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Sub. H. B. No. 125 As Reported by the Senate Judiciary--Civil Justice CommitteeAs Reported by the Senate Judiciary--Civil Justice Committee
127th General Assembly | Regular Session | 2007-2008 |
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Cosponsors:
Representatives DeGeeter, Seitz, McGregor, J., Schneider, Latta, Adams, Gibbs, Setzer, Oelslager, Uecker, McGregor, R., Stewart, J., Stebelton, Fessler, Barrett, Wagoner, Celeste, Reinhard, Widener, Blessing, Book, Carmichael, Lundy, Hughes, Core, Dodd, Batchelder, Boyd, Budish, Chandler, Collier, Distel, Driehaus, Dyer, Evans, Flowers, Goyal, Hagan, J., Healy, Koziura, Letson, Luckie, Otterman, Patton, Yuko
Senators Goodman, Seitz
A BILL
To amend sections 1751.13, 1753.01, 1753.07, 1753.09,
2317.54, 3701.741,
3702.51, and 5111.17, to enact
sections 3721.042,
3963.01 to 3963.11,
and
to
repeal sections
1753.03,
1753.04,
1753.05, and
1753.08 of the
Revised Code
to
establish
certain
uniform
contract provisions
between
health care
providers and contracting
entities,
to establish
standardized
credentialing,
to
require
the
Department of Job and
Family
Services to
allow managed care plans to
use
providers to
render care, to modify
the fees
for electronic copies of certain medical records
and
allow
an
authorized person to obtain one
copy of a patient's
medical
record without
charge, to exempt a nursing home that is a
converted county or district home from
administrative rules regarding the toilet rooms
and dining and recreation areas of nursing homes
if certain other requirements are met, to create a
Joint
Legislative
Study
Commission on Most
Favored
Nation Clauses
in
Health Care
Contracts, and to create an Advisory
Committee on
Eligibility and Real Time Claim
Adjudication.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.13, 1753.01, 1753.07, 1753.09,
2317.54, 3701.741,
3702.51, and 5111.17 be amended and sections
3721.042, 3963.01,
3963.02, 3963.03,
3963.04, 3963.05, 3963.06,
3963.07, 3963.08,
3963.09, 3963.10, and 3963.11
of the Revised
Code be enacted to
read as follows:
Sec. 1751.13. (A)(1)(a) A health
insuring corporation shall,
either directly or indirectly, enter
into contracts for the
provision of health care services with a
sufficient number and
types of providers and health care
facilities to ensure that all
covered health care services will
be accessible to enrollees from
a contracted provider or health
care facility.
(b) A health insuring corporation shall not refuse
to
contract with a physician for the provision of health care
services or refuse to recognize a physician as a specialist on
the
basis that the physician attended an educational program or
a
residency program approved or certified by the
American
osteopathic association. A health insuring corporation
shall not
refuse to
contract with a health care facility for the provision
of health
care services on the basis that the health care facility
is
certified or accredited by the
American osteopathic association
or that the health care
facility is an osteopathic
hospital as
defined in section 3702.51 of the
Revised
Code.
(c) Nothing in division
(A)(1)(b)
of this section shall be
construed to require a health insuring
corporation to make a
benefit payment under a closed panel plan
to a physician or health
care facility with which the health
insuring corporation does not
have a contract, provided that
none of the bases set forth in that
division are used as a
reason for failing to make a benefit
payment.
(2) When a health insuring corporation is unable to
provide a
covered health care service from a contracted provider
or health
care facility, the health insuring corporation must
provide that
health care service from a noncontracted provider
or health care
facility consistent with the terms of the
enrollee's policy,
contract, certificate, or agreement. The
health insuring
corporation shall either ensure that the health
care service be
provided at no greater cost to the enrollee than
if the enrollee
had obtained the health care service from a
contracted provider or
health care facility, or make other
arrangements acceptable to the
superintendent of
insurance.
(3) Nothing in this section shall prohibit a health
insuring
corporation from entering into contracts with
out-of-state
providers or health care facilities that are
licensed, certified,
accredited, or otherwise authorized in that
state.
(B)(1) A health insuring
corporation shall, either directly
or indirectly, enter into
contracts with all providers and health
care facilities through
which health care services are provided to
its enrollees.
(2) A health insuring corporation, upon written request,
shall assist its
contracted providers in finding stop-loss or
reinsurance carriers.
(C) A health insuring corporation shall file an annual
certificate with the superintendent certifying that all provider
contracts
and contracts with health care facilities through which
health
care services are being provided contain the following:
(1) A description of the method by which the provider or
health care facility will be notified of the specific health
care
services for which the provider or health care facility
will be
responsible, including any limitations or conditions on
such
services;
(2) The specific hold harmless provision specifying
protection of enrollees set forth as follows:
"[Provider/Health Care
Facility] agrees that in no event,
including but not limited to
nonpayment by the health insuring
corporation, insolvency of the health
insuring corporation, or
breach of this agreement, shall
[Provider/Health Care
Facility]
bill, charge, collect a deposit from, seek
remuneration or
reimbursement from, or have any recourse
against, a subscriber,
enrollee, person to whom health care services have been
provided,
or person acting on behalf of the covered enrollee,
for health
care services provided pursuant to this agreement.
This does not
prohibit [Provider/Health
Care Facility] from collecting
co-insurance, deductibles, or copayments as specifically
provided
in the evidence of coverage, or fees for uncovered
health care
services delivered on a fee-for-service basis to
persons
referenced above, nor from any recourse against the
health
insuring corporation or its successor."
(3) Provisions requiring the provider or health care
facility
to continue to provide covered health care services to
enrollees
in the event of the health insuring corporation's
insolvency or
discontinuance of operations. The
provisions shall require the
provider or health care facility to
continue to provide covered
health care services to enrollees as
needed to complete any
medically necessary procedures commenced
but unfinished at the
time of the health insuring corporation's
insolvency or
discontinuance of operations. 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
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
department
of job and family 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.
(f) A provision that violates Chapter 3963. of the Revised
Code.
(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
notify its
affected enrollees of the termination of a
contract 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. 1753.01. As used in this chapter:
(A) "Economic profiling" means a health insuring
corporation's use of economic performance data and economic
information in determining whether to contract with a provider
for
the provision of covered health care services to enrollees
as a
participating provider.
(B) "Basic, "basic health care services," "enrollee," "health
care
facility," "health care services," "health insuring
corporation,"
"medical
record," "person," "primary care provider,"
"provider," "specialty health care services,"
"subscriber," and
"supplemental health care services"
have the
same
meanings as in
section 1751.01 of
the Revised Code.
Sec. 1753.07. (A)(1) Prior to entering into a
participation
contract with a provider under
section 1751.13 of the Revised
Code, a health insuring
corporation shall disclose basic
information regarding its
programs and procedures to the provider,
upon the provider's
request. The information shall include all of
the following:
(1)(a) How a participating provider is reimbursed for the
participating
provider's
services, including the range and
structure of
any financial risk sharing arrangements, a
description of
any incentive plans, and, if reimbursed according
to a type of
fee-for-service arrangement, the level of
reimbursement for the
participating provider's services;
(2)(b) Insofar as division (A)(1) of section 3963.03 of the
Revised Code is applicable, all of the information that is
described in that division and is not included in division
(A)(1)(a) of this section.
(2) Prior to entering into a participation contract with a
provider under section 1751.13 of the Revised Code, a health
insuring corporation shall disclose the following information upon
the provider's request:
(a) How referrals to other participating providers or to
nonparticipating providers are made;
(3)(b) The availability of dispute resolution procedures and
the potential for cost to be incurred;
(4)(c) How a participating provider's name and address will
be used in
marketing materials.
(B) A health insuring corporation shall provide
all of the
following to a participating provider:
(1) Any material incorporated by reference into the
participation contract, that is not otherwise available as a
public record, if
such material affects the participating
provider;
(2) Administrative manuals related to provider
participation,
if any;
(3) Insofar as division (B) of section 3963.03 of the Revised
Code is applicable, the summary disclosure form with the
disclosures required under that division;
(4) A signed and dated copy of the final participation
contract.
(C) Nothing in this section requires a health insuring
corporation providing specialty health care services or
supplemental health care services to disclose the health insuring
corporation's
aggregate maximum allowable fee table used to
determine providers' fees or fee schedules.
Sec. 1753.09. (A) Except as provided in division
(D) of this
section, prior to
terminating the participation of a provider on
the
basis of the participating provider's failure to meet the
health insuring
corporation's standards for quality or utilization
in the delivery of health
care
services, a health insuring
corporation shall give the
participating provider notice of the
reason or reasons for its
decision to terminate the provider's
participation and an opportunity to take
corrective action. The
health insuring corporation shall
develop a performance
improvement plan in conjunction with the
participating provider.
If after being afforded the opportunity
to comply with the
performance improvement plan, the participating provider
fails to
do so, the health insuring corporation may terminate the
participation of the provider.
(B)(1) A participating provider whose participation has
been
terminated under division
(A) of this section may appeal
the
termination to the appropriate medical director of the
health
insuring corporation. The medical director shall give
the
participating provider an opportunity to discuss with the
medical
director the reason or reasons for the termination.
(2) If a satisfactory resolution of a participating
provider's appeal cannot be reached under division
(B)(1) of this
section, the participating provider
may appeal the termination to
a panel composed of participating
providers
who have comparable or
higher levels of
education and training than the participating
provider making
the appeal. A representative of the participating
provider's
specialty shall be a member of the panel, if possible.
This
panel shall hold a hearing, and shall render its
recommendation in the
appeal within thirty days after holding the
hearing. The
recommendation shall be presented to the medical
director and to the
participating provider.
(3) The medical director shall review and consider the
panel's recommendation before making a decision. The decision
rendered by the medical director shall be final.
(C) A
provider's status as a participating provider shall
remain in effect during
the appeal
process set forth in division
(B) of this
section unless the termination was based on any of the
reasons
listed in division (D) of this
section.
(D) Notwithstanding division (A) of this section, a
provider's participation may be
immediately terminated if the
participating provider's conduct presents an
imminent risk of harm
to
an enrollee or enrollees; or if there has occurred unacceptable
quality of care, fraud, patient abuse, loss of clinical
privileges, loss of professional liability coverage, incompetence,
or loss of
authority to practice in the participating provider's
field; or if a
governmental action has
impaired the participating
provider's ability to practice.
(E) Divisions (A) to (D) of this section apply
only to
providers who are natural persons.
(F)(1) Nothing in this
section prohibits a health insuring
corporation from rejecting a
provider's application for
participation, or from
terminating a participating provider's
contract, if the health
insuring corporation determines that the
health care needs of
its enrollees are being met and no need
exists for the
provider's or participating provider's services.
(2) Nothing in this section shall be construed as prohibiting
a health
insuring corporation from terminating a participating
provider who does not
meet the terms
and conditions of the
participating provider's contract.
(3) Nothing in this section shall be construed as prohibiting
a health insuring corporation from terminating a participating
provider's contract pursuant to any provision of the contract
described in division (E)(2) of section 3963.02 of the
Revised
Code, except that, notwithstanding any provision of a
contract
described in that division, this section applies to the
termination of a
participating provider's contract for any of the
causes described
in divisions (A), (D), and (F)(1) and (2) of
this section.
(G) The superintendent of insurance may adopt
rules as
necessary to implement and enforce sections 1753.04 to
1753.06,
1753.07, and 1753.09 of the Revised
Code. Such rules shall be
adopted in accordance with
Chapter 119. of the
Revised
Code. The
director of health
may make recommendations to the superintendent
for rules
necessary to implement and enforce sections 1753.04 to
1753.06, 1753.07, and 1753.09
of the Revised
Code. In adopting any
rules
pursuant to this division, the superintendent shall consider
the
recommendations of the director.
Sec. 2317.54. No hospital, home health agency,
ambulatory
surgical facility, or provider
of a hospice care program shall be
held liable for a physician's
failure to obtain an informed
consent from
the physician's
patient prior to a
surgical or
medical procedure or course of procedures, unless the
physician is
an employee of the hospital, home health agency,
ambulatory
surgical facility, or
provider of a hospice care program.
Written consent to a surgical or medical procedure or
course
of procedures shall, to the extent that it fulfills all
the
requirements in divisions (A), (B), and (C) of this section,
be
presumed to be valid and effective, in the absence of proof by
a
preponderance of the evidence that the person who sought such
consent was not acting in good faith, or that the execution of
the
consent was induced by fraudulent misrepresentation of
material
facts, or that the person executing the consent was not
able to
communicate effectively in spoken and written English or
any other
language in which the consent is written. Except as
herein
provided, no evidence shall be admissible to impeach,
modify, or
limit the authorization for performance of the
procedure or
procedures set forth in such written consent.
(A) The consent sets forth in general terms the nature and
purpose of the procedure or procedures, and what the procedures
are expected to accomplish, together with the reasonably known
risks, and, except in emergency situations, sets forth the names
of the physicians who shall perform the intended surgical
procedures.
(B) The person making the consent acknowledges that such
disclosure of information has been made and that all questions
asked about the procedure or procedures have been answered in a
satisfactory manner.
(C) The consent is signed by the patient for whom the
procedure is to be performed, or, if the patient for any reason
including, but not limited to, competence, infancy minority, or
the fact
that, at the latest time that the consent is needed, the
patient
is under the influence of alcohol, hallucinogens, or
drugs, lacks
legal capacity to consent, by a person who has legal
authority to
consent on behalf of such patient in such
circumstances, including either of the following:
(1) The parent, whether the parent is an adult or a minor, of
the parent's minor child;
(2) An adult whom the parent of the minor child has given
written authorization to consent to a surgical or medical
procedure or course of procedures for the parent's minor child.
Any use of a consent form that fulfills the requirements
stated in divisions (A), (B), and (C) of this section has no
effect on the common law rights and liabilities, including the
right of a physician to obtain the oral or implied consent of a
patient to a medical procedure, that may exist as between
physicians and patients on July 28, 1975.
As used in this section the term "hospital" has the
same
meaning
as in
section
2305.113
of the Revised Code;
"home health
agency" has the
same meaning
as in
section
5101.61 of
the Revised
Code;
"ambulatory surgical
facility" has the meaning
as in
division (A) of section 3702.30 of
the Revised Code; and
"hospice
care program"
has the
same meaning
as in
section 3712.01 of
the
Revised Code. The
provisions of this division apply to
hospitals,
doctors of
medicine, doctors of osteopathic medicine,
and doctors
of
podiatric medicine.
Sec. 3701.741. (A) Through December 31, 2008, each Each
health
care provider and medical records
company shall provide
copies of
medical records in accordance with this
section.
(B) Except as provided in divisions (C) and (E)
of this
section, a health care provider
or medical records company that
receives a request for a copy of a patient's
medical record shall
charge not more than the amounts set forth in this section.
(1) If the request is made by the patient or the patient's
personal representative, total
costs for copies and all services
related to those copies shall
not
exceed the sum of the following:
(a) With Except as provided in division (B)(1)(b) of this
section, with respect to data recorded on paper or electronically,
the following
amounts:
(i) Two dollars and fifty seventy-four cents per page for the
first ten
pages;
(ii) Fifty-one Fifty-seven cents per page for pages eleven
through fifty;
(iii) Twenty Twenty-three cents per page for pages fifty-one
and higher;
(b) With respect to data resulting from an x-ray, magnetic
resonance imaging (MRI), or computed axial tomography (CAT) scan
and recorded other than on paper or film, one
dollar and seventy
eighty-seven
cents
per page;
(c) The actual cost of any related postage incurred by the
health care provider or medical records company.
(2) If the request is made other than by the patient or the
patient's personal representative, total costs for copies and all
services related to those copies shall not exceed the sum of the
following:
(a) An initial fee of fifteen sixteen dollars and thirty-five
eighty-four cents,
which shall
compensate for the
records search;
(b) With Except as provided in division (B)(2)(c) of this
section, with respect to data recorded on paper or electronically,
the following
amounts:
(i) One dollar and two eleven cents per page for the first
ten
pages;
(ii) Fifty-one Fifty-seven cents per page for pages eleven
through fifty;
(iii) Twenty Twenty-three cents per page for pages fifty-one
and higher.
(c) With respect to data resulting from an x-ray, magnetic
resonance imaging (MRI), or computed axial tomography (CAT) scan
and recorded other than on paper or film, one
dollar and seventy
eighty-seven
cents
per page;
(d) The actual cost of any related postage incurred by the
health care
provider or medical records company.
(C)(1) A On request, a health care provider or medical
records company
shall
provide one copy of the patient's medical
record and one copy of any records regarding treatment performed
subsequent to the original request, not including copies of
records already provided, without charge to the following:
(a) The bureau of workers' compensation, in accordance with
Chapters 4121. and 4123. of the Revised Code and the rules adopted
under those
chapters;
(b) The industrial commission, in accordance with Chapters
4121.
and 4123. of the Revised Code and the rules adopted under
those chapters;
(c) The department of job and family services or a county
department of job and family services, in accordance
with
Chapters 5101. and 5111. of the Revised Code and the rules adopted
under
those chapters;
(d) The attorney general, in accordance with sections 2743.51
to 2743.72 of the Revised Code and any rules that may be adopted
under those sections;
(e) A patient or, patient's personal representative, or
authorized person if
the
medical
record is necessary to support a
claim under Title
II or
Title XVI
of the "Social Security
Act," 49
Stat. 620 (1935), 42
U.S.C.A. 401
and 1381, as amended, and the
request
is accompanied
by
documentation that a claim has been
filed.
(2) Nothing in division (C)(1) of this section requires a
health care provider or medical records company to provide a copy
without charge to any person or entity not listed in division
(C)(1) of this section.
(D) Division (C) of this section shall not be construed
to
supersede any rule of the bureau of workers' compensation, the
industrial
commission, or the department of job and family
services.
(E) A health care provider or medical
records company may
enter into a contract with either of the following for
the copying
of medical records at a fee other
than as provided in division
(B)
of this section:
(1) A patient, a patient's personal representative, or an
authorized person;
(2) An insurer authorized under Title XXXIX of the Revised
Code to do the business of sickness and accident insurance in this
state or health insuring corporations holding a certificate of
authority under Chapter 1751. of the Revised Code.
(F) This section does not apply to medical records the
copying of
which is covered by
section 173.20 of the Revised Code
or by 42
C.F.R. 483.10.
Sec. 3702.51. As used in sections 3702.51 to 3702.62 of
the
Revised Code:
(A)
"Applicant" means any person that submits an
application
for a certificate of need and who is designated in
the application
as the applicant.
(B)
"Person" means any individual, corporation, business
trust, estate, firm, partnership, association, joint stock
company, insurance company, government unit, or other entity.
(C)
"Certificate of need" means a written approval granted
by
the director of health to an applicant to authorize conducting
a
reviewable activity.
(D)
"Health service area" means a geographic region
designated by the director of health under section 3702.58 of the
Revised Code.
(E)
"Health service" means a clinically related service,
such
as a diagnostic, treatment, rehabilitative, or preventive
service.
(F)
"Health service agency" means an agency designated to
serve a health service area in accordance with section 3702.58 of
the Revised Code.
(G)
"Health care facility" means:
(1) A hospital registered under section 3701.07 of the
Revised Code;
(2) A nursing home licensed under section 3721.02 of the
Revised Code, or by a political subdivision certified under
section 3721.09 of the Revised Code;
(3) A county home or a county nursing home as defined in
section 5155.31 of the Revised Code that is certified under Title
XVIII or XIX of the
"Social Security Act," 49 Stat. 620 (1935),
42
U.S.C.A. 301, as amended;
(4) A freestanding dialysis center;
(5) A freestanding inpatient rehabilitation facility;
(6) An ambulatory surgical facility;
(7) A freestanding cardiac catheterization facility;
(8) A freestanding birthing center;
(9) A freestanding or mobile diagnostic imaging center;
(10) A freestanding radiation therapy center.
A health care facility does not include the offices of
private physicians and dentists whether for individual or group
practice, residential facilities licensed under section
5123.19 of
the Revised Code, or an institution for
the sick that is operated
exclusively for patients who use
spiritual means for
healing and
for whom the acceptance of medical
care is inconsistent with their
religious beliefs, accredited by a
national accrediting
organization, exempt
from federal income
taxation under section
501 of the Internal
Revenue Code of 1986,
100 Stat. 2085, 26
U.S.C.A. 1, as
amended, and providing
twenty-four hour nursing
care pursuant to the exemption
in
division (E) of section 4723.32
of the Revised Code from
the
licensing requirements of Chapter
4723. of the Revised Code.
(H)
"Medical equipment" means a single unit of medical
equipment or a single system of components with related functions
that is used to provide health services.
(I)
"Third-party payer" means a health insuring corporation
licensed under Chapter
1751.
of the Revised Code, a health
maintenance organization as defined in
division (K) of this
section, an
insurance company that issues sickness and accident
insurance in
conformity with Chapter 3923. of the Revised Code, a
state-financed health insurance program under Chapter 3701.,
4123., or 5111. of the Revised Code, or any self-insurance plan.
(J)
"Government unit" means the state and any county,
municipal corporation, township, or other political subdivision
of
the state, or any department, division, board, or other agency
of
the state or a political subdivision.
(K)
"Health maintenance organization" means a public or
private organization organized under the law of any state that is
qualified under section 1310(d) of Title XIII of the
"Public
Health Service Act," 87 Stat. 931 (1973), 42 U.S.C.
300e-9.
(L)
"Existing health care facility" means either of the
following:
(1) A health care
facility that is licensed or otherwise
authorized to operate in
this state in accordance with applicable
law, including a county home or a county nursing home that is
certified as of February 1, 2008, under Title XVIII or Title XIX
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.
301,
as amended, is staffed and
equipped to provide health care
services, and is actively providing
health services;
(2) A health care facility that is licensed or otherwise
authorized to operate in this state in accordance with applicable
law, including a county home or a county nursing home that is
certified as of February 1, 2008, under Title XVIII or Title XIX
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.
301,
as amended, or that has beds registered under section 3701.07
of
the Revised Code as skilled nursing beds or long-term care beds
and has provided services for at least three hundred sixty-five
consecutive days within the twenty-four months immediately
preceding the date a certificate of need application is filed with
the director of health.
(M)
"State" means the state of Ohio, including, but not
limited to, the general assembly, the supreme court, the offices
of all elected state officers, and all departments, boards,
offices, commissions, agencies, institutions, and other
instrumentalities of the state of Ohio.
"State" does not include
political subdivisions.
(N)
"Political subdivision" means a municipal corporation,
township, county, school district, and all other bodies corporate
and politic responsible for governmental activities only in
geographic areas smaller than that of the state to which the
sovereign immunity of the state attaches.
(O)
"Affected person" means:
(1) An applicant for a certificate of need, including an
applicant whose application was reviewed comparatively with the
application in question;
(2) The person that requested the reviewability ruling in
question;
(3) Any person that resides or regularly uses health care
facilities within the geographic area served or to be served by
the health care services that would be provided under the
certificate of need or reviewability ruling in question;
(4) Any health care facility that is located in the health
service area where the health care services would be provided
under the certificate of need or reviewability ruling in question;
(5) Third-party payers that reimburse health care
facilities
for services in the health service area where the
health care
services would be provided under the certificate of need or
reviewability ruling in question;
(6) Any other person who testified at a public hearing
held
under division (B) of section 3702.52 of the Revised Code or
submitted written comments in the course of review of the
certificate of need application in question.
(P)
"Osteopathic hospital" means a hospital registered
under
section 3701.07 of the Revised Code that advocates
osteopathic
principles and the practice and perpetuation of
osteopathic
medicine by doing any of the following:
(1) Maintaining a department or service of osteopathic
medicine or a committee on the utilization of osteopathic
principles and methods, under the supervision of an osteopathic
physician;
(2) Maintaining an active medical staff, the majority of
which is comprised of osteopathic physicians;
(3) Maintaining a medical staff executive committee that
has
osteopathic physicians as a majority of its members.
(Q)
"Ambulatory surgical facility" has the same meaning as
in
section 3702.30 of the Revised Code.
(R) Except as otherwise provided in division (T) of this
section, and until
the termination date specified in section
3702.511 of the Revised Code,
"reviewable activity" means any of
the following:
(1) The addition
by any person of any of the following
health
services, regardless of the amount of operating costs or
capital
expenditures:
(a) A heart, heart-lung, lung, liver, kidney, bowel,
pancreas, or bone marrow transplantation service, a stem cell
harvesting and
reinfusion service, or a service for
transplantation
of any other organ unless transplantation of the
organ is
designated by public health council rule not to be a
reviewable
activity;
(b) A cardiac catheterization service;
(c) An open-heart surgery service;
(d) Any new, experimental medical technology
that is
designated by rule of the public health council.
(2) The acceptance of high-risk patients, as defined in
rules
adopted under section 3702.57 of the Revised Code, by any
cardiac
catheterization service that was initiated without a
certificate
of
need pursuant to division
(R)(3)(b) of the version
of this
section in effect
immediately prior to April 20,
1995;
(3)(a) The establishment, development, or construction of a
new health care facility other than a new long-term care facility
or a new
hospital;
(b) The establishment, development, or construction of a new
hospital or
the relocation of an existing hospital;
(c) The relocation of hospital beds, other than long-term
care,
perinatal, or pediatric intensive care beds, into or out of
a rural
area.
(4)(a) The replacement of an existing hospital;
(b) The replacement of an existing hospital obstetric or
newborn care unit or freestanding birthing
center.
(5)(a) The renovation of a hospital
that involves
a capital
expenditure, obligated on or after
June 30, 1995, of five million
dollars or more,
not including
expenditures for equipment,
staffing, or operational costs. For
purposes of division (R)(5)(a)
of this
section, a capital
expenditure is obligated:
(i) When a contract enforceable under Ohio law is entered
into for the construction, acquisition, lease, or financing of a
capital
asset;
(ii) When the governing body of a hospital takes formal
action to
commit its own funds for a construction project
undertaken by the hospital as
its own contractor;
(iii) In the case of donated property, on the date the gift
is
completed under applicable Ohio law.
(b) The renovation of a hospital obstetric or newborn care
unit
or freestanding birthing center that involves a capital
expenditure of five
million dollars or more, not including
expenditures for equipment, staffing,
or operational costs.
(6) Any change in the health care services, bed capacity,
or
site, or any other failure to conduct the reviewable activity
in
substantial accordance with the approved application for which
a
certificate of need was granted, if the change is made prior to
the date the activity for which the certificate was issued ceases
to be a
reviewable activity;
(7) Any of the following changes in perinatal bed capacity
or
pediatric
intensive care bed capacity:
(a) An increase in bed capacity;
(b) A change in service or service-level
designation of
newborn care beds or obstetric beds in a hospital or
freestanding
birthing center, other than a change of service that is provided
within the service-level designation of newborn care or obstetric
beds as
registered by the department of health;
(c) A relocation of perinatal or pediatric
intensive care
beds from one physical facility or
site to another, excluding the
relocation of beds within a
hospital or freestanding birthing
center or the relocation of beds among buildings of a
hospital or
freestanding birthing
center at the same site.
(8) The expenditure of more than one hundred ten per cent
of
the maximum expenditure specified in a certificate of need;
(9) Any transfer of a certificate of need issued prior to
April
20, 1995, from the person
to whom it was issued to another
person before the project that
constitutes a reviewable activity
is completed, any agreement
that contemplates the transfer of a
certificate of need issued prior to that
date upon
completion of
the project, and any transfer of the controlling
interest in an
entity that holds a certificate of need issued prior to that
date.
However, the transfer of a certificate of need issued prior to
that
date or agreement to
transfer such a certificate of need from
the person to whom the
certificate of need was issued to an
affiliated or related person
does not constitute a reviewable
transfer of a certificate of
need for the purposes of this
division, unless the transfer
results in a change in the person
that holds the
ultimate controlling interest in the certificate of
need.
(10)(a) The acquisition by any person of any of the
following
medical
equipment,
regardless of the amount of operating
costs or
capital expenditure:
(i) A cobalt radiation therapy unit;
(ii) A linear accelerator;
(iii) A gamma knife unit.
(b) The acquisition by any person of medical equipment with
a
cost of two million dollars or more. The cost of acquiring
medical
equipment
includes the sum of the following:
(i) The greater of its fair market value or the cost of its
lease
or purchase;
(ii) The cost of installation and any other activities
essential
to the acquisition of the equipment and its placement
into service.
(11) The addition of another cardiac
catheterization
laboratory to an existing cardiac
catheterization service.
(S) Except as provided in division
(T) of this section,
"reviewable activity" also means any of the following
activities,
none of which are subject to a termination date:
(1) The establishment, development, or construction of a
new
long-term care facility;
(2) The replacement of an existing long-term care
facility;
(3) The renovation of a long-term care facility that
involves
a capital expenditure of two million dollars or more,
not
including expenditures for equipment, staffing, or
operational
costs;
(4) Any of the following changes in long-term care bed
capacity:
(a) An increase in bed capacity;
(b) A relocation of beds from one
physical facility or site
to another, excluding the relocation
of beds within a long-term
care facility or among buildings of a
long-term care facility at
the same site;
(c) A recategorization of hospital
beds registered under
section 3701.07 of the
Revised
Code from another registration
category to skilled nursing beds or long-term care beds.
(5) Any change in the health services, bed capacity, or
site,
or any other failure to conduct the reviewable activity in
substantial accordance with the approved application for which a
certificate of need concerning long-term care beds was granted,
if
the change is made within five years after the implementation
of
the reviewable activity for which the certificate was
granted;
(6) The expenditure of more than one hundred ten per cent
of
the maximum expenditure specified in a certificate of need
concerning long-term care beds;
(7) Any transfer of a certificate of need that concerns
long-term care beds and was issued prior to
April 20, 1995, from
the person
to whom it was issued to another person before the
project that
constitutes a reviewable activity is completed, any
agreement
that contemplates the transfer of such a certificate of
need
upon completion of the project, and any transfer of the
controlling interest in an entity that holds such a certificate
of
need. However, the transfer of a certificate of need that
concerns
long-term care beds and was issued prior to
April 20,
1995, or
agreement to
transfer such a certificate of need from the
person
to whom the
certificate was issued to an affiliated or
related
person does
not constitute a reviewable transfer of a
certificate
of need
for purposes of this division, unless the
transfer results
in a
change in the person that holds the ultimate
controlling
interest in the certificate of need.
(T)
"Reviewable activity" does not include any of the
following activities:
(1) Acquisition of computer hardware or software;
(2) Acquisition of a telephone system;
(3) Construction or acquisition of parking facilities;
(4) Correction of cited deficiencies that are in violation
of
federal, state, or local fire, building, or safety laws and
rules
and that constitute an imminent threat to public health or
safety;
(5) Acquisition of an existing health care facility that
does
not involve a change in the number of the beds, by service,
or in
the number or type of health services;
(6) Correction of cited deficiencies identified by
accreditation surveys of the joint commission on accreditation of
healthcare organizations or of the American osteopathic
association;
(7) Acquisition of medical equipment to replace the same
or
similar equipment for which a certificate of need has been
issued
if the replaced equipment is removed from service;
(8) Mergers, consolidations, or other corporate
reorganizations of health care facilities that do not involve a
change in the number of beds, by service, or in the number or
type
of health services;
(9) Construction, repair, or renovation of bathroom
facilities;
(10) Construction of laundry facilities, waste disposal
facilities, dietary department projects, heating and air
conditioning projects, administrative offices, and portions of
medical office buildings used exclusively for physician services;
(11) Acquisition of medical equipment to conduct research
required by the United States food and drug administration or
clinical trials sponsored by the national institute of health.
Use
of medical equipment that was acquired without a certificate
of
need under division (T)(11) of this section and for
which
premarket approval has been granted by the United States food and
drug administration to provide services for which patients or
reimbursement entities will be charged shall be a reviewable
activity.
(12) Removal of asbestos from a health care facility.
Only that portion of a project that meets the requirements
of
division (T) of this section is not a reviewable
activity.
(U)
"Small rural hospital" means a hospital that is
located
within a rural area, has fewer than
one hundred beds, and to which
fewer than four thousand persons
were admitted during the most
recent calendar year.
(V)
"Children's hospital" means any of the following:
(1) A hospital registered under section 3701.07 of the
Revised Code that provides general pediatric medical and surgical
care, and in which at least seventy-five per cent of annual
inpatient discharges for the preceding two calendar years were
individuals less than eighteen years of age;
(2) A distinct portion of a hospital registered under
section
3701.07 of the Revised Code that provides general
pediatric
medical and surgical care, has a total of at least one
hundred
fifty registered pediatric special care and pediatric
acute care
beds, and in which at least seventy-five per cent of
annual
inpatient discharges for the preceding two calendar years
were
individuals less than eighteen years of age;
(3) A distinct portion of a hospital, if the hospital is
registered under section 3701.07 of the Revised Code as a
children's hospital and the children's hospital meets all the
requirements of division (V)(1) of this section.
(W)
"Long-term care facility" means any of the following:
(1) A nursing home licensed under section 3721.02 of the
Revised Code or by a political subdivision certified under section
3721.09 of
the Revised Code;
(2) The portion of any facility, including a county home or
county
nursing home, that is certified as a skilled nursing
facility or a nursing
facility under Title XVIII or XIX of the
"Social Security Act";
(3) The portion of any hospital that contains beds
registered
under
section 3701.07 of the Revised Code as skilled
nursing beds
or long-term care
beds.
(X)
"Long-term care bed" means a bed in a long-term care
facility.
(Y)
"Perinatal bed" means a bed in a hospital that is
registered under
section 3701.07 of the Revised Code as a newborn
care bed or obstetric bed, or
a bed in a freestanding birthing
center.
(Z)
"Freestanding birthing center" means any facility in
which
deliveries routinely occur, regardless of whether
the
facility is located on the campus of another health care facility,
and
which is not licensed under Chapter 3711. of
the Revised
Code
as a level one, two, or three maternity
unit or a limited
maternity unit.
(AA)(1)
"Reviewability ruling" means a ruling issued by the
director of health under division (A) of section 3702.52 of the
Revised Code
as to whether a particular proposed project is or is
not a
reviewable activity.
(2)
"Nonreviewability ruling" means a ruling issued under
that division that a particular proposed project is not a
reviewable
activity.
(BB)(1)
"Metropolitan
statistical area" means an area of
this
state designated a
metropolitan statistical area or primary
metropolitan
statistical area in United
States office of
management and
budget bulletin No. no. 93-17,
June 30, 1993, and
its
attachments.
(2)
"Rural area" means any area of this state not located
within a metropolitan statistical area.
(CC) "County nursing home" has the same meaning as in section
5155.31 of the Revised Code.
Sec. 3721.042. The director of health may not deny a nursing
home license to a facility seeking a license under this chapter as
a nursing home on the grounds that the facility does not satisfy a
requirement established in rules adopted under section 3721.04 of
the Revised Code regarding the toilet rooms and dining and
recreational areas of nursing
homes if all of
the following
requirements are met:
(A) The facility seeks a license under this chapter because
it is a county home or district home being sold under section
5155.31 of the Revised Code to a person who may not operate the
facility without a nursing home license under this chapter.
(B) The requirement would not have applied to the facility
had the facility been a nursing home first licensed under this
chapter before October 20, 2001.
(C) The facility was a nursing facility, as defined in
section 5111.20 of the Revised Code, on the date immediately
preceding the date the facility is sold to the person seeking the
license.
Sec. 3963.01. As used in this chapter:
(A) "Affiliate" means any person or entity that has ownership
or control of a contracting entity, is owned or controlled by a
contracting entity, or is under common ownership or control with a
contracting entity.
(B) "Basic health care services" has the same meaning as in
division (A) of section 1751.01 of the Revised Code, except that
it does not include any
services listed in that division that are
provided by a pharmacist or nursing home.
(C) "Contracting entity" means any person that has a primary
business purpose of contracting with participating providers for
the delivery of
health care services.
(D) "Credentialing" means the process of assessing and
validating the qualifications of a provider applying to be
approved by a contracting entity to provide basic health care
services, specialty health care services, or supplemental
health
care services to enrollees.
(E) "Edit" means adjusting one or more procedure codes billed
by a participating provider on a claim for payment or a
practice
that results in any of the following:
(1) Payment for some, but not all of the procedure codes
originally billed by a participating provider;
(2) Payment for a different procedure code than the procedure
code originally billed by a participating provider;
(3) A reduced payment as a result of services provided to an
enrollee that are claimed under more than one procedure code on
the same service date.
(F) "Electronic claims transport" means to accept and
digitize claims or to accept claims already digitized, to place
those claims into a format that complies with the electronic
transaction standards issued by the United States department of
health and human services pursuant to the "Health Insurance
Portability and Accountability Act of 1996," 110 Stat. 1955, 42
U.S.C. 1320d, et seq., as those electronic standards are
applicable to the parties and as those electronic standards are
updated from time to time, and to electronically transmit those
claims to the appropriate contracting entity, payer, or
third-party administrator.
(G)
"Enrollee" means any person eligible for health care
benefits under a health benefit plan, including an eligible
recipient of medicaid under Chapter 5111. of the Revised Code, and
includes all of the
following terms:
(1) "Enrollee" and "subscriber" as defined by section 1751.01
of
the Revised Code;
(2) "Member" as defined by section 1739.01 of the Revised
Code;
(3) "Insured" and "plan member" pursuant to Chapter 3923. of
the
Revised Code;
(4) "Beneficiary" as defined by section 3901.38 of the
Revised
Code.
(H) "Health care contract" means a contract entered into,
materially
amended, or
renewed between a contracting entity and
a
participating provider for the
delivery of basic health care
services, specialty health care services, or
supplemental
health
care services to
enrollees.
(I) "Health care services" means basic health care services,
specialty health care services,
and supplemental health care
services.
(J) "Material amendment" means an amendment to a health care
contract that decreases the participating provider's payment or
compensation, changes the administrative procedures in a way that
may reasonably be expected to significantly increase the
provider's administrative expenses, or adds a new product. A
material amendment does not include any of the following:
(1) A decrease in payment or compensation resulting solely
from a change in a published fee schedule upon which the payment
or compensation is based and the date of applicability is clearly
identified in the contract;
(2) A decrease in payment or compensation that was
anticipated under the terms of the contract, if the amount and
date of applicability of the decrease is clearly identified in the
contract;
(3) An administrative change that may significantly increase
the provider's administrative expense, the specific applicability
of which is clearly identified in the contract;
(4) Changes to an existing prior authorization,
precertification, notification, or referral program that do not
substantially increase the provider's administrative expense;
(5) Changes to an edit program or to specific edits if the
participating provider is provided notice of the changes pursuant
to division (A)(1) of section 3963.04 of the Revised Code and the
notice includes information sufficient for the provider to
determine the effect of the change;
(6) Changes to a health care contract described in division
(B) of section 3963.04 of the Revised Code.
(K) "Participating provider" means a provider that has a
health care contract with a contracting entity and is entitled to
reimbursement for health care services
rendered to an enrollee
under the health care contract.
(L) "Payer" means any person that assumes the financial risk
for the payment of claims under a health care contract or the
reimbursement for health care services provided to enrollees by
participating providers pursuant to a health care contract.
(M)
"Primary enrollee" means a person who is responsible for
making payments 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 care plan.
(N) "Procedure codes" includes the American medical
association's current procedural terminology code, the American
dental association's current dental terminology, and the centers
for medicare and medicaid services health care common procedure
coding system.
(O) "Product" means one of the following types of categories
of coverage
for which a participating provider
may be obligated
to
provide
health care services pursuant to a
health care
contract:
(1) A health maintenance organization or other product
provided by a health insuring corporation;
(2) A preferred provider organization;
(4) Medicaid or the children's buy-in program established
under section 5101.5211 to 5101.5216 of the Revised Code;
(5) Workers' compensation.
(P) "Provider" means a physician, podiatrist, dentist,
chiropractor, optometrist, psychologist, physician assistant,
advanced
practice nurse,
occupational therapist, massage
therapist,
physical therapist,
professional counselor,
professional clinical
counselor, hearing
aid dealer, orthotist,
prosthetist, home
health agency, hospice care program, or
hospital, or a provider
organization or physician-hospital
organization that is acting exclusively as an administrator on
behalf of a provider to facilitate the provider's participation in
health care contracts. "Provider"
does not mean a
pharmacist,
pharmacy, nursing home, or a provider organization or
physician-hospital organization that leases the provider
organization's or physician-hospital organization's network to a
third party or contracts directly with employers or health and
welfare funds.
(Q) "Specialty health care services" has the same meaning as
in section 1751.01 of the Revised Code, except that it does not
include any services listed in division (B) of section 1751.01 of
the Revised Code that are provided by a pharmacist or a nursing
home.
(R) "Supplemental health care services" has the same meaning
as in division (B) of section 1751.01 of the Revised Code, except
that it does not include any services listed in that division that
are provided by a pharmacist or nursing home.
Sec. 3963.02. (A)(1) No contracting entity shall sell, rent,
or give a third party the contracting entity's rights to a
participating
provider's services pursuant to the contracting
entity's health
care contract with the participating provider
unless one of the
following applies:
(a) The third party accessing the participating provider's
services under the health care contract is an employer or other
entity providing coverage for health care services to its
employees or members, and that employer or entity has a contract
with the contracting entity or its affiliate for the
administration or processing of claims for payment for services
provided pursuant to the health care contract with the
participating provider.
(b) The third party accessing the participating provider's
services under the health care contract either is an affiliate or
subsidiary of the contracting entity or is providing
administrative services to, or receiving
administrative services
from, the contracting entity or an
affiliate or subsidiary of the
contracting entity.
(c) The health care contract specifically provides that it
applies to network rental arrangements and states that one purpose
of the contract is selling, renting, or giving the contracting
entity's rights to the services of the participating provider,
including other preferred provider organizations, and the third
party accessing the participating provider's services is any of
the following:
(i) A payer or a third-party administrator or other entity
responsible for administering claims on behalf of the payer;
(ii) A preferred provider organization or preferred provider
network that receives access to the participating provider's
services pursuant to an arrangement with the preferred provider
organization or preferred provider network in a contract with the
participating provider that is in compliance with division
(A)(1)(c) of this section, and is required to comply with all of
the terms, conditions, and affirmative obligations to which the
originally contracted primary participating provider network is
bound under its
contract with the participating provider,
including, but not
limited to, obligations concerning patient
steerage and the
timeliness and manner of reimbursement.
(iii) An entity that is engaged in the business of providing
electronic claims transport between the contracting entity and the
payer or third-party administrator and complies with all of the
applicable terms, conditions, and affirmative obligations of the
contracting entity's contract with the participating provider
including, but not limited to, obligations concerning patient
steerage and the timeliness and manner of reimbursement.
(2) The contracting entity that sells, rents, or gives the
contracting entity's rights to the participating provider's
services pursuant to the contracting entity's health care contract
with the participating provider as provided in division (A)(1) of
this section shall do both of the following:
(a) Maintain a web page that contains a listing of third
parties described in divisions (A)(1)(b) and (c) of this
section
with whom a contracting entity contracts for the purpose
of
selling, renting, or giving the contracting entity's rights to
the services of participating providers that is updated at least
every six months and is accessible to all participating providers,
or maintain a toll-free telephone number accessible to all
participating providers by means of which participating providers
may access the same listing of third parties;
(b) Require that the third party accessing the participating
provider's services through the participating provider's health
care contract is obligated to comply with all of the applicable
terms and conditions of the contract, including, but not limited
to, the products for which the participating provider has agreed
to provide services, except that a payer receiving administrative
services from the contracting entity or its affiliate shall be
solely responsible for payment to the participating provider.
(3) Any information disclosed to a participating provider
under this section shall be considered proprietary and shall not
be distributed by the participating provider.
(4) Except as provided in division (A)(1) of this section, no
entity shall sell, rent, or give a
contracting
entity's rights
to the participating provider's
services pursuant
to a health
care contract.
(B)(1) No contracting entity shall require, as a condition of
contracting with the contracting entity, that a participating
provider provide services for all of the products offered by the
contracting entity.
(2) Division (B)(1) of this section shall not be construed to
do any of the following:
(a) Prohibit any participating provider from voluntarily
accepting an offer by a contracting entity to provide health care
services under all of the contracting entity's products;
(b) Prohibit any contracting entity from offering any
financial incentive or other form of consideration specified in
the health care contract for a participating provider to provide
health care services under all of the contracting
entity's
products;
(c) Require any contracting entity to contract with a
participating provider to provide health care services for less
than all of the
contracting entity's products if the
contracting
entity
does not wish to do so.
(3)(a) Notwithstanding division (B)(2) of this section, no
contracting entity shall require, as a condition of contracting
with the contracting entity, that the participating provider
accept any future product offering that the contracting entity
makes.
(b) If a participating provider refuses to accept any future
product offering that the contracting entity makes, the
contracting entity may terminate the health care contract based on
the participating provider's refusal upon
written notice to the
participating provider no sooner than one
hundred eighty days
after the refusal.
(4) Once the contracting entity and the participating
provider have signed the health care contract, it is presumed that
the financial incentive or other form of consideration that is
specified in the health care contract pursuant to division
(B)(2)(b) of this section is the financial incentive or other form
of consideration that was offered by the contracting entity to
induce the participating provider to enter into the contract.
(C) No contracting entity shall require, as a condition of
contracting with the contracting entity, that a participating
provider waive or forego any right or benefit expressly conferred
upon a
participating
provider by state or federal law.
However,
this division does not prohibit a
contracting entity from
restricting a participating
provider's scope
of practice for
the services to be provided
under the contract.
(D) No health care contract shall do any of the following:
(1) Prohibit any participating provider from entering into a
health care
contract with any other contracting entity;
(2) Prohibit any contracting entity from entering into a
health care contract with any other provider;
(3) Preclude its use or disclosure for the purpose of
enforcing this chapter or other state or federal law, except that
a health care contract may require that appropriate measures be
taken to preserve the confidentiality of any proprietary or
trade-secret information.
(E)(1) In addition to any other lawful reasons for
terminating a health care contract, a health care contract may
only be
terminated under the
circumstances
described in
division (A)(3)
of section 3963.04 of the
Revised Code.
(2) If the health care contract provides for termination for
cause by either party, the health care contract shall state the
reasons that may be used for termination for cause, which terms
shall be reasonable. Once the contracting entity and the
participating provider have signed the health care contract, it is
presumed that the reasons stated in the health care contract for
termination for cause by either party are reasonable. Subject to
division (E)(3) of this section,
the health care contract shall
state the time by which the parties
must provide notice of
termination for cause and to whom the
parties shall give the
notice.
(3) Nothing in divisions (E)(1) and (2) of this section shall
be construed as prohibiting any health insuring corporation from
terminating a participating provider's contract for any of the
causes described in divisions (A), (D), and (F)(1) and (2) of
section 1753.09 of the Revised Code. Notwithstanding any provision
in a health care contract pursuant to division (E)(2) of this
section, section 1753.09 of the Revised Code applies to the
termination of a participating provider's contract for any of the
causes described in divisions (A), (D), and (F)(1) and (2) of
section 1753.09 of the Revised Code.
(4) Subject to sections 3963.01 to 3963.11 of the Revised
Code, nothing in this section prohibits the termination of a
health care contract without cause if the health care contract
otherwise provides for termination without cause.
(F)(1) Disputes among parties to a health care
contract that
only concern the
enforcement of the contract rights
conferred by
section 3963.02, divisions (A) and (D) of section
3963.03,
and
section 3963.04 of the Revised Code are subject to a
mutually
agreed
upon arbitration mechanism that is binding on all
parties. The
arbitrator may award reasonable attorney's fees and
costs for
arbitration relating to the enforcement of this section
to the
prevailing party.
(2) The arbitrator shall make
the arbitrator's decision in
an arbitration proceeding having due
regard for any applicable
rules, bulletins, rulings, or decisions
issued by the department
of insurance or any court concerning the
enforcement of the
contract rights conferred by section 3963.02,
divisions (A) and
(D) of section 3963.03, and section 3963.04 of
the Revised Code.
(3) A party shall not simultaneously maintain an
arbitration
proceeding as described in division (F)(1) of this
section and
pursue a complaint with the superintendent of
insurance to
investigate the subject matter of the arbitration
proceeding.
However, if
a
complaint is filed with the department of
insurance, the
superintendent may choose to investigate the
complaint or, after
reviewing the complaint, advise the
complainant to proceed with
arbitration to resolve the complaint.
The superintendent may
request to receive a copy of
the results
of the arbitration. If
the superintendent of insurance notifies
an insurer or a health insuring corporation in writing
that the
superintendent has initiated a market conduct
examination into
the specific subject matter of the arbitration
proceeding pending
against that insurer or health
insuring corporation, the
arbitration proceeding shall be stayed at the
request of the
insurer or
health insuring corporation pending the outcome of the
market conduct investigation by
the
superintendent.
Sec. 3963.03. (A) Each health care contract shall include all
of the
following information:
(1)(a) Information sufficient for the participating provider
to determine the
compensation or payment terms for health care
services, including
all of the following, subject to division
(A)(1)(b) of this section:
(i) The manner of payment, such as fee-for-service,
capitation, or risk;
(ii) The fee schedule of procedure codes reasonably expected
to be billed by a participating provider's specialty for services
provided
pursuant to the health care contract and the associated
payment or
compensation for each procedure code. A fee schedule
may be
provided electronically. Upon request, a contracting
entity shall
provide a participating provider with the fee
schedule for any other procedure
codes requested and a written
fee schedule, that shall not be
required more frequently than
twice per year excluding when it is
provided in connection with
any change to the schedule. This
requirement may be satisfied by
providing a clearly
understandable, readily available mechanism,
such as a specific
web site address, that allows a participating
provider to
determine the effect of procedure codes on payment or
compensation
before a service is provided or a claim is
submitted.
(iii) The
effect, if any, on payment
or
compensation if
more than
one procedure code applies to the
service also shall
be stated.
This requirement may be satisfied
by
providing a
clearly
understandable, readily available
mechanism,
such as a
specific
web site address, that allows a
participating provider
to
determine the effect
of procedure
codes on payment or
compensation before a service is
provided or
a claim is
submitted.
(b) If the contracting entity is unable to include the
information described in division (A)(1)(a)(ii) and (iii) of this
section,
the contracting entity shall include both of the
following types
of information instead:
(i) The methodology used to calculate any fee schedule, such
as relative value unit system and conversion factor or percentage
of billed charges. If
applicable, the methodology disclosure
shall include the name of
any relative value unit system, its
version, edition, or
publication date, any applicable conversion
or geographic factor,
and any date by which compensation or fee
schedules may be changed
by the methodology as anticipated at the
time of contract.
(ii) The identity of any internal processing edits
,
including the publisher, product name,
version,
and version
update of any editing software.
(c) If the contracting entity is not the payer and is unable
to include the information described in division (A)(1)(a) or (b)
of this section, then the contracting entity shall provide by
telephone a readily available
mechanism, such as a specific web
site address, that allows
the participating provider to obtain
that information from the
payer.
(2) Any product or network for which the participating
provider is to
provide
services;
(3) The term of the health care contract;
(4) A specific web site address that contains the identity of
the contracting entity or payer responsible for the
processing of
the participating provider's compensation or payment;
(5) Any internal mechanism provided by the contracting entity
to resolve disputes concerning the interpretation or application
of the terms and conditions of the contract. A contracting entity
may satisfy this requirement by providing a clearly
understandable, readily available mechanism, such as a specific
web site address or an appendix, that allows a participating
provider to determine the procedures for the internal mechanism to
resolve those disputes.
(6) A list of addenda, if any, to the contract.
(B)(1) Each contracting entity shall include a summary
disclosure form with a health care contract that includes all of
the information specified in division (A) of this section. The
information in
the summary disclosure form shall refer to the
location in the health care contract, whether a page number,
section of the contract, appendix, or other identifiable location,
that specifies the provisions in the contract to which the
information in the form refers.
(2) The summary disclosure form shall include all of the
following statements:
(a) That the form is a guide to the health care contract and
that the terms and conditions of the health care contract
constitute the contract rights of the parties;
(b) That reading the form is not a substitute for reading the
entire health care contract;
(c) That by signing the health care contract, the
participating provider will be bound by the contract's terms and
conditions;
(d) That the terms and conditions of the health care contract
may be amended pursuant to section 3963.04 of the Revised Code and
the participating provider is encouraged to carefully read any
proposed amendments sent after execution of the contract;
(e) That nothing in the summary disclosure form creates any
additional rights or causes of action in favor of either party.
(3) No contracting entity that includes any information in
the summary disclosure form with the reasonable belief that the
information is truthful or accurate shall be subject to a civil
action for damages or to binding arbitration based on the summary
disclosure form. Division (B)(3) of this section does not impair
or affect any power of the department of insurance to enforce any
applicable law.
(4) The summary disclosure form described in divisions (B)(1)
and (2) of this section shall be in substantially the following
form:
"SUMMARY DISCLOSURE FORM
[ ] Other ............... See ...............
(b) Fee schedule available at ...............
(c) Fee calculation schedule available at ...............
(d) Identity of internal processing edits available at
...............
(e) Information in (c) and (d) is not required if information
in (b) is provided.
(2) List of products or networks covered by this contract
(3) Term of this contract ...............
(4) Contracting entity or payer responsible for processing
payment available at ...............
(5) Internal mechanism for resolving disputes regarding
contract terms available at ...............
(7) Telephone number to access a readily available mechanism,
such as a specific web site address, to allow a participating
provider to receive the information in
(1) through (6) from the
payer.
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
The information provided in this Summary Disclosure Form is a
guide to the attached Health Care Contract as defined in section
3963.01(G) of the Ohio Revised Code. The terms and conditions of
the attached Health Care Contract constitute the contract rights
of the parties.
Reading this Summary Disclosure Form is not a substitute for
reading the entire Health Care Contract. When you sign the Health
Care Contract, you will be bound by its terms and conditions.
These terms and conditions may be amended over time pursuant to
section 3963.04 of the Ohio Revised Code. You are encouraged to
read any proposed amendments that are sent to you after execution
of the Health Care Contract.
Nothing in this Summary Disclosure Form creates any
additional rights or causes of action in favor of either party."
(C) When a contracting entity presents a proposed health care
contract for consideration by a provider, the
contracting entity
shall provide in writing or make reasonably
available the
information required in division (A)(1) of this
section.
(D) The contracting entity shall identify any utilization
management, quality improvement, or a similar program that the
contracting entity uses to review, monitor, evaluate, or assess
the
services provided pursuant to a health care contract. The
contracting entity shall disclose the policies, procedures, or
guidelines of such a program applicable to a participating
provider upon request
by the participating provider within
fourteen days after the date of the
request.
(E) Nothing in this section shall be construed as preventing
or affecting the application of section 1753.07 of the Revised
Code that would otherwise apply to a contract with a participating
provider.
(F) The requirements of division (C) of this section do not
prohibit a contracting entity from
requiring a reasonable
confidentiality agreement between the provider and the contracting
entity regarding the
terms of the proposed health care contract.
If either party
violates the confidentiality agreement, a party
to the
confidentiality agreement may bring a civil action to
enjoin the
other party from continuing any act that is in
violation of the
confidentiality agreement, to recover damages,
to terminate the
contract, or to obtain any combination of
relief.
Sec. 3963.04. (A)(1) If an amendment to a health care
contract is not a material amendment,
the contracting entity
shall provide the participating provider
notice of the amendment
at least fifteen days prior to the
effective
date of the
amendment. The contracting entity shall
provide all
other
notices to the participating provider pursuant
to the health
care contract.
(2)
A material amendment to a health care contract
shall
occur only if the contracting entity provides to
the
participating provider the material amendment in writing and
notice of
the material amendment not later than ninety days prior
to the
effective date of the material amendment. The notice shall
be
conspicuously entitled "Notice of Material Amendment to
Contract."
(3) If within
fifteen days after
receiving the material
amendment and notice
described in division
(A)(2)
of this
section, the participating
provider objects in
writing to the
material
amendment, and there
is no resolution of
the
objection, either
party may terminate
the health care
contract
upon written notice
of termination
provided to the other
party
not later than sixty
days prior to
the effective date of
the
material amendment.
(4) If the participating provider does not object to the
material amendment
in the manner described in division (A)(3) of
this section, the material
amendment shall be effective as
specified in
the notice described
in division (A)(2) of this
section.
(B)(1) Division (A) of this section does not apply if the
delay caused by compliance with that division could result in
imminent harm to an enrollee, if the material amendment of a
health care
contract is required by state or federal law, rule,
or regulation, or if the provider
affirmatively accepts the
material amendment in writing and agrees
to an earlier effective
date than otherwise required by division
(A)(2) of this section.
(2) This section does not apply under any of the following
circumstances:
(a) The participating
provider's payment or compensation is
based on the current
medicaid or medicare physician fee schedule,
and the change in payment or
compensation results solely from a
change in that physician fee
schedule.
(b) A routine change or update of the health care contract is
made in response to any addition, deletion, or revision of any
service code, procedure code, or reporting code, or a pricing
change is made by any third party source.
For purposes of division (B)(2)(b) of this section:
(i) "Service code, procedure code, or reporting code" means
the current procedural terminology (CPT), current dental
terminology (CDT), the healthcare common
procedure coding system
(HCPCS), the international classification
of diseases (ICD), or
the drug topics redbook average wholesale
price (AWP).
(ii) "Third party source" means the American medical
association, American dental association, the centers for medicare
and medicaid services, the
national center for health statistics,
the department of health
and human services office of the
inspector general, the Ohio
department of insurance, or the Ohio
department of job and family
services.
(C) Notwithstanding divisions (A) and (B) of this section, a
health care contract may be amended by operation
of law as
required by any applicable state or federal law, rule,
or
regulation. Nothing in this section shall be construed to
require
the renegotiation of a health care contract that is in
existence
before the effective date of this section, until the
time that
the contract is renewed or materially amended.
Sec. 3963.05. (A) The department of insurance shall prescribe
the credentialing application form used by the council for
affordable quality healthcare (CAQH) in electronic or paper format
for physicians.
The
department of insurance also shall prepare
the standard
credentialing form for all other providers and shall
make the standard credentialing form as simple, straightforward,
and easy to use as possible, having due regard for those
credentialing forms that are widely in use in the state by
contracting entities and that best serve these goals.
(B) No contracting entity shall fail to use the applicable
standard
credentialing form described in division (A) of this
section when
initially credentialing or recredentialing providers
in connection
with policies, health care contracts,
and
agreements providing
basic health care services, specialty health
care services, or supplemental health care
services.
(C) No contracting entity shall require a provider to
provide
any information in addition to the information required
by the
applicable
standard credentialing form described in
division (A)
of this
section in connection with policies, health
care
contracts, and
agreements providing basic health care
services, specialty health care services, or supplemental
health
care services.
(D) The credentialing process described in this section does
not prohibit a contracting entity from limiting the scope of any
participating provider's basic health care services, specialty
health care services, or supplemental health care
services.
(E) The requirement that the department of insurance prepare
the standard credentialing form for all other providers does not
include preparing the standard credentialing form for a hospital.
Sec. 3963.06. (A) If a provider, upon the oral or written
request of a contracting entity to submit a credentialing form,
submits a credentialing form that is not complete, the contracting
entity that receives the form shall notify the provider of the
deficiency electronically, by facsimile, or by certified mail,
return receipt
requested, not later than twenty-one days after
the contracting
entity receives the form.
(B) If a contracting entity receives any information that is
inconsistent with the information given by the provider in the
credentialing form, the contracting entity may request the
provider to submit a written clarification of the inconsistency.
The contracting entity shall send the request described in this
division electronically, by facsimile, or by certified mail,
return
receipt
requested.
(C)(1) Except as otherwise provided in division (C)(2) of
this section, the credentialing process under this section starts
when
a provider initially submits a credentialing form upon the
oral or
written request of a contracting entity, and the provider
shall submit the credentialing form to the contracting entity
electronically, by facsimile, or by certified mail, return receipt
requested. Subject to
division (C)(3) of this section, a
contracting entity
shall
complete the credentialing
process not
later than ninety
days
after the contracting entity receives
that credentialing form
from the provider. The contracting entity
shall allow the provider
to submit a credentialing application
prior to the provider's
employment. A contracting entity that
does not complete the
credentialing process within the ninety-day
period specified in
this division is liable for either a civil
penalty payable to the
provider in the amount of five hundred
dollars per day, including
weekend days, starting at the
expiration of that ninety-day period
until the provider's
credentialing application is
granted or denied or retroactive
reimbursement to the provider
according to the terms of the
contract for any basic health care services, specialty health care
services, or
supplemental health care services the provider
provided to
enrollees starting at the expiration of that
ninety-day period
until the provider's credentialing application
is granted or
denied. When the credentialing process of the
contracting entity
exceeds the ninety-day period, the contracting
entity shall select
the liability to which the contracting entity
is subject and shall
inform the provider of the contracting
entity's selection.
(2) The credentialing process for a medicaid managed care
plan starts
when the provider submits a credentialing form and
the provider's
national provider number issued by the centers for
medicare and
medicaid services.
(3)
The requirement that the credentialing process be
completed within the ninety-day period specified in division
(C)(1) of this section does not apply to a contracting entity if a
provider that submits a credentialing form to the contracting
entity under that division is a hospital.
(D) Any communication between the provider and the
contracting entity shall be electronically, by facsimile, or by
certified mail, return receipt requested.
(E) If the state medical board or its agent has primary
source verified the medical education, graduate medical education,
and examination history of the physician, or the status of the
physician with the educational commission for foreign medical
graduates, if applicable, the contracting entity may accept the
documentation of primary source verification from the state
medical board's web site or from its agent and is not required to
perform primary source verification of the medical education,
graduate medical education, and examination history of the
physician or the status of the physician with the educational
commission for foreign medical graduates, if applicable, as a
condition for initially credentialing or recredentialing the
physician.
Sec. 3963.07. (A) All remittance notices sent by a payer,
whether written
or electronic, shall include both of the
following:
(1) The name of the payer issuing the payment to the
participating
provider;
(2) The name of the contracting entity through which the
payment rate and any discount are claimed, if the contracting
entity is different from the payer.
(B) Division (A) of this section takes effect March 31, 2009.
Sec. 3963.08. The superintendent of insurance shall adopt
any rules necessary for the implementation of this chapter.
Sec. 3963.09. (A) A series of violations of this chapter by
any person regulated by the department of insurance under Title
XVII or Title XXXIX of the Revised Code that, taken together,
constitute a pattern or practice of violating this chapter may be
defined as an unfair and deceptive insurance practice under
sections 3901.19 to 3901.26 of the Revised Code.
(B) The superintendent of insurance may conduct a market
conduct examination of any person regulated by the department of
insurance under Title XVII or Title XXXIX of the Revised Code to
determine whether any violation of this chapter has occurred. When
conducting that type of examination, the superintendent of
insurance may assess the costs of the examination against the
person examined. The superintendent may enter into a consent
agreement to impose any administrative assessment or fine for
conduct discovered that may be a violation of this chapter. All
costs, assessments, and fines collected under this section shall
be deposited to the credit of the department of insurance
operating fund.
Sec. 3963.10. This chapter does not apply with respect to
any of the following:
(A) A contract or provider agreement between a provider and
the state or federal
government, a state agency, or federal
agency for
health care services provided through a program for
medicaid or
medicare;
(B) A contract for payments made to providers for rendering
health care
services to claimants pursuant to claims made under
Chapter 4121.,
4123., 4127., or 4131. of the Revised Code;
(C) An exclusive contract between a health insuring
corporation and a single group of providers in a specific
geographic
area to provide or arrange for the provision of health
care services.
Sec. 3963.11. (A) No contracting entity shall do any of the
following:
(1) Offer to a provider other than a hospital a health care
contract that includes a most favored nation clause;
(2) Enter into a health care contract with a provider other
than a hospital that includes a most favored nation clause;
(3) Amend an existing health care contract previously entered
into with a provider other than a hospital to include a most
favored nation clause.
(B) This section shall not go into effect until three years
after the effective date of this section.
(C) As used in this section:
(1) "Contracting entity," "health care contract," "health
care services," "participating provider," and "provider" have the
same meanings as in section 3963.01 of the Revised Code.
(2) "Most favored nation clause" means a provision in a
health care contract that does any of the following:
(a) Prohibits, or grants a contracting entity an option to
prohibit, the participating provider from contracting with another
contracting entity to provide health care services at a lower
price than the payment specified in the contract;
(b) Requires, or grants a contracting entity an option to
require, the participating provider to accept a lower payment in
the event the participating provider agrees to provide health care
services to any other contracting entity at a lower price;
(c) Requires, or grants a contracting entity an option to
require, termination or renegotiation of the existing health care
contract in the event the participating provider agrees to provide
health care services to any other contracting entity at a lower
price;
(d) Requires the participating provider to disclose the
participating provider's contractual reimbursement rates with
other contracting entities.
Sec. 5111.17. (A)
The department of
job and
family services
may enter into contracts
with managed
care organizations,
including health insuring corporations, under which the
organizations are authorized to
provide, or
arrange for the
provision of, health care services to
medical
assistance
recipients
who are required or permitted to obtain health care
services through managed care
organizations as part of the care
management system
established under
section 5111.16 of the
Revised Code.
(B) The director of job and family services
may
adopt rules
in accordance with
Chapter 119. of the Revised Code to
implement
this section.
(C) The department of job and family services shall allow
managed care
plans to use providers to render care upon
completion of
the managed care plan's credentialing process.
Section 2. That existing sections 1751.13, 1753.01, 1753.07,
1753.09, 2317.54, 3701.741, 3702.51, and 5111.17 and sections
1753.03,
1753.04, 1753.05, and
1753.08 of
the Revised Code are
hereby
repealed.
Section 3. Sections 3963.01 to 3963.11 of the Revised Code,
as enacted by this act, shall apply only to contracts that are
delivered, issued for delivery, or renewed or materially amended
in this
state on or after the effective date of this act. A
health
insuring corporation having fewer than fifteen thousand
enrollees
shall comply with the provisions of this section within
twelve
months after the effective date of this act.
Section 4. Section 3963.06 of the Revised
Code, as enacted
by
this act, takes effect ninety days after the effective date of
this act.
Section 5. (A) As used in this section and Section 6 of this
act:
(1) "Most favored nation clause" means a provision in a
health care contract that does any of the following:
(a) Prohibits, or grants a contracting entity an option to
prohibit, the participating provider from contracting with another
contracting entity to provide health care services at a lower
price than the payment specified in the contract;
(b) Requires, or grants a contracting entity an option to
require, the participating provider to accept a lower payment in
the event the participating provider agrees to provide health care
services to any other contracting entity at a lower price;
(c) Requires, or grants a contracting entity an option to
require, termination or renegotiation of the existing health care
contract in the event the participating provider agrees to provide
health care services to any other contracting entity at a lower
price;
(d) Requires the participating provider to disclose the
participating provider's contractual reimbursement rates with
other contracting entities.
(2) "Contracting entity," "health care contract," "health
care services," "participating provider," and "provider" have the
same meanings as in section 3963.01 of the Revised Code, as
enacted by this act.
(B) No health care contract that includes a most favored
nation clause shall be entered into, and no health care contract
at the instance of a contracting entity
shall be amended or
renewed to include a most favored
nation clause, for
a period of
two years after the effective date
of this act,
subject to
extension as provided in Section 6 of this
act. This section does
not
apply to and does not prohibit the continued use of a most
favored nation
clause in a health care contract that is between a
contracting
entity and a hospital and that is in existence on the
effective
date of this act even if the health care contract is
materially
amended with respect to any provision of the health
care contract
other than the most favored nation clause during
the two-year
period specified in this section or during any
extended period of
time as provided in Section 6 of this act.
Section 6. (A) There is hereby created the Joint Legislative
Study Commission on Most Favored Nation Clauses in Health Care
Contracts consisting of seventeen members as follows:
(1) The Superintendent of Insurance;
(2) Two members of the House of Representatives, one
representing the majority party and one representing the minority
party;
(3) Two members of the Senate, one representing the majority
party and one representing the minority party;
(4) Three providers who are individuals;
(5) Two representatives of hospitals;
(6) Two representatives of contracting entities regulated by
the Department of Insurance under Title XVII of the Revised Code;
(7) Two representatives of contracting entities regulated by
the Department of Insurance under Title XXXIX of the Revised Code;
(8) One representative of an employer that pays for the
health insurance coverage of its employees;
(9) A licensed attorney with an expertise in antitrust law
who represents providers;
(10) A licensed attorney with an expertise in antitrust law
who represents contracting entities that have used most favored
nation clauses in their health care contracts and that are
regulated by the Department of Insurance under either Title XVII
or Title XXXIX of the Revised Code.
(B) The members of the Commission shall be appointed as
follows:
(1) The Speaker of the House of Representatives shall appoint
the two members of the House specified in division (A)(2) of this
section.
(2) The President of the Senate shall appoint the two members
of the Senate specified in division (A)(3) of this section.
(3) The Speaker of the House of Representatives and the
President of the Senate jointly shall appoint the remaining
members specified in divisions (A)(4) to (10) of this section.
(C) Initial appointments to the Commission shall be made
within thirty days after the effective date of this act. The
appointments shall be for the term of the Commission as provided
in division (F)(2) of this section. Vacancies shall be filled in
the same manner provided for original appointments.
(D)(1) The Superintendent of Insurance shall be the
Chairperson of the Commission. Meetings of the Commission shall be
at the call of the Chairperson. All of the members of the
Commission shall be voting members. Meetings of the Commission
shall be held pursuant to section 121.22 of the Revised Code.
(2) The Department of Insurance shall provide office space or
other facilities, any administrative or other technical,
professional, or clerical employees, and any necessary supplies
for the work of the Commission.
(3) The Chairperson of the Commission shall keep the records
of the Commission. Upon submission of the Commission's final
report to the General Assembly under division (F) of this section,
the Chairperson shall deliver all of the Commission's records to
the General Assembly.
(E)(1) The Commission shall study the following areas
pertaining to health care contracts:
(a) The procompetitive and anticompetitive aspects of most
favored nation clauses;
(b) The impact of most favored nation clauses on health care
costs and on the availability of and accessibility to quality
health care;
(c) The costs associated with the enforcement of most favored
nation clauses;
(d) Other state laws and rules pertaining to most favored
nation clauses in their health care contracts;
(e) Matters determined by the Department of Insurance as
relevant to the study of most favored nation clauses;
(f) Any other matters that the Commission considers
appropriate to determine the effectiveness of most favored nation
clauses.
(2) The Commission may take testimony from experts or
interested parties on the areas of its study as described in
division (E)(1) of this section.
(F)(1) Not less than ninety days prior to the expiration of
the two-year period specified in Section 5 of this act, the
Commission shall report its preliminary findings to the General
Assembly and a recommendation of whether to extend that two-year
period for one additional year. If the General Assembly does not
grant the extension, the Commission shall submit its final report
to the General Assembly not later than three months after the
expiration of the two-year period specified in Section 5 of this
act. If the General Assembly grants the extension, the extension
shall be for not more than one year after the expiration of the
two-year period specified in Section 5 of this act, and the
Commission shall submit its final report to the General Assembly
not later than six months prior to the expiration of the one-year
extension.
(2) The final report of the Commission shall include its
findings and recommendations on whether state law should prohibit
or restrict most favored nation clauses in health care contracts.
The Commission shall cease to exist upon the submission of its
final report to the General Assembly.
Section 7. (A) There is hereby created the Advisory Committee
on Eligibility and Real Time Claim Adjudication to study and
recommend mechanisms or standards that will enable providers to
send to and receive from payers sufficient information to enable a
provider to determine at the time of the enrollee's visit the
enrollee's eligibility for services covered by the payer as well
as real time adjudication of provider claims for services.
(B) The Superintendent of Insurance or the Superintendent's
designee shall be a member of the Advisory Committee and shall
appoint at least one representative from each of the following
groups or entities:
(1) Persons eligible for health care benefits under a health
benefit plan;
(4) Health benefit plan issuers;
(5) Other health care providers;
(6) Health care administrators;
(7) Payers of health care benefits, including employers;
(8) Preferred provider networks;
(9) Health care technology vendors;
(10) The Office of Information Technology.
(C) Initial appointments to the Advisory Committee shall be
made within thirty days after the effective date of this act. The
appointments shall be for the term of the Advisory Committee as
provided in division (I) of this section. Vacancies shall be
filled in the same manner provided for original appointments.
Members of the Advisory Committee shall serve without
compensation.
(D)(1) The Superintendent of Insurance shall be the
Chairperson of the Advisory Committee. Meetings of the Advisory
Committee shall be at the call of the Chairperson. All of the
members of the Advisory Committee shall be voting members.
Meetings of the Advisory Committee shall be held pursuant to
section 121.22 of the Revised Code.
(2) The Department of Insurance shall provide office space or
other facilities, any administrative or other technical,
professional, or clerical employees, and any necessary supplies
for the work of the Advisory Committee.
(E)(1) The Advisory Committee shall advise the Superintendent
of Insurance on both of the following:
(a) The technical aspects of using the transaction standards
mandated by the "Health Insurance Portability and Accountability
Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et seq., and the
transaction standards and rules of the Council for Affordable
Quality Healthcare Committee on Operating Rules for Information
Exchange to require health benefit plan issuers and administrators
to provide access to information technology that will enable
physicians and other health care providers to generate a request
for eligibility information at the point of service that is
compliant with those transaction standards;
(b) The data elements that health benefit plan issuers and
administrators are required to make available, using, to the
extent possible, the framework adopted by the Council for
Affordable Quality Healthcare Committee on Operating Rules for
Information Exchange.
(2) The Advisory Committee shall consider including the
following data elements in the information that must be made
available in eligibility and real time adjudication transactions:
(a) The name, date of birth, member identification number,
and coverage status of the patient;
(b) The identification of the payer, insurer, issuer, and
administrator, as applicable;
(c) The name and telephone number of the payer's contact
person;
(e) The name and address of the subscriber;
(f) The patient's relationship to the subscriber;
(h) The type of health benefit plan or product;
(i) The effective date of the health care coverage;
(j) For professional services:
(i) The amount of any copayment;
(ii) The amount of an individual deductible;
(iii) The amount of a family deductible;
(iv) Benefit limitations and maximums.
(k) For facility services:
(i) The amount of any copayment or coinsurance;
(ii) The amount of an individual deductible;
(iii) The amount of a family deductible;
(iv) Benefit limitations and maximums.
(l) Precertification or prior authorization requirements;
(m) Policy maximum limits;
(n) Patient liability for a proposed service;
(o) The health benefit plan coverage amount for a proposed
service.
(F) The Advisory Committee shall make recommendations
regarding all of the following:
(1) The use of internet web site technologies, smart card
technologies, magnetic strip technologies, biometric technologies,
or other information technologies to facilitate the generation of
a request for eligibility information that is compliant with the
transaction standards and rules of the Council for Affordable
Quality Healthcare Committee on Operating Rules for Information
Exchange;
(2) Time frames for the implementation of the recommendations
in division (F)(1) of this section;
(3) When a provider may rely upon the eligibility information
transmitted by a payer regarding a service provided to an enrollee
for purposes of allocating responsibility for payment for services
rendered by the provider. The Advisory Committee shall further
recommend how disputes over enrollee eligibility for services
received shall be resolved taking into consideration the legal
relationship between the provider, the enrollee, and the payer.
(G) The recommendations made by the Advisory Committee shall
not endorse or otherwise limit the choice of products or services
available to health care payers, purchasers, or providers.
(H) Not later than January 1, 2009, the Advisory Committee
shall provide the General Assembly with a report of its findings
and recommendations for legislative action to standardize
eligibility and real time adjudication transactions between
providers and payers. The transaction standards adopted by the
General Assembly shall, at a minimum, comply with the standards
mandated by the "Health Insurance Portability and Accountability
Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et seq., as further
defined in Title 45, part 162 of the Code of Federal Regulations
to the extent that the "Health Insurance Portability and
Accountability Act of 1996" applies to the transaction.
(I) The Advisory Committee shall cease to exist upon the
submission of its report and recommendations to the General
Assembly.
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