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(127th General Assembly)
(Substitute House Bill Number 493)
AN ACT
To amend sections 3923.05 and 3923.80 and to enact
sections
3701.86, 3701.861,
3923.82, and 4731.72
of the Revised
Code and to amend Section 5 of
Sub. H.B. 125 of the 127th General Assembly
regarding
billing for anatomic pathology
services, health benefits for routine patient care
during cancer clinical trials, health benefits for
injuries resulting from use of alcohol or drugs,
and most favored nation clauses in health care
contracts.
Be it enacted by the General Assembly of the State of Ohio:
SECTION 1. That sections 3923.05 and 3923.80 be amended and
sections
3701.86, 3701.861, 3923.82, and 4731.72 of the Revised
Code be
enacted to read as
follows:
Sec. 3701.86. As used in this section and in section
3701.861 of the Revised Code:
(A) "Anatomic pathology services" means all of the following:
(1) Histopathology or surgical pathology;
(2) Cytopathology;
(3) Hematology;
(4) Subcellular or molecular pathology;
(5) Blood banking services performed by pathologists.
(B) "Assignment of benefits" means the transfer of health
care coverage reimbursement benefits or other rights under an
insurance policy, subscription contract, or health care plan by an
insured, subscriber, or plan enrollee to a health care provider,
hospital, or other health care facility.
(C) "Clinical laboratory" means a facility for the
biological, microbiological, serological, chemical,
immunohematological, hematological, biophysical, cytological,
pathological, or other examination of substances derived from the
human body for the purpose of providing information for the
diagnosis, prevention, or treatment of any disease, or in the
assessment or impairment of the health of human beings.
(D) "Cytopathology" means the microscopic examination of
cells from fluids, aspirates, washings, brushings, or smears,
including a Papanicolaou smear (PAP smear or test).
(E) "Hematology" means the microscopic evaluation of bone
marrow aspirates and biopsies performed by a physician or under
the supervision of a physician and peripheral blood smears when
the attending or treating physician or technologist requests that
a blood smear be reviewed by a pathologist.
(F) "Histologic processing" means fixation, processing,
embedding, microtomy, and other special staining, including
histochemical or immunohistochemical staining and in situ
hybridization of clinical human tissues or cells, for pathological
examination.
(G)
"Histopathology" or "surgical pathology" means the gross
and microscopic examination and histologic processing of organ
tissue performed by a physician or under the supervision of a
physician.
(H) "Insurer" means a person authorized under Title XXXIX of
the Revised Code to engage in the business of insurance in this
state, a health insuring corporation, or an entity that is
self-insured and provides benefits to its employees or members.
(I) "Physician" means an individual authorized by Chapter
4731. of the Revised Code to practice medicine and surgery,
osteopathic medicine and surgery, or podiatric medicine and
surgery.
(J) "Referring clinical laboratory" means a clinical
laboratory that refers a patient specimen to another clinical
laboratory
for an anatomic pathology service, but excludes a
laboratory in the
office of one or more physicians that refers a
specimen and does not perform the
professional component of the
anatomic pathology service, as that component is defined in
section 4731.72 of the Revised Code.
(K) "Subcellular or molecular pathology" means the assessment
of a patient specimen for the detection, localization,
measurement, or analysis of one or more protein or nucleic acid
targets performed or interpreted by or under supervision of a
pathologist.
Sec. 3701.861. (A) No clinical laboratory shall present or
cause
to be presented a claim, bill, or demand for payment for
anatomic
pathology services to any person or entity other than
the
following:
(1) The patient who
receives the services or another
individual,
such as a parent, spouse, or guardian, who is
responsible for the
patient's bills;
(2) A responsible insurer or other third-party payor of a
patient who receives the services;
(3) A hospital, public health clinic, or not-for-profit
health clinic ordering the services;
(4) A referring clinical laboratory;
(5) A governmental agency or any person acting on behalf of a
governmental agency;
(6) A physician who is permitted to bill for the services
under division (D) of section 4731.72 of the Revised Code.
(B) Nothing in this section shall be construed to do either
of the following:
(1) Mandate the assignment of benefits for anatomic pathology
services;
(2) Prohibit a clinical laboratory that provides anatomic
pathology services from billing a referring
clinical laboratory
for anatomic pathology services in instances in which
the
referring clinical laboratory sends one or more samples to the
clinical laboratory for purposes of having a
specialist perform
analysis, consultation, or histologic processing.
Sec. 3923.05. Except as provided in section 3923.07 of the
Revised Code, no policy of sickness and accident insurance
delivered, issued for delivery, or used in this state shall
contain provisions respecting the matters set forth in this
section unless such provisions are in the words in which the same
appear in this section. Any such provisions in any such policy
shall be preceded by the appropriate caption appearing in this
section or, at the option of the insurer, by such appropriate
individual or group captions or subcaptions as the superintendent
of insurance may approve.
(A) A provision as follows: Change of occupation. If the
insured be injured or contract sickness after having changed his
the
insured's
occupation to one classified by the insurer as more
hazardous
than that stated in this policy or while doing for
compensation
anything pertaining to an occupation so classified,
the insurer
will pay only such portion of the indemnities provided
in this
policy as the premium paid would have purchased at the
rates and
within the limits fixed by the insurer for such more
hazardous
occupation. If the insured changes his the insured's
occupation
to one
classified by the insurer as less hazardous than
that stated in
this policy, the insurer, upon receipt of proof of
such change of
occupation, will reduce the premium rate
accordingly, and will
return the excess pro rata unearned premium
from the date of
change of occupation or from the policy
anniversary date
immediately preceding receipt of such proof,
whichever is the
more recent. In applying this provision, the
classification for
occupational risk and the premium rates shall
be such as have
been last filed by the insurer prior to the
occurrence of the
loss for which the insurer is liable or prior to
the date of
proof of change in occupation with the state official
having
supervision of insurance in the state where the insured
resided
at the time this policy was issued; but if such filing was
not
required, then the classification of occupational risk and the
premium rates shall be those last made effective by the insurer
in
such state prior to the occurrence of the loss or prior to the
date of proof of change in occupation.
(B) A provision as follows: Misstatement of age. If the
age
of the insured has been misstated, all amounts payable under
this
policy shall be such as the premium paid would have
purchased at
the correct age.
(C) A provision as follows:
(1) Other insurance in this insurer. If an accident or
sickness or accident and sickness policy or policies previously
issued by the insurer to the insured be in force concurrently
herewith, making the aggregate indemnity for ............... in
excess of ......... dollars, the excess insurance shall be void
and all premiums paid for such excess shall be returned to the
insured or to his the insured's estate.
The insurer shall insert the type of coverage or coverages
in
the first blank space in the provision in division (C)(1) of
this
section and the maximum limit of indemnity or indemnities in
the
second blank space in the provision in division (C)(1) of
this
section.
(2) In lieu of the foregoing provision in division (C)(1)
of
this section, a provision as follows: Other insurance in this
insurer. Insurance effective at any time on the insured under a
like policy or policies in this insurer is limited to the one
such
policy elected by the insured, his the insured's
beneficiary or
his the insured's estate, as the case may be, and
the insurer will
return all
premiums paid for all other such policies.
(D) A provision as follows: Insurance with other
insurers. If
there be other valid coverage, not with this
insurer, providing
benefits for the same loss on a provision of
service basis or on
an expense incurred basis and of which this
insurer has not been
given written notice prior to the occurrence
or commencement of
loss, the only liability under any expense
incurred coverage of
this policy shall be for such proportion of
the loss as the amount
which would otherwise have been payable
hereunder plus the total
of the like amounts under all such other
valid coverages for the
same loss of which this insurer had
notice bears to the total like
amounts under all valid coverages
for such loss, and for the
return of such portion of the premiums
paid as shall exceed the
pro-rata portion for the amount so
determined. For the purpose of
applying this provision when
other coverage is on a provision of
service basis, the "like
amount" of such other coverage shall be
taken as the amount which
the services rendered would have cost in
the absence of such
coverage.
If the provision in division (D) of this section is
included
in a policy of sickness and accident insurance which
also contains
the provision in division (E) of this section, the
insurer shall
add to the caption of the provision in division (D)
of this
section the following: Expense incurred benefits.
The insurer may at its option include in the provision in
division (D) of this section a definition of "other valid
coverage" approved as to form by the superintendent. Such
definition shall be limited in subject matter to coverage
provided
by organizations subject to regulation by insurance law
or by
insurance authorities of this or any other state of the
United
States or any province of the Dominion of Canada, and by
hospital
or medical service organizations, and to any other
coverage the
inclusion of which may be approved by the
superintendent. In the
absence of such definition in the
provision in division (D) of
this section, "other valid coverage"
as used in such provision
shall not include group insurance,
automobile medical payments
insurance, or coverage provided by
hospital or medical service
organizations or by union welfare
plans or employer or employee
benefit organizations.
For the purpose of applying the provision in division (D)
of
this section with respect to any insured, any amount of
benefit
provided for such insured pursuant to any compulsory
benefit
statute, including any workers' compensation or
employer's
liability statute, whether provided by governmental
agency or
otherwise, shall in all cases be deemed to be "other
valid
coverage" of which the insurer has had notice.
In applying the provision in division (D) of this section
no
third party liability coverage shall be included as "other
valid
coverage."
(E) A provision as follows: Insurance with other
insurers. If
there be other valid coverage, not with this
insurer, providing
benefits for the same loss on other than an
expense incurred basis
and of which the insurer has not been
given written notice prior
to the occurrence or commencement of
loss, the only liability for
such benefits under this policy
shall be for such proportion of
the indemnities otherwise
provided hereunder for such loss as the
like indemnities of which
the insurer had notice (including the
indemnities under this
policy) bear to the total amount of all
like indemnities for such
loss, and for the return of such portion
of the premium paid as
shall exceed the pro-rata portion for the
indemnities thus
determined.
If the provision in division (E) of this section is
included
in a policy of sickness and accident insurance which
also contains
the provision in division (D) of this section, the
insurer shall
add to the caption of the provision in division (E)
of this
section the following: Other benefits.
The insurer may at its option include in the provision in
division (E) of this section a definition of "other valid
coverage" approved as to form by the superintendent. Such
definition shall be limited in subject matter to coverage
provided
by organizations subject to regulation by insurance law
or by
insurance authorities of this or any other state of the
United
States or any province of the Dominion of Canada, and to
any other
coverage the inclusion of which may be approved by the
superintendent. In the absence of such definition in the
provision
in division (E) of this section, "other valid coverage"
as used in
such provision shall not include group insurance, or
benefits
provided by union welfare plans or by employer or
employee benefit
organizations.
For the purpose of applying the provision in division (E)
of
this section with respect to any insured, any amount of
benefit
provided for such insured pursuant to any compulsory
benefit
statute, including any workers' compensation or
employer's
liability statute, whether provided by a governmental
agency or
otherwise, shall in all cases be deemed to be "other
valid
coverage" of which the insurer has had notice.
In applying the provision in division (E) of this section
no
third party liability coverage shall be included as "other
valid
coverage."
(F) A provision as follows: Relation of earnings to
insurance. If the total monthly amount of loss of time benefits
promised for the same loss under all valid loss of time coverage
upon the insured, whether payable on a weekly or monthly basis,
shall exceed the monthly earnings of the insured at the time
disability commenced or his the insured's average monthly
earnings
for the
period of two years immediately preceding a disability for
which
claim is made, whichever is the greater, the insurer will be
liable only for such proportionate amount of such benefits under
this policy as the amount of such monthly earnings or such
average
monthly earnings of the insured bears to the total amount
of
monthly benefits for the same loss under all such coverage
upon
the insured at the time such disability commences and for
the
return of such part of the premiums paid during such two
years as
shall exced exceed the pro-rata amount of the premiums
for the
benefits actually paid hereunder; this shall not operate
to reduce
the total monthly amount of benefits payable under all
such
coverage upon the insured below the sum of two hundred
dollars or
the sum of the monthly benefits specified in such
coverages,
whichever is the lesser, nor shall this operate to
reduce benefits
other than those payable for loss of time.
The provision in division (F) of this section may be placed
only in a policy of sickness and accident insurance which the
insured has a right to continue in force subject to its terms by
the timely payment of premiums until at least age fifty or in a
policy of sickness and accident insurance issued after the
insured
has attained age forty-four and which the insured has the
right to
continue in force subject to its terms by the timely
payment of
premiums for at least five years from its date of
issue.
The insurer may at its option include in the provision in
division (F) of this section a definition of "valid loss of time
coverage" approved as to form by the superintendent. Such
definition shall be limited in subject matter to coverage
provided
by governmental agencies or by organizations subject to
regulation
by insurance law or by insurance authorities of this
or any other
state of the United States or any province of the
Dominion of
Canada or to any other coverage the inclusion of
which may be
approved by the superintendent or any combination of
such
coverages. In the absence of such definition in the
provision in
division (F) of this section "valid loss of time
coverage" as used
in such provision shall not include any
coverage provided for such
insured pursuant to any compulsory
benefit statute, including any
workers' compensation or
employer's liability statute, whether
provided by a governmental
agency or otherwise, or benefits
provided by union welfare plans
or by employer or employee benefit
organizations.
(G) A provision as follows: Unpaid premium. Upon the
payment
of a claim under this policy, any premium then due and
unpaid or
covered by any note or written order may be deducted
therefrom.
(H) A provision as follows: Conformity with state
statutes.
Any provision of this policy which, on its effective
date, is in
conflict with the statutes of the state in which the
insured
resides on such date is hereby amended to conform to the
minimum
requirements of such statutes.
(I) A provision as follows: Illegal occupation. The
insurer
shall not be liable for any loss to which a contributing
cause was
the insured's commission of or attempt to commit a
felony or to
which a contributing cause was the insured's being
engaged in an
illegal occupation.
(J) A provision as follows: Intoxicants and narcotics.
The
insurer shall not be liable for any loss sustained or
contracted
in consequence of the insured's being intoxicated or
under the
influence of any narcotic unless administered on the
advice of a
physician.
Sec. 3923.80. (A) No Notwithstanding section 3901.71 of the
Revised Code, no health benefit plan or public employee
benefit
plan shall deny
coverage for the costs of any routine
patient
care administered to
an insured participating in any
stage of an
eligible cancer
clinical trial, if that care would be
covered
under the plan if the insured was not participating in a
clinical
trial.
(B) The coverage that may not be excluded under division (A)
of this section is subject to all terms, conditions, restrictions,
exclusions, and limitations that apply to any other coverage under
the plan, policy, or arrangement for services performed by
participating and nonparticipating providers. Nothing in this
section shall be construed as requiring reimbursement to a
provider or facility providing the routine care that does not have
a health care contract with the entity issuing the health benefit
plan or public employee benefit plan, or as prohibiting the entity
issuing a health benefit plan or public employee benefit plan
that
does not have a health care contract with the provider or
facility providing the routine care from negotiating a single case
or other agreement for coverage.
(C) As used in this section:
(1) "Eligible cancer clinical trial" means a cancer clinical
trial that meets all of the following criteria:
(a) A purpose of the trial is to test whether the
intervention potentially improves the trial participant's health
outcomes.
(b) The treatment provided as part of the trial is given with
the intention of improving the trial participant's health
outcomes.
(c) The trial has a therapeutic intent and is not designed
exclusively to test toxicity or disease pathophysiology.
(d) The trial does one of the following:
(i) Tests how to administer a health care service, item, or
drug for the treatment of cancer;
(ii) Tests responses to a health care service, item, or drug
for the treatment of cancer;
(iii) Compares the effectiveness of a health care service,
item, or drug for the treatment of cancer with that of other
health care services, items, or drugs for the treatment of cancer;
(iv) Studies new uses of a health care service, item, or drug
for the treatment of cancer.
(e) The trial is approved by one of the following entities:
(i) The national institutes of health or one of its
cooperative groups or centers under the United States department
of health and human services;
(ii) The United States food and drug administration;
(iii) The United States department of defense;
(iv) The United States department of veterans' affairs.
(2) "Subject of a cancer clinical trial" means the health
care service, item, or drug that is being evaluated in the
clinical trial and that is not routine patient care.
(3) "Health benefit plan" has the same meaning as in section
3924.01 of the Revised Code.
(4) "Routine patient care" means all health care services
consistent with the coverage provided in the health benefit plan
or public employee benefit plan for the treatment of cancer,
including
the type and
frequency of any diagnostic modality,
that is
typically covered for a cancer patient who is not
enrolled in a
cancer clinical trial, and that was not
necessitated solely
because of the trial.
(5) For purposes of this section, a health benefit plan or
public employee benefit plan
may exclude coverage for any of the
following:
(a) A health care service, item, or drug that is the subject
of the cancer clinical trial;
(b) A health care service, item, or drug provided solely to
satisfy data collection and analysis needs for the cancer clinical
trial that is not used in the direct clinical management of the
patient;
(c) An investigational or experimental drug or device that
has not been
approved for market by the United States food and
drug
administration;
(d) Transportation, lodging, food, or other expenses for the
patient, or a family member or companion of the patient, that are
associated with the travel to or from a facility providing the
cancer clinical trial;
(e) An item or drug provided by the cancer clinical trial
sponsors free of charge for any patient;
(f) A service, item, or drug that is eligible for
reimbursement by a person other than the insurer, including the
sponsor of the cancer clinical trial.
Sec. 3923.82. (A) As used in this section, "health benefit
plan" has the same meaning as in section 3924.01 of the Revised
Code.
(B) Notwithstanding section 3901.71 of the
Revised Code, no
health benefit plan or public employee benefit plan shall contain
a provision
that limits or excludes an insured's coverage under
the plan for a
loss or expense the insured sustains that is the
result of the insured's use
of alcohol or other drugs or both and
the loss or expense is otherwise
covered under the plan.
(C) Nothing in this section shall be construed as doing
either of the following:
(1) Requiring coverage for the treatment of alcohol or
substance abuse except as otherwise required by law;
(2) Prohibiting the enforcement of an exclusion based on
injuries sustained by an insured during the commission of an
offense by the insured in which the insured is convicted of or
pleads guilty or no contest to a felony.
(D) Not later than four years after the effective date of
this section, the department of insurance shall conduct an
analysis of the impact of the requirements of this section on the
cost of and coverage provided by health benefit plans in this
state and prepare a written report of its findings from the
analysis. The department shall submit the report to the governor
and, in accordance with
section 101.68 of the Revised Code, to
the general assembly.
Sec. 4731.72. (A) As used in this section:
(1) "Anatomic
pathology services," "assignment of benefits,"
"histologic
processing,"
"insurer,"
"physician," and "referring
clinical
laboratory" have
the same
meanings as in section
3701.86 of the
Revised Code.
(2) "Professional component of an anatomic pathology service"
means the entire anatomic pathology service other than histologic
processing.
(3) "Technical component of an anatomic pathology service"
means only histologic processing.
(B) No physician shall present or cause to be
presented a
claim, bill, or demand for payment for anatomic
pathology
services to any person or entity other than the following:
(1) The patient who
receives the services or another
individual, such as a parent, spouse, or guardian, who is
responsible for the patient's bills;
(2) A responsible insurer or other third-party payor of a
patient who receives the services;
(3) A hospital, public health clinic, or not-for-profit
health clinic ordering the services;
(4) A referring clinical laboratory;
(5) A governmental agency or any person acting on behalf of a
governmental agency;
(6) A physician who is permitted to bill for the services
under division (D) of this section.
(C)
Except as provided in division (D) of this section,
no
physician
shall
charge, bill, or
otherwise solicit payment,
directly or
indirectly, for anatomic pathology
services unless
the services
are personally rendered by the
physician or
rendered under the
on-site supervision of the
physician.
(D)(1) A
physician who performs the professional component of
an anatomic
pathology service on a patient specimen may bill for
the amount incurred in doing either of the following:
(a) Having a clinical laboratory or another physician perform
the technical component of the anatomic pathology service;
(b) Obtaining another physician's consultation regarding the
patient specimen.
(2) A physician may bill for having a clinical laboratory or
another physician perform an anatomic pathology service on a
dermatology specimen, but only if the billing physician discloses
to the person or entity being billed both of the following:
(a) The name and address of the clinical laboratory or
physician who performed the service;
(b) The amount the billing physician was charged by or paid
to the clinical laboratory or physician who performed the service.
(E) A violation of division (B) or (C) of this section
constitutes a reason for taking action under division (B)(20) of
section 4731.22 of the Revised Code.
(F) Nothing in this section shall be construed to mandate the
assignment of
benefits for anatomic pathology
services.
SECTION 2. That existing sections 3923.05 and 3923.80 of the
Revised Code are hereby repealed.
SECTION 3. That existing Section 5 of Sub.
H.B. 125 of the
127th General Assembly be amended to read as follows:
Sec. 5. (A) As used in this section and Section 6 of this
act Sub. H.B. 125 of the 127th General Assembly:
(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 Sub. H.B. 125 of the 127th General Assembly.
(B) No With respect to a contracting entity and a provider
other than a hospital, 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 three
years after the effective date
of this
act,
subject to
extension as provided in
Section 6 of this
act
Sub. H.B. 125 of
the 127th General Assembly. This
(C) With respect to a contracting entity and a hospital, 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 Sub. H.B. 125 of the 127th General Assembly,
subject to extension as provided in Section 6 of Sub. H.B. 125 of
the 127th General Assembly.
(D) 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 Sub. H.B. 125 of the 127th General Assembly 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 Sub. H.B. 125 of the 127th General
Assembly.
SECTION 4. That existing Section 5
of Sub. H.B. 125 of the
127th General Assembly is hereby repealed.
SECTION 5. Sections 3923.05 and
3923.82 of
the Revised
Code, as amended or enacted by this act,
shall apply only to
health benefit plans that are delivered, issued for delivery, or
renewed in this state on or after one hundred eighty days after
the effective
date of this
act.
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