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As Passed by the Senate
122nd General Assembly
Regular Session
1997-1998 | Sub. H. B. No. 698 |
REPRESENTATIVES VAN VYVEN-GARCIA-
SENATORS SUHADOLNIK-DRAKE
A BILL
To amend sections 1701.03, 1705.03, 1705.04, 1705.53, 1739.01, 1751.01,
1751.02, 1751.03, 1751.05, 1751.06,
1751.11, 1751.12, 1751.13, 1751.14, 1751.15,
1751.16, 1751.20,
1751.31, 1751.32, 1751.46, 1751.55, 1751.58, 1751.59,
1751.60, 1751.62, 1751.81, 1785.01, 1785.02, 1785.03, 1785.08,
1907.161, 2305.252, 3701.75, 3901.21, 3901.38, 3917.01, 3917.06,
3923.021,
3923.122, 3923.57, 3923.571, 3923.58, 3924.01,
3924.03, 3924.033, 3924.08, 3924.09,
3924.10, 3924.11, 3924.13, 3999.22, 4715.22, 4715.39, 4723.16, 4725.114,
4729.161, 4731.226,
4731.65, 4732.28, 4734.091, 4755.471, 5111.25, 5111.251, 5111.264, 5111.81,
5112.01, 5112.08, 5725.18, and
5729.03,
to enact sections 5.2217, 1751.141, 1751.321, 3701.18, 3702.141, and 4503.104,
and to repeal sections 3924.05,
5111.75, 5111.77, 5111.771,
and 5111.811 of
the Revised Code and to amend Section 3 of Am. Sub.
S.B. 67 of the 122nd General Assembly, Section 6 of Am. Sub. S.B. 154 of the
122nd General Assembly, and Section 194 of Am. Sub. H.B. 215 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
revise 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,
to revise the premium tax imposed on domestic and foreign
insurance companies that operate a health insuring corporation
as a line of business, to make related revisions in the phase-in
schedule for the tax,
to authorize a form of group life insurance as conversion
coverage for certain former employees and members, to remove the
coverage limitation on group term life insurance insuring the
spouse and dependent children of an insured employee or member,
to add a member to the committee created
under Am. Sub. S.B. 154 of the 122nd General Assembly to study
the continuing education requirements for insurance agents,
to revise the standards for using electronic signatures in
records of health care facilities, to specify when certain existing
health care facilities are required to
improve the structure or fixtures of the facility in order to comply with the
safety and quality-of-care
standards and quality-of-care data reporting requirements
established by the Director of Health,
to extend the Department of Health's study of cardiac catheterization performed
without an on-site open-heart surgery service, to create the Save Our Sight
Fund to support eye health and safety programs for children, to require the
Registrar of Motor Vehicles and deputy registrars to request contributions to
the fund from applicants for motor vehicle registration and renewal, to require
the Department of Health to develop informational materials on eye care and
safety, to allow a dentist to authorize a dental hygienist to provide dental
hygiene services when the dentist is not physically present if certain
conditions are met, to authorize the State Dental Board to adopt rules allowing
certified dental assistants to polish the clinical crowns of teeth, to
designate June as "Prostate Cancer Awareness Month,"
to authorize mechanotherapists to engage in their practice with
certain other health care professionals in a combined form of a
professional corporation, limited liability company,
partnership, or professional association, and to change the
manner of determining the amount of the per day, per patient reimbursement
that the Department of Human Services pays for the reasonable capital costs of
eligible nursing facilities and intermediate care facilities for the mentally
retarded, in specified circumstances in which there is a transfer or lease
between related parties.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1701.03, 1705.03, 1705.04, 1705.53, 1739.01, 1751.01,
1751.02, 1751.03, 1751.05,
1751.06, 1751.11, 1751.12, 1751.13, 1751.14, 1751.15, 1751.16,
1751.20, 1751.31, 1751.32, 1751.46, 1751.55, 1751.58, 1751.59, 1751.60,
1751.62, 1751.81, 1785.01, 1785.02, 1785.03, 1785.08, 1907.161, 2305.252,
3701.75,
3901.21, 3901.38, 3917.01, 3917.06, 3923.021, 3923.122, 3923.57,
3923.571,
3923.58,
3924.01, 3924.03, 3924.033, 3924.08,
3924.09, 3924.10, 3924.11, 3924.13, 3999.22, 4715.22, 4715.39, 4723.16,
4725.114, 4729.161,
4731.226, 4731.65, 4732.28, 4734.091, 4755.471, 5111.25, 5111.251, 5111.264,
5111.81, 5112.01, 5112.08,
5725.18, and 5729.03 be amended
and sections 5.2217, 1751.141, 1751.321, 3701.18, 3702.141, and 4503.104
of the Revised Code be enacted to read as follows:
Sec. 5.2217. THE MONTH OF JUNE SHALL BE DESIGNATED AS
"PROSTATE CANCER AWARENESS MONTH."
Sec. 1701.03. (A) A corporation may be formed under this
chapter for any purpose or combination of purposes for which
individuals lawfully may associate themselves, except that, if
the Revised Code contains special provisions pertaining to the
formation of any designated type of corporation other than a
professional association, as defined in section 1785.01 of the
Revised Code, a corporation of that type shall be formed in
accordance with the special provisions.
(B) On and after July
1, 1994, a corporation may be formed under this chapter for the
purpose of carrying on the practice of any profession, including,
but not limited to, a corporation for the purpose of providing
public accounting or certified public accounting services, a
corporation for the erection, owning, and conducting of a
sanitarium for receiving and caring for patients, medical and
hygienic treatment of patients, and instruction of nurses in the
treatment of disease and in hygiene, a corporation for the
purpose of providing architectural, landscape architectural,
professional engineering, or surveying services or any
combination of those types of services, and a corporation for the
purpose of providing a combination of the professional services, as defined in
section 1785.01 of the Revised Code, of optometrists authorized under Chapter 4725.
of the Revised Code, chiropractors authorized under Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under Chapter 4723. of the Revised Code,
pharmacists
authorized under Chapter 4729.
of the Revised
Code, physical therapists
authorized under sections 4755.40 to 4755.53 of the
Revised
Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
and
doctors of medicine and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery authorized under Chapter 4731.
of the Revised Code. This chapter does not
restrict, limit, or otherwise affect the authority or
responsibilities of any agency, board, commission, department,
office, or other entity to license, register, and otherwise
regulate the professional conduct of individuals or organizations
of any kind rendering professional services, as defined in
section 1785.01 of the Revised Code, in this state or to regulate
the practice of any profession that is within the jurisdiction of
the agency, board, commission, department, office, or other
entity, notwithstanding that an individual is a director,
officer, employee, or other agent of a corporation formed under
this chapter and is rendering professional services or engaging
in the practice of a profession through a corporation formed
under this chapter or that the organization is a corporation
formed under this chapter.
(C) Nothing in division (A) or (B) of this section
precludes the organization of a professional association in
accordance with this chapter and Chapter 1785. of the Revised
Code or the formation of a limited liability company under
Chapter 1705. of the Revised Code with respect to a business, as
defined in section 1705.01 of the Revised Code.
(D) No
corporation formed for the
purpose of providing a combination of the professional services, as defined in
section 1785.01 of the Revised Code, of optometrists authorized under Chapter 4725.
of the Revised Code, chiropractors authorized under Chapter 4734. of the Revised Code,
psychologists authorized under Chapter 4732. of the Revised Code, registered or
licensed practical nurses authorized under Chapter 4723. of the Revised Code,
pharmacists
authorized under Chapter 4729.
of the Revised
Code, physical therapists
authorized under sections 4755.40 to 4755.53 of the
Revised
Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
and
doctors of medicine and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery authorized under Chapter 4731.
of the Revised Code shall
control the professional clinical judgment exercised within accepted and
prevailing standards of practice of a
licensed, certificated, or otherwise legally authorized optometrist,
chiropractor, psychologist, nurse, pharmacist, physical therapist,
MECHANOTHERAPIST, or doctor
of medicine and surgery,
osteopathic
medicine and
surgery, or podiatric medicine and surgery in rendering care, treatment, or
professional advice to an individual patient.
This division does not prevent a hospital, as defined in section 3727.01
of the Revised
Code, insurer, as defined in section 3999.36
of the Revised
Code, or intermediary organization, as defined
in section 1751.01 of the Revised
Code, from entering into a contract with a
corporation described in this division that includes a provision requiring
utilization review, quality assurance, peer review, or other performance or
quality standards. Those activities shall not be construed as controlling the
professional clinical judgment of an individual practitioner listed in this
division.
Sec. 1705.03. (A) A limited liability company may sue and be sued.
(B) Unless otherwise provided in its articles of organization, a limited
liability company may take property of any description or any interest in
property of any description by gift, devise, or bequest and may make donations
for the public welfare or for charitable, scientific, or educational purposes.
(C) In carrying out the purposes stated in its articles of organization or
operating agreement and
subject to limitations prescribed by law or in its articles of organization or
its operating agreement, a limited liability company may do all of the
following:
(1) Purchase or otherwise acquire, lease as lessee or lessor, invest in,
hold, use, encumber, sell, exchange, transfer, and dispose of property of any
description or any interest in property of any description;
(2) Make contracts;
(3) Form or acquire the control of other domestic or foreign limited
liability companies;
(4) Be a shareholder, partner, member, associate, or participant in other
profit or nonprofit enterprises or ventures;
(5) Conduct its affairs in this state and elsewhere;
(6) Render in this state and elsewhere a professional service, the kinds of
professional services
authorized under Chapters 4703. and 4733. of the Revised Code, or a
combination of the professional services of
optometrists authorized under Chapter 4725. of the Revised Code, chiropractors
authorized under Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under
Chapter 4723. of the Revised Code,
pharmacists
authorized under Chapter 4729.
of the Revised
Code, physical therapists
authorized under sections 4755.40 to 4755.53 of the
Revised
Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
and doctors of medicine and
surgery, osteopathic medicine and surgery, or podiatric medicine and surgery
authorized under Chapter 4731. of the Revised Code;
(7) Borrow money;
(8) Issue, sell, and pledge its notes, bonds, and other evidences of
indebtedness;
(9) Secure any of its obligations by mortgage, pledge, or deed of trust of
all or any of its property;
(10) Guarantee or secure obligations of any person;
(11) Do all things permitted by law and exercise all authority within or
incidental to the purposes stated in its articles of organization.
(D) In addition to the authority conferred by division (C) of this section
and irrespective of the purposes stated in its articles of organization or
operating agreement but
subject to any limitations stated in those articles or its operating
agreement, a limited liability company may invest funds not currently needed
in its business in any securities if the investment does not cause the company
to acquire control of another enterprise whose activities and operations are
not incidental to the purposes stated in the articles of organization of the
company.
(E)(1) No lack of authority or limitation upon the authority of a limited
liability company shall be asserted in any action except as follows:
(a) By the state in an action by it against the company;
(b) By or on behalf of the company in an action against a manager, an
officer, or any member as a member;
(c) By a member as a member in an action against the company, a manager, an
officer, or any member as a member;
(d) In an action involving an alleged improper issue of a membership interest
in the company.
(2) Division (E)(1) of this section applies to any action commenced in this
state upon any contract made in this state by a foreign limited liability
company.
Sec. 1705.04. (A) One or more persons, without regard to
residence, domicile, or state of organization, may form a limited
liability company. The company is
formed when one or more persons or their authorized representative signs and
files with the secretary of
state articles of organization that set forth all of the
following:
(1) The name of the company;
(2) Except as provided in division (B) of this section,
the period of its duration, which may be perpetual;
(3) The address to which interested persons may direct
requests for copies of any operating agreement and any bylaws of
the company;
(4) Any other provisions that are from the operating
agreement or that are not inconsistent with applicable law and
that the members elect to set out in the articles for the
regulation of the affairs of the company.
(B) If the articles of organization or operating agreement do not set
forth the
period of the duration of the limited liability company, its
duration shall be perpetual.
(C) If a limited liability company is formed under this
chapter for the purpose of rendering a professional service,
the kinds of professional services authorized under Chapters
4703. and 4733. of the Revised Code, or a combination of the
professional services of optometrists authorized under Chapter 4725.
of the Revised Code, chiropractors authorized under Chapter 4734. of the
Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under
Chapter 4723. of the Revised Code, pharmacists authorized under Chapter
4729. of the Revised Code, physical therapists authorized
under sections 4755.40 to 4755.53 of the Revised Code, MECHANOTHERAPISTS
AUTHORIZED UNDER SECTION 4731.151 of the Revised Code, and
doctors
of medicine and surgery, osteopathic medicine and surgery, or
podiatric medicine and surgery authorized under Chapter 4731.
of the Revised Code, the following apply:
(1) Each member, employee, or other agent of the company
who renders a professional service in this state and, if the
management of the company is not reserved to its members, each
manager of the company who renders a professional service in this
state shall be licensed, certificated, or otherwise
legally authorized to render
in this state the same kind of professional service; if
applicable, the kinds of professional services authorized under
Chapters 4703. and 4733. of the Revised Code; or, if applicable,
any of the kinds of professional services of optometrists authorized under
Chapter 4725. of the Revised Code, chiropractors
authorized under Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under
Chapter 4723. of the Revised Code, pharmacists authorized under Chapter
4729. of the Revised Code, physical therapists authorized
under sections 4755.40 to 4755.53 of the Revised Code, MECHANOTHERAPISTS
AUTHORIZED UNDER SECTION 4731.151 of the Revised Code, or
doctors of medicine and surgery, osteopathic medicine and surgery, or
podiatric medicine and surgery authorized under Chapter 4731. of the Revised
Code.
(2) Each member, employee, or other agent of the company
who renders a professional service in another state and, if the
management of the company is not reserved to its members, each
manager of the company who renders a professional service in
another state shall be licensed, certificated, or
otherwise legally authorized
to render that professional service in the other state.
(D) Except for the provisions of this chapter pertaining
to the personal liability of members, employees, or other agents
of a limited liability company and, if the management of the
company is not reserved to its members, the personal liability of
managers of the company, this chapter does not restrict, limit,
or otherwise affect the authority or responsibilities of any
agency, board, commission, department, office, or other entity to
license, certificate, register, and otherwise regulate the
professional
conduct of individuals or organizations of any kind rendering
professional services in this state or to regulate the practice
of any profession that is within the jurisdiction of the agency,
board, commission, department, office, or other entity,
notwithstanding that the individual is a member or manager of a
limited liability company and is rendering the professional
services or engaging in the practice of the profession through
the limited liability company or that the organization is a
limited liability company.
(E) No limited liability company formed
for the
purpose of providing a combination of the professional services, as defined in
section 1785.01 of the Revised Code, of optometrists authorized under Chapter 4725.
of the Revised Code, chiropractors authorized under Chapter 4734. of the Revised Code,
psychologists authorized under Chapter 4732. of the Revised Code,
registered
or licensed practical nurses authorized under Chapter 4723. of the Revised Code,
pharmacists authorized under Chapter 4729. of the Revised
Code, physical therapists authorized under sections 4755.40 to
4755.53 of the Revised Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION
4731.151 of the Revised Code, and
doctors of medicine and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery authorized under Chapter 4731.
of the Revised Code shall
control the
professional clinical judgment exercised within accepted and prevailing
standards of practice of a licensed, certificated, or otherwise
legally authorized optometrist, chiropractor, psychologist, nurse, pharmacist,
physical therapist, MECHANOTHERAPIST, or doctor
of medicine
and
surgery, osteopathic medicine and surgery, or podiatric medicine and surgery
in
rendering care, treatment, or professional advice to an individual
patient.
This division does not prevent a hospital, as defined in section 3727.01
of the Revised
Code, insurer, as defined in section 3999.36
of the Revised
Code, or intermediary organization, as defined
in section 1751.01 of the Revised
Code, from entering into a contract with a
limited liability company described in this division that includes a provision
requiring utilization review, quality assurance, peer review, or other
performance or quality standards. Those activities shall not be construed as
controlling the professional clinical judgment of an individual practitioner
listed in this division.
Sec. 1705.53. Subject to any contrary provisions of the Ohio Constitution,
the laws of the state under which a foreign limited liability company is
organized govern its organization and internal affairs and the liability of
its members. A foreign limited liability company may not be denied a
certificate of registration as a foreign limited liability company in this
state because of any difference between the laws of the state under which it
is organized and the laws of this state. However, a foreign limited liability
company that applies for registration under this chapter to render a
professional service in this state, as a condition to obtaining and
maintaining a certificate of registration, shall comply with the requirements
of division (C) of section 1705.04 of the Revised Code
and shall comply with the requirements of Chapters 4703.
and 4733. of the Revised Code if the kinds of
professional services authorized under those chapters are to be
rendered or with the
requirements of Chapters 4723., 4725.,
4729., 4731., 4732.,
4734., and 4755. of the Revised Code if a combination of the professional services of
optometrists
authorized
under Chapter 4725. of the Revised Code, chiropractors authorized under
Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under
Chapter 4723. of the Revised Code,
pharmacists
authorized under Chapter 4729.
of the Revised
Code, physical therapists
authorized under sections 4755.40 to 4755.53 of the
Revised
Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
and doctors of medicine and surgery,
osteopathic medicine and surgery, or podiatric medicine and surgery authorized
under Chapter 4731. of the Revised Code are to be rendered.
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 CERTIFIED nurse practitioners,
CERTIFIED NURSE ANESTHETISTS, CLINICAL NURSE SPECIALISTS, CERTIFIED NURSE
MIDWIVES, 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 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. 1751.05. (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 GROUP 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;
HOWEVER, NOTHING IN DIVISION
(D)(3)(b)
OF THIS SECTION PRECLUDES A HEALTH INSURING CORPORATION
FROM ENGAGING IN UTILIZATION REVIEW AS DESCRIBED IN THE EVIDENCE
OF COVERAGE.
(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 DIVISIONS (C) AND (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) 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 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 COVERED HEALTH CARE SERVICES THAT CONSTITUTE
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 THAT ACCEPTS
COMPENSATION 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, IN ACCORDANCE WITH THE
TERMS OF THE CONTRACT, 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. 1751.14. (A) Any
policy, contract, or agreement for health care services
authorized by this chapter that is issued, delivered, or renewed
in this state and that provides that coverage of an unmarried
dependent child will terminate upon attainment of the limiting
age for dependent children specified in the policy, contract, or
agreement, shall also provide in substance that attainment of
the limiting age shall not operate to terminate the coverage of
the child if the child is and continues to be both:
(1) Incapable of self-sustaining employment by reason of
mental retardation or physical handicap;
(2) Primarily dependent upon the subscriber for support
and maintenance.
(B) Proof of incapacity and dependence for purposes of division
(A) of this section shall be furnished to the health insuring
corporation within thirty-one
days of the child's attainment of the limiting age. Upon
request, but not more frequently than annually, the health
insuring corporation may require proof satisfactory to it of the
continuance of such incapacity and dependency.
(C) Nothing in this
section shall be construed to require a health insuring
corporation to cover a dependent child who is mentally retarded
or physically handicapped if the policy, contract, or agreement
is underwritten on evidence of insurability based on health
factors set forth in the application, or if the dependent child
does not satisfy the conditions of the policy, contract, or
agreement as to any requirement for evidence of insurability or
any other provision of the policy, contract, or agreement,
satisfaction of which is required for coverage thereunder to
take effect. In any such case, the terms of the policy,
contract, or agreement shall apply with regard to the coverage
or exclusion of the dependent from such coverage.
(D) This section does
not apply to any health insuring corporation, policy, contract, or
agreement
offering only supplemental health care services or specialty health care
services.
Sec. 1751.141. A HEALTH INSURING CORPORATION SHALL
PROVIDE COVERAGE, IN ACCORDANCE WITH THE TERMS OF THE CONTRACT, 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 AT THE TIME THEY APPLY FOR ENROLLMENT.
(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. 1751.16. (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. 1751.32. Each health insuring corporation, annually, on or
before the first day of March,
shall file a report with the superintendent of insurance and the
director of health, covering the preceding calendar year.
The report shall be verified by an officer of the health
insuring corporation, shall be in the form the superintendent
prescribes, and shall include:
(A) A financial
statement of the health insuring corporation, including its
balance sheet and receipts and disbursements for the preceding
year, which reflect, at a minimum:
(1) All premium rate and other payments received for
health care services rendered;
(2) Expenditures with respect to all categories of
providers, facilities, insurance companies, and other persons
engaged to fulfill obligations of the health insuring
corporation arising out of its health care policies, contracts,
certificates, and agreements;
(3) Expenditures for capital improvements or additions
thereto, including, but not limited to, construction,
renovation, or purchase of facilities and equipment.
(B) A description of the
enrollee population and composition, group and nongroup;
(C) A summary of
enrollee written complaints and their disposition;
(D) A statement of the
number of subscriber policies, contracts, certificates, and
agreements that have been terminated by action of the health
insuring corporation, including the number of enrollees
affected;
(E) A summary of the
information compiled pursuant to division
(B)(5) of section 1751.04 of the Revised Code;
(F) A current report of
the names and addresses of the persons responsible for the
conduct of the affairs of the health insuring corporation as
required by section 1751.03 of the Revised
Code. Additionally, the report shall include
the amount of wages, expense reimbursements, and other payments
to these persons for services to the health insuring
corporation, and shall include a full disclosure of the
financial interests related to the operations of the health
insuring corporation acquired by these persons during the
preceding year.
(G) An audit report
certified by an independent certified public accountant in the
form prescribed by the superintendent by rule;
(H) An actuarial opinion
in the form prescribed by the superintendent by rule;
(I)(H) Any other
information relating to the performance of the health insuring
corporation that is necessary to enable the superintendent to
carry out the superintendent's duties under this chapter.
Sec. 1751.321. EACH HEALTH INSURING CORPORATION,
ANNUALLY, ON OR BEFORE THE FIRST DAY OF JUNE, SHALL FILE WITH
THE SUPERINTENDENT OF INSURANCE AND THE DIRECTOR OF HEALTH AN
AUDIT REPORT CERTIFIED BY AN INDEPENDENT CERTIFIED PUBLIC
ACCOUNTANT COVERING THE PRECEDING CALENDAR YEAR. THE REPORT
SHALL BE VERIFIED BY AN OFFICER OF THE HEALTH INSURING
CORPORATION AND SHALL BE IN THE FORM PRESCRIBED BY
THE SUPERINTENDENT BY RULE.
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 REPRESENT THE FAIR MARKET VALUE OF THE
SERVICES PROVIDED AND 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 CORPORATION 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 IN ACCORDANCE WITH DIVISION (B) OF SECTION 1751.18 of the Revised Code.
(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."
(D) AT LEAST ONCE IN
EVERY TWELVE-MONTH PERIOD, A HEALTH INSURING CORPORATION SHALL
PROVIDE TO ALL LATE ENROLLEES, AS DEFINED IN SECTION 3924.01 OF
THE REVISED
CODE, WHO ARE IDENTIFIED BY THE
CONTRACT HOLDER, THE OPTION TO ENROLL IN THE GROUP CONTRACT.
THE ENROLLMENT OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF
THIRTY CONSECUTIVE DAYS. ALL DELAYS OF COVERAGE IMPOSED UNDER
THE GROUP CONTRACT, INCLUDING ANY AFFILIATION PERIOD, SHALL
BEGIN ON THE DATE THE HEALTH INSURING CORPORATION RECEIVES
NOTICE OF THE LATE ENROLLEE'S APPLICATION OR REQUEST FOR
COVERAGE, AND SHALL RUN CONCURRENTLY WITH EACH OTHER.
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. 1751.81. (A) As used in this section:
(1) "Enrollee" includes the representative of an enrollee.
(2) "Necessary information" includes the results of any face-to-face
clinical
evaluation or second opinion that may be required.
(B) A health insuring corporation shall maintain written
procedures for making
utilization review determinations and for notifying enrollees, and
participating providers and
health care facilities
acting on behalf of enrollees, of its determinations.
(C) For initial determinations, a health insuring corporation
shall make the
determination within two business days after obtaining all necessary
information
regarding a proposed admission, procedure, or health care service requiring a
review
determination.
(1) In the case of a determination to certify an admission, procedure, or
health care service, the health insuring corporation shall notify the provider
or health care facility rendering the health care service by
telephone OR FACSIMILE within three business days after making the
initial certification,
and
shall provide written or electronic confirmation of the telephone notification
to the enrollee and the provider or health care facility within two business
days after making the
telephone notification.
(2) In the case of an adverse determination, the health insuring
corporation shall notify the
provider or health care facility rendering the health care service by
telephone within three business days after making
the adverse determination, and shall provide written or electronic
confirmation of the telephone notification to the enrollee and the
provider or health care facility within one business day after making the
telephone notification.
(D) For concurrent review determinations, a health insuring
corporation shall
make the determination within one business day after obtaining all necessary
information.
(1) In the case of a determination to certify an extended stay or
additional health care services, the health insuring corporation shall notify
the provider or health care facility
rendering the health care service by telephone OR FACSIMILE within one
business day after
making the certification, and
shall provide written or electronic confirmation to the enrollee and the
provider or health care facility within one business day after the telephone
notification. The written notification shall include the number of extended
days or next review date, the new total number of days of health care services
approved,
and the date of admission or initiation of health care services.
(2) In the case of an adverse determination, the health insuring
corporation shall notify the provider or health care facility rendering the
health care service by telephone within one business day after
making the adverse determination, and shall provide written or electronic
confirmation to the enrollee and the provider or health care facility
within one business day after
the telephone notification. The health care service to the enrollee shall be
continued, with
standard copayments and deductibles, if applicable, until the enrollee has
been notified of the
determination.
(E) For retrospective review determinations, a health insuring
corporation
shall make
the determination within thirty business days after receiving all necessary
information.
(1) In the case of a certification, the health insuring corporation may
notify the
enrollee and the provider or health care facility rendering the health care
service in writing.
(2) In the case of an adverse determination, the health insuring
corporation shall notify
the enrollee and the provider or health care facility rendering the health
care service, in writing, within five
business days after making the adverse determination.
(F) The time frames set forth in divisions (C),
(D), and (E) of this section for determinations and
notifications shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the health
insuring corporation. The health insuring corporation shall maintain written
procedures for
making expedited utilization review determinations and notifications of
enrollees and
providers or health care facilities when warranted by the medical condition
of the enrollee.
(G) A written notification of an adverse determination shall
include the principal reason or reasons for the determination, instructions
for initiating an appeal or reconsideration of the determination, and
instructions for requesting a written statement of the clinical rationale
used to make the determination. A health insuring corporation shall provide
the clinical
rationale for an adverse determination in writing
to any party who received
notice of the adverse determination and who follows the instructions for a
request.
(H) A health insuring corporation shall have written procedures
to
address the
failure or inability of a health care facility, provider, or enrollee to
provide all
necessary information for review. If the health care facility, provider, or
enrollee will not
release necessary information, the health insuring corporation may deny
certification.
Sec. 1785.01. As used in this chapter:
(A) "Professional service" means any type of professional
service that may be performed only pursuant to a license,
certificate, or other legal authorization issued pursuant to
Chapter 4701., 4703., 4705.,
4715., 4723., 4725., 4729., 4731.,
4732., 4733., 4734., or 4741., sections 4755.01
to 4755.12,
or 4755.40 to 4755.56 of the Revised Code to
certified
public accountants, licensed public accountants, architects,
attorneys, dentists, nurses,
optometrists, pharmacists,
doctors of medicine and surgery, doctors of osteopathic
medicine and surgery, doctors of podiatric medicine and surgery,
practitioners of the limited branches of
medicine or surgery specified in section 4731.15 of
the Revised Code, MECHANOTHERAPISTS, psychologists, professional
engineers,
chiropractors, veterinarians, occupational therapists,
and physical therapists.
(B) "Professional association" means an association
organized under this chapter for the sole purpose of rendering
one of the professional services authorized under Chapter 4701.,
4703., 4705., 4715., 4723., 4725., 4729., 4731., 4732., 4733.,
4734., or 4741., sections 4755.01 to 4755.12, or
4755.40 to 4755.56 of the Revised Code, a
combination of the
professional services authorized under Chapters 4703. and 4733.
of the Revised Code, or a combination of the professional services
of optometrists authorized under Chapter 4725. of the Revised Code, chiropractors
authorized under Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses authorized under
Chapter 4723. of the Revised Code,
pharmacists authorized under Chapter 4729. of the Revised
Code, physical therapists authorized under sections 4755.40 to
4755.53 of the Revised Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION
4731.151 of the Revised Code, and doctors of
medicine and surgery, osteopathic medicine and surgery, or podiatric medicine
and surgery authorized under Chapter 4731. of the Revised Code.
Sec. 1785.02. An individual or group of individuals each
of whom is licensed, certificated, or otherwise legally
authorized to render within this state the same kind of professional
service, a group
of individuals each of whom is licensed, certificated, or
otherwise legally authorized
to render within this state the professional service authorized under
Chapter 4703. or 4733. of the Revised
Code, or a group of individuals each of whom is licensed,
certificated, or otherwise legally authorized to render within
this state the professional service of optometrists authorized
under Chapter 4725. of the Revised
Code, chiropractors authorized under
Chapter 4734. of the Revised Code,
psychologists authorized under
Chapter 4732. of the Revised Code,
registered or licensed practical nurses authorized under
Chapter 4723. of the Revised Code,
pharmacists
authorized under Chapter 4729.
of the Revised
Code, physical therapists
authorized under sections 4755.40 to 4755.53 of the
Revised
Code, MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
or
doctors of medicine and surgery, osteopathic medicine
and surgery, or podiatric medicine and surgery authorized under
Chapter 4731. of the Revised Code
may organize and become a shareholder or shareholders of a
professional association. Any group of individuals described in this section
who may be rendering one of the professional services as an organization
created otherwise than pursuant to this chapter may incorporate under and
pursuant to this chapter by amending the agreement establishing
the organization in a manner that the agreement as amended
constitutes articles of incorporation prepared and filed in the
manner prescribed in section 1785.08 of the Revised Code and by
otherwise complying with the applicable requirements of this chapter.
Sec. 1785.03. A professional association may render a particular
professional service only through officers, employees, and agents who are
themselves duly licensed, certificated, or otherwise
legally authorized to render the professional service within this
state. As used in this section,
"employee" does not include clerks,
bookkeepers, technicians, or other individuals who are not usually and
ordinarily considered by custom and practice to be rendering a
particular professional service for which a
license, certificate, or other legal authorization is
required and does not
include any other person who performs all of that person's
employment under the direct supervision and control of an officer, agent, or
employee who renders a particular
professional service to the public on behalf
of the professional association.
No professional association formed
for the
purpose of providing a combination of the professional services, as defined in
section 1785.01 of the Revised Code, of optometrists authorized under Chapter
4725. of the Revised Code, chiropractors authorized under Chapter 4734.
of the
Revised Code, psychologists authorized under Chapter 4732. of the Revised
Code, registered
or licensed practical nurses authorized under Chapter 4723. of the Revised
Code, pharmacists authorized under Chapter 4729. of the Revised Code, physical
therapists authorized under sections 4755.40 to 4755.53 of the Revised Code,
MECHANOTHERAPISTS AUTHORIZED UNDER SECTION 4731.151 of the Revised Code,
and doctors OF medicine and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery authorized under Chapter 4731.
of the Revised Code shall control the professional
clinical judgment exercised within accepted and prevailing standards of
practice of a licensed, certificated, or otherwise legally authorized
optometrist, chiropractor, psychologist, nurse, pharmacist, physical
therapist, MECHANOTHERAPIST, or doctor of medicine and surgery,
osteopathic
medicine and surgery, or podiatric medicine and surgery in rendering care,
treatment, or professional advice to an individual patient.
This division does not prevent a hospital, as defined in section 3727.01
of the Revised Code, insurer, as defined in section 3999.36
of the Revised Code, or intermediary organization, as defined
in section 1751.01 of the Revised
Code, from entering into a contract with a
professional association described in this division that includes a provision
requiring utilization review, quality assurance, peer review, or other
performance or quality standards. Those activities shall not be construed as
controlling the professional clinical judgment of an individual practitioner
listed in this division.
Sec. 1785.08. Chapter 1701. of the Revised Code applies to professional
associations, including their organization and the manner of filing articles
of incorporation, except that the requirements of division (A) of section
1701.06 of the Revised Code do not apply to professional associations. If any
provision of this chapter conflicts with any provision of Chapter 1701. of the
Revised Code, the provisions of this chapter shall take precedence. A
professional association for the practice of medicine
and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery or for the combined practice of
optometry, chiropractic, psychology, nursing, pharmacy, physical therapy,
MECHANOTHERAPY, medicine and surgery,
osteopathic medicine and surgery, or podiatric
medicine and surgery may provide in its articles of
incorporation or bylaws that its directors may have terms of office not
exceeding six years.
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. 3701.18. (A) AS USED IN THIS
SECTION:
(1) "AMBLYOPIA" MEANS REDUCED VISION IN AN EYE THAT HAS NOT
RECEIVED ADEQUATE USE DURING EARLY CHILDHOOD.
(2) "501(c) ORGANIZATION" MEANS AN ORGANIZATION EXEMPT FROM
FEDERAL
INCOME TAXATION PURSUANT TO 26 U.S.C.A. 501(a) AND
(c).
(B) THERE IS HEREBY CREATED IN THE STATE TREASURY
THE SAVE OUR SIGHT FUND. THE FUND SHALL CONSIST OF VOLUNTARY
CONTRIBUTIONS DEPOSITED AS PROVIDED IN SECTION 4503.104 OF THE
REVISED
CODE. ALL INVESTMENT EARNINGS
FROM THE FUND SHALL BE CREDITED TO THE FUND.
(C) THE DIRECTOR OF HEALTH SHALL USE THE MONEY IN
THE SAVE OUR SIGHT FUND AS FOLLOWS:
(1) TO PROVIDE SUPPORT TO 501(c) ORGANIZATIONS THAT OFFER
VISION
SERVICES IN ALL COUNTIES OF THE STATE AND HAVE DEMONSTRATED EXPERIENCE IN THE
DELIVERY OF VISION SERVICES TO DO ONE OR MORE OF THE FOLLOWING:
(a) IMPLEMENT A VOLUNTARY CHILDREN'S VISION SCREENING
TRAINING AND
CERTIFICATION PROGRAM FOR VOLUNTEERS, CHILD DAY-CARE PROVIDERS,
NURSES, TEACHERS, HEALTH CARE PROFESSIONALS PRACTICING IN PRIMARY CARE
SETTINGS, AND OTHERS SERVING CHILDREN;
(b) PROVIDE MATERIALS FOR THE PROGRAM IMPLEMENTED UNDER DIVISION
(C)(1)(a) OF THIS SECTION;
(c) DEVELOP AND IMPLEMENT A REGISTRY AND
TARGETED VOLUNTARY CASE MANAGEMENT SYSTEM TO DETERMINE WHETHER
CHILDREN WITH AMBLYOPIA ARE RECEIVING PROFESSIONAL EYE CARE AND
TO PROVIDE THEIR PARENTS WITH INFORMATION AND
SUPPORT REGARDING THEIR CHILD'S VISION CARE;
(d) ESTABLISH A MATCHING GRANT PROGRAM FOR THE
PURCHASE AND DISTRIBUTION OF PROTECTIVE EYEWEAR
TO CHILDREN;
(e) PROVIDE VISION HEALTH AND SAFETY PROGRAMS AND
MATERIALS FOR CLASSROOMS.
(2) FOR THE PURPOSE OF SECTION 4503.104 of the Revised Code, TO DEVELOP AND DISTRIBUTE
INFORMATIONAL MATERIALS ON THE IMPORTANCE OF EYE CARE AND SAFETY TO THE
REGISTRAR OF MOTOR VEHICLES AND EACH DEPUTY REGISTRAR;
(3) TO PAY COSTS INCURRED BY THE DIRECTOR IN ADMINISTERING THE FUND;
(4) TO REIMBURSE THE BUREAU OF MOTOR VEHICLES FOR THE ADMINISTRATIVE COSTS
INCURRED IN PERFORMING ITS DUTIES UNDER SECTION 4503.104 of the Revised Code.
(D) A 501(c)
ORGANIZATION SEEKING FUNDING FROM THE SAVE OUR SIGHT FUND FOR ANY OF THE
PROJECTS SPECIFIED IN DIVISION (C) OF THIS SECTION SHALL SUBMIT A
REQUEST FOR
THE FUNDING TO THE DIRECTOR
IN ACCORDANCE WITH RULES ADOPTED UNDER
DIVISION (E) OF THIS SECTION. THE
DIRECTOR SHALL DETERMINE THE APPROPRIATENESS OF AND APPROVE OR
DISAPPROVE PROJECTS FOR FUNDING AND APPROVE OR DISAPPROVE THE
DISBURSEMENT OF MONEY FROM THE SAVE OUR SIGHT FUND.
(E) THE PUBLIC HEALTH COUNCIL SHALL ADOPT RULES IN ACCORDANCE
WITH CHAPTER 119. OF THE REVISED CODE TO IMPLEMENT
THIS SECTION. THE RULES SHALL INCLUDE THE PARAMETERS OF THE PROJECTS
SPECIFIED IN DIVISION (C)(1) OF THIS SECTION THAT MAY BE FUNDED WITH
MONEY IN THE SAVE OUR SIGHT FUND AND PROCEDURES FOR 501(c)
ORGANIZATIONS TO
REQUEST FUNDING FROM THE FUND.
Sec. 3701.75. (A) As used in this section:
(1) "Electronic
record" means a record communicated, received, or stored by electronic,
magnetic, optical, or similar means for storage in an information system or
transmission from one information system to another. "Electronic record"
includes a record that is communicated, received, or stored by electronic data
interchange, electronic mail, facsimile,
telex, or similar methods of communication.
(2) "Electronic signature" means any of the following
attached to or associated with an electronic record
by an individual to authenticate the record:
(a) A code consisting of a combination of
letters, numbers, characters, or symbols that is adopted or
executed by an individual as that individual's electronic
signature;
(b) A computer-generated signature code created
for an individual;
(c) An electronic image of an individual's
handwritten signature created by using a pen computer.
(3) "Health care record" means any document
or combination of documents pertaining to a patient's medical history,
diagnosis, prognosis, or medical condition that is generated and maintained in
the process of the patient's treatment.
(B) Any
ALL NOTES, ORDERS, AND OBSERVATIONS ENTERED INTO A
HEALTH CARE RECORD, INCLUDING ANY INTERPRETIVE
REPORTS
OF DIAGNOSTIC TESTS OR SPECIFIC TREATMENTS, SUCH AS RADIOLOGIC OR
ELECTROCARDIOGRAPHIC REPORTS, OPERATIVE REPORTS, REPORTS OF PATHOLOGIC
EXAMINATION OF TISSUE, AND SIMILAR REPORTS, SHALL BE AUTHENTICATED BY
THE INDIVIDUAL WHO MADE OR AUTHORIZED THE ENTRY. AN
entry into a health care
record
may be authenticated by executing handwritten signatures or
handwritten initials directly on the entry
or by executing an electronic signature.
An ENTRY THAT IS AN electronic signature executed in accordance with
an
electronic signature
system that is certified by the
department of health under division (C) of this section shall be
considered for all legal purposes to be the same as having
executed a handwritten signature or handwritten initials, except when any
federal law governing state participation in a federal program requires that
entries into health care records RECORD MAY be authenticated
only by handwritten
signatures or handwritten initials. The AN electronic
signature generated by a
certified system
shall be
presumed to be the signature of the individual to whom it is assigned and to
be
affixed for the purpose of authenticating an entry into a health care
record.
(C)(1) The department of health shall administer a program under
which entities that create and maintain health care records may receive
certification from the department of their electronic signature systems. The
department shall determine the types of entities that are eligible to have
their electronic signature systems certified under this section.
The department shall certify an eligible entity's electronic signature
system if all of the following apply:
(a)(1) The
entity RESPONSIBLE FOR CREATING AND MAINTAINING THE HEALTH CARE RECORD
adopts a
policy that permits the use of electronic signatures
on electronic records.
(b)(2) The entity's electronic signature
system utilizes either a two-level
access control mechanism that assigns a unique identifier to each user or a
biometric access control device.
(c)(3) The entity takes steps to
safeguard against
unauthorized access to the system and forgery of
electronic signatures.
(d)(4) The system includes a process to
verify that the individual affixing the electronic signature
has reviewed the contents of the entry and
determined that the entry contains what that individual intended.
(e)(5) The policy adopted by the entity
pursuant to division (C)(B)(1)(a) of this section
prescribes all of the following:
(i)(a) A procedure by which each user of the system must
certify in
writing
that the user will
follow the confidentiality and security policies
maintained by the entity for the system;
(ii)(b) Penalties for misusing the system;
(iii)(c) Training for all users of the
system
that includes an explanation of the appropriate use of the system and the
consequences for
not complying with the entity's confidentiality and security policies.
(2) In lieu of
making a direct determination of compliance under division (C)(1) of
this section, the department may
accept the approval of any private or public organization that has reviewed
the entity's system, if the department determines that the
organization has standards at least as stringent as those
specified in division (C)(1) of this section. Organizations
with standards for approval of electronic signature systems that the
department
may accept include
the joint commission on accreditation of healthcare
organizations, the American osteopathic association, the
United
States food and drug
administration, and the United
States health care financing
administration. If an entity receives approval of its electronic signature
system in this manner, and is
subsequently cited by the private or public organization for a violation that
involves the entity's system, the entity shall
immediately
notify the department of the citation and the department shall withdraw its
certification.
(3) The public health council shall adopt rules in accordance with
Chapter 119. of the Revised Code as
necessary for the department's administration of
the program for certifying the electronic signature systems of entities that
create and maintain health care records.
Sec. 3702.141. (A) AS
USED IN THIS SECTION, "EXISTING HEALTH CARE FACILITY" HAS THE
SAME MEANING AS IN SECTION 3702.51 OF THE
REVISED
CODE.
(B) SECTION 3702.14 OF
THE REVISED
CODE SHALL NOT BE CONSTRUED TO
REQUIRE ANY EXISTING HEALTH CARE FACILITY THAT IS CONDUCTING AN
ACTIVITY SPECIFIED IN SECTION 3702.11 OF THE
REVISED
CODE, WHICH ACTIVITY WAS
INITIATED ON OR BEFORE MARCH 20, 1997, TO ALTER, UPGRADE,
OR OTHERWISE IMPROVE THE STRUCTURE
OR FIXTURES OF THE FACILITY IN ORDER TO COMPLY WITH ANY RULE
ADOPTED UNDER SECTION 3702.11 OF THE
REVISED
CODE RELATING TO THAT ACTIVITY,
UNLESS ONE OF THE FOLLOWING APPLIES:
(1) THE FACILITY INITIATES A CONSTRUCTION, RENOVATION, OR
RECONSTRUCTION PROJECT THAT INVOLVES A CAPITAL EXPENDITURE OF AT
LEAST FIFTY THOUSAND DOLLARS, NOT INCLUDING EXPENDITURES
FOR EQUIPMENT OR STAFFING OR OPERATIONAL COSTS, AND
THAT DIRECTLY INVOLVES THE AREA IN WHICH THE EXISTING SERVICE IS
CONDUCTED.
(2) THE FACILITY INITIATES ANOTHER ACTIVITY SPECIFIED IN
SECTION 3702.11 OF THE REVISED
CODE.
(3) THE FACILITY INITIATES A SERVICE LEVEL DESIGNATION
CHANGE FOR OBSTETRIC AND NEWBORN CARE.
(4) THE FACILITY PROPOSES TO ADD A CARDIAC
CATHETERIZATION LABORATORY TO AN EXISTING CARDIAC
CATHETERIZATION SERVICE.
(5) THE FACILITY PROPOSES TO ADD AN OPEN-HEART OPERATING
ROOM TO AN EXISTING OPEN-HEART SURGERY SERVICE.
(6) THE DIRECTOR OF HEALTH DETERMINES, BY CLEAR AND
CONVINCING EVIDENCE, THAT FAILURE TO COMPLY WITH THE RULE WOULD
CREATE AN IMMINENT RISK TO THE HEALTH AND WELFARE OF ANY
PATIENT.
(C) IF DIVISION
(B)(4) OR (5) OF THIS SECTION
APPLIES, ANY ALTERATION, UPGRADE, OR OTHER IMPROVEMENT REQUIRED
SHALL APPLY ONLY TO THE PROPOSED ADDITION TO THE EXISTING
SERVICE IF THE COST OF THE ADDITION IS LESS THAN THE CAPITAL
EXPENDITURE THRESHOLD SET FORTH IN DIVISION
(B)(1) OF THIS SECTION.
(D) NO PERSON OR
GOVERNMENT ENTITY SHALL DIVIDE OR OTHERWISE SEGMENT A
CONSTRUCTION, RENOVATION, OR RECONSTRUCTION PROJECT IN ORDER TO
EVADE APPLICATION OF THE CAPITAL EXPENDITURE THRESHOLD SET FORTH
IN DIVISION (B)(1) OF THIS
SECTION.
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 individual sickness
and accident insurance policy
ISSUED TO AN INDIVIDUAL WHO IS NOT A FEDERALLY ELIGIBLE INDIVIDUAL OR A
NONEMPLOYER-RELATED GROUP SICKNESS AND ACCIDENT
INSURANCE POLICY, but in no
event shall such waiting period exceed two hundred seventy days.
FOR PURPOSES OF DIVISION
(O) OF THIS SECTION, "FEDERALLY
ELIGIBLE INDIVIDUAL" MEANS AN ELIGIBLE INDIVIDUAL AS DEFINED IN
45
C.F.R.
148.103.
(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. 3901.38. (A) As used in this section and section 3901.381 of the
Revised Code:
(1) "Beneficiary" means any policyholder, subscriber,
member, employee, or other person who is eligible for benefits
under a benefits contract.
(2) "Benefits contract" means a sickness and accident
insurance policy providing hospital, surgical, or medical expense
coverage, or a health insuring
corporation
contract or other policy or
agreement under which a third-party payer agrees to reimburse for covered
health care or dental services rendered to beneficiaries, up to
the limits and exclusions contained in the benefits contract.
(3) "Completed claim" means a proof of loss or a claim for
payment for health care services which has been submitted to the
appropriate claims processing office of the third-party payer
accompanied by sufficient documentation for the third-party payer
to determine proof of loss and reasonably required by the
third-party payer to accept or reject the claim.
(4) "Hospital" has the same meaning set forth in section
3727.01 of the Revised Code.
(5) "Proof of loss" means a claim for payment for health
care services which has been submitted to the appropriate claims
processing office of the third-party payer accompanied by
sufficient documentation for the third-party payer to determine
benefits payable under the benefits contract and reasonably
required by the third-party payer to accept or reject the claim.
(6) "Provider" means a hospital, nursing home, physician,
podiatrist, dentist, pharmacist, chiropractor, or other licensed
health care provider entitled to reimbursement by a third-party
payer for services rendered to a beneficiary under a benefits
contract.
(7) "Reimburse" means indemnify, make payment, or
otherwise accept responsibility for payment for health care
services rendered to a beneficiary, or arrange for the provision
of health care services to a beneficiary.
(8) "Third-party payer" means any of the following:
(a) An insurance company;
(b) A health insuring corporation;
(c) A preferred provider organization;
(d) A labor organization;
(e)(d) An employer;
(f)(e) An intermediary
organization, as defined in section 1751.01
of the Revised Code, that is not a health
delivery network contracting solely with self-insured employers;
(g)(f) An administrator subject to sections 3959.01 to
3959.16 of the Revised Code;
(h)(g) A health delivery network, as defined in section
1751.01 of the
Revised Code;
(i)(h) Any other person that is obligated pursuant to a
benefits contract to reimburse for covered health care services
rendered to beneficiaries under such contract.
(B)(1) Except as provided in division (B)(2) of this
section and in section 3901.381 of the Revised Code,
within twenty-four days of the receipt of a completed
claim from a provider or a beneficiary for reimbursement for
health care services rendered by the provider to a beneficiary, a
third-party payer shall, in accordance with division (D) of this
section, make payment of any amount due on such claim.
(2) A third-party payer and a provider may, in negotiating
a reimbursement contract, agree to any time period by which a
third-party payer shall, subject to division (D) of this section,
make payment of any amount due on a completed claim. Nothing in
this division shall be construed as limiting in any manner the
application of the requirements of this section to any benefits
or reimbursement contract.
(3) Any provider or beneficiary aggrieved with respect to
any act of a third-party payer that such provider or beneficiary
believes to be a violation of division (B)(1) or (2) of this
section may file a written complaint with the superintendent of
insurance. If a series of such complaints is received by the
superintendent with respect to a particular third-party payer and
if, after investigation, the superintendent finds that such
third-party payer has engaged in a series of such violations
which, taken together, constitute a consistent pattern or a
practice of such third-party payer to violate division (B)(1) or
(2) of this section, the superintendent shall issue an order
requiring such third-party payer to cease and desist from
engaging in such violations and to pay a late payment penalty as
specified in divisions (B)(4) and (5) of this section with
respect to the claims the superintendent finds were not timely
paid. In the order, the superintendent shall specify the reasons
for the superintendent's finding and order and state that a
hearing conducted
pursuant to Chapter 119. of the Revised Code shall be held within
fifteen days after requested in writing by the third-party payer.
The provisions of this division (B)(3) of this section are in
addition to, and not in lieu of, such other remedies as providers
and beneficiaries may otherwise have by law.
(4)(a) The late payment penalty shall be computed based
upon the number of days that have elapsed between the date
payment is due in accordance with division (B)(1) or (2) of this
section and the date payment is actually sent.
(b) The interest rate for determining the amount of the
late payment penalty shall be the rate agreed to by the provider
and the third-party payer or the rate specified by and determined
in accordance with division (A) of section 1343.01 of the Revised
Code.
(5) A provider and a third-party payer may enter into a
contractual agreement in which the timing of payments by the
third-party payer is not directly related to the receipt of a
completed claim. Such contractual arrangement may include
periodic interim payment arrangements, capitation payment
arrangements, or other payment arrangements acceptable to the
provider and the third-party payer. Except as agreed to under
such contract, this section does not apply to such payment
arrangements.
(6) Any late payment penalty due and payable by a
third-party payer in accordance with this section shall not be
used to reduce benefits or payments otherwise payable under a
benefits contract.
(C) No third-party payer shall refuse to process or pay
within the time period required under division (B)(1) or (2) of
this section a completed claim submitted by a provider on the
ground the beneficiary has not been discharged from the hospital
or the treatment has not been completed, if the submitted claim
covers services actually rendered and charges actually incurred
over at least a thirty-day period.
(D)(1) Notwithstanding section 1742.10 1751.13 or
division (I)(2) of section 3923.04 of the Revised Code, a
reimbursement contract entered into or renewed on or after June 29,
1988, between a
third-party payer and a hospital shall provide that reimbursement
for any service provided by a hospital pursuant to a
reimbursement contract and covered under a benefits contract
shall be made directly to the hospital.
(2) If the third-party payer and the hospital have not
entered into a contract regarding the provision and reimbursement
for covered services, the third-party payer shall accept and
honor a completed and validly executed assignment of benefits
with a hospital by a beneficiary, except when the third-party
payer has notified the hospital in writing of the conditions
under which the third-party payer will not accept and honor an
assignment of benefits. Such notice shall be made annually.
(3) A third-party payer may not refuse to accept and honor
a validly executed assignment of benefits with a hospital
pursuant to division (D)(2) of this section for medically
necessary hospital services provided on an emergency basis.
(E) A series of violations which taken together,
constitute a consistent pattern or a practice of violation of any
of the provisions of this section is an unfair and deceptive act
pursuant to sections 3901.19 to 3901.23 of the Revised Code and
is subject to proceedings pursuant to those sections.
Sec. 3917.01. (A) Group life insurance is that form of
life insurance covering not less than ten employees with or
without medical examination, written under a policy issued to the
employer, or to a trustee of a trust created by such employer,
the premium on which is to be paid by the employer, by the
employer and employees jointly, or by such trustee out of funds
contributed by the employer or by the employer and employees
jointly, and insuring only all of the employer's employees
or all of any
classes thereof, determined by sex, age, or conditions pertaining
to the employment, for amounts of insurance based upon some plan
which will preclude individual selection, for the benefit of
persons other than the employer; but when the premium is to be
paid by the employer and employee jointly and the benefits of the
policy are offered to all eligible employees, not less than
seventy-five per cent of such employees may be so insured. Such
group policy may provide that "employees" includes retired
employees of the employer and the officers, managers, employees,
and retired employees of subsidiary or affiliated corporations
and the individual proprietors, partners, employees, and retired
employees of affiliated individuals and firms, when the business
of such subsidiary or affiliated corporations, firms, or
individuals is controlled by the common employer through stock
ownership, contract, or otherwise. This section does not define
as a group the lives covered by a policy issued on more than one
life which provides for payments upon the death of any one or
more or upon the death of each of the lives so insured, and upon
which the premium rates charged are computed on the same basis as
used by the issuing company on single life policies and upon its
regular forms of insurance.
(B) As used in sections 3917.01 to 3917.06 of the Revised
Code, the following forms of life insurance are group life
insurance:
(1) Life insurance covering the members of one or more
companies, batteries, troops, battalions, divisions, or other
units of the national guard or naval militia of any state,
written under a policy issued to the commanding general of the
national guard or commanding officer of the naval militia, who is
the employer for the purposes of such sections, the premium on
which is to be paid by the members of such units for the benefit
of persons other than the employer; provided that when the
benefits of the policy are offered to all eligible members of a
unit of the national guard or naval militia, not less than
seventy-five per cent of the members of such a unit may be
insured;
(2) Life insurance covering the members of one or more
troops or other units of the state troopers or state police of
any state, written under a policy issued to the commanding
officer of the state troopers or state police who is the employer
for the purposes of such sections, the premium on which is to be
paid by the members of such units for the benefit of persons
other than the employer; provided that when the benefits of the
policy are offered to all eligible members of a unit of the state
troopers or state police, not less than seventy-five per cent of
the members of such a unit may be insured;
(3) Life insurance covering the members of any labor
union, written under a policy issued to such union which is the
employer for the purposes of such sections, the premium on which
is to be paid by the union or by the union and its members
jointly, and insuring only all of its members, who are actively
engaged in the same occupation, for amounts of insurance based
upon some plan which will preclude individual selection, for the
benefit of persons other than the union or its officials;
provided that in case the insurance policy is cancellable at the
end of any policy year at the option of the insurance company and
that the basis of premium rates may be changed by the insurance
company at the beginning of any policy year, all members of a
labor union may be insured; and provided that when the premium is
to be paid by the union and its members jointly and the benefits
are offered to all eligible members, not less than seventy-five
per cent of such members may be insured; and provided that when
members apply and pay for additional amounts of insurance, a
smaller percentage of members may be insured for such additional
amounts if they pass satisfactory medical examinations or submit
satisfactory evidence of insurability;
(4) Life insurance written under a policy issued to a
creditor, who shall be deemed the policyholder, to insure debtors
of the creditor, subject to the following requirements:
(a) The debtors eligible for insurance under the policy
shall be all of the debtors of the creditor, excepting that no debtor is
eligible
unless
the indebtedness constitutes an obligation to repay that
is binding upon the debtor during the
debtor's lifetime at and from the date the insurance becomes effective
upon the debtor's life. The policy may provide that
"debtors" includes the debtors of one or more subsidiary corporations and the
debtors of one or more affiliated corporations, proprietors, or partnerships
if the business of the
policyholder and of such affiliated corporations, proprietors, or
partnerships is under common control through stock ownership,
contract, or otherwise.
(b) The premium for the policy shall be paid by the
policyholder, either from the creditor's funds, or from charges
collected from the insured debtors, or from both. A policy on
which part or all of the premium is to be derived from the
collection from the insured debtors of identifiable charges not
required of uninsured debtors shall not include debtors under
obligations outstanding at its date of issue without evidence of
individual insurability unless at least seventy-five per cent of
the then eligible debtors elect to pay the required charges. A
policy on which no part of the premium is to be derived from the
collection of such identifiable charges must insure all eligible
debtors, or all except any as to whom evidence of individual
insurability is not satisfactory to the insurer.
(c) The policy may be issued only if the group of eligible
debtors is then receiving new entrants at the rate of at least
one hundred persons yearly, or may reasonably be expected to
receive at least one hundred new entrants during the first policy
year, and continues to receive not less than one hundred new
entrants to the group yearly, and only if the policy reserves to
the insurer the right to require evidence of individual
insurability if less than seventy-five per cent of the new
entrants become insured. The policy may exclude from the classes
eligible for insurance classes of debtors determined by age.
(d) The amount of insurance on the life of any debtor may
be determined by the age of the debtor based upon a plan which
will preclude individual selection and shall at no time exceed
the amount owed by the debtor that is repayable in
installments to the creditor.
(e) The insurance shall be payable to the policyholder.
Such payment shall reduce or extinguish the unpaid indebtedness
of the debtor to the extent of such payment.
(5) Life insurance covering the members of any duly
organized corporation or association of veterans or veteran
society or association of the World War veterans, written under a
policy issued to such corporation, association, or society which
is the employer for the purpose of such sections, the premium on
which is to be paid by the corporation, association, society, and
its members jointly, and insuring all of its members who are
actively engaged in any occupation for amounts of insurance based
upon some plan which will preclude individual selection for the
benefit of persons other than the corporation, association, or
society or its officials; provided that when the premium is to be
paid by the corporation, association, or society and its members
jointly and the benefits are offered to all eligible members, not
less than seventy-five per cent of such members may be insured;
and provided that when members apply and pay for additional
amounts of insurance, a smaller percentage of members may be
insured for such additional amounts if they pass satisfactory
medical examinations or submit satisfactory evidence of
insurability;
(6) Life insurance covering the members of any
organization of agriculturists or horticulturists organized under
the co-operative laws of this state, written under a policy
issued to such co-operative association which is the employer for
the purpose of such sections, the premium on which is to be paid
by the association or by the association and its members jointly,
and insuring all of its members who are actively engaged in
agricultural or horticultural pursuits, for an amount of
insurance based upon some plan which will preclude individual
selection, and for the benefit of persons other than the
association or its officials; provided that when the premium is
to be paid by the corporation, association, or society and its
members jointly and the benefits are offered to all eligible
members, not less than seventy-five per cent of such members may
be insured; provided that when members apply and pay for
additional amounts of insurance, a smaller percentage of members
may be insured for such additional amounts if they pass
satisfactory medical examinations or submit satisfactory evidence
of insurability;
(7) Life insurance covering employees of a political
subdivision or district of this state, or of an educational or
other institution supported in whole or in part by public funds,
or of any classes thereof, determined by conditions pertaining to
employment, or of this state or any department or division
thereof, written under a policy issued to such political
subdivision, district, or institution, or the proper official or
board of this state or of such state department or division
thereof, which is the employer for the purpose of such sections,
the premium on which is to be paid by such employees, unless
otherwise provided by law, charter, or ordinance, for the benefit
of persons other than the employer; provided that when the
benefits of the policy are offered to all eligible employees of a
political subdivision or district of the state or of an
educational or other institution supported in whole, or in part
by public funds, or of this state or a state department or
division thereof, not less than seventy-five per cent of such
employees may be insured; and provided that when employees apply
and pay for additional amounts of insurance, a smaller percentage
of employees may be insured for such additional amounts if they
pass satisfactory medical examinations or submit satisfactory
evidence of insurability; and provided that upon acquisition by a
political subdivision of any privately owned property or
enterprise, the employees of which have been covered by a group
policy of life or other insurance as employees of such private
employer, such political subdivision and insurance company may
continue such contract in force upon similar conditions as the
last preceding private employer;
(8) Life insurance covering the members, or the members
and the employees of members of any duly organized association,
other than an association subject to any other provision of this
division, written under a policy issued to such association,
which association is the employer for the purpose of such
sections, the premium on which is to be paid by the insured
members or their employees, insuring members and their employees
for amounts of insurance based upon some plan which will preclude
individual selection except as provided in this section, for the
benefit of persons other than the association; provided the
association has been in existence for at least two years
immediately preceding the purchase of the insurance; provided
that there must be at least fifty insured members in any group;
and provided that the association has been organized and is
maintained in good faith for purposes other than that of
obtaining insurance;
(9) Life insurance issued to trustees of a trust fund
established jointly by one or more employers in the same
industry, on the one hand, and one or more labor unions
representing as bargaining agents employees of such employers, on
the other hand, or by two or more employers in the same industry,
or by two or more labor unions, which trustees shall be deemed
the policyholder to insure employees of the employers or members
of unions for the benefit of persons other than the employers or
the unions or the trustees, subject to the following
requirements:
(a) The persons eligible for such insurance shall be all
of the employees of the employers, or all of the members of the
unions, or all of any class of such employees determined by sex,
age, or conditions pertaining to their employment, or to
membership in the unions, or to any or all of them. The policy
may provide that "employees" includes the retired employees of
the employer and the officers, managers, employees, and retired
employees of subsidiary or affiliated corporations and the
individual proprietors, partners, employees, and retired
employees of affiliated individuals and firms, when the business
of such subsidiary or affiliated corporations, firms, or
individuals is controlled by the common employer through stock
ownership, contract, or otherwise. The policy may provide that
"employees" includes the individual proprietor or partners if the
employer is an individual proprietor or a partnership. The policy
may provide that "employees" includes the trustees or their
employees, or both, if their duties are principally connected
with such trusteeship.
(b) The premium for the policy shall be paid by the
trustees, either wholly from funds contributed by the employers
of the insured persons, or partly from such funds and partly from
funds contributed by the insured employees. If part of the
premium is to be derived from funds contributed by the insured
employees, then such policy may be placed in force only if it
covers at least seventy-five per cent of the then eligible
employees. A policy on which no part of the premium is derived
from funds contributed by the insured employees must insure all
eligible employees.
(c) Any policy must insure at least ten persons at date of
issue.
(d) The amounts of insurance under the policy must be
based upon some plan precluding individual selection by the
insured persons or the policyholder or the employers or the
unions or the trustees.
(10) Life insurance covering the members of a credit
union, which shall be deemed to be the employer for the purposes
of this section, the premium on which is to be paid by the credit
union or by the credit union and its members jointly, and
insuring all of its eligible members for amounts of insurance not
in excess of the share balance as to each member, and for the
benefit of persons other than the credit union or its officers;
provided that in the determination of the eligibility of members
there may be classifications and limitations based upon age;
provided also that when the premium is to be paid by the credit
union and its members jointly and the benefits are offered to all
eligible members, not less than seventy-five per cent of such
members may be so insured; provided also that in obtaining such
insurance, the officers of the credit union shall consider
proposals from any licensed insurer; provided also that members
may be required to provide evidence of insurability satisfactory
to the insurer.
(11) Life insurance covering the members of any duly
organized corporation or association of members of the Ohio
national guard, the Ohio naval militia, and the Ohio military
reserve, which shall have been in existence for at least two
years immediately preceding the purchase of such insurance,
written under a policy issued to such corporation or association,
which corporation or association is the employer for the purpose
of such sections, the premium on which is to be paid by the
insured members, insuring members for amounts of insurance based
upon some plan which will preclude individual selection, except
as provided in this section, for the benefit of persons other
than the corporation or association, provided that there must be
at least fifty insured members in any group, and provided further
that unless seventy-five per cent of all members or one thousand
members, whichever is the lesser number, are insured, each member
must pass a satisfactory medical examination in order to be
insured; and provided that, when members apply and pay for
additional amounts of insurance, they may be insured for such
additional amounts if they pass satisfactory medical examinations
or submit satisfactory evidence of insurability.
(12) LIFE INSURANCE THAT IS WRITTEN UNDER A POLICY
ISSUED TO A TRUSTEE UNDER A TRUST ESTABLISHED BY AN INSURER FOR
THE PURPOSE OF PROVIDING CONTINUED GROUP LIFE INSURANCE COVERAGE
TO THOSE FORMER EMPLOYEES,
FORMER MEMBERS, OR FORMER MEMBERS AND THE EMPLOYEES OF SUCH MEMBERS, AND THEIR
SPOUSES AND DEPENDENT CHILDREN,
PREVIOUSLY COVERED UNDER POLICIES OF GROUP LIFE INSURANCE ISSUED
BY THE INSURER TO EMPLOYERS OR TRUSTEES PURSUANT TO
DIVISION (A) OF THIS SECTION, TO ASSOCIATIONS PURSUANT TO DIVISION
(B)(8) OF THIS SECTION, OR TO TRUSTEES PURSUANT TO DIVISION
(B)(9) OF THIS SECTION, AND
THAT IS EVIDENCED BY THE ISSUANCE OF A CERTIFICATE OF INSURANCE
TO SUCH FORMER EMPLOYEES OR MEMBERS; PROVIDED THAT THE AMOUNT OF THE CONTINUED
LIFE
INSURANCE COVERAGE MADE AVAILABLE TO A FORMER EMPLOYEE OR MEMBER AND TO
THE EMPLOYEE'S OR MEMBER'S SPOUSE AND DEPENDENTS SHALL NOT EXCEED THE AMOUNT
OF THE GROUP LIFE INSURANCE COVERAGE PREVIOUSLY PROVIDED TO
THE EMPLOYEE OR MEMBER AND THE EMPLOYEE'S OR MEMBER'S ELIGIBLE DEPENDENTS AT
THE TIME
OF THE
EMPLOYEE'S SEPARATION FROM EMPLOYMENT OR THE MEMBER'S TERMINATION OF
MEMBERSHIP.
(C) Any policy issued pursuant to this section, except a
policy issued to a creditor pursuant to division (B) (4) of this
section, may be extended, in the form of group term life
insurance only, to insure the spouse and dependent children of an
insured employee or member, or any class or classes thereof,
subject to the following requirements:
(1) The premiums for the group term life insurance shall
be paid by the policyholder, either from the employer, union or
association funds, or from funds contributed by the employer,
union, or association, or from funds contributed by the insured
employee or member, or from both.
(2) The amounts of insurance under the policy must be
based upon some plan precluding individual selection either by
the insured employee or member or by the policyholder, provided
that group term life insurance upon the life of a spouse or
dependent child shall not exceed the lesser of (a) ten thousand
dollars, or (b) one-half of the amount of insurance on the life
of the insured employee or member under the group policy.
(3) Upon termination of the group term life insurance with
respect to the spouse of any insured employee or member by reason
of such person's termination of employment or membership or
death, the spouse insured pursuant to this section shall have the
same conversion rights as to the group term life insurance on the
spouse's life as is provided for the insured employee or
member.
(4) Only one certificate need be issued for delivery to an
insured employee or member if a statement concerning any
dependent's coverage is included in such certificate.
Sec. 3917.06. No policy of group life insurance shall be
issued or delivered in this state until a copy of its form has
been filed with the superintendent of insurance and formally
approved by him THE SUPERINTENDENT; nor shall such policy be so
issued or delivered unless it contains in substance the following provisions:
(A) A provision that the policyholder is entitled to a
grace period of thirty-one days for the payment of any premiums
due except the first during which grace period the death benefit
coverage shall continue in force, unless the policyholder has
given the insurer written notice of discontinuance in advance of
the date of discontinuance and in accordance with the terms of
the policy; the policy may provide that the policyholder is
liable to the insurer for the payment of a pro rata premium for
the time the policy was in force during such grace period;
(B) A provision that the policy is incontestable after two
years from its date of issue, except for nonpayment of premiums
and except for violation of the conditions of the policy relating
to military or naval service in time of war;
(C) A provision that the policy and the application
submitted in connection therewith constitute the entire contract
between the parties, and that all statements contained in such
application are deemed, in the absence of fraud, representations
and not warranties, and that no such statement shall be used in
defense to a claim under the policy, unless it is contained in a
written application;
(D) A provision for the equitable adjustment of the
premium or the amount of insurance payable in the event of a
misstatement of the age of an employee or other person whose life
is insured under a group life policy;
(E) Except in the case of a policy described in division
(B)(4) of section 3917.01 of the Revised Code, a provision that
the company will issue to the policyholder for delivery to each
person whose life is insured under such policy, an individual
certificate setting forth a statement as to the insurance
protection to which he THE PERSON is entitled, to whom payable,
together with provision to the effect that in case of the termination of
the employment for any reason or of membership in the classes
eligible for insurance under the policy, such person is entitled
to have issued to him THE PERSON by the company, without
evidence of insurability, and upon application made to the company within
thirty-one days after such termination, and upon the payment of
the premium applicable to the class of risk to which he THE
PERSON belongs and to the form and amount of the policy at his
THE PERSON'S then attained age, EITHER a policy of life
insurance in any one
of the forms
customarily issued by the company, except term insurance, in any
amount not in excess of the amount of his THE PERSON'S
protection under such THE group insurance policy at the time of
such THE termination,
as he THE PERSON elects OR, IF APPLICABLE, THE COVERAGE
DESCRIBED IN DIVISION (B)(12) OF SECTION 3917.01 of the Revised Code;
(F) A provision that if the group policy terminates or is
amended so as to terminate the insurance of any class of insured
persons, every person insured thereunder at the date of such
termination whose insurance terminates and who has been so
insured for at least five years prior to such termination date is
entitled to have issued to him THE PERSON by the insurer an
individual policy of life insurance, subject to the same conditions as are
provided by division (E) of this section, except that the group
policy may provide that the amount of such individual policy
shall not exceed the smaller of (1) the amount of the person's
life insurance protection ceasing because of the termination of
OR amendment of the group policy, less the amount of any life
insurance for which he THE PERSON is or becomes eligible under
any group
policy issued or reinstated by the same or another insurer within
thirty-one days after such termination, and (2) two thousand
dollars;
(G) A provision that if a person insured under the group
policy dies during the period within which he THE PERSON would
have been entitled to have an individual policy issued to him THE
PERSON in accordance with division (E) or (F) of this section, and before
such an
individual policy has become effective, the amount of life
insurance which he THE PERSON would have been entitled to have
issued to him THE PERSON under such individual policy shall be
payable as a claim under the group policy, whether or not application for the
individual policy or the payment of the first premium therefor has been
made;
(H) A provision that to the group or class of persons
originally insured there shall be added from time to time all new
employees of the employer or other persons eligible to insurance
in such group or class;
(I) In the case of a policy issued to a labor union
covering all members of the union, a notice that the annual
renewable term premium depends upon the attained ages of the
members in the group and increases with advancing ages.
Policies of group life insurance, when issued in this state
by any company not organized under the laws of this state, may
contain, when issued, any provision required by the law of the
state, territory, or district of the United States under which
the company is organized; and policies issued in other states or
countries by companies organized in this state, may contain any
provision required or permitted by the laws of the state,
territory, district, or country in which the same are issued.
Any such policy may be issued or delivered in this state which in
the opinion of the superintendent contains provisions on any one
or more of the requirements of this section more favorable to the
policyholder or to the person whose life is insured under such
policy than such requirements.
The group life insurance policy together with any
application in connection therewith shall be available for
inspection during regular business hours at the office of the
policyholder where such policy is on file, by any beneficiary
thereunder or by an authorized representative of such
beneficiary.
Except as provided in sections 3917.01 to 3917.06,
inclusive, of the Revised Code, no contract of life insurance
shall be made covering a group in this state.
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. 3923.57. Notwithstanding any provision of this
chapter, every individual policy of sickness and accident
insurance that is delivered, issued for delivery, or renewed in
this state is subject to the following conditions, as applicable:
(A) Pre-existing conditions provisions shall not exclude
or limit coverage for a period beyond twelve months following the
policyholder's effective date of coverage and may only relate to
conditions during the six months immediately preceding the
effective date of coverage.
(B) In determining whether a pre-existing conditions
provision applies to a policyholder or dependent, each policy
shall credit the time the policyholder or dependent was covered
under a previous policy, contract, or plan
if the previous
coverage was continuous to a date not more than thirty
days prior
to the effective date of the new coverage, exclusive of any
applicable service waiting period under the policy.
(C)(1) Except as otherwise provided in
division (C) of this section,
an insurer that provides an individual sickness and accident
insurance policy to an individual shall renew or continue in
force such coverage at the option of the individual.
(2) An insurer may nonrenew or discontinue coverage of
an individual in the individual market based only on one or more
of the following reasons:
(a) The individual failed to pay premiums or
contributions in accordance with the terms of the policy or the
insurer has not received timely premium payments.
(b) The individual performed an act or practice
that constitutes fraud or made an intentional misrepresentation
of material fact under the terms of the policy.
(c) The insurer is ceasing to offer coverage in
the individual market in accordance with division
(D) of this section and the
applicable laws of this state.
(d) If the insurer offers coverage in the
market through a network plan, the individual no longer resides,
lives, or works in the service area, or in an area for which the
insurer is authorized to do business; provided, however, that
such coverage is terminated uniformly without regard to any
health status-related factor of covered individuals.
(e) If the coverage is made available in the
individual market only through one or more bona fide
associations, the membership of the individual in the
association, on the basis of which the coverage is provided,
ceases; provided, however, that such coverage is terminated
under division
(C)(2)(e)
of this section uniformly without regard to any health
status-related factor of covered individuals.
AN INSURER OFFERING COVERAGE TO INDIVIDUALS SOLELY THROUGH MEMBERSHIP IN A
BONA FIDE ASSOCIATION SHALL NOT BE DEEMED, BY VIRTUE OF THAT OFFERING, TO BE
IN THE INDIVIDUAL MARKET FOR PURPOSES OF SECTIONS 3923.58 AND 3923.581 OF THE
REVISED CODE. SUCH AN INSURER SHALL NOT BE REQUIRED TO
ACCEPT
APPLICANTS FOR COVERAGE IN THE INDIVIDUAL MARKET PURSUANT TO SECTIONS 3923.58
AND 3923.581 OF THE REVISED CODE UNLESS THE INSURER ALSO
OFFERS COVERAGE TO INDIVIDUALS OTHER THAN THROUGH BONA FIDE ASSOCIATIONS.
(3) An insurer may cancel or decide not to renew the coverage of a
dependent of an individual if the dependent 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 dependent.
(D)(1) If an insurer decides to
discontinue offering a particular type of health insurance
coverage offered in the individual market, coverage of such type
may be discontinued by the insurer if the insurer does all of
the following:
(a) Provides notice to each individual provided
coverage of this type in such market of the discontinuation at
least ninety days prior to the date of the discontinuation of
the coverage;
(b) Offers to each individual provided coverage
of this type in such market, the option to purchase any other
individual health insurance coverage currently being offered by
the insurer for individuals in that market;
(c) In exercising the option to discontinue
coverage of this type and in offering the option of coverage
under division
(D)(1)(b)
of this section, acts uniformly without regard to any
health status-related factor of covered individuals or of
individuals who may become eligible for such coverage.
(2) If an insurer elects to discontinue offering all
health insurance coverage in the individual market in this
state, health insurance coverage may be discontinued by the
insurer only if both of the following apply:
(a) The insurer provides notice to the
department of insurance and to each individual of the
discontinuation at least one hundred eighty days prior to the
date of the expiration of the coverage.
(b) All health insurance delivered or issued
for delivery in this state in such market is discontinued and
coverage under that health insurance in that market is not
renewed.
(3) In the event of a discontinuation under division
(D)(2) of this section in the
individual market, the insurer shall not provide for the
issuance of any health insurance coverage in the market and this
state during the five-year period beginning on the date of the
discontinuation of the last health insurance coverage not so
renewed.
(E) Nothwithstanding NOTWITHSTANDING divisions (C)
and (D) of this section, an insurer may, at the time of coverage renewal,
modify
the health insurance coverage for a policy form offered to
individuals in the individual market if the modification is
consistent with the law of this state and effective on a uniform
basis among all individuals with that policy form.
(F) Such policies are subject to sections 2743
and 2747 of the "Health
Insurance
Portability and
Accountability
Act of 1996,"
Pub.
L.
No. 104-191, 110
Stat. 1955, 42
U.S.C.A.
300gg-43 and 300gg-47, as
amended.
(G) Sections 3924.031
and 3924.032 of the Revised
Code shall apply to sickness
and accident insurance policies offered in the individual market
in the same manner as they apply to health benefit plans offered
in the small employer market.
In accordance with 45
C.F.R.
148.102, divisions (C) to
(G) of this section also apply
to all group sickness and accident insurance policies that are
not sold in connection with an employment-related group health
plan and that provide more than short-term, limited duration
coverage.
In applying divisions
(C) to
(G) of this section with
respect to health insurance coverage that is made available by
an insurer in the individual market to individuals only through
one or more associations, the term "individual" includes the
association of which the individual is a member.
For purposes of this section, any policy issued pursuant to division
(C) of section 3923.13 of the
Revised Code
in connection with a public or private college or university student health
insurance program is considered to be issued to a bona fide association and
is
not subject to divisions (C) to
(G) of this section.
As used in this section, "bona fide association" has
the same meaning as in section 3924.03 of the
Revised
Code, and "health status-related factor" and "network plan"
have the same meanings as in
section 3924.031 of the Revised
Code.
This section does not apply to any policy that provides
coverage for specific diseases or accidents only, or to any
hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer
than six months, or other policy that offers only supplemental
benefits.
Sec. 3923.571. 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) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, AN
INSURER SHALL PROVIDE TO ALL LATE ENROLLEES, AS
DEFINED IN SECTION 3924.01 OF THE
REVISED
CODE, WHO ARE IDENTIFIED BY THE POLICYHOLDER, THE OPTION TO ENROLL IN
THE GROUP POLICY. THE ENROLLMENT OPTION SHALL BE
PROVIDED FOR A MINIMUM PERIOD OF THIRTY CONSECUTIVE DAYS.
ALL DELAYS OF COVERAGE IMPOSED UNDER THE GROUP POLICY,
INCLUDING ANY PRE-EXISTING CONDITION EXCLUSION PERIOD OR SERVICE
WAITING PERIOD, SHALL BEGIN ON THE DATE THE INSURER RECEIVES
NOTICE OF THE LATE ENROLLEE'S APPLICATION OR REQUEST FOR
COVERAGE, AND SHALL RUN CONCURRENTLY WITH EACH OTHER.
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 OHIO 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
OHIO 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 plan BASIC AND STANDARD
PLANS 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) AT LEAST ONCE IN EVERY TWELVE-MONTH PERIOD, A
CARRIER SHALL PROVIDE TO ALL LATE ENROLLEES WHO ARE IDENTIFIED BY THE SMALL
EMPLOYER, THE
OPTION TO ENROLL IN THE HEALTH BENEFIT PLAN. THE ENROLLMENT
OPTION SHALL BE PROVIDED FOR A MINIMUM PERIOD OF THIRTY
CONSECUTIVE DAYS. ALL DELAYS OF COVERAGE IMPOSED UNDER THE
HEALTH BENEFIT PLAN, INCLUDING ANY PRE-EXISTING CONDITION
EXCLUSION PERIOD, AFFILIATION PERIOD, OR SERVICE WAITING PERIOD,
SHALL BEGIN ON THE DATE THE CARRIER RECEIVES NOTICE OF THE LATE
ENROLLEE'S APPLICATION OR REQUEST FOR COVERAGE, AND SHALL RUN
CONCURRENTLY WITH EACH OTHER.
(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. 3924.033. (A) Each carrier,
in connection with the offering of a health benefit plan to a
small employer, shall disclose to the employer, as part of its
solicitation and sales materials, that the information described
in division (B) of this section
is available upon request.
(B) A carrier shall
provide the following information to a small employer upon
request:
(1) The provisions of the plan concerning the
carrier's right to change premium rates and the factors that may
affect changes in premium rates;
(2) The provisions of the plan relating to
renewability of coverage;
(3) The provisions of the plan relating to any
pre-existing condition exclusion;
(4) The benefits and premiums available under all
health benefit plans for which the employer is qualified.
(C)(B) The information
described in division (B)(A) of
this section shall be provided in a manner determined to be
understandable by the average small employer, and in a manner
sufficient to reasonably inform a small employer regarding the
employer's rights and obligations under the health benefit
plan.
(D)(C) Nothing in this
section requires a carrier to disclose any information that is by law
proprietary and trade secret information.
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 ADMINISTRATOR
OF THE PROGRAM, and
setting forth the powers and duties of the administering insurer;
ADMINISTRATOR. THE ADMINISTRATOR MAY BE A CARRIER AS
DEFINED IN SECTION 3924.01 OF THE
REVISED
CODE OR A PERSON LICENSED AS AN
ADMINISTRATOR UNDER CHAPTER
3959. OF THE REVISED
CODE, OR THE BOARD MAY, IN ITS
SOLE DISCRETION, CHOOSE TO SERVE AS ADMINISTRATOR OF THE
PROGRAM.
(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 SEHCplan OHC PLANS
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 SEHCplan OHC PLANS which,
when offered
by a carrier,
is ARE 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., 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.
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. 3924.13. (A) Following the close of each calendar year,
the administering insurer ADMINISTRATOR of the Ohio health
reinsurance program shall determine the net premiums, the program
expenses for administration, and the incurred losses, if any, for
the year, taking into account investment income and other
appropriate gains and losses. For purposes of this section, health
benefit plan premiums earned by MEWAs shall be established
by adding paid claim losses and administrative expenses of the
MEWA. Health benefit plan premiums and benefits paid by
a carrier that are less than an amount determined by the board
of directors of the program to justify the cost of collection
shall not be considered for purposes of determining assessments.
For purposes of this division, "net premiums" means health
benefit plan premiums, less administrative expense allowances.
(B) Any net loss for the year shall be recouped first by
assessments of carriers in accordance with this division.
Assessments shall be apportioned by the board among all carriers
participating in the program in proportion to their respective
shares of the total premiums, net of reinsurance premiums paid
for coverage under this program earned in the state from health
benefit plans covering small employers that are issued by
participating members during the calendar year coinciding with or
ending during the fiscal year of the program, or on any other
equitable basis reflecting coverage of small employers as may be
provided in the plan of operation. An assessment shall be made
pursuant to this division against a health insuring corporation that is
approved by the secretary
of health and
human services as a federally qualified health maintenance
organization pursuant to the "Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended, subject to an assessment
adjustment formula adopted by the board for such health
insuring corporations that recognizes
the restrictions
imposed on the entities by federal law. The
adjustment
formula shall be adopted by the board prior to the first
anniversary of the program's operation. In no event shall the
assessment made pursuant to this division exceed, on an
annual basis, one per cent
of the carrier's Ohio small employer
group premium as reported on its most recent annual statement
filed with the superintendent of insurance. If an excess is
actuarially projected, the superintendent may take any action necessary to
lower the assessment to the maximum level of one per cent.
(C) If assessments exceed actual losses and administrative
expenses of the program, the excess shall be held at interest and
used by the board to offset future losses or to reduce program
premiums. As used in this division, "future losses" includes
reserves for incurred but not reported claims.
(D) Each carrier's proportion of participation in the
program shall be determined annually by the board based on
annual statements and other reports deemed necessary by the
board and filed by the carrier with the board. MEWAs
shall report to the board claims payments made and administrative
expenses incurred in this state on an annual basis
on a form prescribed by the superintendent.
(E) Provision shall be made in the plan of operation for
the imposition of an interest penalty for late payment of
assessments.
(F) A carrier may seek from the superintendent a
deferment, in whole or in part, from any assessment issued by the
board. The superintendent may defer, in whole or in part, the
assessment of a carrier if, in the opinion of the superintendent,
payment of the assessment would endanger the carrier's ability to
fulfill its contractual obligations.
(G) In the event an assessment against a carrier is
deferred in whole or in part, the amount by which the assessment
is deferred may be assessed against the other carriers in a
manner consistent with the basis for assessments set forth in
this section. In such event, the other carriers assessed shall
have a claim in the amount of the assessment against the carrier
receiving the deferment. The carrier receiving the deferment
shall remain liable to the program for the amount deferred. The
superintendent may attach appropriate conditions to any
deferment.
Sec. 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. 4503.104. IN ADDITION TO THE FEES COLLECTED
UNDER
SECTIONS 4503.10 AND 4503.102 OF THE
REVISED
CODE, THE REGISTRAR OF MOTOR VEHICLES OR DEPUTY
REGISTRAR SHALL ASK EACH PERSON APPLYING FOR
OR RENEWING A MOTOR VEHICLE REGISTRATION WHETHER THE PERSON
WISHES TO MAKE A ONE-DOLLAR VOLUNTARY CONTRIBUTION TO
THE SAVE OUR SIGHT FUND ESTABLISHED UNDER SECTION 3701.18 OF THE
REVISED
CODE. EVERY APPLICATION FOR
REGISTRATION OR RENEWAL NOTICE SHALL STATE WHETHER
THE OWNER OF THE MOTOR VEHICLE WISHES TO MAKE A ONE-DOLLAR
VOLUNTARY CONTRIBUTION TO THE SAVE OUR SIGHT FUND
ESTABLISHED UNDER SECTION 3701.18 OF THE
REVISED
CODE. THE REGISTRAR OR DEPUTY
REGISTRAR SHALL ALSO MAKE AVAILABLE TO EACH PERSON APPLYING FOR
OR RENEWING A MOTOR VEHICLE REGISTRATION INFORMATIONAL MATERIALS
ON THE IMPORTANCE OF EYE CARE AND SAFETY PROVIDED BY THE DIRECTOR OF HEALTH
UNDER DIVISION (C)(2) OF SECTION 3701.18 OF THE REVISED
CODE.
ALL DONATIONS COLLECTED UNDER THIS SECTION DURING EACH
CALENDAR QUARTER SHALL BE FORWARDED BY THE REGISTRAR TO THE TREASURER OF
STATE, WHO SHALL
DEPOSIT THEM INTO THE SAVE OUR SIGHT FUND.
Sec. 4715.22. (A) AS USED IN THIS SECTION, "HEALTH
CARE FACILITY" MEANS EITHER OF THE FOLLOWING:
(1) A HOSPITAL REGISTERED UNDER SECTION 3701.07 OF THE REVISED
CODE;
(2) A "HOME" AS DEFINED IN SECTION 3721.01 OF THE REVISED
CODE.
(B) A licensed dental hygienist may SHALL
practice UNDER THE SUPERVISION, ORDER, CONTROL, AND FULL RESPONSIBILITY OF
A DENTIST LICENSED UNDER THIS CHAPTER. A DENTAL HYGIENIST MAY PRACTICE in
a dental office, public or private school, hospital HEALTH CARE
FACILITY, dispensary, or public institution, provided the
service is rendered under the supervision of a licensed dentist of this
state. EXCEPT AS PROVIDED IN DIVISION
(C) OR (D) OF THIS SECTION, A DENTAL
HYGIENIST MAY NOT PROVIDE DENTAL HYGIENE SERVICES TO A PATIENT
WHEN THE SUPERVISING DENTIST IS NOT PHYSICALLY PRESENT AT THE
LOCATION WHERE THE DENTAL HYGIENIST IS PRACTICING.
(C) A DENTAL HYGIENIST
MAY PROVIDE, FOR NOT MORE THAN FIFTEEN CONSECUTIVE BUSINESS
DAYS, DENTAL HYGIENE SERVICES TO A PATIENT WHEN THE SUPERVISING
DENTIST IS NOT PHYSICALLY PRESENT AT THE LOCATION
AT WHICH THE SERVICES ARE PROVIDED IF ALL OF THE FOLLOWING
REQUIREMENTS ARE MET:
(1) THE DENTAL HYGIENIST HAS AT LEAST TWO YEARS AND A MINIMUM OF THREE
THOUSAND HOURS OF EXPERIENCE IN THE PRACTICE OF
DENTAL HYGIENE.
(2) THE DENTAL HYGIENIST HAS SUCCESSFULLY COMPLETED A
COURSE APPROVED BY THE
STATE DENTAL BOARD IN THE
IDENTIFICATION AND PREVENTION OF POTENTIAL MEDICAL
EMERGENCIES.
(3) THE DENTAL HYGIENIST COMPLIES WITH WRITTEN PROTOCOLS
FOR EMERGENCIES THE SUPERVISING DENTIST ESTABLISHES.
(4) THE DENTAL HYGIENIST DOES NOT PERFORM, WHILE THE
SUPERVISING DENTIST IS ABSENT FROM THE LOCATION, PROCEDURES WHILE THE PATIENT
IS ANESTHETIZED, DEFINITIVE ROOT PLANING, DEFINITIVE
SUBGINGIVAL CURETTAGE, OR OTHER PROCEDURES IDENTIFIED IN RULES
THE STATE DENTAL BOARD ADOPTS.
(5) THE SUPERVISING DENTIST HAS EVALUATED THE DENTAL
HYGIENIST'S SKILLS.
(6) THE SUPERVISING DENTIST EXAMINED THE PATIENT NOT MORE
THAN SEVEN MONTHS PRIOR TO THE DATE THE DENTAL HYGIENIST
PROVIDES THE DENTAL HYGIENE SERVICES TO THE PATIENT.
(7) THE DENTAL HYGIENIST COMPLIES WITH WRITTEN PROTOCOLS OR WRITTEN
STANDING ORDERS THAT THE SUPERVISING DENTIST ESTABLISHES.
(8) THE SUPERVISING DENTIST COMPLETED AND EVALUATED A
MEDICAL AND DENTAL HISTORY OF THE PATIENT NOT MORE THAN ONE YEAR
PRIOR TO THE DATE THE DENTAL HYGIENIST PROVIDES DENTAL HYGIENE
SERVICES TO THE PATIENT AND, EXCEPT WHEN THE DENTAL HYGIENE SERVICES
ARE PROVIDED IN A HEALTH CARE FACILITY, THE SUPERVISING DENTIST
DETERMINES THAT THE PATIENT IS IN A MEDICALLY STABLE
CONDITION.
(9) IF THE DENTAL HYGIENE SERVICES ARE PROVIDED IN A
HEALTH CARE FACILITY, A DOCTOR OF MEDICINE AND
SURGERY OR OSTEOPATHIC MEDICINE AND SURGERY WHO HOLDS A CURRENT
CERTIFICATE ISSUED UNDER
CHAPTER 4731. OF THE
REVISED
CODE OR A REGISTERED NURSE
LICENSED UNDER CHAPTER 4723. OF
THE REVISED
CODE IS PRESENT IN THE HEALTH CARE FACILITY WHEN THE SERVICES ARE
PROVIDED.
(10) IN ADVANCE OF THE
APPOINTMENT FOR DENTAL HYGIENE SERVICES, THE PATIENT IS NOTIFIED THAT THE
SUPERVISING DENTIST WILL BE ABSENT FROM THE
LOCATION AND THAT THE DENTAL HYGIENIST CANNOT DIAGNOSE THE PATIENT'S
DENTAL HEALTH CARE STATUS.
(11) THE DENTAL HYGIENIST IS EMPLOYED BY, OR UNDER
CONTRACT WITH, ONE OF THE FOLLOWING:
(a) THE SUPERVISING DENTIST;
(b) A DENTIST LICENSED UNDER THIS CHAPTER WHO IS
ONE OF THE FOLLOWING:
(i) THE EMPLOYER OF THE SUPERVISING
DENTIST;
(ii) A SHAREHOLDER IN A PROFESSIONAL ASSOCIATION
FORMED UNDER CHAPTER
1785. OF THE REVISED
CODE OF WHICH THE SUPERVISING
DENTIST IS A SHAREHOLDER;
(iii) A MEMBER OR MANAGER OF A LIMITED LIABILITY
COMPANY FORMED UNDER
CHAPTER 1705. OF THE
REVISED
CODE OF WHICH THE SUPERVISING
DENTIST IS A MEMBER OR MANAGER;
(iv) A SHAREHOLDER IN A CORPORATION FORMED
UNDER DIVISION (B) OF
SECTION 1701.03 OF THE REVISED
CODE OF WHICH THE SUPERVISING
DENTIST IS A SHAREHOLDER;
(v) A PARTNER OR EMPLOYEE OF A PARTNERSHIP OR A
LIMITED LIABILITY PARTNERSHIP FORMED UNDER
CHAPTER 1775. OF THE
REVISED
CODE OF WHICH THE SUPERVISING
DENTIST IS A PARTNER OR EMPLOYEE.
(c) A GOVERNMENT ENTITY THAT EMPLOYS THE DENTAL HYGIENIST
TO PROVIDE DENTAL HYGIENE SERVICES IN A PUBLIC SCHOOL OR IN
CONNECTION WITH OTHER PROGRAMS THE GOVERNMENT ENTITY
ADMINISTERS.
(D) A DENTAL HYGIENIST MAY PROVIDE DENTAL HYGIENE SERVICES TO A
PATIENT
WHEN THE SUPERVISING DENTIST IS NOT PHYSICALLY PRESENT AT THE LOCATION AT
WHICH
THE SERVICES ARE PROVIDED IF
THE SERVICES ARE PROVIDED AS PART OF A DENTAL HYGIENE PROGRAM THAT IS
APPROVED BY THE STATE DENTAL BOARD AND ALL OF THE FOLLOWING REQUIREMENTS ARE
MET:
(1) THE PROGRAM IS OPERATED THROUGH A SCHOOL DISTRICT
BOARD
OF EDUCATION OR THE GOVERNING BOARD OF AN EDUCATIONAL SERVICE CENTER; THE
BOARD
OF HEALTH OF A CITY OR GENERAL HEALTH DISTRICT OR THE AUTHORITY HAVING THE
DUTIES OF A BOARD OF HEALTH UNDER SECTION 3709.05 OF THE REVISED
CODE; A NATIONAL, STATE, DISTRICT, OR LOCAL DENTAL ASSOCIATION; OR
ANY
OTHER PUBLIC OR PRIVATE ENTITY RECOGNIZED BY THE STATE DENTAL BOARD.
(2) THE SUPERVISING DENTIST IS EMPLOYED BY OR A VOLUNTEER FOR, AND THE
PATIENTS
ARE REFERRED BY, THE ENTITY THROUGH WHICH THE PROGRAM IS OPERATED.
(3) THE SERVICES ARE PERFORMED AFTER EXAMINATION AND DIAGNOSIS BY THE DENTIST
AND IN ACCORDANCE WITH THE DENTIST'S WRITTEN TREATMENT PLAN.
(E) NO PERSON SHALL DO
EITHER OF THE FOLLOWING:
(1) PRACTICE DENTAL HYGIENE IN A MANNER THAT IS SEPARATE
OR OTHERWISE INDEPENDENT FROM THE DENTAL PRACTICE OF A
SUPERVISING DENTIST;
(2) ESTABLISH OR MAINTAIN AN OFFICE OR PRACTICE THAT IS
PRIMARILY DEVOTED TO THE PROVISION OF DENTAL HYGIENE SERVICES.
(F) THE STATE DENTAL
BOARD SHALL ADOPT RULES UNDER DIVISION
(C) OF SECTION 4715.03 OF THE
REVISED
CODE IDENTIFYING PROCEDURES A
DENTAL HYGIENIST MAY NOT PERFORM WHEN PRACTICING IN THE ABSENCE
OF THE SUPERVISING DENTIST PURSUANT TO DIVISION
(C) OR (D) OF THIS SECTION.
Sec. 4715.39. (A) The state dental board may adopt rules, in
accordance with Chapter 119. of the Revised Code, defining DEFINE
THE duties
which THAT may be performed by DENTAL ASSISTANTS AND OTHER
INDIVIDUALS DESIGNATED BY THE BOARD AS qualified personnel, and may
adopt
rules establishing. IF DEFINED, THE DUTIES SHALL BE DEFINED IN
RULES ADOPTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED
CODE. THE RULES MAY INCLUDE training and practice standards for
DENTAL ASSISTANTS AND OTHER qualified
personnel; such. THE standards may include examination
and issuance of
a certificate. IF THE BOARD ISSUES A CERTIFICATE, THE RECIPIENT SHALL
DISPLAY THE CERTIFICATE IN A CONSPICUOUS LOCATION IN ANY OFFICE IN WHICH THE
RECIPIENT IS EMPLOYED TO PERFORM THE DUTIES AUTHORIZED BY THE CERTIFICATE.
THE BOARD'S RULES MAY ALLOW A DENTAL ASSISTANT TO POLISH THE
CLINICAL CROWNS OF TEETH IF ALL OF THE FOLLOWING REQUIREMENTS ARE MET:
(1) THE DENTAL ASSISTANT'S POLISHING ACTIVITIES ARE LIMITED TO THE USE OF
A RUBBER CUP ATTACHED TO A SLOW-SPEED ROTARY DENTAL HAND PIECE.
(2) THE DENTIST SUPERVISING THE ASSISTANT SUPERVISES NOT MORE THAN TWO
DENTAL ASSISTANTS ENGAGING IN POLISHING ACTIVITIES AT ANY GIVEN TIME.
(3) THE DENTAL ASSISTANT IS CERTIFIED BY THE DENTAL ASSISTING NATIONAL
BOARD OR THE OHIO COMMISSION ON DENTAL ASSISTANT CERTIFICATION.
(4) THE DENTAL ASSISTANT RECEIVES A CERTIFICATE FROM THE BOARD AUTHORIZING
THE ASSISTANT TO ENGAGE IN THE POLISHING ACTIVITIES. THE BOARD MAY ISSUE THE
CERTIFICATE ONLY IF THE INDIVIDUAL HAS SUCCESSFULLY
COMPLETED TRAINING IN THE POLISHING OF CLINICAL CROWNS THROUGH A PROGRAM
ACCREDITED BY THE COMMISSION ON DENTAL ACCREDITATION OR EQUIVALENT TRAINING
APPROVED BY THE BOARD. THE TRAINING SHALL
INCLUDE COURSES IN BASIC DENTAL ANATOMY AND INFECTION
CONTROL, FOLLOWED BY A COURSE IN CORONAL POLISHING THAT INCLUDES DIDACTIC,
PRECLINICAL, AND CLINICAL
TRAINING; ANY OTHER TRAINING
REQUIRED BY THE BOARD; AND A SKILLS ASSESSMENT THAT INCLUDES SUCCESSFUL
COMPLETION OF STANDARDIZED TESTING.
(B) Subject to the rules of the board, licensed dentists may
assign to DENTAL ASSISTANTS AND OTHER qualified personnel dental
procedures that do not
require the professional competence or skill of the licensed
dentist or dental hygienist as the board by rule authorizes such
DENTAL ASSISTANTS AND OTHER QUALIFIED
personnel to perform. The performance of dental procedures by
DENTAL ASSISTANTS AND OTHER
qualified personnel shall be under direct supervision and full
responsibility of the licensed dentist.
(C) Nothing in this section shall be construed by rule of the
state dental board or otherwise to authorize " DO THE FOLLOWING:
(1) AUTHORIZE DENTAL ASSISTANTS OR OTHER qualified
personnel" as that term is used in this section to engage in the
practice of dental hygiene as defined by sections 4715.22 and
4715.23 of the Revised Code or to perform the duties of a dental
hygienist, including the removal of calcarious deposits or
accretions on the crowns and roots of teeth,
or as authorizing;
(2) AUTHORIZE
the assignment of diagnosis, treatment ANY OF THE FOLLOWING:
(a) DIAGNOSIS;
(b) TREATMENT planning and prescription
(, including prescription for drugs and medicaments or
authorization for restorative, prosthodontic, or orthodontic
appliances), or surgical;
(c) SURGICAL procedures on hard or soft tissue of the
oral cavity, or any other intraoral procedure that contributes to
or results in an irremediable alteration of the oral anatomy or
the;
(d) THE making of final impressions from which casts are made
to
construct any dental restoration.
(D) No dentist shall assign any DENTAL ASSISTANT OR OTHER
INDIVIDUAL ACTING IN THE CAPACITY OF qualified personnel to perform
any dental procedure such personnel are THAT THE ASSISTANT OR OTHER
INDIVIDUAL IS not authorized by board
rule to perform. No DENTAL ASSISTANT OR OTHER INDIVIDUAL ACTING IN THE
CAPACITY OF qualified personnel shall perform any dental
procedure other than in accordance with board rule or ANY DENTAL
PROCEDURE that such
personnel are THE ASSISTANT OR OTHER INDIVIDUAL IS not authorized
by board rule to perform.
Sec. 4723.16. (A) An individual whom the board of
nursing licenses, certificates, or otherwise legally authorizes to engage
in the practice of nursing as a registered nurse or as a licensed practical
nurse may render the professional services of a registered or licensed
practical nurse within this
state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a
limited liability company formed under Chapter 1705. of the
Revised Code, a partnership, or a professional association
formed under Chapter 1785. of the Revised Code.
This division does not
preclude an individual of that nature from rendering
professional services as a registered or licensed practical nurse through
another form of business entity, including, but not limited to, a nonprofit
corporation or foundation, or in another manner that is
authorized by or in accordance with this chapter, another
chapter of the Revised Code, or rules of the board of
nursing adopted pursuant to this chapter.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry
under Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732.
of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under this chapter;
(5) Pharmacists who are
authorized to practice pharmacy under
Chapter 4729. of the
Revised
Code;
(6) Physical therapists who are authorized to practice
physical therapy under sections 4755.40 to 4755.53 of the
Revised
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery, osteopathic
medicine and surgery, or podiatric medicine and surgery who are
licensed, certificated, or otherwise legally authorized for their respective
practices under
Chapter 4731. of the Revised
Code.
This division shall apply notwithstanding a provision
of a code of ethics applicable to a nurse
that
prohibits a registered or licensed practical nurse from
engaging in the practice of nursing as a registered nurse or as a licensed
practical nurse in combination with a person who is
licensed, certificated, or otherwise legally authorized to
practice optometry, chiropractic, psychology, pharmacy, physical therapy,
MECHANOTHERAPY, medicine and surgery,
osteopathic medicine and surgery,
or podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the
practice of nursing as a registered nurse or as a licensed practical nurse.
Sec. 4725.114. (A) An individual whom the state board of
optometry licenses, certificates, or otherwise legally authorizes to engage
in the practice of optometry may render the professional services of an
optometrist within this
state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a
limited liability company formed under Chapter 1705. of the
Revised Code, a partnership, or a professional association
formed under Chapter 1785. of the Revised Code.
This division does not
preclude an individual of that nature from rendering
professional services as an optometrist through another form of
business entity, including, but not limited to, a nonprofit
corporation or foundation, or in another manner that is
authorized by or in accordance with this chapter, another
chapter of the Revised Code, or rules of the state
board of optometry adopted pursuant to this chapter.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry under
Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732. of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under Chapter 4723. of the Revised Code;
(5) Pharmacists who are
authorized to practice pharmacy under
Chapter 4729. of the
Revised
Code;
(6) Physical therapists who are authorized to practice
physical therapy under sections 4755.40 to 4755.53 of the
Revised
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery, osteopathic
medicine and surgery, or podiatric medicine and surgery who are
authorized for their respective
practices under Chapter 4731. of the Revised
Code.
This division shall apply notwithstanding a provision
of a code of ethics applicable to an optometrist
that
prohibits an optometrist from engaging in
the practice of optometry in combination with a person who is
licensed, certificated, or otherwise legally authorized to
practice chiropractic, psychology, nursing, pharmacy, physical therapy,
MECHANOTHERAPY, medicine and surgery, osteopathic
medicine and surgery,
or podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the
practice of optometry.
Sec. 4729.161. (A) An individual registered with the state
board of
pharmacy to engage
in the practice of pharmacy may render the professional services of
a pharmacist within this
state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a
limited liability company formed under Chapter 1705. of the
Revised Code, a partnership, or a professional association
formed under Chapter 1785. of the Revised Code.
This division does not
preclude an individual of that nature from rendering
professional services as a pharmacist through another form of
business entity, including, but not limited to, a nonprofit
corporation or foundation, or in another manner that is
authorized by or in accordance with this chapter, another
chapter of the Revised Code, or rules of the state
board of pharmacy adopted pursuant to this chapter.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry under
Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732. of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under Chapter 4723. of the Revised Code;
(5) Pharmacists who are authorized to practice pharmacy under
Chapter 4729. of the Revised Code;
(6) Physical therapists who are authorized to practice physical therapy
under sections 4755.40 to 4755.53 of the Revised Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery, osteopathic
medicine and surgery, or podiatric medicine and surgery who are
authorized for their respective
practices under Chapter 4731. of the Revised
Code.
This division shall apply notwithstanding a provision
of a code of ethics applicable to a pharmacist
that
prohibits a pharmacist from engaging in
the practice of pharmacy in combination with a person who is
licensed, certificated, or otherwise legally authorized to
practice optometry, chiropractic, psychology, nursing, physical therapy,
MECHANOTHERAPY, medicine and surgery, osteopathic
medicine and surgery,
or podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the
practice of pharmacy.
Sec. 4731.226. (A)(1) An individual whom the state medical board
licenses, certificates, or otherwise legally authorizes to engage in the
practice of medicine and surgery, osteopathic medicine and
surgery, or podiatric medicine and surgery may render the
professional services of a doctor of medicine and surgery,
osteopathic medicine and surgery, or podiatric medicine and
surgery within this state through a corporation formed under
division (B) of section 1701.03 of the Revised
Code, a limited liability
company formed under Chapter 1705. of the Revised
Code, a partnership, or a professional association formed under
Chapter 1785. of the Revised Code. This division DIVISION
(A)(1) OF THIS SECTION
does not preclude an individual of that nature from rendering
professional services as a doctor of medicine and surgery,
osteopathic medicine and surgery, or podiatric medicine and
surgery through another form of business entity, including, but
not limited to, a nonprofit corporation or foundation, or in
another manner that is authorized by or in accordance with
this chapter, another chapter of the Revised Code, or rules
of the state medical board adopted pursuant to this chapter.
(2) AN INDIVIDUAL
WHOM THE STATE MEDICAL BOARD AUTHORIZES TO ENGAGE IN THE PRACTICE OF
MECHANOTHERAPY MAY RENDER THE PROFESSIONAL SERVICES OF A
MECHANOTHERAPIST WITHIN THIS STATE THROUGH A CORPORATION FORMED
UNDER DIVISION (B) OF SECTION
1701.03 OF THE REVISED
CODE, A LIMITED LIABILITY
COMPANY FORMED UNDER CHAPTER
1705. OF THE REVISED
CODE, A PARTNERSHIP, OR A
PROFESSIONAL ASSOCIATION FORMED UNDER
CHAPTER 1785. OF THE
REVISED
CODE. DIVISION
(A)(2) OF THIS SECTION DOES NOT
PRECLUDE AN INDIVIDUAL OF THAT NATURE FROM RENDERING
PROFESSIONAL SERVICES AS A MECHANOTHERAPIST THROUGH ANOTHER FORM
OF BUSINESS ENTITY, INCLUDING, BUT NOT LIMITED TO, A NONPROFIT
CORPORATION OR FOUNDATION, OR IN ANOTHER MANNER THAT IS
AUTHORIZED BY OR IN ACCORDANCE WITH THIS CHAPTER, ANOTHER
CHAPTER OF THE REVISED
CODE, OR RULES OF
THE STATE MEDICAL BOARD ADOPTED PURSUANT TO THIS CHAPTER.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry under
Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732.
of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under
Chapter 4723. of the Revised Code;
(5) Pharmacists who are
authorized to practice pharmacy under
Chapter 4729. of the
Revised
Code;
(6) Physical therapists who are authorized to practice
physical therapy under sections 4755.40 to 4755.53 of the
Revised
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery,
osteopathic medicine and surgery, or podiatric medicine and
surgery who are authorized for their respective practices under this chapter.
This division (C) DIVISION (B) OF THIS
SECTION shall apply notwithstanding a provision of a code of ethics
described in
division (B)(18) of section 4731.22 of the Revised
Code
that prohibits a EITHER OF THE FOLLOWING:
(1) A doctor of
medicine and surgery, osteopathic medicine and surgery, or
podiatric medicine and surgery from engaging in the doctor's
authorized practice in combination with a person who is
licensed, certificated, or otherwise legally authorized to
engage in the practice of optometry, chiropractic, psychology, nursing,
pharmacy, or physical therapy, OR MECHANOTHERAPY, but
who is not also licensed, certificated, or otherwise legally authorized to
practice medicine and surgery, osteopathic medicine and surgery,
or podiatric medicine and surgery.
(2) A
MECHANOTHERAPIST FROM ENGAGING IN THE PRACTICE OF MECHANOTHERAPY
IN COMBINATION WITH A PERSON WHO IS LICENSED, CERTIFICATED, OR
OTHERWISE LEGALLY AUTHORIZED TO ENGAGE IN THE PRACTICE OF
OPTOMETRY, CHIROPRACTIC, PSYCHOLOGY, NURSING, PHARMACY, PHYSICAL
THERAPY, MEDICINE AND SURGERY, OSTEOPATHIC MEDICINE AND SURGERY,
OR PODIATRIC MEDICINE AND SURGERY, BUT WHO IS NOT ALSO LICENSED,
CERTIFICATED, OR OTHERWISE LEGALLY AUTHORIZED TO ENGAGE IN THE
PRACTICE OF MECHANOTHERAPY.
Sec. 4731.65. As used in sections 4731.65 to 4731.71 of
the Revised Code:
(A)(1) "Clinical laboratory services" means either of the following:
(a) Any examination of materials derived from the human
body for the purpose of providing information for the diagnosis,
prevention, or treatment of any disease or impairment or for the
assessment of health;
(b) Procedures to determine, measure, or otherwise
describe the presence or absence of various substances or
organisms in the body.
(2) "Clinical laboratory services" does not include the
mere collection or preparation of specimens.
(B) "Designated health services" means any of the
following:
(1) Clinical laboratory services;
(2) Home health care services;
(3) Outpatient prescription drugs.
(C) "Fair market value" means the value in arms-length
transactions, consistent with general market value and:
(1) With respect to rentals or leases, the value of rental
property for general commercial purposes, not taking into account
its intended use;
(2) With respect to a lease of space, not adjusted to
reflect the additional value the prospective lessee or lessor
would attribute to the proximity or convenience to the lessor if
the lessor is a potential source of referrals to the lessee.
(D) "Governmental health care program" means
any program
providing health care benefits that is administered by the
federal government, this state, or a political subdivision of
this state, 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, health care coverage for public
employees, health care benefits administered by the bureau of
workers' compensation, the medical assistance program established
under Chapter 5111. of the Revised Code, and disability assistance medical
assistance established
under Chapter 5115. of the Revised Code.
(E)(1) "Group practice" means a group of two
or more
holders of certificates under this chapter legally organized as a
partnership, professional corporation or association, limited liability
company, foundation, nonprofit corporation, faculty practice plan,
or similar group practice entity, including an organization comprised of a
nonprofit medical clinic that contracts with a professional
corporation or association of physicians to provide medical
services exclusively to patients of the clinic in order to comply
with section 1701.03 of the Revised Code
and including a corporation, limited liability company,
partnership, or professional association described in division
(B) of section 4731.226 of the Revised Code formed
for the purpose of providing a combination of the professional services of
optometrists who are licensed, certificated, or otherwise legally authorized
to practice optometry under Chapter 4725. of the Revised
Code, chiropractors who
are licensed, certificated, or otherwise legally authorized to practice
chiropractic under Chapter 4734. of the Revised Code,
psychologists who are licensed, certificated, or
otherwise legally authorized to practice psychology under
Chapter 4732. of the Revised Code, registered or licensed
practical nurses who are licensed, certificated, or otherwise
legally authorized to practice nursing under
Chapter 4723. of the Revised Code,
pharmacists who are licensed,
certificated, or otherwise legally authorized to practice
pharmacy under Chapter 4729. of
the Revised Code, physical
therapists who are licensed, certificated, or otherwise legally
authorized to practice physical therapy under sections 4755.40
to 4755.53 of the Revised
Code,
MECHANOTHERAPISTS WHO ARE LICENSED, CERTIFICATED, OR
OTHERWISE LEGALLY AUTHORIZED TO PRACTICE MECHANOTHERAPY UNDER
SECTION 4731.151 OF THE REVISED
CODE,
and of doctors of
medicine and surgery, osteopathic medicine and surgery, or podiatric medicine
and surgery who are licensed, certificated, or otherwise legally authorized
for their respective practices under this chapter, to which all of the
following apply:
(a) Each physician who is a member of the group practice
provides substantially the full range of services that the
physician routinely provides, including medical care,
consultation, diagnosis, or treatment, through the joint use of
shared office space, facilities, equipment, and personnel.
(b) Substantially all of the services of the members of the group are
provided
through the group and
are billed in the name of the group and amounts so received are
treated as receipts of the group.
(c) The overhead expenses of and the income from the
practice are distributed in accordance with methods previously
determined by members of the group.
(d) The group practice meets any other requirements that
the state medical board applies in rules adopted under section
4731.70 of the Revised Code.
(2) In the case of a faculty practice plan associated with
a hospital with a medical residency training program in which
physician members may provide a variety of specialty services and
provide professional services both within and outside the group,
as well as perform other tasks such as research, the criteria in
division (E)(1) of this section apply only
with respect to
services rendered within the faculty practice plan.
(F) "Home health care services" and
"immediate family" have the same meanings as in
the rules adopted under section 4731.70 of the Revised Code.
(G) "Hospital" has the same meaning as in section
3727.01 of the Revised Code.
(H) A "referral" includes both of the following:
(1) A request by a holder of a certificate under this
chapter for an item or service, including a request for a
consultation with another physician and any test or procedure
ordered by or to be performed by or under the supervision of the
other physician;
(2) A request for or establishment of a plan of care by a
certificate holder that includes the provision of designated health services.
(I) "Third-party payer" has the same meaning
as in section 3901.38 of the Revised Code.
Sec. 4732.28. (A) An individual whom the state board of
psychology licenses, certificates, or otherwise legally authorizes to engage
in the practice of psychology may render the professional services of a
psychologist within this
state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a
limited liability company formed under Chapter 1705. of the
Revised Code, a partnership, or a professional association
formed under Chapter 1785. of the Revised Code.
This division does not
preclude an individual of that nature from rendering
professional services as a psychologist through another form of
business entity, including, but not limited to, a nonprofit
corporation or foundation, or in another manner that is
authorized by or in accordance with this chapter, another
chapter of the Revised Code, or rules of the state
board of psychology adopted pursuant to this chapter.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry
under Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under this chapter;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under
Chapter 4723. of the Revised Code;
(5) Pharmacists who are
authorized to practice pharmacy under
Chapter 4729. of the
Revised
Code;
(6) Physical therapists who are authorized to practice
physical therapy under sections 4755.40 to 4755.53 of the
Revised
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery, osteopathic
medicine and surgery, or podiatric medicine and surgery who are
authorized for their respective practices under
Chapter 4731. of the Revised
Code.
This division shall apply notwithstanding a provision
of a code of ethics applicable to a psychologist
that
prohibits a psychologist from engaging in
the practice of psychology in combination with a person who is
licensed, certificated, or otherwise legally authorized to
practice optometry, chiropractic, nursing, pharmacy, physical therapy,
MECHANOTHERAPY, medicine and surgery, osteopathic
medicine and surgery,
or podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the
practice of psychology.
Sec. 4734.091. (A) An individual whom the chiropractic examining
board licenses, certificates, or otherwise legally authorizes to engage in the
practice of chiropractic may render the professional services of a
chiropractor within this state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a limited liability company formed
under
Chapter 1705. of the Revised Code, a partnership, or a professional
association
formed under Chapter 1785. of the Revised Code. This division does not
preclude an
individual of that nature from rendering professional services as a
chiropractor
through another form of business entity, including, but not limited to, a
nonprofit corporation or foundation, or in another manner that is authorized
by or in accordance with this chapter, another chapter of the Revised Code, or rules of the
chiropractic examining board adopted pursuant to this chapter.
(B) A corporation, limited liability company, partnership, or
professional association described in division (A) of this section
may be formed for the purpose of providing a combination of the professional
services of the following individuals who are licensed, certificated, or
otherwise legally
authorized to practice their respective professions:
(1) Optometrists who are authorized to practice optometry, under
Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice
chiropractic under this chapter;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732. of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under
Chapter 4723. of the Revised Code;
(5) Pharmacists who are
authorized to practice pharmacy under
Chapter 4729. of the
Revised
Code;
(6) Physical therapists who are authorized to practice
physical therapy under sections 4755.40 to 4755.53 of the
Revised
Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and
surgery, osteopathic medicine and surgery, or podiatric medicine and surgery
who are authorized for their
respective practices under Chapter 4731. of the Revised Code.
This division shall
apply notwithstanding a provision of a code of ethics described in division
(A)(9) of section 4734.10 of the Revised Code that
prohibits an individual from engaging in the practice
of chiropractic in combination with a person who is licensed, certificated, or
otherwise authorized for the practice of optometry, psychology, nursing,
pharmacy, physical therapy, MECHANOTHERAPY, medicine and
surgery, osteopathic medicine and
surgery, or podiatric medicine
and surgery, but who is not also licensed, certificated, or otherwise
legally
authorized to engage in the practice of chiropractic.
Sec. 4755.471. (A) An individual whom the physical therapy
section of the Ohio occupational therapy, physical therapy, and
athletic trainers board licenses, certificates, or otherwise legally
authorizes to engage
in the practice of physical therapy may render the professional services of a
physical therapist within this
state through a corporation formed under division
(B) of section 1701.03 of the Revised Code, a
limited liability company formed under Chapter 1705. of the
Revised Code, a partnership, or a professional association
formed under Chapter 1785. of the Revised Code.
This division does not
preclude an individual of that nature from rendering
professional services as a physical therapist through another form of
business entity, including, but not limited to, a nonprofit
corporation or foundation, or in another manner that is
authorized by or in accordance with sections 4755.40 to 4755.53 of the Revised Code, another
chapter of the Revised Code, or rules of the Ohio
occupational therapy, physical therapy, and athletic trainers board adopted
pursuant to sections 4755.40 to 4755.53 of the Revised Code.
(B) A corporation,
limited liability company, partnership, or professional
association described in division (A) of this section may be
formed for the purpose of providing a combination of the
professional services of the following individuals who are licensed,
certificated, or otherwise legally authorized to practice
their respective professions:
(1) Optometrists who are authorized to practice optometry
under Chapter 4725. of the Revised Code;
(2) Chiropractors who are authorized to practice chiropractic under
Chapter 4734. of the Revised Code;
(3) Psychologists who are authorized to practice
psychology under Chapter 4732. of the Revised Code;
(4) Registered or licensed practical nurses who are
authorized to practice nursing as registered nurses or as
licensed practical nurses under
Chapter 4723. of the Revised Code;
(5) Pharmacists who are authorized to practice pharmacy under
Chapter 4729. of the Revised Code;
(6) Physical therapists who are authorized to practice physical therapy
under sections 4755.40 to 4755.53 of the Revised Code;
(7) MECHANOTHERAPISTS WHO ARE AUTHORIZED TO PRACTICE
MECHANOTHERAPY UNDER SECTION 4731.151 OF THE
REVISED
CODE;
(8) Doctors of medicine and surgery, osteopathic
medicine and surgery, or podiatric medicine and surgery who are
authorized for their respective practices under
Chapter 4731. of the Revised
Code.
This division shall apply notwithstanding a provision
of a code of ethics applicable to a physical therapist
that
prohibits a physical therapist from engaging in
the practice of physical therapy in combination with a person who is
licensed, certificated, or otherwise legally authorized to
practice optometry, chiropractic, psychology, nursing, pharmacy,
MECHANOTHERAPY, medicine and
surgery,
osteopathic
medicine and surgery,
or podiatric medicine and surgery, but who is not also licensed,
certificated, or otherwise legally authorized to engage in the
practice of physical therapy.
Sec. 5111.25. (A) The department of human services shall pay each eligible
nursing facility a per resident per day rate for its reasonable capital costs
established prospectively each fiscal year for each facility. Except as
otherwise provided in sections 5111.20 to 5111.32 of the Revised Code, the
rate shall be based on the facility's capital costs for the calendar year
preceding the fiscal year in which the rate will be paid. The rate shall
equal the sum of divisions (A)(1) to (3) of this section:
(1) The lesser of the following:
(a) Eighty-eight and sixty-five one-hundredths per cent of
the facility's desk-reviewed, actual, allowable, per diem cost of
ownership and eighty-five per cent of the facility's actual,
allowable, per diem cost of nonextensive renovation determined
under division (F) of this section;
(b) Eighty-eight and sixty-five one-hundredths per cent of the following
limitation:
(i) For the fiscal year beginning July 1, 1993, sixteen
dollars per resident day;
(ii) For the fiscal year beginning July 1, 1994, sixteen
dollars per resident day, adjusted to reflect the rate of
inflation for the twelve-month period beginning July 1, 1992, and
ending June 30, 1993, using the consumer price index for shelter
costs for all urban consumers for the north central region,
published by the United States bureau of labor statistics;
(iii) For subsequent fiscal years, the limitation in
effect during the previous fiscal year, adjusted to reflect the
rate of inflation for the twelve-month period beginning on the
first day of July for the calendar year preceding the calendar
year that precedes the fiscal year and ending on the following
thirtieth day of June, using the consumer price index for shelter
costs for all urban consumers for the north central region,
published by the United States bureau of labor statistics.
(2) Any efficiency incentive determined under division (D)
of this section;
(3) Any amounts for return on equity determined under
division (H) of this section.
Buildings shall be depreciated using the straight line
method over forty years or over a different period approved by
the department. Components and equipment shall be depreciated
using the straight-line method over a period designated in rules
adopted by the department in accordance with Chapter 119. of the
Revised Code, consistent with the guidelines of the American
hospital association, or over a different period approved by the
department. Any rules adopted under this division that specify
useful lives of buildings, components, or equipment apply only to
assets acquired on or after July 1, 1993. Depreciation for costs
paid or reimbursed by any government agency shall not be included
in cost of ownership or renovation unless that part of the
payment under sections 5111.20 to 5111.32 of the Revised Code is
used to reimburse the government agency.
(B) The capital cost basis of nursing facility assets
shall be determined in the following manner:
(1) For purposes of calculating the rate to be paid for the
fiscal year beginning July 1, 1993, for facilities
with dates of licensure on or before
June 30, 1993, the capital cost basis shall be equal to the
following:
(a) For facilities that have not had a change of ownership
during the period beginning January 1, 1993 and ending June 30,
1993, the desk-reviewed, actual, allowable capital cost basis
that is listed on the facility's cost report for the cost
reporting period ending December 31, 1992, plus the actual,
allowable capital cost basis of any assets constructed or
acquired after December 31, 1992, but before July 1, 1993, if the
aggregate capital costs of those assets would increase the
facility's rate for capital costs by twenty or more cents per
resident per day.
(b) For facilities that have a date of licensure or had a
change of ownership during the period beginning January 1, 1993,
and ending June 30, 1993, the actual, allowable capital cost
basis of the person or government entity that owns the facility
on June 30, 1993.
Capital cost basis shall be calculated as provided in
division (B)(1) of this section subject to approval by the United
States health care financing administration of any necessary
amendment to the state plan for providing medical assistance.
The department shall include the actual, allowable capital
cost basis of assets constructed or acquired during the period
beginning January 1, 1993, and ending June 30, 1993, in the
calculation for the facility's rate effective July 1, 1993, if
the aggregate capital costs of the assets would increase the
facility's rate by twenty or more cents per resident per day and
the facility provides the department with sufficient
documentation of the costs before June 1, 1993. If the facility
provides the documentation after that date, the department shall
adjust the facility's rate to reflect the costs of the assets one
month after the first day of the month after the department
receives the documentation.
(2) Except as provided in division (B)(4) of this
section, for purposes of calculating the rates to be paid for
fiscal years beginning after June 30, 1994, for
facilities with dates of licensure on or before June 30,
1993, the capital cost basis of each asset shall be equal to the
desk-reviewed, actual, allowable, capital cost basis that is
listed on the facility's cost report for the calendar year
preceding the fiscal year during which the rate will be paid.
(3) For facilities with dates of licensure after June
30, 1993, the capital cost basis shall be determined in
accordance
with the principles of the medicare program established under
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, except as otherwise provided in
sections 5111.20 to 5111.32 of the Revised Code.
(4) If EXCEPT AS PROVIDED IN DIVISION (B)(5) OF THIS
SECTION, IF a provider transfers AN INTEREST IN a facility to
another provider
after June 30, 1993, there shall be no increase in the capital
cost basis of the asset if the providers are related parties. If
the providers are not related parties OR IF THEY ARE RELATED PARTIES AND
DIVISION (B)(5) OF THIS SECTION REQUIRES THE ADJUSTMENT OF THE
CAPITAL COST BASIS UNDER THIS DIVISION, the basis of the asset
shall be adjusted by the lesser of the following:
(a) One-half of the change in construction costs during
the time that the transferor held the asset, as calculated by the
department of human services using the "Dodge building cost
indexes, northeastern and north central states," published by
Marshall and Swift;
(b) One-half of the change in the consumer price index for
all items for all urban consumers, as published by the United
States bureau of labor statistics, during the time that the
transferor held the asset.
(5) IF A PROVIDER TRANSFERS AN INTEREST IN A
FACILITY TO ANOTHER PROVIDER WHO IS A RELATED PARTY, THE CAPITAL COST BASIS OF
THE ASSET
SHALL BE ADJUSTED AS SPECIFIED IN DIVISION
(B)(4) OF THIS SECTION FOR A TRANSFER TO A PROVIDER THAT IS NOT A
RELATED PARTY IF ALL OF THE FOLLOWING CONDITIONS ARE MET:
(a) THE RELATED PARTY IS A RELATIVE
OF OWNER;
(b) THE PROVIDER MAKING THE TRANSFER
RETAINS NO OWNERSHIP INTEREST IN THE FACILITY;
(c) THE UNITED STATES INTERNAL REVENUE SERVICE
HAS ISSUED A RULING THAT THE TRANSFER IS AN ARM'S LENGTH
TRANSACTION FOR PURPOSES OF FEDERAL INCOME TAXATION;
(d) EXCEPT IN THE CASE OF HARDSHIP
CAUSED BY A CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT,
OR IN THE CASE OF A PROVIDER MAKING THE TRANSFER WHO IS AT LEAST SIXTY-FIVE
YEARS OF AGE,
NOT LESS THAN TWENTY YEARS HAVE ELAPSED SINCE, FOR THE SAME
FACILITY, THE CAPITAL COST BASIS WAS ADJUSTED MOST RECENTLY UNDER DIVISION
(B)(5) OF THIS SECTION OR
ACTUAL, ALLOWABLE COST OF OWNERSHIP WAS DETERMINED MOST RECENTLY UNDER
DIVISION
(C)(9) OF THIS SECTION.
(C) As used in this division, "lease expense" means lease
payments in the case of an operating lease and depreciation
expense and interest expense in the case of a capital lease. As
used in this division, "new lease" means a lease, to a different
lessee, of a nursing facility that previously was operated under
a lease.
(1) Subject to the limitation specified in division (A)(1)
of this section, for a lease of a facility that was effective on
May 27, 1992, the entire lease expense is an actual, allowable
cost of ownership during the term of the existing lease. The
entire lease expense also is an actual, allowable cost of
ownership if a lease in existence on May 27, 1992, is renewed
under either of the following circumstances:
(a) The renewal is pursuant to a renewal option that was
in existence on May 27, 1992;
(b) The renewal is for the same lease payment amount and
between the same parties as the lease in existence on May 27,
1992.
(2) Subject to the limitation specified in division (A)(1)
of this section, for a lease of a facility that was in existence
but not operated under a lease on May 27, 1992, actual, allowable
cost of ownership shall include the lesser of the annual lease
expense or the annual depreciation expense and imputed interest
expense that would be calculated at the inception of the lease
using the lessor's entire historical capital asset cost basis,
adjusted by the lesser of the following amounts:
(a) One-half of the change in construction costs during
the time the lessor held each asset until the beginning of the
lease, as calculated by the department using the "Dodge building
cost indexes, northeastern and north central states," published
by Marshall and Swift;
(b) One-half of the change in the consumer price index for
all items for all urban consumers, as published by the United
States bureau of labor statistics, during the time the lessor
held each asset until the beginning of the lease.
(3) Subject to the limitation specified in division (A)(1)
of this section, for a lease of a facility with a date of
licensure on or after May 27, 1992, that is initially operated
under a lease, actual, allowable cost of ownership shall include
the annual lease expense if there was a substantial commitment of
money for construction of the facility after December 22, 1992,
and before July 1, 1993. If there was not a substantial
commitment of money after December 22, 1992, and before July 1,
1993, actual, allowable cost of ownership shall include the
lesser of the annual lease expense or the sum of the following:
(a) The annual depreciation expense that would be
calculated at the inception of the lease using the lessor's
entire historical capital asset cost basis;
(b) The greater of the lessor's actual annual amortization
of financing costs and interest expense at the inception of the
lease or the imputed interest expense calculated at the inception
of the lease using seventy per cent of the lessor's historical
capital asset cost basis.
(4) Subject to the limitation specified in division (A)(1)
of this section, for a lease of a facility with a date of
licensure on or after May 27, 1992, that was not initially
operated under a lease and has been in existence for ten years,
actual, allowable cost of ownership shall include the lesser of
the annual lease expense or the annual depreciation expense and
imputed interest expense that would be calculated at the
inception of the lease using the entire historical capital asset
cost basis of the lessor, adjusted by the lesser of the
following:
(a) One-half of the change in construction costs during
the time the lessor held each asset until the beginning of the
lease, as calculated by the department using the "Dodge building
cost indexes, northeastern and north central states," published
by Marshall and Swift;
(b) One-half of the change in the consumer price index for
all items for all urban consumers, as published by the United
States bureau of labor statistics, during the time the lessor
held each asset until the beginning of the lease.
(5) Subject to the limitation specified in division (A)(1)
of this section, for a new lease of a facility that was operated
under a lease on May 27, 1992, actual, allowable cost of
ownership shall include the lesser of the annual new lease
expense or the annual old lease payment. If the old lease was in
effect for ten years or longer, the old lease payment from the
beginning of the old lease shall be adjusted by the lesser of the
following:
(a) One-half of the change in construction costs from the
beginning of the old lease to the beginning of the new lease, as
calculated by the department using the "Dodge building cost
indexes, northeastern and north central states," published by
Marshall and Swift;
(b) One-half of the change in the consumer price index for
all items for all urban consumers, as published by the United
States bureau of labor statistics, from the beginning of the old
lease to the beginning of the new lease.
(6) Subject to the limitation specified in division (A)(1)
of this section, for a new lease of a facility that was not in
existence or that was in existence but not operated under a lease
on May 27, 1992, actual, allowable cost of ownership shall
include the lesser of annual new lease expense or the annual
amount calculated for the old lease under division (C)(2), (3),
(4), or (6) of this section, as applicable. If the old lease was
in effect for ten years or longer, the lessor's historical
capital asset cost basis shall be adjusted by the lesser of the
following for purposes of calculating the annual amount under
division (C)(2), (3), (4), or (6) of this section:
(a) One-half of the change in construction costs from the
beginning of the old lease to the beginning of the new lease, as
calculated by the department using the "Dodge building cost
indexes, northeastern and north central states," published by
Marshall and Swift;
(b) One-half of the change in the consumer price index for
all items for all urban consumers, as published by the United
States bureau of labor statistics, from the beginning of the old
lease to the beginning of the new lease.
In the case of a lease under division (C)(3) of this
section of a facility for which a substantial commitment of money
was made after December 22, 1992, and before July 1, 1993, the
old lease payment shall be adjusted for the purpose of
determining the annual amount.
(7) For any revision of a lease described in division
(C)(1), (2), (3), (4), (5), or (6) of this section, or for any
subsequent lease of a facility operated under such a lease, other
than execution of a new lease, the portion of actual, allowable
cost of ownership attributable to the lease shall be the same as
before the revision or subsequent lease.
(8) EXCEPT AS PROVIDED IN DIVISION
(C)(9) OF THIS SECTION, IF A
PROVIDER LEASES AN INTEREST IN A FACILITY TO ANOTHER PROVIDER WHO IS A RELATED
PARTY,
THE RELATED PARTY'S ACTUAL, ALLOWABLE COST OF OWNERSHIP SHALL
INCLUDE THE LESSER OF THE ANNUAL LEASE EXPENSE OR THE REASONABLE
COST TO THE LESSOR.
(9) IF A PROVIDER LEASES AN INTEREST IN A FACILITY TO ANOTHER PROVIDER WHO
IS A
RELATED PARTY, REGARDLESS OF THE DATE OF THE LEASE, THE RELATED
PARTY'S ACTUAL, ALLOWABLE COST OF OWNERSHIP SHALL INCLUDE THE ANNUAL LEASE
EXPENSE, SUBJECT TO THE LIMITATIONS SPECIFIED IN DIVISIONS
(C)(1) TO (7) OF THIS SECTION,
IF ALL OF THE FOLLOWING CONDITIONS ARE MET:
(a) THE RELATED PARTY IS A RELATIVE OF OWNER;
(b) IF THE LESSOR RETAINS AN
OWNERSHIP INTEREST, IT IS IN ONLY THE REAL PROPERTY AND ANY IMPROVEMENTS
ON THE REAL PROPERTY;
(c) THE UNITED STATES INTERNAL REVENUE SERVICE
HAS ISSUED A RULING THAT THE LEASE IS AN ARM'S LENGTH TRANSACTION
FOR PURPOSES OF FEDERAL INCOME TAXATION;
(d) EXCEPT IN THE CASE OF HARDSHIP
CAUSED BY A CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT,
OR IN THE CASE OF A LESSOR WHO IS AT LEAST SIXTY-FIVE YEARS OF AGE, NOT LESS
THAN
TWENTY YEARS HAVE ELAPSED SINCE, FOR THE SAME FACILITY, THE
CAPITAL COST BASIS WAS ADJUSTED MOST RECENTLY UNDER DIVISION
(B)(5) OF THIS SECTION OR
ACTUAL, ALLOWABLE COST OF OWNERSHIP WAS DETERMINED MOST RECENTLY UNDER
DIVISION
(C)(9) OF THIS SECTION.
(10) This division does not apply to leases of specific
items of equipment.
(D)(1) Subject to division (D)(2) of this section, the department shall pay
each nursing facility an efficiency incentive that is equal to fifty per cent
of the difference between the following:
(a) Eighty-eight and sixty-five one-hundredths per cent of the facility's
desk-reviewed, actual, allowable, per diem cost of ownership;
(b) The applicable amount specified in division (E) of
this section.
(2) The efficiency incentive paid to a
nursing facility shall not exceed the greater of the following:
(a) The efficiency incentive the facility was paid
during the fiscal year ending June 30, 1994;
(b) Three dollars per resident per day, adjusted
annually for rates paid beginning July 1, 1994, for the
inflation rate for the twelve-month period beginning on the first
day of July of the calendar year preceding the calendar
year that precedes the fiscal year for which the efficiency
incentive is determined and ending on the thirtieth day of the
following June, using the consumer price index for
shelter costs for all urban consumers for the north central
region, as published by the United States
bureau of labor statistics.
(3) For purposes of calculating the efficiency
incentive,
depreciation for costs that are paid or reimbursed by any
government agency shall be considered as costs of ownership, and
renovation costs that are paid under division (F) of this section
shall not be considered costs of ownership.
(E) The following amounts shall be used to calculate
efficiency incentives for nursing facilities under this section:
(1) For facilities with dates of licensure prior to
January 1, 1958, four dollars and twenty-four cents per patient
day;
(2) For facilities with dates of licensure after December
31, 1957, but prior to January 1, 1968:
(a) Five dollars and twenty-four cents per patient day if
the cost of construction was three thousand five hundred dollars
or more per bed;
(b) Four dollars and twenty-four cents per patient day if
the cost of construction was less than three thousand five
hundred dollars per bed.
(3) For facilities with dates of licensure after December
31, 1967, but prior to January 1, 1976:
(a) Six dollars and twenty-four cents per patient day if
the cost of construction was five thousand one hundred fifty
dollars or more per bed;
(b) Five dollars and twenty-four cents per patient day if
the cost of construction was less than five thousand one hundred
fifty dollars per bed, but exceeded three thousand five hundred
dollars per bed;
(c) Four dollars and twenty-four cents per patient day if
the cost of construction was three thousand five hundred dollars
or less per bed.
(4) For facilities with dates of licensure after December
31, 1975, but prior to January 1, 1979:
(a) Seven dollars and twenty-four cents per patient day if
the cost of construction was six thousand eight hundred dollars
or more per bed;
(b) Six dollars and twenty-four cents per patient day if
the cost of construction was less than six thousand eight hundred
dollars per bed but exceeded five thousand one hundred fifty
dollars per bed;
(c) Five dollars and twenty-four cents per patient day if
the cost of construction was five thousand one hundred fifty
dollars or less per bed, but exceeded three thousand five hundred
dollars per bed;
(d) Four dollars and twenty-four cents per patient day if
the cost of construction was three thousand five hundred dollars
or less per bed.
(5) For facilities with dates of licensure after December
31, 1978, but prior to January 1, 1981:
(a) Seven dollars and seventy-four cents per patient day
if the cost of construction was seven thousand six hundred
twenty-five dollars or more per bed;
(b) Seven dollars and twenty-four cents per patient day if
the cost of construction was less than seven thousand six hundred
twenty-five dollars per bed but exceeded six thousand eight
hundred dollars per bed;
(c) Six dollars and twenty-four cents per patient day if
the cost of construction was six thousand eight hundred dollars
or less per bed but exceeded five thousand one hundred fifty
dollars per bed;
(d) Five dollars and twenty-four cents per patient day if
the cost of construction was five thousand one hundred fifty
dollars or less but exceeded three thousand five hundred dollars
per bed;
(e) Four dollars and twenty-four cents per patient day if
the cost of construction was three thousand five hundred dollars
or less per bed.
(6) For facilities with dates of licensure in 1981 or any
year thereafter prior to December 22, 1992, the following amount:
(a) For facilities with construction costs less than seven
thousand six hundred twenty-five dollars per bed, the applicable
amounts for the construction costs specified in divisions
(E)(5)(b) to (e) of this section;
(b) For facilities with construction costs of seven
thousand six hundred twenty-five dollars or more per bed, six
dollars per patient day, provided that for 1981 and annually
thereafter prior to December 22, 1992, department shall do both
of the following to the six-dollar amount:
(i) Adjust the amount for fluctuations in construction
costs calculated by the department using the "Dodge building cost
indexes, northeastern and north central states," published by
Marshall and Swift, using 1980 as the base year;
(ii) Increase the amount, as adjusted for inflation under
division (E)(6)(b)(i) of this section, by one dollar and
seventy-four cents.
(7) For facilities with dates of licensure on or after
January 1, 1992, seven dollars and ninety-seven cents, adjusted
for fluctuations in construction costs between 1991 and 1993 as
calculated by the department using the "Dodge building cost
indexes, northeastern and north central states," published by
Marshall and Swift, and then increased by one dollar and
seventy-four cents.
For the fiscal year that begins July 1, 1994, each of the
amounts listed in divisions (E)(1) to (7) of this section shall
be increased by twenty-five cents. For the fiscal year that
begins July 1, 1995, each of those amounts shall be increased by
an additional twenty-five cents. For subsequent fiscal years,
each of those amounts, as increased for the prior fiscal year,
shall be adjusted to reflect the rate of inflation for the
twelve-month period beginning on the first day of July of the
calendar year preceding the calendar year that precedes the
fiscal year and ending on the following thirtieth day of June,
using the consumer price index for shelter costs for all urban
consumers for the north central region, as published by the
United States bureau of labor statistics.
If the amount established for a nursing facility under this
division is less than the amount that applied to the facility
under division (B) of former section 5111.25 of the Revised Code,
as the former section existed immediately prior to December 22,
1992, the amount used to calculate the efficiency incentive for
the facility under division (D)(2) of this section shall be the
amount that was calculated under division (B) of the former
section.
(F) Beginning July 1, 1993, regardless of the facility's
date of licensure or the date of the nonextensive renovations,
the rate for the costs of nonextensive renovations for nursing
facilities shall be eighty-five per cent of the desk-reviewed,
actual, allowable, per diem, nonextensive renovation costs. This
division applies to nonextensive renovations regardless of
whether they are made by an owner or a lessee. If the tenancy of
a lessee that has made nonextensive renovations ends before the
depreciation expense for the renovation costs has been fully
reported, the former lessee shall not report the undepreciated
balance as an expense.
(1) For a nonextensive renovation made after July 1, 1993,
to qualify for payment under this division, both of the following
conditions must be met:
(a) At least five years have elapsed since the date of
licensure of the portion of the facility that is proposed to be
renovated, except that this condition does not apply if the
renovation is necessary to meet the requirements of federal,
state, or local statutes, ordinances, rules, or policies.
(b) The provider has obtained prior approval from the
department of human services, and if required the director of
health has granted a certificate of need for the renovation under
section 3702.52 of the Revised Code. The provider shall submit a
plan that describes in detail the changes in capital assets to be
accomplished by means of the renovation and the timetable for
completing the project. The time for completion of the project
shall be no more than eighteen months after the renovation
begins. The department of human services shall adopt rules in
accordance with Chapter 119. of the Revised Code that specify
criteria and procedures for prior approval of renovation
projects. No provider shall separate a project with the intent
to evade the characterization of the project as a renovation or
as an extensive renovation. No provider shall increase the scope
of a project after it is approved by the department of human
services unless the increase in scope is approved by the
department.
(2) The payment provided for in this division is the only
payment that shall be made for the costs of a nonextensive
renovation. Nonextensive renovation costs shall not be included
in costs of ownership, and a nonextensive renovation shall not
affect the date of licensure for purposes of calculating the
efficiency incentive under divisions (D) and (E) of this section.
(G) The owner of a nursing facility operating under a
provider agreement shall provide written notice to the department
of human services at least forty-five days prior to entering into
any contract of sale for the facility or voluntarily terminating
participation in the medical assistance program. After the date
on which a transaction of sale is closed, the owner shall refund to the
department the amount of excess depreciation paid to the facility by the
department for each year the owner has operated the facility under a provider
agreement and prorated according to the number of medicaid patient days for
which the facility has received payment. If a nursing facility is sold after
five or fewer years of operation under a provider
agreement, the refund to the
department shall be equal to the excess depreciation paid to the facility. If
a nursing facility is sold after more than five years but less than ten years
of operation under a provider agreement, the refund to the department shall
equal the excess depreciation paid to the facility multiplied by
twenty per cent, multiplied by the difference between ten and the
number of years that the facility was operated under a provider
agreement. If a nursing facility is sold after ten or more years
of operation under a provider agreement, the owner shall not
refund any excess depreciation to the department. The
owner of a facility that is sold or that
voluntarily terminates participation in the medical assistance
program also shall refund any other amount that the department
properly finds to be due after the audit conducted under this
division. For the purposes of this division, "depreciation paid
to the facility" means the amount paid to the nursing facility
for cost of ownership pursuant to this section less any amount
paid for interest costs, amortization of financing
costs, and lease expenses. For the purposes of this
division, "excess depreciation" is the nursing facility's depreciated
basis, which is the owner's cost less accumulated depreciation,
subtracted from the purchase price net of selling costs
but not exceeding the amount
of depreciation paid to the facility.
A cost report shall be filed with the department within
ninety days after the date on which the transaction of sale is
closed or participation is voluntarily terminated. The report
shall show the accumulated depreciation, the sales price, and
other information required by the department. The amount of the
last two monthly payments to a nursing facility made pursuant to
division (A)(1) of section 5111.22 of the Revised Code before a
sale or termination of participation shall be held in escrow by a
bank, trust company, or savings and loan association, except that
if the amount the owner will be required to refund under this
section is likely to be less than the amount of the last two
monthly payments, the department shall take one of the following
actions instead of withholding the amount of the last two monthly
payments:
(1) In the case of an owner that owns other facilities
that participate in the medical assistance program, obtain a
promissory note in an amount sufficient to cover the amount
likely to be refunded;
(2) In the case of all other owners, withhold the amount
of the last monthly payment to the nursing facility.
The department shall, within ninety days following the
filing of the cost report, audit the cost report and issue an
audit report to the owner. The department also may audit any
other cost report that the facility has filed during the previous
three years. In the audit report, the department shall state its
findings and the amount of any money owed to the department by
the nursing facility. The findings shall be subject to
adjudication conducted in accordance with Chapter 119. of the
Revised Code. No later than fifteen days after the owner agrees
to a settlement, any funds held in escrow less any amounts due to
the department shall be released to the owner and amounts due to
the department shall be paid to the department. If the amounts
in escrow are less than the amounts due to the department, the
balance shall be paid to the department within fifteen days after
the owner agrees to a settlement. If the department does not
issue its audit report within the ninety-day period, the
department shall release any money held in escrow to the owner.
For the purposes of this section, a transfer of corporate stock,
the merger of one corporation into another, or a consolidation
does not constitute a sale.
If a nursing facility is not sold or its participation is
not terminated after notice is provided to the department under
this division, the department shall order any payments held in
escrow released to the facility upon receiving written notice
from the owner that there will be no sale or termination. After
written notice is received from a nursing facility that a sale or
termination will not take place, the facility shall provide
notice to the department at least forty-five days prior to
entering into any contract of sale or terminating participation
at any future time.
(H) The department shall pay each eligible proprietary
nursing facility a return on the facility's net equity computed
at the rate of one and one-half times the average interest rate
on special issues of public debt obligations issued to the
federal hospital insurance trust fund for the cost reporting
period, except that no facility's return on net equity shall
exceed one dollar per patient day.
When calculating the rate for return on net equity, the
department shall use the greater of the facility's inpatient days
during the applicable cost reporting period or the number of
inpatient days the facility would have had during that period if
its occupancy rate had been ninety-five per cent.
(I) If a nursing facility would receive a lower rate for
capital costs for assets in the facility's possession on July 1,
1993, under this section than it would receive under former
section 5111.25 of the Revised Code, as the former section
existed immediately prior to December 22, 1992, the facility
shall receive for those assets the rate it would have received
under the former section for each fiscal year beginning on or
after July 1, 1993, until the rate it would receive under this
section exceeds the rate it would have received under the former
section. Any facility that receives a rate calculated under the
former section 5111.25 of the Revised Code for assets in the
facility's possession on July 1, 1993, also shall receive a rate
calculated under this section for costs of any assets it
constructs or acquires after July 1, 1993.
Sec. 5111.251. (A) The department of human services shall
pay each eligible intermediate care facility for the mentally
retarded for its reasonable capital costs, a per resident per day
rate established prospectively each fiscal year for each
intermediate care facility for the mentally retarded. Except as
otherwise provided in sections 5111.20 to 5111.32 of the Revised
Code, the rate shall be based on the facility's capital costs for
the calendar year preceding the fiscal year in which the rate
will be paid. The rate shall equal the sum of the following:
(1) The facility's desk-reviewed, actual, allowable, per
diem cost of ownership for the preceding cost reporting period,
limited as provided in divisions (C) and (F) of this section;
(2) Any efficiency incentive determined under division (B)
of this section;
(3) Any amounts for renovations determined under division
(D) of this section;
(4) Any amounts for return on equity determined under
division (I) of this section.
Buildings shall be depreciated using the straight line
method over forty years or over a different period approved by
the department. Components and equipment shall be depreciated
using the straight line method over a period designated by the
department in rules adopted in accordance with Chapter 119. of
the Revised Code, consistent with the guidelines of the American
hospital association, or over a different period approved by the
department of human services. Any rules adopted under this division
that specify
useful lives of buildings, components, or equipment apply only to
assets acquired on or after July 1, 1993. Depreciation for costs
paid or reimbursed by any government agency shall not be included
in costs of ownership or renovation unless that part of the
payment under sections 5111.20 to 5111.32 of the Revised Code is
used to reimburse the government agency.
(B) The department of human services shall pay to each intermediate
care
facility for the mentally retarded an efficiency incentive equal
to fifty per cent of the difference between any desk-reviewed,
actual, allowable cost of ownership and the applicable limit on
cost of ownership payments under division (C) of this section. For purposes
of computing the efficiency incentive, depreciation for costs paid or
reimbursed by any government agency shall be considered as a cost of
ownership, and the applicable limit under division (C) of this section shall
apply both to facilities with more than eight beds and facilities with eight
or fewer beds. The efficiency incentive paid to a facility with eight or
fewer beds shall not exceed
three dollars per patient day, adjusted annually for the
inflation rate for the twelve-month period beginning on the first
day of July of the calendar year preceding the calendar year that
precedes the fiscal year for which the efficiency incentive is
determined and ending on the thirtieth day of the following June,
using the consumer price index for shelter costs for all urban
consumers for the north central region, as published by the
United States bureau of labor statistics.
(C) Cost of ownership payments to intermediate care
facilities for the mentally retarded with more than eight beds
shall not exceed the following limits:
(1) For facilities with dates of licensure prior to
January 1, l958, not exceeding two dollars and fifty cents per
patient day;
(2) For facilities with dates of licensure after December
31, l957, but prior to January 1, l968, not exceeding:
(a) Three dollars and fifty cents per patient day if the
cost of construction was three thousand five hundred dollars or
more per bed;
(b) Two dollars and fifty cents per patient day if the
cost of construction was less than three thousand five hundred
dollars per bed.
(3) For facilities with dates of licensure after December
31, l967, but prior to January 1, l976, not exceeding:
(a) Four dollars and fifty cents per patient day if the
cost of construction was five thousand one hundred fifty dollars
or more per bed;
(b) Three dollars and fifty cents per patient day if the
cost of construction was less than five thousand one hundred
fifty dollars per bed, but exceeds three thousand five hundred
dollars per bed;
(c) Two dollars and fifty cents per patient day if the
cost of construction was three thousand five hundred dollars or
less per bed.
(4) For facilities with dates of licensure after December
31, l975, but prior to January 1, l979, not exceeding:
(a) Five dollars and fifty cents per patient day if the
cost of construction was six thousand eight hundred dollars or
more per bed;
(b) Four dollars and fifty cents per patient day if the
cost of construction was less than six thousand eight hundred
dollars per bed but exceeds five thousand one hundred fifty
dollars per bed;
(c) Three dollars and fifty cents per patient day if the
cost of construction was five thousand one hundred fifty dollars
or less per bed, but exceeds three thousand five hundred dollars
per bed;
(d) Two dollars and fifty cents per patient day if the
cost of construction was three thousand five hundred dollars or
less per bed.
(5) For facilities with dates of licensure after December
31, l978, but prior to January 1, l980, not exceeding:
(a) Six dollars per patient day if the cost of
construction was seven thousand six hundred twenty-five dollars
or more per bed;
(b) Five dollars and fifty cents per patient day if the
cost of construction was less than seven thousand six hundred
twenty-five dollars per bed but exceeds six thousand eight
hundred dollars per bed;
(c) Four dollars and fifty cents per patient day if the
cost of construction was six thousand eight hundred dollars or
less per bed but exceeds five thousand one hundred fifty dollars
per bed;
(d) Three dollars and fifty cents per patient day if the
cost of construction was five thousand one hundred fifty dollars
or less but exceeds three thousand five hundred dollars per bed;
(e) Two dollars and fifty cents per patient day if the
cost of construction was three thousand five hundred dollars or
less per bed.
(6) For facilities with dates of licensure after
December 31, 1979, but prior to
January 1, 1981, not exceeding:
(a) Twelve dollars per patient day if the beds were originally licensed as
residential facility beds by the department of mental retardation and
developmental disabilities;
(b) Six dollars per patient day if the beds were originally
licensed as nursing home beds by the department of health.
(7) For facilities with dates of licensure after December 31,
1980, but prior to January 1, 1982, not exceeding:
(a) Twelve dollars per patient day if the beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Six dollars and forty-five cents per patient day if the beds
were originally licensed as nursing home beds by the department of health.
(8) For facilities with dates of licensure after December 31,
1981, but prior to January 1, 1983, not exceeding:
(a) Twelve dollars per patient day if the beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Six dollars and seventy-nine cents per patient day if the beds
were originally licensed as nursing home beds by the department of health.
(9) For facilities with dates of licensure after December 31,
1982, but prior to January 1, 1984, not exceeding:
(a) Twelve dollars per patient day if the beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Seven dollars and nine cents per patient day if the beds were
originally licensed as nursing home beds by the department of health.
(10) For facilities with dates of licensure after December 31,
1983, but prior to January 1, 1985, not exceeding:
(a) Twelve dollars and twenty-four cents per patient day if the
beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Seven dollars and twenty-three cents per patient day if the
beds were
originally licensed as nursing home beds by the department of health.
(11) For facilities with dates of licensure after December 31,
1984, but prior to January 1, 1986, not exceeding:
(a) Twelve dollars and fifty-three cents per patient day if the
beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Seven dollars and forty cents per patient day if the
beds were
originally licensed as nursing home beds by the department of health.
(12) For facilities with dates of licensure after December 31,
1985, but prior to January 1, 1987, not exceeding:
(a) Twelve dollars and seventy cents per patient day if the
beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Seven dollars and fifty cents per patient day if the
beds were
originally licensed as nursing home beds by the department of health.
(13) For facilities with dates of licensure after December 31,
1986, but prior to January 1, 1988, not exceeding:
(a) Twelve dollars and ninety-nine cents per patient day if the
beds were originally
licensed as residential facility beds by the department of mental retardation
and developmental disabilities;
(b) Seven dollars and sixty-seven cents per patient day if the
beds were
originally licensed as nursing home beds by the department of health.
(14) For facilities with dates of licensure after December 31,
1987, but prior to January 1, 1989, not exceeding thirteen dollars and
twenty-six cents per patient day;
(15) For facilities with dates of licensure after December 31,
1988, but prior to January 1, 1990, not exceeding thirteen dollars and
forty-six cents per patient day;
(16) For facilities with dates of licensure after December 31,
1989, but prior to January 1, 1991, not exceeding thirteen dollars and
sixty cents per patient day;
(17) For facilities with dates of licensure after December 31,
1990, but prior to January 1, 1992, not exceeding thirteen dollars and
forty-nine cents per patient day;
(18) For facilities with dates of licensure after December 31,
1991, but prior to January 1, 1993, not exceeding thirteen dollars and
sixty-seven cents per patient day;
(19) For facilities with dates of licensure after December 31,
1992, not exceeding fourteen dollars and twenty-eight cents per patient day.
(D) Beginning January 1, 1981, regardless of the original
date of licensure, the department of human services shall pay a rate for
the per
diem capitalized costs of renovations to intermediate care
facilities for the mentally retarded made after January 1, l981,
not exceeding six dollars per patient day using 1980 as the base
year and adjusting the amount annually until June 30, 1993, for
fluctuations in construction costs calculated by the department
using the "Dodge building cost indexes, northeastern and north
central states," published by Marshall and Swift. The payment
provided for in this division is the only payment that shall be
made for the capitalized costs of a nonextensive renovation of an
intermediate care facility for the mentally retarded.
Nonextensive renovation costs shall not be included in cost of
ownership, and a nonextensive renovation shall not affect the
date of licensure for purposes of division (C) of this section.
This division applies to nonextensive renovations regardless of
whether they are made by an owner or a lessee. If the tenancy of
a lessee that has made renovations ends before the depreciation
expense for the renovation costs has been fully reported, the
former lessee shall not report the undepreciated balance as an
expense.
For a nonextensive renovation to qualify for payment under
this division, both of the following conditions must be met:
(1) At least five years have elapsed since the date of
licensure or date of an extensive renovation of the portion of
the facility that is proposed to be renovated, except that this
condition does not apply if the renovation is necessary to meet
the requirements of federal, state, or local statutes,
ordinances, rules, or policies.
(2) The provider has obtained prior approval from the
department of human services. The provider shall submit a plan that
describes in
detail the changes in capital assets to be accomplished by means
of the renovation and the timetable for completing the project.
The time for completion of the project shall be no more than
eighteen months after the renovation begins. The department of human
services
shall adopt rules in accordance with Chapter 119. of the Revised
Code that specify criteria and procedures for prior approval of
renovation projects. No provider shall separate a project with
the intent to evade the characterization of the project as a
renovation or as an extensive renovation. No provider shall
increase the scope of a project after it is approved by the
department of human services unless the increase in scope is
approved by the department.
(E) The amounts specified in divisions (C) and (D) of this
section shall be adjusted beginning July 1, 1993, for the
estimated inflation for the twelve-month period beginning on the
first day of July of the calendar year preceding the calendar
year that precedes the fiscal year for which rate will be paid
and ending on the thirtieth day of the following June, using the
consumer price index for shelter costs for all urban consumers
for the north central region, as published by the United States
bureau of labor statistics.
(F)(1) For facilities of eight or fewer beds that have
dates of licensure or have been granted project authorization by
the department of mental retardation and developmental
disabilities before July 1, 1993, and for facilities of eight or
fewer beds that have dates of licensure or have been granted
project authorization after that date if the facilities
demonstrate that they made substantial commitments of funds on or
before that date, cost of ownership shall not exceed eighteen
dollars and thirty cents per resident per day. The
eighteen-dollar and thirty-cent amount shall be increased by the
change in the "Dodge building cost indexes, northeastern and
north central states," published by Marshall and Swift, during
the period beginning June 30, 1990, and ending July 1, 1993, and
by the change in the consumer price index for shelter costs for
all urban consumers for the north central region, as published by
the United States bureau of labor statistics, annually
thereafter.
(2) For facilities with eight or fewer beds that have
dates of licensure or have been granted project authorization by
the department of mental retardation and developmental
disabilities on or after July 1, 1993, for which substantial
commitments of funds were not made before that date, cost of
ownership payments shall not exceed the applicable amount
calculated under division (F)(1) of this section, if the
department of human services gives prior approval for
construction of the facility. If the department does not give
prior approval, cost of ownership payments shall not exceed the
amount specified in division (C) of this section.
(3) Notwithstanding divisions (D) and (F)(1) and (2) of
this section, the total payment for cost of ownership, cost of
ownership efficiency incentive, and capitalized costs of
renovations for an intermediate care facility for the mentally
retarded with eight or fewer beds shall not exceed the sum of the
limitations specified in divisions (C) and (D) of this
section.
(G) Notwithstanding any provision of this section or
section 5111.24 of the Revised Code, the department of human services
may adopt
rules in accordance with Chapter 119. of the Revised Code that
provide for a calculation of a combined maximum payment limit for
indirect care costs and cost of ownership for intermediate care
facilities for the mentally retarded with eight or fewer beds.
(H) After June 30, 1980, the owner of an intermediate care
facility for the mentally retarded operating under a provider
agreement shall provide written notice to the department of human
services at least forty-five days prior to entering into any
contract of sale for the facility or voluntarily terminating
participation in the medical assistance program. After the date
on which a transaction of sale is closed, the owner shall refund
to the department the amount of excess depreciation paid to the
facility by the department for each year the owner has operated
the facility under a provider agreement and prorated according to
the number of medicaid patient days for which the facility has
received payment. If an intermediate care facility for the
mentally retarded is sold after five or fewer years of operation
under a provider agreement, the refund to the department shall be
equal to the excess depreciation paid to the facility. If an
intermediate care facility for the mentally retarded is sold
after more than five years but less than ten years of operation
under a provider agreement, the refund to the department shall
equal the excess depreciation paid to the facility multiplied by
twenty per cent, multiplied by the number of years less than ten
that a facility was operated under a provider agreement. If an
intermediate care facility for the mentally retarded is sold
after ten or more years of operation under a provider agreement,
the owner shall not refund any excess depreciation to the
department. For the purposes of this division, "depreciation
paid to the facility" means the amount paid to the intermediate
care facility for the mentally retarded for cost of ownership
pursuant to this section less any amount paid for interest costs.
For the purposes of this division, "excess depreciation" is the
intermediate care facility for the mentally retarded's
depreciated basis, which is the owner's cost less accumulated
depreciation, subtracted from the purchase price but not
exceeding the amount of depreciation paid to the facility.
A cost report shall be filed with the department within
ninety days after the date on which the transaction of sale is
closed or participation is voluntarily terminated for an
intermediate care facility for the mentally retarded subject to
this division. The report shall show the accumulated
depreciation, the sales price, and other information required by
the department. The amount of the last two monthly payments to
an intermediate care facility for the mentally retarded made
pursuant to division (A)(1) of section 5111.22 of the Revised
Code before a sale or voluntary termination of participation
shall be held in escrow by a bank, trust company, or savings and
loan association, except that if the amount the owner will be
required to refund under this section is likely to be less than
the amount of the last two monthly payments, the department shall
take one of the following actions instead of withholding the
amount of the last two monthly payments:
(1) In the case of an owner that owns other facilities
that participate in the medical assistance program, obtain a
promissory note in an amount sufficient to cover the amount
likely to be refunded;
(2) In the case of all other owners, withhold the amount
of the last monthly payment to the intermediate care facility for
the mentally retarded.
The department shall, within ninety days following the
filing of the cost report, audit the report and issue an audit
report to the owner. The department also may audit any other
cost reports for the facility that have been filed during the
previous three years. In the audit report, the department shall
state its findings and the amount of any money owed to the
department by the intermediate care facility for the mentally
retarded. The findings shall be subject to an adjudication
conducted in accordance with Chapter 119. of the Revised Code.
No later than fifteen days after the owner agrees to a
settlement, any funds held in escrow less any amounts due to the
department shall be released to the owner and amounts due to the
department shall be paid to the department. If the amounts in
escrow are less than the amounts due to the department, the
balance shall be paid to the department within fifteen days after
the owner agrees to a settlement. If the department does not
issue its audit report within the ninety-day period, the
department shall release any money held in escrow to the owner.
For the purposes of this section, a transfer of corporate stock,
the merger of one corporation into another, or a consolidation
does not constitute a sale.
If an intermediate care facility for the mentally retarded
is not sold or its participation is not terminated after notice
is provided to the department under this division, the department
shall order any payments held in escrow released to the facility
upon receiving written notice from the owner that there will be
no sale or termination of participation. After written notice is
received from an intermediate care facility for the mentally
retarded that a sale or termination of participation will not
take place, the facility shall provide notice to the department
at least forty-five days prior to entering into any contract of
sale or terminating participation at any future time.
(I) The department of human services shall pay each
eligible proprietary intermediate care facility for the mentally
retarded a return on the facility's net equity computed at the
rate of one and one-half times the average of interest rates on
special issues of public debt obligations issued to the federal
hospital insurance trust fund for the cost reporting period. No
facility's return on net equity paid under this division shall
exceed one dollar per patient day.
In calculating the rate for return on net equity, the
department shall use the greater of the facility's inpatient days
during the applicable cost reporting period or the number of
inpatient days the facility would have had during that period if
its occupancy rate had been ninety-five per cent.
(J)(1) EXCEPT AS PROVIDED IN DIVISION
(J)(2) OF THIS SECTION, IF A
PROVIDER LEASES OR TRANSFERS AN INTEREST IN A FACILITY TO ANOTHER PROVIDER WHO
IS A
RELATED PARTY, THE RELATED PARTY'S ALLOWABLE COST OF OWNERSHIP
SHALL INCLUDE THE LESSER OF THE FOLLOWING:
(a) THE ANNUAL LEASE EXPENSE OR
ACTUAL COST OF OWNERSHIP, WHICHEVER IS APPLICABLE;
(b) THE REASONABLE COST TO THE LESSOR
OR PROVIDER MAKING THE TRANSFER.
(2) IF A PROVIDER LEASES OR TRANSFERS AN INTEREST IN A
FACILITY TO ANOTHER PROVIDER WHO IS A RELATED PARTY, REGARDLESS OF THE DATE OF
THE LEASE
OR TRANSFER, THE RELATED PARTY'S ALLOWABLE COST OF OWNERSHIP
SHALL INCLUDE THE ANNUAL LEASE EXPENSE OR ACTUAL COST OF
OWNERSHIP, WHICHEVER IS APPLICABLE, SUBJECT TO THE LIMITATIONS
SPECIFIED IN DIVISIONS (B) TO
(I) OF THIS SECTION, IF ALL OF THE
FOLLOWING CONDITIONS ARE MET:
(a) THE RELATED PARTY IS A RELATIVE
OF OWNER;
(b) IN THE CASE OF A LEASE, IF THE LESSOR RETAINS ANY OWNERSHIP
INTEREST, IT IS IN ONLY THE REAL PROPERTY AND ANY IMPROVEMENTS ON THE REAL
PROPERTY;
(c) IN THE CASE OF A TRANSFER, THE
PROVIDER MAKING THE TRANSFER RETAINS NO OWNERSHIP INTEREST IN
THE FACILITY;
(d) THE UNITED STATES INTERNAL REVENUE SERVICE
HAS ISSUED A RULING THAT THE LEASE OR TRANSFER IS AN ARM'S LENGTH
TRANSACTION FOR PURPOSES OF FEDERAL INCOME TAXATION;
(e) EXCEPT IN THE CASE OF HARDSHIP
CAUSED BY A CATASTROPHIC EVENT, AS DETERMINED BY THE DEPARTMENT,
OR IN THE CASE OF A LESSOR OR PROVIDER MAKING THE TRANSFER WHO IS AT LEAST
SIXTY-FIVE YEARS OF AGE, NOT LESS THAN TWENTY YEARS HAVE ELAPSED SINCE, FOR
THE SAME FACILITY, ALLOWABLE COST OF OWNERSHIP WAS DETERMINED
MOST RECENTLY
UNDER THIS DIVISION.
Sec. 5111.264. The EXCEPT AS PROVIDED IN SECTION 5111.25 OR
5111.251
of the Revised Code, THE costs of goods, services, and facilities, furnished to a
provider by a related party are includable in the allowable costs of the
provider at the reasonable cost to the related party.
Sec. 5111.81. (A) There is hereby established the pharmacy and
therapeutics committee of the department of human services. The committee
shall consist of eight members and shall be appointed by the director
of human services. The membership of the committee shall include: two
pharmacists licensed under Chapter 4729. of the Revised Code; two doctors of
medicine and two doctors of osteopathy licensed under Chapter 4731. of the
Revised Code; a registered nurse licensed under Chapter 4723. of the Revised
Code; and a pharmacologist who has a doctoral degree. The committee shall
elect one of its members as chairperson.
(B) In the absence of fraud or bad faith, neither the pharmacy
and therapeutics committee nor a current or former member, agent,
representative, employee, or independent contractor of the committee shall be
held liable in damages to a person as the result of an act, omission,
proceeding, conduct, or decision relating to the official duties undertaken or
performed pursuant to this section, section 5111.811 of the Revised
Code, or
rules promulgated pursuant to section 111.15 or Chapter 119. of the Revised
Code. If a current or former member, agent, representative, employee, or
independent
contractor of the committee requests the state to defend the current or
former member, agent, representative, employee, or independent contractor
against a claim or in an action arising out of an act, omission, proceeding,
conduct, or
decision relating to official duties undertaken or performed, if the request
is made in writing at a reasonable time before the trial of the claim or in
the action, and if the person requesting the defense cooperates in good faith
in the defense of the claim or action, the state shall provide and pay for the
defense of the claim or action and shall pay any resulting judgment,
compromise, or settlement. The state shall not pay that part of a claim or
judgment that is for punitive or exemplary damages.
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.
Sec. 5725.18. (A) An annual franchise tax on the privilege of
being an insurance company is hereby levied on each domestic
insurance company. In the month of May, annually, the treasurer
of state shall charge for collection from each domestic insurance
company a franchise tax in the amount computed in accordance with
the following, as applicable:
(1) With respect to a domestic insurance company
that is a health insuring
corporation,
one per cent of
all premium rate payments received, exclusive of payments received
under 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 pursuant to the medical assistance program
established under Chapter 5111.
of the Revised
Code, as
reflected in its annual report for the preceding calendar year;
(2) With respect to a domestic
insurance company that is not a health insuring corporation,
one and four-tenths per cent of the
gross amount of premiums received from
policies covering risks within this state,
EXCLUSIVE OF PREMIUMS RECEIVED UNDER 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 PURSUANT TO THE MEDICAL
ASSISTANCE PROGRAM ESTABLISHED UNDER
CHAPTER 5111. OF THE
REVISED
CODE,
as reflected in its annual
statement for the preceding calendar year, AND, IF THE COMPANY
OPERATES A
HEALTH INSURING CORPORATION AS A LINE OF BUSINESS, ONE PER CENT
OF ALL PREMIUM RATE PAYMENTS RECEIVED FROM THAT LINE OF BUSINESS, EXCLUSIVE OF
PAYMENTS
RECEIVED UNDER 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 PURSUANT TO THE MEDICAL ASSISTANCE PROGRAM
ESTABLISHED UNDER CHAPTER 5111.
OF THE REVISED CODE, AS REFLECTED IN ITS
ANNUAL STATEMENT FOR THE PRECEDING CALENDAR YEAR.
(B) The gross amount
of premium rate payments or premiums used to compute the applicable tax
in accordance with division (A)
of this section is subject to
the deductions prescribed by section
5729.03 of the Revised Code for foreign insurance companies. The
objects of such tax are those declared in section 5725.24 of the
Revised Code, to which only such tax shall be applied.
(C) In no case shall such tax be less than
two hundred fifty dollars.
Sec. 5729.03. (A) If the superintendent of insurance finds the
annual statement required by section 5729.02 of the Revised Code
to be correct, the superintendent shall compute
the following amount, as applicable, of the balance
of such gross
amount, after deducting such
return premiums and considerations received for reinsurance, and
charge such amount to such company as a tax upon the business
done by it in this state for the period covered by such annual
statement:
(1) If the company is a health insuring corporation, one per cent of the
balance of premium rate payments received, exclusive of payments received
under 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 pursuant to the medical assistance program established
under Chapter 5111. of the Revised Code,
as reflected in its annual report;
(2) If the company is not a health insuring corporation, one and
four-tenths per cent of the balance of premiums received,
EXCLUSIVE OF PREMIUMS RECEIVED UNDER 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 PURSUANT TO THE MEDICAL
ASSISTANCE PROGRAM ESTABLISHED UNDER
CHAPTER 5111. OF THE
REVISED
CODE,
as reflected in its annual statement, AND, IF THE COMPANY OPERATES A
HEALTH INSURING CORPORATION AS A LINE OF BUSINESS, ONE PER CENT
OF THE BALANCE OF PREMIUM RATE PAYMENTS RECEIVED FROM THAT LINE OF BUSINESS,
EXCLUSIVE OF
PAYMENTS RECEIVED UNDER 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 PURSUANT TO THE MEDICAL ASSISTANCE PROGRAM
ESTABLISHED UNDER CHAPTER 5111.
OF THE REVISED CODE, AS REFLECTED IN ITS
ANNUAL STATEMENT.
(B) Any insurance policies that were not
issued in violation of Title XXXIX of the Revised Code and
that were issued prior to April 15, 1967, by a life insurance company
organized and operated without profit to any private shareholder
or individual, exclusively for the purpose of aiding educational
or scientific institutions organized and operated without profit
to any private shareholder or individual, are not subject to the
tax imposed by this section. All taxes collected pursuant to
this section shall be credited to the general revenue fund.
(C) In no case shall the tax imposed under this section be less
than two hundred fifty dollars.
Section 2. That existing sections 1701.03, 1705.03, 1705.04, 1705.53, 1739.01,
1751.01, 1751.02, 1751.03,
1751.05, 1751.06, 1751.11, 1751.12, 1751.13, 1751.14, 1751.15, 1751.16,
1751.20, 1751.31, 1751.32, 1751.46, 1751.55, 1751.58, 1751.59,
1751.60, 1751.62, 1751.81, 1785.01, 1785.02, 1785.03, 1785.08, 1907.161,
2305.252, 3701.75, 3901.21, 3901.38, 3917.01, 3917.06, 3923.021,
3923.122,
3923.57,
3923.571,
3923.58, 3924.01, 3924.03, 3924.033,
3924.08, 3924.09, 3924.10, 3924.11, 3924.13, 3999.22, 4715.22, 4715.39,
4723.16, 4725.114,
4729.161, 4731.226, 4731.65, 4732.28, 4734.091, 4755.471, 5111.25, 5111.251,
5111.264, 5111.81, 5112.01,
5112.08, 5725.18, and 5729.03 and
sections
3924.05, 5111.75, 5111.77, 5111.771, and 5111.811 of the
Revised Code are
hereby repealed.
Section 3. 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 4. That existing Section 3 of Am. Sub. S.B. 67 of the 122nd General
Assembly is hereby repealed.
Section 5. That Section 6 of Am. Sub. S.B. 154 of the 122nd General Assembly
be amended to read as follows:
"Sec. 6. The Insurance Agent Education
Advisory Council operating pursuant to section 3905.483 of the
Revised Code shall create a temporary committee to conduct a
special study of the continuing education requirements for
insurance agents as set forth in the Revised Code and the
Administrative Code. The committee shall be composed of the
eleven members of the Insurance Agent Education Advisory Council
appointed by the Superintendent of Insurance pursuant to section
3905.483 of the Revised Code; A REPRESENTATIVE, APPOINTED BY THE
GOVERNOR, OF THE ASSOCIATION OF FRATERNAL
INSURANCE COUNSELORS; a representative, appointed
by the
Governor, of private entities engaged in the business of
providing continuing education to agents; a representative, appointed by the
Governor, of financial institutions;
two members of the House of Representatives, one from each party, appointed by
the Speaker of the House of
Representatives; and two members of the Senate, one from each party, appointed
by the President of the Senate. The Superintendent or the
Superintendent's designee shall serve on the committee as a
nonvoting member.
The committee shall hold an organizational meeting within thirty
days after the effective date of this section JUNE
30, 1998. At the organizational meeting, the voting members of the
committee shall elect a chairperson and a vice-chairperson for the
committee. The committee shall meet at the call of the
chairperson.
The committee shall study all aspects of the continuing
education requirements for insurance agents as set forth in the
Revised Code and the Administrative Code, and shall be charged
with providing findings and recommendations on how any aspect of
these requirements may be improved.
The study shall include, but is not limited to, an examination
of issues related to the following questions:
(A)Will a reduction in the
biennialcontinuing education requirement satisfy
the continuing education requirements imposed by other states on
nonresident agents?
(B)What are the best methods for
assuring the quality of continuing education courses and
programs of study?
(C)Is the Superintendent of Insurance's
annual approval of a continuing education course or program of
study necessary if there is no change in the course'sorprogram's curriculum, or could a course
or program of study be approved for a longer period of time?
(D)Could the process of approval for
continuing education courses and programs of study be
streamlined, to provide for a more timely and efficient process
of approval?
(E) Should an agent receive continuing education
credit for completing courses or programs of study that pertain
to subjects outside of the agent's area of practice or
licensure?
(F)What is the optimal number of hours
of instruction a statutory continuing education requirement
should require agents to complete?
(G)Should continuing education
requirements include a minimum number of hours of courses or
programs of study on ethics?
(H) Should the completion of a
correspondence course, which course requires the successful
completion of a test on the course material, be an optional
method for an agent's fulfillment of continuing education
requirements?
(I) Should minimum requirements be
established for instructors of continuing education courses,
such as minimum industry experience and a current agent's
license?
(J) Should an agent be limited as to the number of
hours of continuing education credit that the agent may earn
from private providers and associations or from insurance
companies, as a percentage of the total number of hours of
continuing education credit that the agent earns, or is
permitted to earn, during a single compliance period?
(K) Should an agent receive continuing education
credit for completing sales-related courses or programs of
study?
(L) Should an agent's receipt of any special
designation exempt the agent from the completion of further
continuing education requirements?
(M) Has the continuing education requirement improved
the quality of licensed insurance agents?
(N) Would a system in which agents certified their
compliance with continuing education requirements to the
Superintendent, which system included a program of random
verification of agent compliance by the Department of Insurance,
be a feasible alternative to the current system of continuing
education compliance verification?
The committee shall hold a sufficient number of public hearings
outside of Franklin County to provide interested parties
throughout the state a chance to voice their opinions and make
recommendations with regard to the continuing education
requirements for insurance agents.
The committee shall issue an interim report within nine months
after the effective date of this section JUNE
30, 1998. The committee shall issue its final report within eighteen
months after the effective date of this section JUNE
30, 1998. Copies of the interim and the final reports shall be
submitted, at the time of their issuance, to the Speaker of the House of
Representatives, to the President
of the Senate, to the Governor, to the chair of the House
committee having primary jurisdiction over insurance
legislation, to the chair of the Senate committee having primary
jurisdiction over insurance legislation, to the Superintendent
of Insurance, and to the Insurance Agent Education Advisory
Council. The committee may request staff assistance from the
Legislative Service Commission as needed for the completion of
the reports. Upon the issuance of its final report, the
committee shall cease to exist."
Section 6. That existing Section 6 of Am. Sub. S.B. 154 of the 122nd General
Assembly is hereby repealed.
Section 7. That Section 194 of Am. Sub.
H.B. 215 of the 122nd General Assembly be amended to read as
follows:
"Sec. 194. Insurance Tax Phase-in Schedules
Sections 1731.07, 5725.18, 5725.181, 5729.03, and 5729.031 of the
Revised Code, as amended or enacted by this act
AM. SUB. H.B. 215 OR SUB.
H.B. 698 OF THE 122nd GENERAL
ASSEMBLY, shall first apply to
tax year 1999 and shall be implemented according to the
following schedule:
(A) For tax years 1999 through 2002, the tax imposed under section 5729.03 of
the Revised Code on the gross premiums of
foreign insurance companies that are not health insuring corporations shall
be EQUAL THE SUM OF THE AMOUNTS computed
UNDER DIVISIONS (A)(1) AND
(2) OF THIS SECTION.
(1) WITH RESPECT TO THE GROSS PREMIUMS OF THE COMPANY,
EXCLUSIVE OF PREMIUMS RECEIVED UNDER MEDICARE OR MEDICAID,
THE AMOUNT COMPUTED
using the following rates:
| The percentage of |
For Tax Year | premiums is |
1999 | 2.3% |
2000 | 2.09% |
2001 | 1.84% |
2002 | 1.62% |
(2) WITH RESPECT TO
PREMIUM RATE PAYMENTS RECEIVED BY THE COMPANY, EXCLUSIVE OF
PAYMENTS RECEIVED UNDER MEDICARE OR
MEDICAID, IF THE COMPANY
OPERATES A HEALTH INSURING CORPORATION AS A LINE OF BUSINESS,
THE AMOUNT COMPUTED USING THE FOLLOWING RATES:
| _THE PERCENTAGE OF PREMIUM |
_FOR_TAX_YEAR | RATE PAYMENTS IS |
1999 | .21% |
2000 | .42% |
2001 | .60% |
2002 | .80% |
(B) For tax years 1999 through 2002, the tax imposed under section 5725.18 of
the Revised Code on domestic insurance companies that are not health insuring
corportaions CORPORATIONS shall equal the sum of the
amounts computed under division DIVISIONS (B)(1) and (2) of this
section.
(1) The tax computed according to the method prescribed in section 5725.181
of the Revised Code, as enacted by this act
AM. SUB. H.B. 215 OF THE
122nd GENERAL ASSEMBLY, multiplied by the
percentage prescribed as follows:
| Multiply the tax under |
| section 5725.181 of |
For Tax Year | the Revised Code by |
1999 | 79% |
2000 | 58% |
2001 | 40% |
2002 | 20% |
(2) The tax computed using ACCORDING TO the percentage of
gross premiums METHOD prescribed by IN section
5725.18 of the Revised Code, as amended by this act SUB.
H.B. 698 OF THE 122nd
GENERAL ASSEMBLY, multiplied by the
percentage prescribed as follows:
| Multiply the tax |
| under amended section |
| 5725.18 of the |
For Tax Year | Revised Code by |
1999 | 21% |
2000 | 42% |
2001 | 60% |
2002 | 80% |
(C) For tax years 1999 through 2002, the tax
imposed under sections 5725.18 and 5729.03 of the Revised Code on domestic and
foreign insurance companies that are health insuring corporations shall be
computed using the following rates:
|
The percentage of premium
|
For Tax Year
|
rate payments is
|
1999
|
.21%
|
2000
|
.42%
|
2001
|
.60%
|
2002
|
.80%
|
(D) For tax years 1999 through 2002, the minimum tax for domestic insurance
companies taxed under sections 5725.18 and 5725.181 of the Revised Code,
the minimum tax for foreign insurance companies taxed under section 5729.03 of
the Revised Code, and the minimum tax for COMPANIES THAT ARE health
insuring corporations taxed
under those sections shall equal the amount prescribed as follows:
For Tax Year | The minimum tax is |
1999 | $50 |
2000 | $100 |
2001 | $150 |
2002 | $200 |
(E) For tax years 1999 through 2002, the credit available under section
5729.031 of the Revised Code may be claimed against the tax imposed on foreign
insurance companies as computed under division (A) of this section, against
the tax imposed on domestic insurance companies as computed under division (B)
of this section, or against the tax imposed on COMPANIES THAT ARE
health insuring corporations as computed under division (C) of this section.
The credit shall equal a percentage of
the amount computed under division (C) of section 5729.031 of the Revised Code
according to the following schedule:
| Percentage of |
For Tax Year | credit allowed |
1999 | 20% |
2000 | 40% |
2001 | 60% |
2002 | 80% |
As used in this section, "health insuring corporation" has the same meaning
as in section 1751.01 of the Revised Code, and "tax year" means the calendar
year in which the tax imposed on the insurance company or health insuring
corporation is charged."
Section 8. That existing Section 194 of Am. Sub. H.B. 215 of
the 122nd General Assembly is hereby repealed.
Section 9. Pursuant to the authority granted under section
3905.29 of the Revised Code, the Superintendent of Insurance
shall modify the forms on which annual financial statements are
submitted by domestic and foreign insurance companies to
include, as a separate item, the amount of premium rate payments
received, exclusive of payments received under Medicare or
Medicaid, by any such insurance company that operates a health
insuring corporation as a line of business.
Section 10. (A) Until November 1, 1999, the
Director of Health shall not adopt any rule, whether by
adopting, amending, or rescinding a rule or by submitting a rule
for review under section 119.032 of the Revised Code, that has
the effect of allowing cardiac catheterization to be performed
without an on-site open-heart surgery service.
(B) In 1999, the Director of Health shall appear
three times before the standing committee of the House of
Representatives that primarily deals with health matters and the
standing committee of the Senate that primarily deals with
health matters to report on the progress of the Department of
Health in collecting statewide and national data on the outcomes
of cardiac catheterization performed without an on-site
open-heart surgery service. The first appearance before each committee shall
be made
not later than April 1, 1999. The second appearance shall be
made not sooner than 30 days after the first appearance, but not
later than June 1, 1999. The third appearance shall be made not
sooner than 30 days after the second appearance, but not
later than October 1, 1999. At the third appearance, the
Director shall make a final report on the Department's findings.
The Director shall submit a written copy of the report to the
Speaker of the House of Representatives and the President of the
Senate.
Section 11. For purposes of determining whether a dental hygienist has met the
experience requirements specified in division (C)(1) of section 4715.22 of the
Revised Code, as amended by this act, all experience that the dental hygienist
obtained prior to the effective date of this act shall be counted.
Section 12. Sections 3701.18 and 4503.104 of the Revised Code, as enacted by
this act, shall take effect on the first day of the month that follows the
month that includes the day that is the ninetieth day after the effective of
this act.
Section 13. The amendment of sections 5112.01 and 5112.08 of the Revised Code
by this act is not intended to supersede the repeal of those sections
effective July 1, 1999.
Section 14. The repeal of sections 5111.75, 5111.77, 5111.771, and 5111.811 of
the Revised Code is intended to confirm that such repeal was the result
intended by the General Assembly in enacting Am. Sub. S.B. 62 and Am. Sub.
S.B. 150 of the 121st General Assembly. The earlier of the two acts, Am. Sub.
S.B. 62, repealed the sections in pursuance of its specific purpose of
abolishing the Legislative Committee on Medicaid Oversight. The later of the
two acts, Am. Sub. S.B. 150, purportedly amended the sections as they related
to its general purpose of revising the health care and insurance laws. The
later act, Am. Sub. S.B. 150, did not have a purpose sufficiently independent
from that of Am. Sub. S.B. 62 such as to revive the sections.
Section 15. 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.
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