERAGE THAT PROVIDES FOR THE COVERAGE
OF BENEFICIARIES UNDER ANY CONTRACT COVERING OFFICERS OR
EMPLOYEES OF THE STATE THAT HAS BEEN ENTERED INTO
BY THE DEPARTMENT OF ADMINISTRATIVE
SERVICES,
if both of the following
apply:
(1) The evidence of coverage has been approved by the
United States department of health and
human services, the United States office of personnel
management, or the Ohio department of human services, OR THE
DEPARTMENT OF ADMINISTRATIVE SERVICES.
(2) The evidence of coverage is filed with the
superintendent of insurance prior to use and is accompanied by
documentation of approval from the
United States department of health and
human services, the United States office of personnel
management, or the Ohio department of human services, OR THE
DEPARTMENT OF ADMINISTRATIVE SERVICES.
Sec. 1751.12. (A)(1) No
contractual periodic prepayment and no premium rate for nongroup and
conversion policies for health care services, or any amendment
to them, may be used by any health insuring corporation at any
time until the contractual periodic prepayment and premium rate, or
amendment, have been filed with the superintendent of insurance,
and shall not be effective until the expiration of sixty days
after their filing unless the superintendent sooner gives
approval. THE FILING SHALL BE ACCOMPANIED BY AN ACTUARIAL
CERTIFICATION IN THE FORM PRESCRIBED BY THE
SUPERINTENDENT.
The superintendent shall disapprove the filing, if
the superintendent determines within the sixty-day period that
the contractual periodic prepayment or premium rate, or amendment, is
not in accordance with sound actuarial principles or is not
reasonably related to the applicable coverage and
characteristics of the applicable class of enrollees. The
superintendent shall notify the health insuring corporation of
the disapproval, and it shall thereafter be unlawful for the
health insuring corporation to use the contractual periodic
prepayment or premium rate, or amendment.
(2) No contractual periodic prepayment for group
policies for health care services shall be used until the
contractual periodic prepayment has been filed with
the superintendent. THE FILING SHALL BE ACCOMPANIED BY AN ACTUARIAL
CERTIFICATION IN THE FORM PRESCRIBED BY THE
SUPERINTENDENT.
The superintendent may reject a filing made
under division (A)(2) of this section at any time, with
at least thirty days' written notice to a health insuring
corporation, if the contractual periodic prepayment is not
in accordance with sound
actuarial principles or is not reasonably related to the
applicable coverage and characteristics of the applicable class
of enrollees.
(3) At any time, the superintendent, upon at least thirty
days' written notice to a health insuring corporation, may
withdraw the approval given under division (A)(1) of this section,
deemed or actual, of any contractual
periodic prepayment or premium rate, or amendment, based on
information that either of the following applies:
(a) The contractual
periodic prepayment or premium rate, or amendment, is not in
accordance with sound actuarial principles.
(b) The contractual
periodic prepayment or premium rate, or amendment, is not reasonably
related to the applicable coverage and characteristics of the
applicable class of enrollees.
(4) Any disapproval under division (A)(1) of this section,
any rejection of a filing made under division (A)(2) of
this section, or any
withdrawal of approval under division (A)(3) of this section, shall
be effected by a written notice, which shall state the specific
basis for the disapproval, rejection, or withdrawal and shall be issued
in accordance with Chapter 119. of the
Revised Code.
(B) Notwithstanding division (A) of this section, a
health insuring corporation may use a contractual periodic
prepayment or premium rate for policies used for the coverage of
beneficiaries enrolled in Title
XVIII of the "Social Security Act," 49
Stat. 620 (1935), 42
U.S.C.A.
301, as amended, pursuant to a medicare risk contract or
medicare cost contract, or for policies used for the coverage of
beneficiaries enrolled in the federal employees health benefits
program pursuant to 5
U.S.C.A.
8905, or for policies used for the coverage of beneficiaries
enrolled in Title
XIX of the "Social Security Act," 49
Stat. 620 (1935), 42
U.S.C.A.
301, as amended, known as the
medical assistance program or medicaid, provided
by the Ohio department of human services under Chapter 5111.
of the Revised Code, or for policies used for the coverage
of beneficiaries under any other federal health care program regulated by a
federal regulatory body,
OR FOR POLICIES USED FOR THE COVERAGE OF BENEFICIARIES
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF
ADMINISTRATIVE SERVICES,
if both of the following
apply:
(1) The contractual periodic prepayment or premium rate has been approved
by the United States department of health and
human services, the United States office of personnel
management, or the Ohio department of human services, OR THE
DEPARTMENT OF ADMINISTRATIVE SERVICES.
(2) The contractual periodic prepayment or premium rate is filed with the
superintendent prior to use and is accompanied by
documentation of approval from the
United States department of health and
human services, the United
States office of personnel
management, or the Ohio
department of human services, OR THE DEPARTMENT OF ADMINISTRATIVE
SERVICES.
(C) The administrative
expense portion of all contractual periodic prepayment or
premium rate filings submitted to the superintendent for review must
reflect the actual cost of administering the product. The
superintendent may require that the administrative expense portion of the
filings be itemized and supported.
(D)(1) Copayments and
deductibles must be reasonable and must not be a barrier to the
necessary utilization of services by enrollees.
(2) A health insuring corporation may not impose
copayment charges on basic health care services that exceed
thirty per cent of the total cost of providing any single
covered health care service, except for physician office visits,
emergency health
services, and urgent care services. The total cost of providing
a health care service is the cost to the health insuring
corporation of providing the health care service to its
enrollees
as reduced by any applicable provider discount.
An open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of
providing any single covered health care service.
(3) To ensure that copayments are not a barrier to the
utilization of basic health care services, a health insuring
corporation may not impose, in any contract year, on any
subscriber or enrollee, copayments that exceed two hundred per
cent of the total annual premium rate to the subscriber or enrollees. This
limitation of
two hundred per cent does not include any reasonable copayments
that are not a barrier to the necessary utilization of health
care services by enrollees and that are imposed on physician
office visits, emergency health services, urgent care services,
supplemental health care services, or specialty health care services.
(E) A health insuring
corporation shall not impose lifetime maximums on basic health
care services. However, a health insuring corporation may
establish a benefit limit for inpatient hospital services that
are provided pursuant to a policy, contract, certificate, or
agreement for supplemental health care services.
Sec. 1751.13. (A)(1) A health
insuring corporation shall, either directly or indirectly, enter
into contracts for the provision of health care services with a
sufficient number and types of providers and health care
facilities to ensure that all covered health care services will
be accessible to enrollees from a contracted provider or health
care facility.
(2) When a health insuring corporation is unable to
provide a covered health care service from a contracted provider
or health care facility, the health insuring corporation must
provide that health care service from a noncontracted provider
or health care facility consistent with the terms of the
enrollee's policy, contract, certificate, or agreement. The
health insuring corporation shall either ensure that the health
care service be provided at no greater cost to the enrollee than
if the enrollee had obtained the health care service from a
contracted provider or health care facility, or make other
arrangements acceptable to the superintendent of
insurance.
(3) Nothing in this section shall prohibit a health
insuring corporation from entering into contracts with
out-of-state providers or health care facilities that are
licensed, certified, accredited, or otherwise authorized in that
state.
(B)(1) A health insuring
corporation shall, either directly or indirectly, enter into
contracts with all providers and health care facilities through
which health care services are provided to its enrollees.
(2) A health insuring corporation, upon written request, shall assist its
contracted providers in finding stop-loss or reinsurance carriers.
(C) A health insuring corporation shall file an annual
certificate with the superintendent certifying that all provider contracts
and contracts with health care facilities through which health
care services are being provided contain the following:
(1) A description of the method by which the provider or
health care facility will be notified of the specific health
care services for which the provider or health care facility
will be responsible, including any limitations or conditions on
such services;
(2) The specific hold harmless provision specifying
protection of enrollees set forth as follows:
"[Provider/Health Care
Facility] agrees that in no event, including but not limited to
nonpayment by the health insuring corporation, insolvency of the health
insuring corporation, or breach of this agreement, shall
[Provider/Health Care
Facility] bill, charge, collect a deposit from, seek
remuneration or reimbursement from, or have any recourse
against, a subscriber,
enrollee, person to whom health care services have been
provided, or person acting on behalf of the covered enrollee,
for health care services provided pursuant to this agreement.
This does not prohibit [Provider/Health
Care Facility] from collecting
co-insurance, deductibles, or copayments as specifically
provided in the evidence of coverage, or fees for uncovered
health care services delivered on a fee-for-service basis to
persons referenced above, nor from any recourse against the
health insuring corporation or its successor."
(3) Provisions requiring the provider or health care
facility to continue to provide covered health care services to
enrollees in the event of the health insuring corporation's
insolvency or discontinuance of operations. The
provisions shall require the provider or health care facility to
continue to provide covered health care services to enrollees as
needed to complete any medically necessary procedures commenced
but unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A MEDICALLY
NECESSARY PROCEDURE SHALL
INCLUDE THE RENDERING OF ALL MEDICALLY NECESSARY FOLLOW-UP CARE
FOR THAT PROCEDURE. If an enrollee is
receiving necessary inpatient care at a hospital, the provisions
may limit the required provision of covered health care services
relating to that inpatient care in accordance with division
(D)(3) of section 1751.11 of the Revised
Code, and may also limit such required provision of
covered health care services to the period ending thirty days
after the health insuring corporation's insolvency or
discontinuance of operations.
The provisions required by division (C)(3) of this
section shall not require any provider or health care facility
to continue to provide any covered health care service after the
occurrence of any of the following:
(a) The end of the thirty-day period following the entry
of a liquidation order under Chapter 3903. of the
Revised Code;
(b) The end of the enrollee's period of coverage for a
contractual prepayment or premium;
(c) The enrollee obtains equivalent coverage with another
health insuring corporation or insurer, or the enrollee's
employer obtains such coverage for the enrollee;
(d) The enrollee or the enrollee's employer terminates
coverage under the contract;
(e) A liquidator effects a transfer of the health
insuring corporation's obligations under the contract under
division (A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and
responsibilities of the health insuring corporation, and of the
contracted providers and health care facilities, with respect to
administrative policies and programs, including, but not limited
to, payments systems, utilization review, quality assessment and
improvement programs, credentialing, confidentiality
requirements, and any applicable federal or state
programs;
(5) A provision regarding the availability and
confidentiality of those health records maintained by providers
and health care facilities to monitor and evaluate the quality
of care, to conduct evaluations and audits, and to determine on
a concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees.
The provision shall include terms requiring the provider or
health care facility to make these health records available to
appropriate state and federal authorities involved in assessing
the quality of care or in investigating the grievances or
complaints of enrollees, and requiring the provider or health
care facility to comply with applicable state and federal laws
related to the confidentiality of medical or health
records.
(6) A provision that states that contractual rights and
responsibilities may not be assigned or delegated by the
provider or health care facility without the prior written
consent of the health insuring corporation;
(7) A provision requiring the provider or health care
facility to maintain adequate professional liability and
malpractice insurance. The provision shall also require the
provider or health care facility to notify the health insuring
corporation not more than ten days after the provider's or
health care facility's receipt of notice of any reduction or
cancellation of such coverage.
(8) A provision requiring the provider or health care
facility to observe, protect, and promote the rights of
enrollees as patients;
(9) A provision requiring the provider or health care
facility to provide health care services without discrimination
on the basis of a patient's participation in the health care
plan, age, sex, ethnicity, religion, sexual preference, health
status, or disability, and without regard to the source of
payments made for health care services rendered to a patient.
This requirement shall not apply to circumstances when the
provider or health care facility appropriately does not render
services due to limitations arising from the provider's or
health care facility's lack of training, experience, or skill,
or due to licensing restrictions.
(10) A provision containing the specifics of any
obligation on the PRIMARY CARE provider or health care facility
to provide,
or to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week;
(11) A provision setting forth procedures for the
resolution of disputes arising out of the contract;
(12) A provision stating that the hold harmless provision
required by division (C)(2) of
this section shall survive the termination of the contract with respect to
services covered and provided under the contract during the time the contract
was in effect, regardless of the reason for the termination, including the
insolvency of the health insuring corporation;
(13) A provision requiring those terms that are used in
the contract and that are defined by this chapter, be used in
the contract in a manner consistent with those
definitions.
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF
BENEFICIARIES ENROLLED IN TITLE
XVIII OF THE
"SOCIAL
SECURITY
ACT," 49
STAT. 620 (1935), 42
U.S.C.A.
301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR
MEDICARE COST CONTRACT, OR TO THE COVERAGE OF BENEFICIARIES
ENROLLED IN THE FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM
PURSUANT TO 5
U.S.C.A.
8905, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN
TITLE
XIX OF THE
"SOCIAL
SECURITY
ACT," 49
STAT. 620 (1935), 42
U.S.C.A.
301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR
MEDICAID, PROVIDED BY THE OHIO
DEPARTMENT OF HUMAN SERVICES UNDER
CHAPTER 5111. OF THE
REVISED
CODE, OR TO THE COVERAGE OF
BENEFICIARIES UNDER ANY FEDERAL HEALTH CARE PROGRAM REGULATED BY
A FEDERAL REGULATORY BODY, OR TO THE COVERAGE OF BENEFICIARIES
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF
ADMINISTRATIVE SERVICES.
(D) No health insuring
corporation contract with a provider or health care facility
shall do either of the following:
(1) Offer an inducement to the provider or health care
facility, directly or indirectly, to reduce or limit medically
necessary health care services to a covered enrollee;
(2) Penalize a provider or health care facility that
assists an enrollee to seek a reconsideration of the health
insuring corporation's decision to deny or limit benefits to the
enrollee.
(E) Any contract between
a health insuring corporation and an intermediary organization
shall clearly specify that the health insuring corporation must
approve or disapprove the participation of any provider or
health care facility with which the intermediary organization
contracts.
(F) If an intermediary organization that is not a health delivery
network contracting solely with self-insured employers subcontracts with a
provider or health care facility, the subcontract with the provider or health
care facility shall do all of the following:
(1) Contain the provisions required by divisions
(C) and (G) of this section, as made
applicable to an intermediary organization, without the inclusion of
inducements or penalties described in division (D) of this
section;
(2) Acknowledge that the health insuring corporation is a
third-party beneficiary to the agreement;
(3) Acknowledge the health insuring corporation's role in
approving the participation of the provider or health care
facility, pursuant to division
(E) of this section.
(G) Any provider
contract or contract with a health care facility shall clearly
specify the health insuring corporation's statutory
responsibility to monitor and oversee the offering of covered
health care services to its enrollees.
(H)(1) A health insuring
corporation shall maintain its provider contracts and its contracts with
health care facilities at one or more of its places of business in
this state, and shall provide copies of these contracts to
facilitate regulatory review upon written notice by the
superintendent of insurance.
(2) Any contract with an intermediary organization shall
include provisions requiring the intermediary organization to
provide the superintendent with regulatory access to all books,
records, financial information, and documents related to the
provision of health care services to subscribers and enrollees
under the contract. The contract shall require the intermediary
organization to maintain such books, records, financial
information, and documents at its principal place of business in
this state and to preserve them for at least three years in a
manner that facilitates regulatory review.
(I)(1) A health insuring corporation shall provide notice
NOTIFY ITS AFFECTED ENROLLEES
of the termination of any A contract with FOR THE
PROVISION OF HEALTH CARE SERVICES BETWEEN THE HEALTH INSURING CORPORATION
AND a primary care physician
or hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION OF
THE CONTRACT.
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE
PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF
THE SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE
PREVIOUS TWELVE MONTHS.
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR
A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE
PREVIOUS TWELVE MONTHS.
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A
PRIMARY CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE
TERMINATION OF THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION
OF THE CONTRACT TERMINATION IS MAILED TO A SUBSCRIBER AT THE
SUBSCRIBER'S LAST KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do
not apply to any health insuring corporation that, on the effective
date of this section JUNE 4, 1997, holds a
certificate of authority or
license to operate under Chapter 1740. of the Revised
Code.
(K) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER
1, 1998.
Sec. 1751.141. A HEALTH INSURING CORPORATION SHALL
PROVIDE COVERAGE FOR A SUBSCRIBER'S DEPENDENT CHILDREN LIVING
OUTSIDE THE HEALTH INSURING CORPORATION'S APPROVED SERVICE AREA
IF A COURT ORDER REQUIRES THE SUBSCRIBER TO PROVIDE HEALTH CARE
COVERAGE TO THE DEPENDENT CHILDREN.
Sec. 1751.15. (A) After a health insuring corporation has furnished,
directly or indirectly, basic health care services for a period of twenty-four
months, and if it currently meets the financial requirements set forth in
section 1751.28 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, it shall hold an annual open enrollment period of not less than
thirty days during its month of licensure
for individuals who are not federally eligible
individuals.
(B) During the open enrollment period described in division
(A) of this section, the health insuring corporation shall accept
applicants and their dependents 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 health
insuring corporation subject to review by the superintendent;
(2) If less than its capacity, one per cent of the health
insuring corporation's total number of subscribers residing in
this state as of the immediately preceding thirty-first day of
December.
(C) Where a health insuring corporation demonstrates to the satisfaction of
the superintendent that such open enrollment would jeopardize its economic
viability, the superintendent may do any of the following:
(1) Waive the requirement for open enrollment;
(2) Impose a limit on the number of applicants and their
dependents that must be enrolled;
(3) Authorize such underwriting restrictions upon open
enrollment as are necessary to do any of the following:
(a) Preserve its financial stability;
(b) Prevent excessive adverse selection;
(c) Avoid unreasonably high or unmarketable charges for coverage
of health care services.
(D)(1) A request to the superintendent under division
(C) of this section for any restriction, limit, or waiver during an
open enrollment period must be accompanied by supporting documentation,
including financial data. In reviewing the request, the superintendent may
consider various factors, including the size of the health insuring
corporation, the health insuring corporation's net worth and profitability,
the health insuring corporation's delivery system structure, and the effect on
profitability of prior open enrollments.
(2) Any action taken by the superintendent under division
(C) of this section shall be
effective for a period of not more than one year. At the
expiration of such time, a new demonstration of the health
insuring corporation's need for the restriction, limit, or
waiver shall be made before a new restriction, limit, or waiver
is granted by the superintendent.
(3) Irrespective of the granting of any restriction,
limit, or waiver by the superintendent, a health insuring
corporation may reject an applicant or a dependent of the
applicant during its open enrollment period if the applicant or
dependent:
(a) Was eligible for and was covered under any employer-sponsored health care
coverage, or if employer-sponsored health care coverage was available at the
time of open enrollment;
(b) Is eligible for continuation coverage under state or
federal law;
(c) Is eligible for medicare, and the health insuring corporation does not
have an agreement on appropriate payment mechanisms with the governmental
agency administering the medicare program.
(E) A health insuring corporation shall not be required either to enroll
applicants or their dependents 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 insuring
corporation if such applicants or their dependents were enrolled
or to make the effective date of benefits for applicants or
their dependents enrolled under this section earlier than ninety
days after the date of enrollment.
(F) A health insuring corporation shall not be required to cover the fees or
costs, or both, for any basic health care service related to a transplant of a
body organ if the transplant occurs within one year after the effective date
of an enrollee's coverage under this section. This limitation on coverage
does not apply to a newly born child who meets the requirements for coverage
under section 1751.61 of the Revised Code.
(G) Each health insuring corporation required to hold an open enrollment
pursuant to division (A) of this section shall file with the superintendent,
not later than sixty days prior to the commencement of the proposed open
enrollment period, the following documents:
(1) The proposed public notice of open enrollment;
(2) The evidence of coverage approved pursuant to section
1751.11 of the Revised
Code that will be used during open enrollment;
(3) The contractual periodic prepayment and premium rate
approved pursuant to section 1751.12 of the Revised Code that will be
applicable during open enrollment;
(4) Any solicitation document approved pursuant to
section 1751.31 of the Revised Code to be sent to applicants, including the
application form that will be used during open enrollment;
(5) A list of the proposed dates of publication of the
public notice, and the names of the newspapers in which the
notice will appear;
(6) Any request for a restriction, limit, or waiver with
respect to the open enrollment period, along with any supporting
documentation.
(H)(1) An open enrollment period shall not satisfy the requirements of this
section unless the health insuring corporation provides adequate public notice
in accordance with divisions (H)(2) and (3) of this section. No public notice
shall be used until the form of the public
notice has been filed by the health insuring corporation with
the superintendent. If the superintendent does not disapprove
the public notice within sixty days after it is filed, it shall
be deemed approved, unless the superintendent sooner gives
approval for the public notice. If the superintendent
determines within this sixty-day period that the public notice
fails to meet the requirements of this section, the
superintendent shall so notify the health insuring corporation
and it shall be unlawful for the health insuring corporation to
use the public notice. Such disapproval shall be effected by a
written order, which shall state the grounds for disapproval and
shall be issued in accordance with Chapter 119. of the Revised Code.
(2) A public notice pursuant to division (H)(1) of this section shall be
published in at least one newspaper of general circulation in each county in
the health insuring corporation'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, or until the enrollment limitation is reached,
whichever occurs first. The notice published during the last
week of open enrollment shall appear not less than five days
before the end of the open enrollment period. It shall be at
least two newspaper columns wide or two and one-half inches
wide, whichever is larger. The first two lines of the text
shall be published in not less than twelve-point, boldface type.
The remainder of the text of the notice shall be published in
not less than eight-point type. The entire public notice shall
be surrounded by a continuous black line not less than
one-eighth of an inch wide.
(3) The following information shall be included in the
public notice provided under division (H)(2) of this section:
(a) The dates that open enrollment will be held and the date coverage
obtained under the open enrollment will become effective;
(b) Notice that an applicant or the applicant's dependents will not be denied
coverage during open enrollment because of a preexisting health condition, but
that some limitations and restrictions may apply;
(c) The address where a person may obtain an application;
(d) The telephone number that a person may call to request an application or
to ask
questions;
(e) The date the first payment will be due;
(f) The actual rates or range of rates that will be applicable for
applicants;
(g) Any limitation
granted by the superintendent on the number of applications that
will be accepted by the health insuring corporation.
(4) Within thirty days after the end of an open
enrollment period, the health insuring corporation shall submit
to the superintendent proof of publication for the public
notices, and shall report the total number of applicants and
their dependents enrolled during the open enrollment
period.
(I)(1) No health insuring corporation may employ any scheme, plan, or device
that restricts the ability of any person to enroll during open
enrollment.
(2) No health insuring corporation may require enrollment
to be made in person. Every health insuring corporation shall
permit application for coverage by mail. A representative of
the health insuring corporation may visit an applicant who has
submitted an application by mail, in order to explain the
operations of the health insuring corporation and to answer any
questions the applicant may have. Every health insuring
corporation shall make open enrollment applications and
solicitation documents readily available to any potential
applicant who requests such material.
(J) An application postmarked on the last day of an open enrollment period
shall qualify as a valid application, regardless of the date on which it is
received by the health insuring corporation.
(K) This section does not apply to any health insuring
corporation that offers only supplemental health
care services or specialty health care services, or to any health insuring
corporation that offers plans only through Title XVIII or Title XIX of the
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A.
301, as amended, and that has no other commercial enrollment, or to any health
insuring corporation that offers plans only through other federal health care
programs regulated by federal regulatory bodies and that has no other
commercial enrollment,OR TO ANY HEALTH INSURING CORPORATION THAT
OFFERS
PLANS ONLY THROUGH CONTRACTS COVERING OFFICERS OR EMPLOYEES OF
THE STATE THAT HAVE BEEN ENTERED INTO BY THE
DEPARTMENT OF ADMINISTRATIVE SERVICES AND THAT HAS NO OTHER
COMMERCIAL ENROLLMENT.
(L) Each health
insuring corporation shall accept federally eligible individuals
for open enrollment coverage as provided in section 3923.581 of
the Revised
Code. A health insuring
corporation may reinsure coverage of any federally eligible
individual acquired under that 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.
(M) As used in this
section, "federally eligible individual" means an eligible
individual as defined in 45
C.F.R.
148.103.
Sec. 1751.151. AT LEAST ONCE IN EVERY TWELVE-MONTH
PERIOD, A HEALTH INSURING CORPORATION SHALL PROVIDE TO
ALL ELIGIBLE EMPLOYEES OF A GROUP COVERED BY A GROUP HEALTH CARE
PLAN OF THE HEALTH INSURING CORPORATION, INCLUDING LATE
ENROLLEES AS DEFINED IN SECTION 3924.01 OF THE
REVISED
CODE, THE OPTION TO ENROLL IN
THE GROUP HEALTH CARE PLAN. THE ENROLLMENT OPTION SHALL BE
PROVIDED FOR A MINIMUM PERIOD OF THIRTY CONSECUTIVE DAYS.
Sec. 1751.16. (A) Except as provided in division (F) of
this section, every group contract issued by a health insuring
corporation shall provide an option for conversion to an
individual contract issued on 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 has been given by the health insuring corporation to the
subscriber.
(2) The subscriber is, or is eligible to be, covered for
benefits at least comparable to the group contract under any of
the following:
(a) Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended;
(b) Any act of congress or law under this or any other state of the
United States providing coverage at least comparable to the benefits under
division (A)(2)(a) of this section;
(c) Any policy of insurance or health care plan providing coverage at least
comparable to the benefits under division (A)(2)(a)
of this section.
(B)(1) The direct-payment contract offered by the health insuring
corporation
pursuant to division (A) of this section
shall provide
the following:
(a) In the case of an individual who is not a
federally eligible individual, benefits comparable to benefits
in any of the individual contracts then being issued to
individual subscribers by the health insuring
corporation;
(b) In the case of a federally eligible
individual, 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 division
(B)(1)(b) of this
section, 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. The contractual
periodic prepayments charged for such plans 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.
(2) The direct payment contract offered pursuant to
division (A) of this section
may include a coordination of benefits provision as approved by
the superintendent.
(3) For purposes of division
(B) of this section "federally
eligible individual" means an eligible individual as defined in
45
C.F.R.
148.103.
(C) The option for conversion shall be available:
(1) Upon the death of the subscriber, 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 the child upon the
child's attaining the limiting age of coverage under the group
contract while covered as a dependent under the contract;
(3) Upon the divorce, dissolution, or annulment of the
marriage of the subscriber, to the divorced spouse, or, in the
event of annulment, to the former spouse of the
subscriber.
(D) No health insuring corporation shall use age as the basis for refusing to
renew a converted contract.
(E) Written notice of
the conversion option provided by this section shall be given to
the subscriber by the health insuring corporation by mail. The
notice shall be sent 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 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 subscriber shall have an additional
period within which to exercise the privilege. This additional
period shall expire fifteen days after the subscriber receives
notice, but in no event shall the period extend beyond sixty
days after the expiration of the thirty-day conversion
period.
(F) This section does not apply to any group contract offering only
supplemental health care services or specialty health care services.
Sec. 1751.20. (A) No health
insuring corporation, or agent, employee, or representative of a
health insuring corporation, shall use any advertisement or
solicitation document, or shall engage in any activity, that is
unfair, untrue, misleading, or deceptive.
(B) No health insuring
corporation shall use a name that is deceptively similar to the
name or description of any insurance or surety corporation doing
business in this state.
(C) All solicitation
documents, advertisements, evidences of coverage, and enrollee
identification cards used by a health insuring corporation shall
contain the health insuring corporation's name. The use of a
trade name, an insurance group designation, the name of a parent
company, the name of a division of an affiliated insurance
company, a service mark, a slogan, a symbol, or other device,
without the name of the health insuring corporation as stated in
its articles of incorporation, shall not satisfy this
requirement if the usage would have the capacity and tendency to
mislead or deceive persons as to the true identity of the health
insuring corporation.
(D) No solicitation
document or advertisement used by a health insuring corporation
shall contain any words, symbols, or physical materials that are
so similar in content, phraseology, shape, color, or other
characteristic to those used by an agency of the federal
government or this state, that prospective enrollees may be led
to believe that the solicitation document or advertisement is
connected with an agency of the federal government or this
state.
(E) A HEALTH INSURING CORPORATION THAT PROVIDES BASIC HEALTH
CARE SERVICES MAY USE
THE PHRASE "HEALTH MAINTENANCE ORGANIZATION" OR THE
ABBREVIATION "HMO" IN ITS MARKETING NAME,
ADVERTISING, SOLICITATION DOCUMENTS, OR MARKETING
LITERATURE, OR IN REFERENCE TO THE PHRASE "DOING BUSINESS AS" OR THE
ABBREVIATION "DBA."
(F) This section does not apply to the coverage of
beneficiaries enrolled in Title XVIII of the
"Social Security Act," 49 Stat. 620
(1935), 42
U.S.C.A.
301, as amended, pursuant to a medicare risk contract or
medicare cost contract, or to the coverage of beneficiaries
enrolled in the federal employee health benefits program
pursuant to 5 U.S.C.A. 8905, or to
the coverage of beneficiaries enrolled in Title
XIX of the "Social Security Act," 49
Stat. 620 (1935), 42 U.S.C.A.
301, as amended, known as the medical assistance program or
medicaid, provided by the Ohio department of human
services under Chapter 5111. of the Revised
Code, or to the coverage of beneficiaries under any
federal health care program regulated by a federal regulatory
body, OR TO THE COVERAGE OF BENEFICIARIES UNDER ANY
CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE THAT HAS
BEEN ENTERED INTO BY THE DEPARTMENT OF
ADMINISTRATIVE SERVICES.
Sec. 1751.31. (A) Any changes
in a health insuring corporation's solicitation document shall
be filed with the superintendent of insurance. The
superintendent, within sixty days of filing, may disapprove any
solicitation document or amendment to it on any of the grounds
stated in this section. Such disapproval shall be effected by
written notice to the health insuring corporation. The notice
shall state the grounds for disapproval and shall be issued in
accordance with Chapter 119. of
the Revised Code.
(B) The solicitation
document shall contain all information necessary to enable a
consumer to make an informed choice as to whether or not to
enroll in the health insuring corporation. The information
shall include a specific description of the health care services
to be available and the approximate number and type of full-time
equivalent medical practitioners. The information shall be
presented in the solicitation document in a manner that is
clear, concise, and intelligible to prospective applicants in
the proposed service area.
(C) Every potential
applicant whose subscription to a health care plan is solicited
shall receive, at or before the time of solicitation, a
solicitation document approved by the superintendent.
(D) Notwithstanding division (A) of this section, a
health insuring corporation may use a solicitation document that
the corporation uses in connection with policies for
beneficiaries of Title XVIII of the
"Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A.
301, as amended, pursuant to a medicare risk contract or
medicare cost contract, or for policies for beneficiaries of the
federal employees health benefits program pursuant to
5 U.S.C.A.
8905, or for policies for beneficiaries of
Title XIX of the "Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A.
301, as amended, known as the medical assistance
program or medicaid, provided by the Ohio department of
human services under Chapter 5111. of the Revised
Code, or for policies for beneficiaries of any other federal health
care program regulated by a federal regulatory body,
OR FOR POLICIES FOR BENEFICIARIES OF CONTRACTS COVERING
OFFICERS OR EMPLOYEES OF THE STATE ENTERED INTO
BY THE DEPARTMENT OF ADMINISTRATIVE SERVICES,
if both of the following
apply:
(1) The solicitation document has been approved by the United
States department of health and human services, the United
States office of personnel management, or the Ohio
department of human services, OR THE DEPARTMENT OF ADMINISTRATIVE
SERVICES.
(2) The solicitation document is filed with the
superintendent of insurance prior to use and is accompanied by
documentation of approval from the
United
States department of health and
human services, the United
States office of personnel
management, or the Ohio
department of human services, OR THE DEPARTMENT OF ADMINISTRATIVE
SERVICES.
(E) No health insuring
corporation, or its agents or representatives, shall use
monetary or other valuable consideration, engage in misleading
or deceptive practices, or make untrue, misleading, or deceptive
representations to induce enrollment. Nothing in this division
shall prohibit incentive forms of remuneration such as
commission sales programs for the health insuring corporation's
employees and agents.
(F) Any person obligated
for any part of a premium rate in connection with an enrollment
agreement, in addition to any right otherwise available to
revoke an offer, may cancel such agreement within seventy-two
hours after having signed the agreement or offer to enroll.
Cancellation occurs when written notice of the cancellation is
given to the health insuring corporation or its agents or other
representatives. A notice of cancellation mailed to the health
insuring corporation shall be considered to have been filed on
its postmark date.
(G) Nothing in this section shall prohibit healthy
lifestyle programs.
Sec. 1751.46. (A) The
superintendent of insurance and the director of health may
contract with qualified persons to make recommendations
concerning the determinations required to be made by the
superintendent or the director relative to an expansion of a
service area pursuant to division
(C) of section 1751.03 of the
Revised Code, an application for a
certificate of authority pursuant to sections 1751.04 and
1751.05 of the Revised
Code, a contractual periodic
prepayment or premium rate pursuant to section 1751.12 of the
Revised Code, and an examination
pursuant to division (B) of
section 1751.34 of the Revised
Code. The recommendations may
be accepted in full or in part, or may be rejected, by the
superintendent or director.
THE TOTAL COST OF A CONTRACT WITH A QUALIFIED PERSON
PURSUANT TO THIS DIVISION SHALL BE BORNE BY THE HEALTH INSURING
CORPORATION THAT IS THE SUBJECT OF THE DETERMINATION REQUIRED TO
BE MADE BY THE SUPERINTENDENT OR THE DIRECTOR.
(B) No qualified person
placed on contract by the superintendent or the director
pursuant to division (A) of
this section shall have a conflict of interest with the
department of insurance, the department of health, or the health
insuring corporation.
Sec. 1751.55. A health insuring corporation policy,
contract, or agreement shall not be construed to exclude illness
or injury upon the ground that the subscriber might have elected
to have such illness or injury covered by workers' compensation
under division (A)(3) of
section 4123.01 CHAPTER 4123. of the Revised
Code unless the policy,
contract, or agreement clearly excludes work or occupational
related illness or injury, or the policy, contract, or
agreement, or a separate writing signed by the subscriber,
informs the subscriber that such coverage is excluded and may be
available to the subscriber under workers' compensation as the
sole proprietor of a business, a member of a partnership, or an
officer of a family farm corporation.
Sec. 1751.58. Except as otherwise provided in 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-21, as amended, the following conditions
apply to all group health insuring corporation contracts
that are sold in connection with an employment-related group
health care plan and that are not subject to section 3924.03 of the
Revised
Code:
(A)(1) Except as
provided in section 2712(b) to
(e) of the "Health
Insurance
Portability and
Accountability
Act of 1996," if a
health insuring corporation 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.
(2) A HEALTH INSURING CORPORATION MAY CANCEL
OR DECIDE NOT TO RENEW THE COVERAGE OF ANY ELIGIBLE EMPLOYEE
OR OF A DEPENDENT OF AN ELIGIBLE EMPLOYEE UNDER THE GROUP
CONTRACT IF THE EMPLOYEE OR DEPENDENT, AS APPLICABLE, HAS
PERFORMED AN ACT OR PRACTICE THAT CONSTITUTES FRAUD OR MADE AN
INTENTIONAL MISREPRESENTATION OF MATERIAL FACT UNDER THE TERMS
OF THE COVERAGE AND IF THE CANCELLATION OR NONRENEWAL IS NOT
BASED, EITHER DIRECTLY OR INDIRECTLY, ON ANY HEALTH
STATUS-RELATED FACTOR IN RELATION TO THE EMPLOYEE OR DEPENDENT.
(B) Such group contracts are subject to division (E)(1)(A)(3)
of
section 3924.03 and sections 3924.033 and 3924.27 of the Revised
Code.
(C) Such group contracts
shall provide for the special enrollment periods described in
section 2701(f) of the
"Health
Insurance
Portability and
Accountability
Act of 1996."
Sec. 1751.59. (A) No individual or group health insuring corporation
policy,
contract, or agreement that makes family coverage
available may be delivered, issued for
delivery, or renewed in this state, unless the policy, contract, or agreement
covers adopted children of the subscriber on the same basis as other
dependents.
(B) The coverage required by this section is subject to the
requirements and
restrictions set forth in section 3924.51 of the Revised
Code. Coverage for dependent
children living outside the health insuring corporation's
approved service area must be provided if a court order requires
the subscriber to provide health care coverage.
Sec. 1751.60. (A) Except as
provided for in divisions (E)
and (F) of this section, every
provider or health care facility that contracts with a health
insuring corporation to provide health care services to the
health insuring corporation's enrollees or subscribers shall
seek compensation for covered services solely from the health
insuring corporation and not, under any circumstances, from the
enrollees or subscribers, except for approved deductibles and
copayments.
(B) No subscriber or
enrollee of a health insuring corporation is liable to any
contracting provider or health care facility for the cost of any
covered health care services, if the subscriber or enrollee has
acted in accordance with the evidence of coverage.
(C) Except as provided
for in divisions (E) and
(F) of this section, every
contract between a health insuring corporation and provider or
health care facility shall contain a provision approved by the
superintendent of insurance requiring the provider or health
care facility to seek compensation solely from the health
insuring corporation and not, under any circumstances, from the
subscriber or enrollee, except for approved deductibles and
copayments.
(D) Nothing in this
section shall be construed as preventing a provider or health
care facility from billing the enrollee or subscriber of a
health insuring corporation for noncovered services.
(E) Upon application by
a health insuring corporation and a provider or health care
facility, the superintendent may waive the requirements of
divisions (A) and
(C) of this section when, in
addition to the reserve requirements contained in section
1751.28 of the Revised
Code, the health insuring
corporation provides sufficient assurances to the superintendent
that the provider or health care facility has been provided with
financial guarantees. No waiver of the requirements of
divisions (A) and
(C) of this section is
effective as to enrollees or subscribers for whom the health
insuring corporation is compensated under a provider agreement
or risk contract entered into pursuant to
Chapter 5111. or 5115. of the
Revised
Code.
(F) The requirements of
divisions (A) to
(C) of this section apply only
to health care services provided to an enrollee or subscriber
prior to the effective date of a termination of a contract
between the health insuring corporation and the provider or
health care facility.
Sec. 1751.62. (A) As used in
this section, "screening mammography" means a radiologic
examination utilized to detect unsuspected breast cancer at an
early stage in an asymptomatic woman and includes the x-ray
examination of the breast using equipment that is dedicated
specifically for mammography, including the x-ray tube, filter,
compression device, screens, film, and cassettes, and that has
an average radiation exposure delivery of less than one rad
mid-breast. "Screening mammography" includes two views for each
breast. The term also includes the professional interpretation
of the film.
"Screening mammography" does not include diagnostic
mammography.
(B) Every individual or
group health insuring corporation policy, contract, or agreement
providing basic health care services that is delivered, issued for delivery,
or renewed in this state
shall provide benefits for the expenses of both of the
following:
(1) Screening mammography to detect the presence of
breast cancer in adult women;
(2) Cytologic screening for the presence of cervical
cancer.
(C) The benefits
provided under division (B)(1)
of this section shall cover expenses in accordance with all of
the following:
(1) If a woman is at least thirty-five years of age but
under forty years of age, one screening mammography;
(2) If a woman is at least forty years of age but under
fifty years of age, either of the following:
(a) One screening
mammography every two years;
(b) If a licensed
physician has determined that the woman has risk factors to
breast cancer, one screening mammography every year.
(3) If a woman is at least fifty years of age but under
sixty-five years of age, one screening mammography every
year.
(D)(1) The benefits
provided under division (B)(1)
of this section shall not exceed eighty-five dollars per year
unless a lower amount is established pursuant to a provider
contract.
(2) The benefit paid in accordance with division
(D)(1) of this section shall
constitute full payment. No institutional or professional
health care provider shall seek or receive remuneration in
excess of the payment made in accordance with division
(D)(1) of this section, except
for approved deductibles and copayments.
(E) The benefits
provided under division (B)(1)
of this section shall be provided only for screening
mammographies that are performed in a health care facility or
mobile mammography screening unit that is accredited under the
American college of radiology
mammography accreditation program or in a hospital as defined in
section 3727.01 of the Revised
Code.
(F) The benefits
provided under divisions (B)(1)
and (2) of this section shall be provided according to the terms
of the subscriber contract.
(G) The benefits
provided under division (B)(2)
of this section shall be provided only for cytologic screenings
that are processed and interpreted in a laboratory certified by
the college of American
pathologists or in a hospital as defined in section 3727.01 of
the Revised
Code.
Sec. 1907.161. (A) As used in this
section, "health care coverage" means sickness and accident insurance or other
coverage of hospitalization, surgical care, major medical care, disability,
dental care, eye care, medical care, hearing aids, and prescription drugs or
any combination of those benefits or services.
(B) The board of county commissioners,
after consultation with the judges of the county court, shall negotiate and
contract for, purchase, or otherwise procure group health care coverage for
the judges and their spouses and dependents from insurance companies
authorized to engage in the business of insurance in this state under
Title XXXIA XXXIX of the Revised Code,
medical care corporations organized under Chapter 1737. of the Revised Code,
health care corporations organized under
Chapter 1738. of the Revised Code, or health maintenance
organizations INSURING CORPORATIONS
organized under
Chapter 1742. 1751. of the Revised Code, except that, if the
county provides group
health care coverage for its
employees, the group health care coverage required by this section shall be
provided, if possible, through the policy or plan under which the group health
care coverage is provided for the county employees.
(C) The portion of the costs, premiums,
or charges for the group health care coverage procured pursuant to division
(B) of this section that is not paid by the
judges of the county court, or all of the costs, premiums, or charges for the
group health care coverage if the judges will not be paying any portion
of those costs, premiums, or charges, shall be paid out of the county
treasury.
Sec. 2305.252. (A) As used in this section:
(1) "Review board, committee, risk management personnel, or corporation"
means any of the following:
(a) A peer review committee of a hospital, a nonprofit health care
corporation that is a member of the hospital or of which the hospital is a
member, or a community mental health center;
(b) A board or committee of a hospital or of a nonprofit health
care corporation that is a member of the hospital or of which the hospital is
a member reviewing professional qualifications or activities of the hospital
medical staff or applicants for admission to the medical staff;
(c) A utilization committee of a state or local society composed
of doctors of medicine or doctors of osteopathic medicine and surgery or
doctors of podiatric medicine;
(d) A peer review committee of nursing home providers or
administrators, including a corporation engaged in performing the
functions of a peer review committee of nursing home providers or
administrators, or a corporation engaged in performing the functions of
another type of peer
review or professional standards review committee;
(e) A peer review committee, professional standards review
committee, or arbitration committee of a state or local society composed of
doctors of medicine, doctors of osteopathic medicine and surgery, doctors of
dentistry, doctors of optometry, doctors of podiatric medicine, psychologists,
or registered pharmacists;
(f) A peer review committee of a health maintenance organization
INSURING CORPORATION
that has at least a two-thirds majority of member physicians in active
practice and that conducts professional credentialing and quality review
activities involving the competence or professional conduct of health care
providers, which conduct adversely affects, or could adversely affect, the
health or welfare of any patient. For purposes of this division, "health
maintenance organization INSURING CORPORATION" includes
wholly-owned WHOLLY OWNED subsidiaries of a health
maintenance organization INSURING CORPORATION.
(g) A peer review committee of any insurer authorized under
Title XXXIX of the Revised Code to do the business of sickness and accident
insurance in this state that has at least a two-thirds majority of physicians
in active practice and that conducts professional credentialing and quality
review activities involving the competence or professional conduct of health
care providers, which conduct adversely affects, or could adversely affect,
the health or welfare of any patient;
(h) A peer review committee of any insurer authorized under
Title XXXIX of the Revised Code to do the business of sickness and accident
insurance in this state that has at least a two-thirds majority of physicians
in active practice and that conducts professional credentialing and quality
review activities involving the competence or professional conduct of a health
care facility that has contracted with the insurer to provide health care
services to insureds, which conduct adversely affects, or could adversely
affect, the health or welfare of any patient;
(i) A peer review committee of an insurer authorized under
Title XXXIX of the Revised Code to do the business of medical professional
liability insurance in this state and that conducts professional quality
review activities involving the competence or professional conduct of health
care providers, which conduct adversely affects, or could affect, the health
or welfare of any patient;
(j) A peer review committee of a health care entity.
(2) "Peer review committee" means a utilization review committee, quality
assurance committee, quality improvement committee, tissue committee,
credentialing committee, and any other committee that conducts professional
credentialing and quality review activities involving the competence or
professional conduct of health care practitioners.
(3) "Health care entity" means a government entity, a for-profit or
nonprofit corporation, a limited liability company, a partnership, a
professional corporation, a state or local society as described in
division (A)(1)(c) of this section, or other health
care organization, including, but not limited to, health care entities
described in division (A)(1) of this section, whether acting on its
own behalf or on behalf of or in affiliation with other health care entities,
that conducts, as part of its purpose, professional credentialing and quality
review activities involving the competence or professional conduct of health
care practitioners.
(4) "Incident report or risk management report" means
a report of an incident involving injury or potential injury to a patient as a
result of patient care by a health care entity that is prepared by or for the
use of a review board, committee, risk management personnel, or corporation
and is within the scope of the functions of that review board, committee, risk
management personnel, or corporation.
(5) "Tort action" means a civil action for
damages for injury, death, or loss to
a patient of a health care entity. "Tort action" includes a product liability
claim but does not include a civil action
for a breach of contract or another agreement between persons.
(B) Notwithstanding any contrary provision of
section 149.43, 1742.141 1751.21, 2305.24, 2305.25, 2305.251,
or 2305.28 of the
Revised Code, an incident report or risk
management report and the contents of an incident report or risk
management report are not subject to discovery in, and are not
admissible in evidence in the trial of, a tort action. An individual who
prepares or has knowledge of the contents of an incident report or risk
management report shall not testify and shall not be required to testify in a
tort action as to the contents of the report.
This division does not prohibit or limit the discovery or admissibility of
testimony or evidence relating to patient care that is within a person's
personal knowledge.
(C) Except as specified in division (B)
of this section, this section does not affect any provision of
section 1742.141 1751.21, 2305.24, 2305.25, 2305.251, or
2305.28 of the
Revised Code that describes, imposes, or confers
an immunity from tort or other civil liability, a forfeiture
of an immunity from tort or other civil liability, a
requirement of confidentiality, a limitation upon the use of
information, data, reports, or records, tort or other civil
liability, or a limitation upon discovery of matter,
introduction into evidence of matter, or testimony pertaining to
matter in a tort or other civil action. This section does not
affect a privileged communication between an attorney and the attorney's
client under section 2317.02 of the Revised Code.
(D) This section shall be considered to be purely remedial in operation and
shall be applied in a remedial manner in any civil action in which this
section is relevant, whether the civil action is pending in court or commenced
on or after the effective date of this section JANUARY
27, 1997, regardless of when the cause
of action accrued and notwithstanding any other section of the Revised Code or
prior rule of law of this state.
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 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 A NONFEDERALLY ELIGIBLE individual sickness
and accident insurance policy
OR A NONEMPLOYER-RELATED GROUP 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 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 any health 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 an employer, for
which an individual would otherwise be eligible;
(b) With respect to a health benefit plan issued to an employer,
excludes or causes the exclusion of an individual from coverage under an
existing employer-provided policy, contract, or plan of health benefits.
(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.
(Y)(1)(a) Limiting coverage under, refusing to issue, canceling,
or refusing to renew, any individual policy or contract of life
insurance, or limiting coverage under or refusing to issue any individual
policy or contract of health insurance, for the reason that the insured or
applicant for insurance is or has
been a victim of domestic violence;
(b) Adding a surcharge or rating factor to a premium of any
individual policy or contract of life or health insurance for the reason that
the insured or applicant for insurance is or has been a victim of domestic
violence;
(c) Denying coverage under, or limiting coverage under, any policy or
contract of life or health insurance, for the reason that a claim under the
policy or contract arises from an incident of domestic violence;
(d) Inquiring, directly or indirectly, of an insured under, or of an
applicant for, a policy or contract of life or health insurance, as to whether
the insured or applicant is or has been a victim of domestic violence,
or inquiring as to whether the insured or applicant has sought shelter or
protection from domestic violence or has sought medical or psychological
treatment as a victim of domestic violence.
(2) Nothing in division (Y)(1) of this section shall be construed to
prohibit an insurer from inquiring as to, or from underwriting or rating a
risk on the basis of, a person's physical or mental condition, even if the
condition has been caused by domestic violence, provided that all of the
following apply:
(a) The insurer routinely considers the condition in underwriting or
in rating risks, and does so in the same manner for a victim of domestic
violence as for an insured or applicant who is not a victim of domestic
violence;
(b) The insurer does not refuse to issue any policy or contract of life or
health insurance or cancel or refuse to
renew any policy or contract of life insurance, solely on the basis of the
condition, except where such refusal to issue, cancellation, or refusal
to renew is based on sound actuarial principles or is related to actual or
reasonably anticipated experience;
(c) The insurer does not consider a person's status as being or as
having been a victim of domestic violence, in itself, to be a physical or
mental condition;
(d) The underwriting or rating of a risk on the basis of the
condition
is not used to evade the intent of division (Y)(1) of this section,
or
of any other provision of the Revised Code.
(3)(a) Nothing in division (Y)(1) of this section shall
be construed to
prohibit an insurer from refusing to issue a policy or contract of life
insurance insuring the life of a person who is or has been a victim of
domestic violence if the person who committed the act of domestic violence is
the applicant for the insurance or would be the owner of the insurance policy
or contract.
(b) Nothing in division (Y)(2) of this section
shall be construed to permit an insurer to cancel or refuse to
renew any policy or contract of health insurance in violation of
the "Health Insurance Portability and
Accountability Act of 1996," 110 Stat.
1955, 42 U.S.C.A.
300gg-41(b), as amended, or in a manner that
violates or is inconsistent with any provision of the
Revised Code that implements the "Health
Insurance Portability and Accountability
Act of 1996."
(4) An insurer is immune from any civil or
criminal liability that otherwise might be incurred or imposed as a result of
any action taken by the insurer to comply with division
(Y) of this section.
(5) As used in division (Y) of this section,
"domestic
violence" means any of the following acts:
(a) Knowingly causing or attempting to cause physical harm to a
family
or household member;
(b) Recklessly causing serious physical harm to a family or
household
member;
(c) Knowingly causing, by threat of force, a family or household
member to believe that the person will cause imminent physical harm to the
family or household member.
For the purpose of division (Y)(5) of this
section,
"family or household member" has the same meaning as in section 2919.25 of
the Revised Code.
Nothing in division (Y)(5)
of this section shall be
construed to require, as a condition to the application of division
(Y) of this section, that
the act described in division (Y)(5) of this section be the basis of
a
criminal prosecution.
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. 3923.021. (A) As used in this section, "benefits
provided are not unreasonable in relation to the premium charged"
means the rates were calculated in accordance with sound
actuarial principles.
(B) With respect to any filing, made pursuant to section
3923.02 of the Revised Code, of any premium rates for any
individual policy of sickness and accident insurance or for any
indorsement or rider pertaining thereto, the superintendent of
insurance may, within thirty days after filing:
(1) Disapprove such filing after finding that the
benefits
provided are unreasonable in relation to the premium charged.
Such disapproval shall be effected by written order of the
superintendent, a copy of which shall be mailed to the insurer
that has made the filing. In the order, the superintendent shall
specify the reasons for the disapproval and state that a
hearing
will be held within fifteen days after requested in writing by
the insurer. If a hearing is so requested, the superintendent
shall also give such public notice as the superintendent
considers appropriate.
The superintendent, within fifteen days after the commencement of
any hearing, shall issue a written order, a copy of which shall
be mailed to the insurer that has made the filing, either
affirming the prior disapproval or approving such filing
after finding that the benefits provided are not unreasonable
in relation
to the premium charged.
(2) Set a date for a public hearing to commence no later
than forty days after the filing. The superintendent shall give
the insurer making the filing twenty days' written notice of the
hearing and shall give such public notice as the
superintendent considers
appropriate. The superintendent, within twenty days after the
commencement of a hearing, shall issue a written order, a copy of
which shall be mailed to the insurer that has made the filing,
either approving such filing if the superintendent finds that
the benefits
provided are not unreasonable in relation to the premium charged,
or disapproving such filing if the superintendent finds that
the benefits
provided are unreasonable in relation to the premium charged.
This division does not apply to any insurer organized or
transacting the business of insurance under Chapter 3907. or
3909. of the Revised Code.
(3) Take no action, in which case such filing shall be
deemed to be approved and shall become effective upon the
thirty-first day after such filing, unless the superintendent has
previously given to the insurer a written approval.
(C) At any time after any filing has been approved
pursuant to this section, the superintendent may, after a hearing
of which at least twenty days' written notice has been given to
the insurer that has made such filing and for which such public
notice as the superintendent considers appropriate has been
given, withdraw
approval of such filing after finding that the
benefits provided
are unreasonable in relation to the premium charged. Such
withdrawal of approval shall be effected by written order of the
superintendent, a copy of which shall be mailed to the insurer
that has made the filing, which shall state the ground for such
withdrawal and the date, not less than forty days after the date
of such order, when the withdrawal or approval shall become
effective.
(D) The superintendent may retain at the insurer's expense
such attorneys, actuaries, accountants, and other experts not
otherwise a part of the superintendent's staff as shall be
reasonably necessary to assist in the preparation for and conduct
of any public hearing under this section. The expense for
retaining such experts and the expenses of the department of
insurance incurred in connection with such public hearing shall
be assessed against the insurer in an amount not to exceed one
one-hundredth of one per cent of the sum of premiums earned plus
net realized investment gain or loss of such insurer as reflected
in the most current annual statement on file with the
superintendent. Any person retained shall be under the direction
and control of the superintendent and shall act in a purely
advisory capacity.
(E) This section does not apply to any filing of any
premium rate or rating formula for individual sickness and
accident insurance policies offered in accordance with division
(L) of section 3923.58 of the Revised Code, or for any
amendment thereto.
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 the following:
(1) In the case of an individual who is not a
federally eligible individual, 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;
(2) In the case of a federally eligible individual, 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 division (A)(2) of this section, 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 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 the
person's
then attained age. However, premiums charged federally eligible
individuals 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 the child upon
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 retirement prior to the time the
employee is, or is
eligible to be, covered by Title XVIII of the Social Security
Act, the employee may elect, in lieu of the continuance of
group insurance,
to have the same conversion rights as would apply had 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 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
the insured fails to furnish the details of 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.
(O) As used in this
section, "federally eligible individual" means an eligible
individual as defined in 45
C.F.R.
148.103.
Sec. 3923.571. Except as otherwise provided in 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-21, as amended, the following conditions apply to all
group policies of sickness and accident insurance that are sold in connection
with an employment-related group health plan and 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 and section 3924.033 of the
Revised Code.
(B)(1) Except as
provided in section 2712(b) to
(e) of the "Health
Insurance
Portability and
Accountability
Act of 1996," 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.
(2) An insurer may cancel or decide not to renew the coverage of an
employee or of a dependent of an employee if the employee or dependent, as
applicable, has performed an act or practice that constitutes fraud or made an
intentional misrepresentation of material fact under the terms of the coverage
and if the cancellation or nonrenewal is not based, either directly or
indirectly, on any health status-related factor in relation to the
employee or dependent.
As used in division (B)(2) of this
section, "health status-related factor" has the same meaning as in section
3924.031 of the Revised
Code.
(C)(1) No such policy, or insurer offering health insurance
coverage in
connection with such a 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 policy 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
section 2701(f) of the
"Health
Insurance
Portability and
Accountability
Act of 1996."
(E) AN INSURER MAY DELAY COVERAGE OF A LATE
ENROLLEE FOR UP TO TWELVE MONTHS. HOWEVER, ANY PRE-EXISTING
CONDITION PROVISION THAT IMPOSES AN EXCLUSIONARY PERIOD ON SUCH
A LATE ENROLLEE SHALL RUN CONCURRENTLY WITH THE DELAY IN
COVERAGE. AS USED IN THIS DIVISION, A "LATE ENROLLEE" MEANS AN
ELIGIBLE EMPLOYEE OR DEPENDENT WHO ENROLLS IN A HEALTH BENEFIT
PLAN OTHER THAN DURING THE FIRST PERIOD IN WHICH THE EMPLOYEE OR
DEPENDENT IS ELIGIBLE 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."
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59
of the Revised Code:
(1) "Health
benefit plan" and "MEWA" have the same meanings as in section
3924.01 of the Revised Code.
(2) "Insurer" means any sickness and accident insurance
company authorized to do business in
this state,
or MEWA authorized to issue insured health benefit plans in this
state. "Insurer" does not include any health insuring corporation that
is owned or operated by an
insurer.
(3) "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.
(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
this division, in the
order in which
they apply for coverage and subject to the limitation set forth
in division (G) of this section. Insurers shall accept for coverage pursuant
to this
section
individuals to whom both of the following conditions apply:
(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.
(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 continuation
of coverage policy under state or federal law.
(C) An insurer shall offer to any individual
accepted
under this section the small employer health care plan BASIC AND
STANDARD PLANS established by the
board of directors of the Ohio health reinsurance
program under
division (A) of section 3924.10 of the Revised Code or a health benefit
plan PLANS
that is ARE substantially similar to the small employer
health care plan BASIC AND STANDARD PLANS 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 PLANS required to be offered under this
division. These
additional A BASIC health benefit plans PLAN shall
provide, at a minimum, the coverage
provided by the small employer OHIO health care
BASIC plan or any health benefit plan
that is substantially similar to the small employer
OHIO health care BASIC plan in
benefit plan design and scope of covered services. A STANDARD HEALTH
BENEFIT PLAN SHALL PROVIDE, AT A MINIMUM, THE COVERAGE PROVIDED BY THE
OHIO HEALTH CARE STANDARD PLAN OR ANY HEALTH BENEFIT PLAN THAT IS
SUBSTANTIALLY SIMILAR TO THE OHIO HEALTH CARE STANDARD 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 OHIO health care BASIC 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.
(E) Premiums charged to individuals under this
section may not exceed an amount that is two and one-half times
the highest rate charged 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 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)(L) 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 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 for any health care supplies or
services provided to the
individual or dependent
who is insured under a policy 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 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 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) 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.
(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. 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
health reinsurance program either on the basis of the
arithmetic mean of all carriers'
premium rates for an SEHC OHC plan sold to groups
with similar case
characteristics by all carriers selling SEHC OHC
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 insuring corporation
authorized to issue
health benefit plans in this state or a MEWA. A
sickness and
accident insurance company that owns or operates a health
insuring corporation, either as a
separate corporation or as
a line of business, shall be considered as a separate carrier
from that health insuring corporation
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) "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
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 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.
(I) "Late enrollee" means an eligible employee or
dependent who enrolls in a small employer's
health
benefit plan other than during the first period in which
the employee or
dependent is eligible
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.
(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.
(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.
(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 enrollment date as to a
condition for which medical advice,
diagnosis, care, or treatment was recommended or received
during a
specified period immediately preceding the
enrollment date. 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.
(M) "Service waiting period" means the period of time
after employment begins before an employee is eligible to be covered for
benefits under the terms of
any applicable health benefit plan offered by the small employer.
(N)(1) "Small employer"
means, in connection with a
group health benefit plan and with respect to a calendar year and a plan year,
an employer who employed an average of at least two but no more
than fifty
eligible employees on business days during the preceding calendar year and
who
employs at least two employees on the first day of the plan year.
(2) For purposes of division (N)(1) of this section,
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.A. 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.
(O) "SEHC OHC plan" means an Ohio small
employer
health
care plan, which is a health benefit THE BASIC, STANDARD, OR CARRIER
REIMBURSEMENT plan for small individuals and
employers AND INDIVIDUALS
established by the board in accordance with section 3924.10 of
the Revised Code.
Sec. 3924.03. Except as otherwise provided in 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-21, as amended, 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
enrollment date and may only
relate
to 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
enrollment date.
Division (A)(1) of
this section is subject to the exceptions set forth in
section 2701(d) of the
"Health
Insurance
Portability and
Accountability
Act of 1996."
(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)(1) 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.
(2) A carrier may cancel or decide not to renew the coverage of
any eligible employee or of a dependent of an eligible employee if the
employee
or dependent, as applicable, has performed an act or practice that constitutes
fraud or made an intentional misrepresentation of material fact under the
terms of the coverage and if the cancellation or nonrenewal is not based,
either directly or indirectly, on any health status-related factor in relation
to the employee or dependent.
As used in division (B)(2) of this
section, "health status-related factor" has the same meaning as in section
3924.031 of the Revised Code.
(C) 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.
If, prior to
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.
(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.
(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 of insurance in accordance with
Chapter 119. of the Revised Code, a carrier shall
offer and make available every health benefit plan that it is actively
marketing 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.
(3) Each health benefit plan shall provide for
the special enrollment periods described in section
2701(f) of the
"Health
Insurance
Portability and
Accountability
Act of 1996."
(4) A CARRIER MAY DELAY COVERAGE OF A LATE
ENROLLEE FOR UP TO TWELVE MONTHS AFTER THE DATE THE APPLICATION IS RECEIVED.
HOWEVER, ANY PRE-EXISTING
CONDITION PROVISION THAT IMPOSES AN EXCLUSIONARY PERIOD ON SUCH
A LATE ENROLLEE SHALL RUN CONCURRENTLY WITH THE DELAY IN
COVERAGE.
(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.
(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. To maintain its status as a "bona fide association," each
association shall annually certify to the superintendent that it
meets the requirements of this paragraph.
Sec. 3924.08. (A) The board of directors of the Ohio
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 insuring corporation
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 OHC plan for
individuals, 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 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 OHC 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 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
1751.16, 3923.122, and 3923.581 of the Revised Code.
Sec. 3924.10. (A) The board of directors of the Ohio health reinsurance
program shall design the SEHCplan OHC BASIC, STANDARD, AND CARRIER REIMBURSEMENT
PLANS which, when offered by a carrier, is ARE eligible for
reinsurance under the program. The board shall establish the
form and level of coverage to be made available by carriers in
their SEHCplan OHC PLANS. In designing
the
plan PLANS the board shall
also establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan PLANS. The forms and
levels
of coverage established by the board shall specify which
components of a health benefit plan PLANS offered by a
carrier may be reinsured. The SEHCplan is OHC
PLANS ARE subject
to division (C) of section 3924.02 of the Revised Code and
to the provisions in Chapters 1751., 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 SEHCplan OHC
PLANS within one
hundred eighty days after its appointment THE EFFECTIVE DATE OF THIS
AMENDMENT. The plan PLANS 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 PLANS.
(C) AnSEHCplan OHC PLANS
established for
use by health
insuring corporations shall be
consistent with the basic
method of operation of such corporations.
(D) Each carrier shall certify to the superintendent of
insurance, in the form and manner prescribed by the
superintendent, that the SEHCplan OHC
PLANS
filed by the carrier
is ARE in substantial compliance with the provisions of the
board
SEHCplan OHC PLANS. Upon receipt by the
superintendent of the
certification, the carrier may use the certified plan PLANS.
(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 SEHCplan OHC
PLANS.
(F) THIS IS AN INTERIM SECTION EFFECTIVE UNTIL OCTOBER
1, 1998.
Sec. 3924.11. Any member of the Ohio 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 any 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
who were not eligible to enroll 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-42, as
amended, eighteen months after
the date the late enrollee becomes a member of the small
employer's plan;
(3) In the case of late enrollees who were eligible to enroll during a
special enrollment period described in section 2701(f) of the
"Health
Insurance Portability and Accountability
Act of
1996," as amended, within sixty days after the commencement of their coverage
under the plan
A SMALL EMPLOYER GROUP OR INDIVIDUAL MAY BE REINSURED
WITHIN SIXTY DAYS AFTER THE COMMENCEMENT OF THE GROUP'S OR
INDIVIDUAL'S COVERAGE UNDER THE 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 OHC 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
OHC CARRIER REIMBURSEMENT 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 OHC CARRIER REIMBURSEMENT 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 OHC CARRIER REIMBURSEMENT 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 OHC
CARRIER REIMBURSEMENT plan.
(G) With respect to coverage provided to an individual acquired under
section 3923.58 or a
federally eligible individual acquired under section 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 such an individual
with the open enrollment reinsurance program
in
accordance with division (G) of this section. 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 section 3923.581 of the Revised Code.
The fund shall be maintained separately from any reinsurance fund established
for small employer OHIO 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 individual health benefit plans, earned
in this state from all health benefit plans covering 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
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 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 section
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
individual market and history of rating and underwriting 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 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)(a) The open enrollment reinsurance program shall
be operated separately from the Ohio
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 health reinsurance program
under section 3924.07 of the Revised Code.
Sec. 3999.22. (A) As used in this section:
(1) "Claim" means any attempt to cause a health care
insurer to make payment of a health care benefit.
(2) "Health care benefit" means the right under a contract
or a certificate or policy of insurance to have a payment made by
a health care insurer for a specified health care service.
(3) "Health care insurer" means any person that is
authorized to do the business of sickness and accident insurance;
any prepaid dental plan, medical care corporation, health care
corporation, dental care corporation, or health maintenance
organization; INSURING CORPORATION, and any legal entity
that is self-insured and
provides health care benefits to its employees or members.
(B) No person shall knowingly solicit, offer, pay, or
receive any kickback, bribe, or rebate, directly or indirectly,
overtly or covertly, in cash or in kind, in return for referring
an individual for the furnishing of health care services or goods
for which whole or partial reimbursement is or may be made by a
health care insurer, except as authorized by the health care or
health insurance contract, policy, or plan. This division does
not apply to any of the following:
(1) Deductibles, copayments, or similar amounts owed by
the person covered by the health care or health insurance
contract, policy, or plan;
(2) Discounts or similar reductions in prices;
(3) Any amount paid within a bona fide legal entity, or
within legal entities under common ownership or control,
including any amount paid to an employee in a bona fide
employment relationship;
(4) Any amount paid as part of a bona fide lease,
management, or other business contract.
(C) Nothing in this section shall be construed to apply to
any of the following:
(1) A provider who provides goods or services requested by
an individual that are not covered by the individual's health
care or health insurance contract, policy, or plan;
(2) A provider who, in good faith, provides goods or
services ordered by another health care provider;
(3) A provider who, in good faith, resubmits a claim
previously submitted that has not been paid or denied within
thirty days of the original submission, if the provider notifies
the payor or returns any duplicate payment within sixty days
after receipt of the duplicate payment;
(4) A provider who, in good faith, makes a diagnosis that
differs from the interpretation of a diagnosis reached by a
health care insurer in the payment of claims.
(D) Whoever violates this section is guilty of a felony of
the fifth degree on a first offense and a felony of the fourth
degree on each subsequent offense.
Sec. 5112.01. As used in sections 5112.02 to 5112.21 of the Revised Code:
(A)(1) "Hospital" means a nonfederal hospital to which
either of the following applies:
(a) The hospital is registered under section 3701.07 of the Revised Code as a
general medical and surgical hospital or a
pediatric general hospital, and provides inpatient hospital
services, as defined in 42 C.F.R. 440.10;
(b) The hospital is recognized under the medicare program
established by Title XVIII of the "Social
Security Act," 49 Stat.
620 (1935), 42 U.S.C.A. 301, as amended, as
a cancer hospital and
is exempt from the medicare prospective payment system.
"Hospital" does not include a hospital operated by a health
maintenance organization INSURING CORPORATION that has been
issued a certificate of
authority under section 1742.05 1751.05 of the Revised Code or
a hospital
that does not charge patients for services.
(2) "Disproportionate share hospital" means a hospital
that meets the definition of a disproportionate share hospital in
rules adopted under section 5112.03 of the Revised Code.
(B) "Bad debt," "charity care," "courtesy care," and
"contractual allowances" have the same meanings given these terms
in regulations adopted under Title XVIII of the
"Social Security
Act."
(C) "Cost reporting period" means the twelve-month period
used by a hospital in reporting costs for purposes of Title
XVIII
of the "Social Security Act."
(D) "Governmental hospital" means a county hospital with more than
five
hundred registered beds or a state-owned and -operated hospital with more
than five hundred registered beds.
(E) "Indigent care pool" means the sum of the following:
(1) The total of assessments to be paid in a program year
by all hospitals under section 5112.06 of the Revised Code, less
the assessments deposited into the legislative budget services fund under
section 5112.19 of the Revised
Code;
(2) The total amount of intergovernmental transfers
required to be made in the same program year by governmental
hospitals under section 5112.07 of the Revised Code, less the
amount of transfers deposited into
the legislative budget services fund under section 5112.19 of the Revised
Code;
(3) The total amount of federal matching funds that will
be made available in the same program year as a result of
payments the department of human services makes to hospitals
under section 5112.08 of the Revised Code.
(F) "Intergovernmental transfer" means any transfer of
money by a governmental hospital under section 5112.07 of the Revised Code.
(G) "Medical assistance program" means the program of
medical assistance established under section 5111.01 of the Revised Code
and Title XIX of the "Social Security Act."
(H) "Program year" means a period beginning the first day of October, or a
later date designated in rules adopted under
section 5112.03 of the Revised Code, and ending the thirtieth day of
September, or an earlier date designated in rules adopted under that
section.
(I) "Registered beds" means the total number of hospital
beds registered with the department of health, as reported in the
most recent "directory of registered hospitals" published by the
department of health.
(J) "Total facility costs" means the total costs for all
services rendered to all patients, including the direct,
indirect, and overhead cost to the hospital of all services,
supplies, equipment, and capital related to the care of patients,
regardless of whether patients are enrolled in a health
maintenance organization INSURING CORPORATION, excluding costs
associated with
providing skilled nursing services in distinct-part nursing
facility units, as shown on the hospital's cost report filed
under section 5112.04 of the Revised Code. Effective October 1,
1993, if rules adopted under section 5112.03 of the Revised Code
so provide, "total facility costs" may exclude costs associated
with providing care to recipients of any of the governmental
programs listed in division (B) of that section.
(K) "Uncompensated care" means bad debt and charity care.
Sec. 5112.08. The director of human services shall adopt
rules under section 5112.03 of the Revised Code establishing a
methodology to pay hospitals that is sufficient to expend all
money in the indigent care pool. Under the rules:
(A) The department of human services shall classify
similar hospitals into groups and allocate funds for distribution
within each group.
(B) The department shall establish a method of allocating
funds to each group of hospitals, taking into consideration the
relative amount of indigent care provided by each group. The
amount to be allocated to each group shall be based on any
combination of the following indicators of indigent care that the
director considers appropriate:
(1) Total costs, volume, or proportion of services to
recipients of the medical assistance program, including
recipients enrolled in health maintenance organizations INSURING
CORPORATIONS;
(2) Total costs, volume, or proportion of services to
low-income patients in addition to recipients of the medical
assistance program, which may include recipients of Title V
of
the "Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301,
as amended, general assistance established under Chapter 5113. of the Revised Code,
and disability assistance established under
Chapter 5115. of the Revised Code;
(3) The amount of uncompensated care provided by the
hospitals;
(4) Other factors that the director considers to be
appropriate indicators of indigent care.
(C) The department shall distribute funds to hospitals in
each group in a manner that first may provide for an additional
payment to individual hospitals that provide a high proportion of
indigent care in relation to the total care provided by the
hospital or in relation to other hospitals. The department shall
establish a formula to distribute the remainder of the funds
allocated to the group to all hospitals in the group. The
formula shall be consistent with section 1923 of the "Social
Security Act," 42
U.S.C.A. 1396r-4, as
amended, and shall be
based on any combination of the indicators of indigent care
listed in division (B) of this section that the
director considers appropriate.
(D) The department shall make payments to each hospital in
installments not later than ten working days after the deadline
established in rules for each hospital to pay an installment on
its assessment under section 5112.06 of the Revised Code. In the
case of a governmental hospital that makes intergovernmental
transfers, the department shall pay an installment under this
section not later than ten working days after the earlier of that
deadline or the deadline established in rules for the
governmental hospital to pay an installment on its
intergovernmental transfer. If the amount in the hospital care
assurance program fund and the hospital care assurance match fund
created under section 5112.18 of the Revised Code is insufficient
to make the total payments for which hospitals are eligible to
receive in any period, the department shall reduce the amount of
each payment by the percentage by which the amount is
insufficient. The department shall pay hospitals any amounts not
paid in the period in which they are due as soon as moneys are
available in the funds.
Section 2. That existing sections 1739.01, 1751.01, 1751.02, 1751.03,
1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 1751.15, 1751.16,
1751.20, 1751.31, 1751.46, 1751.55, 1751.58, 1751.59,
1751.60, 1751.62, 1907.161, 2305.252, 3901.21, 3923.021, 3923.122, 3923.571,
3923.58, 3924.01, 3924.03,
3924.08, 3924.09, 3924.10, 3924.11, 3999.22, 5112.01, and 5112.08 of the
Revised Code are
hereby repealed.
Section 3. That sections 1751.02, 1751.03, 1751.13, and 3924.10
of the Revised Code, as amended by Am. Sub. H.B. 361 of the
122nd General Assembly, be amended to read as follows:
Sec. 1751.02. (A) Notwithstanding any law in this state to the
contrary, any
corporation, as defined in section 1751.01 of the
Revised Code, may apply to the
superintendent of insurance for a certificate of authority to
establish and operate a health insuring corporation. If the corporation
applying for a certificate of authority is a
foreign corporation domiciled in a state without laws
similar to those of this chapter,
the corporation must form a domestic corporation to apply for, obtain, and
maintain a certificate of authority under this chapter.
(B) No person shall
establish, operate, or perform the services of a health insuring corporation
in this state
without obtaining a certificate of authority under this
chapter.
(C) Except as provided by division (D) of this section,
no political subdivision or department, office, or
institution of this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of this state,
shall establish, operate, or perform the services of a health insuring
corporation.
Nothing in this
section shall be construed to preclude a board of county
commissioners, a county board of mental retardation and
developmental disabilities, an alcohol and drug addiction
services board, a board of alcohol, drug addiction, and mental
health services, or a community mental health board, or a public
entity formed by or on behalf of any of these boards, from using
managed care techniques in carrying out the board's or public
entity's duties pursuant to the requirements of
Chapters 307., 329., 340., and
5126. of the Revised
Code. However, no such board
or public entity may operate so as to compete in the private
sector with health insuring corporations holding certificates of
authority under this chapter.
(D) A corporation formed by or on behalf of a publicly owned,
operated, or funded hospital or health care facility may apply to the
superintendent for
a certificate of authority under division (A) of this section to
establish and operate a health insuring corporation.
(E) A health insuring
corporation shall operate in this state in compliance with this
chapter and Chapter 1753. of the Revised Code, and with sections
3702.51 to 3702.62 of the
Revised
Code, and shall operate in
conformity with its filings with the superintendent under this
chapter, including filings made pursuant to sections 1751.03,
1751.11, 1751.12, and 1751.31 of the
Revised
Code.
(F) An insurer licensed under Title XXXIX of
the
Revised Code need not obtain a certificate of
authority as a health insuring corporation to offer an open
panel plan as long as the providers and health care facilities
participating in the open panel plan receive their compensation
directly from the insurer. If the providers and health care
facilities participating in the open panel plan receive their
compensation from any person other than the insurer, or if the
insurer offers a closed panel plan, the insurer must obtain a
certificate of authority as a health insuring corporation.
(G) An intermediary
organization need not obtain a certificate of authority as a
health insuring corporation, regardless of the method of reimbursement to the
intermediary organization,
as long as a health insuring
corporation or a self-insured employer maintains the ultimate responsibility
to assure delivery of all health care services required by the contract
between the health insuring corporation and the subscriber and
the laws of this state or between the self-insured employer and its
employees.
Nothing in this section shall be construed to require any
health care facility, provider, health delivery network, or
intermediary organization that contracts with a health insuring
corporation or self-insured employer, regardless of the method
of reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a
certificate of authority as a health insuring corporation under
this chapter, unless otherwise provided, in the case of
contracts with a self-insured employer, by operation of the
"Employee
Retirement
Income
Security
Act of 1974," 88
Stat. 829, 29
U.S.C.A.
1001, as amended.
(H) Any health delivery
network doing business in this state, INCLUDING ANY
HEALTH DELIVERY NETWORK THAT IS FUNCTIONING AS AN INTERMEDIARY ORGANIZATION
DOING BUSINESS IN THIS
STATE, that is not required to
obtain a certificate of authority under this chapter shall
certify to the superintendent annually, not later than the
first day of July, and shall
provide a statement signed by the highest ranking official which
includes the following information:
(1) The health delivery network's full name and the
address of its principal place of business;
(2) A statement that the health delivery network is not
required to obtain a certificate of authority under this chapter
to conduct its business.
(I) The superintendent
shall not issue a certificate of authority to a health insuring
corporation that is a provider sponsored organization unless all
health care plans to be offered by the health insuring
corporation provide basic health care services.
Substantially all of the physicians and hospitals with
ownership or control of the provider sponsored organization, as
defined in division (W)(X) of
section 1751.01 of the Revised
Code, shall also be
participating providers for the provision of basic health care
services for health care plans offered by the provider sponsored
organization. If a health insuring corporation that is a
provider sponsored organization offers health care plans that do
not provide basic health care services, the health insuring
corporation shall be deemed, for purposes of section 1751.35 of
the Revised Code, to have failed to substantially
comply with this chapter.
Except as specifically provided in this division and in division
(C) of section 1751.28 of the Revised Code,
the provisions of this chapter shall apply to all health insuring corporations
that are provider sponsored organizations in the same manner that these
provisions apply to all health insuring corporations that are not provider
sponsored organizations.
(J) Nothing in this section shall be construed to apply to any
multiple employer welfare arrangement operating pursuant to Chapter
1739. of the Revised Code.
(K) Any person who
violates division (B) of this
section, and any health delivery network that fails to comply
with division (H) of this
section, is subject to the penalties set forth in section
1751.45 of the Revised
Code.
Sec. 1751.03. (A) Each
application for a certificate of authority under this chapter
shall be verified by an officer or authorized representative of
the applicant, shall be in a format prescribed by the
superintendent of insurance, and shall set forth or be
accompanied by the following:
(1) A certified copy of the applicant's articles of
incorporation and all amendments to the articles of
incorporation;
(2) A copy of any regulations adopted for the government
of the corporation, any bylaws, and any similar documents, and a
copy of all amendments to these regulations, bylaws, and
documents. The corporate secretary shall certify that these
regulations, bylaws, documents, and amendments have been
properly adopted or approved.
(3) A list of the names, addresses, and official
positions of the persons responsible for the conduct of the
applicant, including all members of the board, the principal
officers, and the person responsible for completing or filing
financial statements with the department of insurance,
accompanied by a completed original biographical affidavit and
release of information for each of these persons on forms
acceptable to the department;
(4) A full and complete disclosure of the extent and
nature of any contractual or other financial arrangement between
the applicant and any provider or a person listed in division
(A)(3) of this section,
including, but not limited to, a full and complete disclosure of
the financial interest held by any such provider or person in
any health care facility, provider, or insurer that has entered
into a financial relationship with the health insuring
corporation;
(5) A description of the applicant, its facilities, and
its personnel, including, but not limited to, the location,
hours of operation, and telephone numbers of all contracted
facilities;
(6) The applicant's projected annual enrollee population
over a three-year period;
(7) A clear and specific description of the health care
plan or plans to be used by the applicant, including a
description of the proposed providers, procedures for accessing
care, and the form of all proposed and existing contracts
relating to the administration, delivery, or financing of health
care services;
(8) A copy of each type of evidence of coverage and
identification card or similar document to be issued to
subscribers;
(9) A copy of each type of individual or group policy,
contract, or agreement to be used;
(10) The schedule of the proposed contractual periodic
prepayments or premium rates, or both, accompanied by appropriate supporting
data;
(11) A financial plan which provides a three-year
projection of operating results, including the projected
expenses, income, and sources of working capital;
(12) The enrollee complaint procedure to be utilized as
required under section 1751.19 of the
Revised
Code;
(13) A description of the procedures and programs to be implemented on an
ongoing basis to assure the quality of health care services delivered to
enrollees, including, if applicable, a description of a quality
assurance program
complying with the requirements of sections 1751.73 to 1751.75 of the Revised Code;
(14) A statement describing the geographic area or areas
to be served, by county;
(15) A copy of all solicitation documents;
(16) A balance sheet and other financial statements
showing the applicant's assets, liabilities, income, and other
sources of financial support;
(17) A description of the nature and extent of any
reinsurance program to be implemented, and a demonstration that
errors and omission insurance and, if appropriate, fidelity
insurance, will be in place upon the applicant's receipt of a
certificate of authority;
(18) Copies of all proposed or in force related-party or
intercompany agreements with an explanation of the financial
impact of these agreements on the applicant. If the applicant
intends to enter into a contract for managerial or
administrative services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed description
of the person to
provide these services. The description shall include that person's
experience in managing or administering health care plans, a
copy of that person's most recent audited financial statement,
and a completed biographical affidavit on a form acceptable to
the superintendent for each of that person's principal officers
and board members and for any additional employee to be directly
involved in providing managerial or administrative services to
the health insuring corporation. If the person to provide
managerial or administrative services is affiliated with the
health insuring corporation, the contract must provide for
payment for services based on actual costs.
(19) A statement from the applicant's board that the
admitted assets of the applicant have not been and will not be
pledged or hypothecated;
(20) A statement from the applicant's board that the
applicant will submit monthly financial statements during the
first year of operations;
(21) The name and address of the applicant's
Ohio statutory agent for
service of process, notice, or demand;
(22) Copies of all documents the applicant filed with the secretary of
state;
(23) The location of those books and records of the
applicant that must be maintained, WHICH BOOKS AND RECORDS SHALL BE
MAINTAINED in Ohio IF THE APPLICANT IS A DOMESTIC CORPORATION, AND
WHICH MAY
BE MAINTAINED EITHER IN THE APPLICANT'S STATE OF DOMICILE OR IN
OHIO IF THE APPLICANT IS A
FOREIGN CORPORATION;
(24) The applicant's federal identification number,
corporate address, and mailing address;
(25) An internal and external organizational
chart;
(26) A list of the assets representing the initial net
worth of the applicant;
(27) If the applicant has a parent company, the parent
company's guaranty, on a form acceptable to the superintendent,
that the applicant will maintain
Ohio's minimum net worth. If
no parent company exists, a statement regarding the availability
of future funds if needed.
(28) The names and addresses of the applicant's actuary
and external auditors;
(29) If the applicant is a foreign corporation, a copy of the
most recent financial statements filed with the insurance
regulatory agency in the applicant's state of domicile;
(30) If the applicant is a foreign corporation, a statement
from the insurance regulatory agency of the applicant's state of
domicile stating that the regulatory agency has no objection to
the applicant applying for an Ohio license and that the
applicant is in good standing in the applicant's state of
domicile;
(31) Any other information that the superintendent may
require.
(B)(1) A health insuring
corporation, unless otherwise provided for in this chapter
OR IN SECTION 3901.321 OF THE
REVISED
CODE,
shall file a timely notice with the superintendent describing
any change to the corporation's articles of incorporation or
regulations, or any major modification to its operations as set
out in the information required by division
(A) of this section that
affects any of the following:
(a) The solvency of the
health insuring corporation;
(b) The health insuring
corporation's continued provision of services that it has
contracted to provide;
(c) The manner in which
the health insuring corporation conducts its business.
(2) If the change or modification is to be the result of an action
to be taken by the health insuring corporation, the notice shall
be filed with the superintendent prior to the health insuring corporation
taking
the action. The action shall be deemed approved if the
superintendent does not disapprove it within sixty days of
filing.
(3) THE FILING OF A NOTICE PURSUANT TO DIVISION
(B)(1) OR (2) OF THIS SECTION
SHALL ALSO SERVE AS THE SUBMISSION OF A NOTICE WHEN REQUIRED FOR
THE SUPERINTENDENT'S REVIEW FOR PURPOSES OF SECTION 3901.341 OF
THE REVISED
CODE, IF THE NOTICE CONTAINS
ALL OF THE INFORMATION
THAT SECTION 3901.341 OF THE
REVISED
CODE REQUIRES FOR SUCH
SUBMISSIONS AND A COPY OF ANY WRITTEN AGREEMENT. THE FILING OF SUCH A NOTICE,
FOR THE PURPOSE OF SATISFYING THIS
DIVISION AND SECTION 3901.341 OF THE
REVISED
CODE, SHALL BE SUBJECT TO THE
SIXTY-DAY REVIEW PERIOD OF DIVISION
(B)(2) OF THIS SECTION.
(C)(1) No health
insuring corporation shall expand its approved service area
until a copy of the request for expansion, accompanied by
documentation of the network of providers,
FORMS OF ALL PROPOSED OR EXISTING PROVIDER CONTRACTS
RELATING TO THE DELIVERY OF HEALTH CARE SERVICES, A SCHEDULE OF
PROPOSED CONTRACTUAL PERIODIC PREPAYMENTS AND PREMIUM RATES FOR
GROUP CONTRACTS ACCOMPANIED BY APPROPRIATE SUPPORTING
DATA, enrollment
projections, plan of operation, and any other changes have been
filed with the superintendent.
(2) Within ten calendar days after receipt of a complete
filing under division (C)(1) of
this section, the superintendent shall refer the appropriate
jurisdictional issues to the director of health pursuant to
section 1751.04 of the Revised
Code.
(3) Within seventy-five days after the superintendent's receipt
of a complete filing under division
(C)(1) of this section, the
superintendent shall determine whether the plan for expansion is
lawful, fair, and reasonable. The superintendent may not make a
determination until the superintendent has received the
director's certification of compliance, which the director shall
furnish within forty-five days after referral under division
(C)(2) of this section. The
director shall not certify that the requirements of section
1751.04 of the Revised
Code are not met, unless the
applicant has been given an opportunity for a hearing as
provided in division (D) of
section 1751.04 of the Revised
Code. The forty-five-day and
seventy-five-day review periods provided for in division
(C)(3) of this section shall
cease to run as of the date on which the notice of the
applicant's right to request a hearing is mailed and shall
remain suspended until the director issues a final
certification.
(4) If the superintendent has not approved or disapproved
all or a portion of a service area expansion within the
seventy-five-day period provided for in division
(C)(3) of this section, the
filing shall be deemed approved.
(5) Disapproval of all or a portion of the filing shall
be effected by written notice, which shall state the grounds for
the order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code.
Sec. 1751.13. (A)(1)(a) A health
insuring corporation shall, either directly or indirectly, enter
into contracts for the provision of health care services with a
sufficient number and types of providers and health care
facilities to ensure that all covered health care services will
be accessible to enrollees from a contracted provider or health
care facility.
(b) A health insuring corporation shall not refuse
to contract with a physician for the provision of health care
services or refuse to recognize a physician as a specialist on
the basis that the physician attended an educational program or
a residency program approved or certified by the
American Osteopathic
Association. A health insuring corporation shall not refuse to
contract with a health care facility for the provision of health
care services on the basis that the health care facility is
certified or accredited by the
American Osteopathic
Association or that the health care facility is an osteopathic
hospital as defined in section 3702.51 of the
Revised
Code.
(c) Nothing in division
(A)(1)(b)
of this section shall be construed to require a health insuring
corporation to make a benefit payment under a closed panel plan
to a physician or health care facility with which the health
insuring corporation does not have a contract, provided that
none of the bases set forth in that division are used as a
reason for failing to make a benefit payment.
(2) When a health insuring corporation is unable to
provide a covered health care service from a contracted provider
or health care facility, the health insuring corporation must
provide that health care service from a noncontracted provider
or health care facility consistent with the terms of the
enrollee's policy, contract, certificate, or agreement. The
health insuring corporation shall either ensure that the health
care service be provided at no greater cost to the enrollee than
if the enrollee had obtained the health care service from a
contracted provider or health care facility, or make other
arrangements acceptable to the superintendent of
insurance.
(3) Nothing in this section shall prohibit a health
insuring corporation from entering into contracts with
out-of-state providers or health care facilities that are
licensed, certified, accredited, or otherwise authorized in that
state.
(B)(1) A health insuring
corporation shall, either directly or indirectly, enter into
contracts with all providers and health care facilities through
which health care services are provided to its enrollees.
(2) A health insuring corporation, upon written request, shall assist its
contracted providers in finding stop-loss or reinsurance carriers.
(C) A health insuring corporation shall file an annual
certificate with the superintendent certifying that all provider contracts
and contracts with health care facilities through which health
care services are being provided contain the following:
(1) A description of the method by which the provider or
health care facility will be notified of the specific health
care services for which the provider or health care facility
will be responsible, including any limitations or conditions on
such services;
(2) The specific hold harmless provision specifying
protection of enrollees set forth as follows:
"[Provider/Health Care
Facility] agrees that in no event, including but not limited to
nonpayment by the health insuring corporation, insolvency of the health
insuring corporation, or breach of this agreement, shall
[Provide/Health Care
Facility] bill, charge, collect a deposit from, seek
remuneration or reimbursement from, or have any recourse
against, a subscriber,
enrollee, person to whom health care services have been
provided, or person acting on behalf of the covered enrollee,
for health care services provided pursuant to this agreement.
This does not prohibit [Provider/Health
Care Facility] from collecting
co-insurance, deductibles, or copayments as specifically
provided in the evidence of coverage, or fees for uncovered
health care services delivered on a fee-for-service basis to
persons referenced above, nor from any recourse against the
health insuring corporation or its successor."
(3) Provisions requiring the provider or health care
facility to continue to provide covered health care services to
enrollees in the event of the health insuring corporation's
insolvency or discontinuance of operations. The
provisions shall require the provider or health care facility to
continue to provide covered health care services to enrollees as
needed to complete any medically necessary procedures commenced
but unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. THE COMPLETION OF A MEDICALLY
NECESSARY PROCEDURE SHALL
INCLUDE THE RENDERING OF ALL MEDICALLY NECESSARY FOLLOW-UP CARE
FOR THAT PROCEDURE. If an enrollee is
receiving necessary inpatient care at a hospital, the provisions
may limit the required provision of covered health care services
relating to that inpatient care in accordance with division
(D)(3) of section 1751.11 of the Revised
Code, and may also limit such required provision of
covered health care services to the period ending thirty days
after the health insuring corporation's insolvency or
discontinuance of operations.
The provisions required by division (C)(3) of this
section shall not require any provider or health care facility
to continue to provide any covered health care service after the
occurrence of any of the following:
(a) The end of the thirty-day period following the entry
of a liquidation order under Chapter 3903. of the
Revised Code;
(b) The end of the enrollee's period of coverage for a
contractual prepayment or premium;
(c) The enrollee obtains equivalent coverage with another
health insuring corporation or insurer, or the enrollee's
employer obtains such coverage for the enrollee;
(d) The enrollee or the enrollee's employer terminates
coverage under the contract;
(e) A liquidator effects a transfer of the health
insuring corporation's obligations under the contract under
division (A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and
responsibilities of the health insuring corporation, and of the
contracted providers and health care facilities, with respect to
administrative policies and programs, including, but not limited
to, payments systems, utilization review, quality assurance,
assessment, and improvement programs, credentialing, confidentiality
requirements, and any applicable federal or state
programs;
(5) A provision regarding the availability and
confidentiality of those health records maintained by providers
and health care facilities to monitor and evaluate the quality
of care, to conduct evaluations and audits, and to determine on
a concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees.
The provision shall include terms requiring the provider or
health care facility to make these health records available to
appropriate state and federal authorities involved in assessing
the quality of care or in investigating the grievances or
complaints of enrollees, and requiring the provider or health
care facility to comply with applicable state and federal laws
related to the confidentiality of medical or health
records.
(6) A provision that states that contractual rights and
responsibilities may not be assigned or delegated by the
provider or health care facility without the prior written
consent of the health insuring corporation;
(7) A provision requiring the provider or health care
facility to maintain adequate professional liability and
malpractice insurance. The provision shall also require the
provider or health care facility to notify the health insuring
corporation not more than ten days after the provider's or
health care facility's receipt of notice of any reduction or
cancellation of such coverage.
(8) A provision requiring the provider or health care
facility to observe, protect, and promote the rights of
enrollees as patients;
(9) A provision requiring the provider or health care
facility to provide health care services without discrimination
on the basis of a patient's participation in the health care
plan, age, sex, ethnicity, religion, sexual preference, health
status, or disability, and without regard to the source of
payments made for health care services rendered to a patient.
This requirement shall not apply to circumstances when the
provider or health care facility appropriately does not render
services due to limitations arising from the provider's or
health care facility's lack of training, experience, or skill,
or due to licensing restrictions.
(10) A provision containing the specifics of any
obligation on the PRIMARY CARE provider or health care facility
to provide,
or to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week;
(11) A provision setting forth procedures for the
resolution of disputes arising out of the contract;
(12) A provision stating that the hold harmless provision
required by division (C)(2) of
this section shall survive the termination of the contract with respect to
services covered and provided under the contract during the time the contract
was in effect, regardless of the reason for the termination, including the
insolvency of the health insuring corporation;
(13) A provision requiring those terms that are used in
the contract and that are defined by this chapter, be used in
the contract in a manner consistent with those
definitions.
THIS DIVISION DOES NOT APPLY TO THE COVERAGE OF
BENEFICIARIES ENROLLED IN TITLE
XVIII OF THE
"SOCIAL
SECURITY
ACT," 49
STAT. 620 (1935), 42
U.S.C.A.
301, AS AMENDED, PURSUANT TO A MEDICARE RISK CONTRACT OR
MEDICARE COST CONTRACT, OR TO THE COVERAGE OF BENEFICIARIES
ENROLLED IN THE FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM
PURSUANT TO 5
U.S.C.A.
8905, OR TO THE COVERAGE OF BENEFICIARIES ENROLLED IN
TITLE
XIX OF THE
"SOCIAL
SECURITY
ACT," 49
STAT. 620 (1935), 42
U.S.C.A.
301, AS AMENDED, KNOWN AS THE MEDICAL ASSISTANCE PROGRAM OR
MEDICAID, PROVIDED BY THE OHIO
DEPARTMENT OF HUMAN SERVICES UNDER
CHAPTER 5111. OF THE
REVISED
CODE, OR TO THE COVERAGE OF
BENEFICIARIES UNDER ANY FEDERAL HEALTH CARE PROGRAM REGULATED BY
A FEDERAL REGULATORY BODY, OR TO THE COVERAGE OF BENEFICIARIES
UNDER ANY CONTRACT COVERING OFFICERS OR EMPLOYEES OF THE STATE
THAT HAS BEEN ENTERED INTO BY THE DEPARTMENT OF
ADMINISTRATIVE SERVICES.
(D)(1) No health insuring
corporation contract with a provider or health care facility
shall contain any of the following:
(a) A provision that directly or indirectly
offers an inducement to the provider or health care
facility to reduce or limit medically
necessary health care services to a covered enrollee;
(b) A provision that penalizes a
provider or health care facility that
assists an enrollee to seek a reconsideration of the health
insuring corporation's decision to deny or limit benefits to the
enrollee;
(c) A provision that limits or otherwise restricts
the provider's or health care facility's ethical and legal
responsibility to fully advise enrollees about their medical
condition and about medically appropriate treatment
options;
(d) A provision that penalizes a provider or
health care facility for principally advocating for medically
necessary health care services;
(e) A provision that penalizes a provider or health care
facility for providing information or testimony to a legislative
or regulatory body or agency. This shall not be construed to
prohibit a health insuring corporation from penalizing a
provider or health care facility that provides information or
testimony that is libelous or slanderous or that discloses trade
secrets which the provider or health care facility has no
privilege or permission to disclose.
(2) Nothing in this division shall be construed to
prohibit a health insuring corporation from doing either of the
following:
(a) Making a determination not to reimburse or pay
for a particular medical treatment or other health care
service;
(b) Enforcing reasonable peer review or
utilization review protocols, or determining whether a
particular provider or health care facility has complied with
these protocols.
(E) Any contract between
a health insuring corporation and an intermediary organization
shall clearly specify that the health insuring corporation must
approve or disapprove the participation of any provider or
health care facility with which the intermediary organization
contracts.
(F) If an intermediary organization that is not a health delivery
network contracting solely with self-insured employers subcontracts with a
provider or health care facility, the subcontract with the provider or health
care facility shall do all of the following:
(1) Contain the provisions required by divisions
(C) and (G) of this section, as made
applicable to an intermediary organization, without the inclusion of
inducements or penalties described in division (D) of this
section;
(2) Acknowledge that the health insuring corporation is a
third-party beneficiary to the agreement;
(3) Acknowledge the health insuring corporation's role in
approving the participation of the provider or health care
facility, pursuant to division
(E) of this section.
(G) Any provider
contract or contract with a health care facility shall clearly
specify the health insuring corporation's statutory
responsibility to monitor and oversee the offering of covered
health care services to its enrollees.
(H)(1) A health insuring
corporation shall maintain its provider contracts and its contracts with
health care facilities at one or more of its places of business in
this state, and shall provide copies of these contracts to
facilitate regulatory review upon written notice by the
superintendent of insurance.
(2) Any contract with an intermediary organization shall
include provisions requiring the intermediary organization to
provide the superintendent with regulatory access to all books,
records, financial information, and documents related to the
provision of health care services to subscribers and enrollees
under the contract. The contract shall require the intermediary
organization to maintain such books, records, financial
information, and documents at its principal place of business in
this state and to preserve them for at least three years in a
manner that facilitates regulatory review.
(I)(1) A health insuring corporation shall provide notice
NOTIFY ITS AFFECTED ENROLLEES of the termination of any A
contract with FOR THE PROVISION OF HEALTH CARE SERVICES
BETWEEN THE HEALTH INSURING CORPORATION AND a primary care
physician
or hospital, BY MAIL, WITHIN THIRTY DAYS AFTER THE TERMINATION
OF THE CONTRACT.
(a) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE
TERMINATION OF A CONTRACT WITH A PRIMARY CARE PHYSICIAN IF THE
SUBSCRIBER, OR A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH
CARE COVERAGE, HAS RECEIVED HEALTH CARE SERVICES FROM THE
PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS TWELVE MONTHS OR IF
THE SUBSCRIBER OR DEPENDENT HAS SELECTED THE PHYSICIAN AS THE
SUBSCRIBER'S OR DEPENDENT'S PRIMARY CARE PHYSICIAN WITHIN THE
PREVIOUS TWELVE MONTHS.
(b) NOTICE SHALL BE GIVEN TO SUBSCRIBERS OF THE
TERMINATION OF A CONTRACT WITH A HOSPITAL IF THE SUBSCRIBER, OR
A DEPENDENT COVERED UNDER THE SUBSCRIBER'S HEALTH CARE COVERAGE,
HAS RECEIVED HEALTH CARE SERVICES FROM THAT HOSPITAL WITHIN THE
PREVIOUS TWELVE MONTHS.
(2) THE HEALTH INSURING CORPORATION SHALL PAY FOR ALL
COVERED HEALTH CARE SERVICES RENDERED TO AN ENROLLEE BY A
PRIMARY CARE PHYSICIAN OR HOSPITAL BETWEEN THE DATE OF THE
TERMINATION OF THE CONTRACT AND FIVE DAYS AFTER THE NOTIFICATION
OF THE CONTRACT TERMINATION IS MAILED TO A SUBSCRIBER AT THE
SUBSCRIBER'S LAST KNOWN ADDRESS.
(J) Divisions (A) and (B) of this section do
not apply to any health insuring corporation that, on June
4, 1997, holds a
certificate of authority or
license to operate under Chapter 1740. of the Revised
Code.
(K) Nothing in this section shall restrict the governing body of
a hospital from exercising the authority granted it pursuant to section
3701.351 of the Revised Code.
Sec. 3924.10. (A) The board of directors of the Ohio health reinsurance
program shall design the SEHCplan
OHC BASIC, STANDARD, AND CARRIER
REIMBURSEMENT PLANS which, when offered by a
carrier, is ARE eligible for
reinsurance under the program. The board shall establish the
form and level of coverage to be made available by carriers in
their SEHCplan OHC PLANS. In designing
the plan PLANS the board shall
also establish benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plan PLANS. The forms and
levels
of coverage established by the board shall specify which
components of a health benefit plan PLANS offered by a
carrier may be reinsured. The SEHCplan is OHC
PLANS ARE subject
to division (C) of section 3924.02 of the Revised Code and
to the provisions in Chapters 1751., 1753., 3923., and any
other
chapter of the Revised Code that require coverage or the
offer of coverage of a health care service or benefit.
(B) The board shall adopt the SEHCplan OHC
PLANS within one
hundred eighty days after its appointment THE EFFECTIVE DATE OF THIS
AMENDMENT. The plan PLANS 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 PLANS.
(C) AnSEHCplan OHC PLANS
established
for use by health
insuring corporations shall be
consistent with the basic
method of operation of such corporations.
(D) Each carrier shall certify to the superintendent of
insurance, in the form and manner prescribed by the
superintendent, that the SEHCplan OHC
PLANS filed by the carrier
is ARE in substantial compliance with the provisions of the
board
SEHCplan OHC PLANS. Upon receipt by the
superintendent of the
certification, the carrier may use the certified plan PLANS.
(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 SEHCplan OHC
PLANS.
Section 4. That all existing versions of sections 1751.02,
1751.03, 1751.13, and 3924.10 of the Revised Code are hereby
repealed.
Section 5. Sections 3 and 4 of this act shall take effect
October 1, 1998.
Section 6. That Section 3 of Am. Sub. S.B. 67 of the 122nd
General Assembly be amended to read as follows:
"Sec. 3. (A) The certificate of authority of every prepaid dental plan
organization, health care corporation, dental care corporation,
and health maintenance organization licensed
to
operate under Chapter 1736., 1738., 1740., or 1742. of
the Revised Code, respectively, shall renew, by operation of law, on January
1,
1998, as a certificate of authority to operate
under Chapter 1751. of the Revised Code. All assets and
liabilities of the prepaid dental plan organization,
health care corporation, dental care corporation,
or health maintenance organization, including all obligations
under subscriber contracts delivered, issued for delivery, or
renewed prior to the effective date of this section
JUNE 4, 1997, shall be
assumed by the successor entity. Except as otherwise provided
in division (B) of this section, such entity shall, no later
than January 1, 1998, comply with Chapter 1751. of the Revised
Code.
(B)(1) Each entity described in division (A) of this section
shall do both of the following:
(a) Comply with sections 1751.19 and 1751.26
of the Revised Code no later than six months after the effective date of
this
section JUNE 4, 1997.
(b) Comply with section 1751.28 of the Revised Code
by making annual
deposits with the Superintendent of Insurance, no later than the
first day of January of each year, for up to three years,
beginning the first day of January immediately following the
effective date of this section
INCREASING THE ENTITY'S NET WORTH, ON THE
FIRST DAY OF JANUARY IN EACH OF THE YEARS 1998,
1999, AND 2000,BY AN AMOUNT EQUAL TO AT LEAST
ONE-THIRD OF ANY DIFFERENCE BETWEEN THE
ENTITY'S NET WORTH AS OF JUNE
4, 1997, AND THE NET WORTH REQUIRED BY SECTION 1751.28 OF
THE REVISED CODE. EACH ENTITY SHALL ATTAIN
THE NET WORTH REQUIRED BY SECTION 1751.28 OF THE
REVISED CODE NO LATER THAN JANUARY 1,
2000.
(2) Every contract delivered, issued for delivery, or renewed
by an entity described in division (A) of this section prior to
the effective date of this section JUNE 4,
1997, shall comply with
section 1751.13 of the Revised Code no
later than the contract's first renewal date
after the first day of January immediately following the effective date of
this
section JUNE 4, 1997.
(3) Every contract delivered,
issued for delivery, or renewed by an entity described in
division (A) of this section prior to the effective date of this
section JUNE 4, 1997, shall comply with section
1751.31 of the Revised Code no
later than three months after the effective date of this
section JUNE 4, 1997.
(4) An entity described in division (A) of this section may
comply with section 1751.27 of the Revised Code by making annual
deposits with the Superintendent of Insurance, not later than
the first day of January of each year, for up to three years
beginning the first day of January immediately following the effective date
of
this section JUNE 4, 1997. An equal amount shall
be deposited
each year until the total amount required under section 1751.27
of the Revised Code has been deposited."
Section 7. That existing Section 3 of Am. Sub. S.B. 67 of the 122nd General
Assembly is hereby repealed.
Section 8. Section 3901.21 of the Revised Code is presented in this act as a
composite of the section as amended by both Sub. H.B. 374 and Am. Sub. S.B. 70
of the 122nd General Assembly, with the language of neither of the acts shown
in capital letters. Section 3924.08 of the Revised Code is presented in this
act
as a composite of the section as amended by both Sub.
H.B. 374 and Am. Sub. S.B. 67 of the 122nd General Assembly, with the new
language
of
neither of the acts shown in capital letters. This is in
recognition of the principle stated in division (B) of section
1.52 of the Revised Code that such amendments are to be
harmonized where not substantively irreconcilable and constitutes
a legislative finding that such is the resulting version in
effect prior to the effective date of this act.
|