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Sub. S. B. No. 186 As Reported by the House Insurance CommitteeAs Reported by the House Insurance Committee
127th General Assembly | Regular Session | 2007-2008 |
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Cosponsors:
Senators Miller, D., Miller, R., Gardner, Cafaro, Carey, Cates, Fedor, Goodman, Harris, Kearney, Mason, Morano, Mumper, Niehaus, Padgett, Roberts, Sawyer, Schuring, Seitz, Smith, Spada, Wagoner, Wilson
Representatives Adams, Barrett, DeBose, Batchelder
A BILL
To amend sections 1739.05 and 1751.01 and to enact
section 3923.80 of the Revised Code to prohibit
insurers, public employee benefit plans, and
multiple employer welfare arrangements from
excluding coverage for routine patient care
administered as part of a cancer clinical trial.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.05 and 1751.01 be amended and
section 3923.80 of the Revised Code be enacted to read as follows:
Sec. 1739.05. (A) A multiple employer welfare arrangement
that is created pursuant to sections 1739.01 to 1739.22 of the
Revised Code and that operates a group self-insurance program may
be established only if any of the following applies:
(1) The arrangement has and maintains a minimum enrollment
of
three hundred employees of two or more employers.
(2) The arrangement has and maintains a minimum enrollment
of
three hundred self-employed individuals.
(3) The arrangement has and maintains a minimum enrollment
of
three hundred employees or self-employed individuals in any
combination of divisions (A)(1) and (2) of this section.
(B) A multiple employer welfare arrangement that is
created
pursuant to sections 1739.01 to 1739.22 of the Revised
Code and
that operates a group self-insurance program shall
comply with all
laws applicable to self-funded programs in this
state, including
sections 3901.04, 3901.041, 3901.19 to 3901.26,
3901.38, 3901.381
to
3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to
3902.14,
3923.282,
3923.30,
3923.301, 3923.38,
3923.581, 3923.63, 3923.80,
3924.031,
3924.032,
and
3924.27
of the Revised Code.
(C) A multiple employer welfare arrangement created
pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall
solicit
enrollments only through agents or solicitors licensed
pursuant to
Chapter 3905. of the Revised Code to sell or solicit
sickness and
accident insurance.
(D) A multiple employer welfare arrangement created
pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall
provide
benefits only to individuals who are members, employees
of
members, or the dependents of members or employees, or are
eligible for continuation of coverage under section 1751.53 or
3923.38 of the Revised Code or under Title X of the "Consolidated
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29
U.S.C.A. 1161, as amended.
Sec. 1751.01. As used in this chapter:
(A)(1) "Basic health care
services" means the following
services when medically
necessary:
(a) Physician's services, except when such services are
supplemental under division (B)
of this section;
(b) Inpatient hospital services;
(c) Outpatient medical services;
(d) Emergency health services;
(e) Urgent care services;
(f) Diagnostic laboratory services and diagnostic and
therapeutic radiologic services;
(g) Diagnostic and treatment services, other than
prescription drug services, for biologically based mental
illnesses;
(h) Preventive health care services, including, but not
limited to, voluntary family planning services, infertility
services, periodic physical examinations, prenatal obstetrical
care, and well-child care;
(i) Routine patient care for patients enrolled in an eligible
cancer clinical trial pursuant to section 3923.80 of the Revised
Code.
"Basic health care services" does not include experimental
procedures.
Except as provided by divisions (A)(2) and (3) of this
section in
connection with the offering of coverage for diagnostic
and treatment
services for biologically based mental illnesses, a
health insuring corporation shall not offer coverage for
a health
care service, defined as a basic health care service by
this
division, unless it offers coverage for all listed basic
health
care services. However,
this requirement does not apply to the
coverage of beneficiaries
enrolled in Title XVIII of the "Social
Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended,
pursuant
to a medicare 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.
(2) A health insuring corporation may offer coverage for
diagnostic and treatment services for biologically based mental
illnesses without offering coverage for all other basic health
care services. A health insuring corporation may offer coverage
for diagnostic and treatment services for biologically based
mental illnesses alone or in combination with one or more
supplemental health care services. However, a health insuring
corporation that offers coverage for any other basic health care
service shall offer coverage for diagnostic and treatment services
for biologically based mental illnesses in combination with the
offer of coverage for all other listed basic health care services.
(3) A health insuring corporation that offers coverage for
basic health care services is not required to offer coverage for
diagnostic and treatment services for biologically based mental
illnesses in combination with the offer of coverage for all other
listed basic health care services if all of the following apply:
(a) The health insuring corporation submits documentation
certified by an independent member of the American academy of
actuaries to the superintendent of insurance showing that incurred
claims for diagnostic and treatment services for biologically
based mental illnesses for a period of at least six months
independently caused the health insuring corporation's costs for
claims and administrative expenses for the coverage of basic
health care services to increase by more than one per cent per
year.
(b) The health insuring corporation submits a signed letter
from an independent member of the American academy of actuaries to
the superintendent of insurance opining that the increase in costs
described in division (A)(3)(a) of this section could reasonably
justify an increase of more than one per cent in the annual
premiums or rates charged by the health insuring corporation for
the coverage of basic health care services.
(c) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (A)(3)(a) and (b) of this section:
(i) Incurred claims for diagnostic and treatment services for
biologically based mental illnesses for a period of at least six
months independently caused the health insuring corporation's
costs for claims and administrative expenses for the coverage of
basic health care services to increase by more than one per cent
per year.
(ii) The increase in costs reasonably justifies an increase
of more than one per cent in the annual premiums or rates charged
by the health insuring corporation for the coverage of basic
health care services.
Any determination made by the superintendent under this
division is subject to Chapter 119. of the Revised Code.
(B)(1) "Supplemental health
care services" means any health
care services other than basic
health care services that a health
insuring corporation may
offer, alone or in combination with
either basic health care services or other
supplemental health
care services, and includes:
(a) Services of facilities for intermediate or long-term
care, or both;
(b) Dental care services;
(c) Vision care and optometric services including lenses
and
frames;
(d) Podiatric care or foot care services;
(e) Mental health services, excluding diagnostic and
treatment services for biologically based mental illnesses;
(f) Short-term outpatient evaluative and
crisis-intervention
mental health services;
(g) Medical or psychological treatment and referral
services
for alcohol and drug abuse or addiction;
(h) Home health services;
(i) Prescription drug services;
(k) Services of a dietitian licensed under
Chapter 4759. of
the Revised Code;
(l) Physical therapy services;
(m) Chiropractic services;
(n) Any other category of services approved by the
superintendent of insurance.
(2) If a health insuring corporation offers prescription drug
services under this division, the coverage shall include
prescription drug services for the treatment of biologically based
mental illnesses on the same terms and conditions as other
physical diseases and disorders.
(C) "Specialty health care services" means one of the
supplemental health care services listed in division
(B) of this
section, when provided by a health
insuring corporation on an
outpatient-only basis and not in
combination with other
supplemental health care services.
(D) "Biologically based mental illnesses" means
schizophrenia, schizoaffective disorder, major depressive
disorder, bipolar disorder, paranoia and other psychotic
disorders, obsessive-compulsive disorder, and panic disorder, as
these terms are defined in the most recent edition of the
diagnostic and statistical manual of mental disorders published by
the American psychiatric association.
(E) "Closed panel plan" means a health care plan that
requires enrollees to use participating providers.
(F) "Compensation" means remuneration for the
provision of
health care services, determined on other than a
fee-for-service
or discounted-fee-for-service basis.
(G) "Contractual
periodic prepayment" means the formula for
determining the premium rate for all subscribers of a health
insuring
corporation.
(H) "Corporation" means
a corporation formed under Chapter
1701. or 1702. of the
Revised
Code or the similar laws of another
state.
(I) "Emergency health
services" means those health care
services that must be
available on a seven-days-per-week,
twenty-four-hours-per-day
basis in order to prevent jeopardy to an
enrollee's health
status that would occur if such services were
not received as
soon as possible, and includes, where appropriate,
provisions
for transportation and indemnity payments or service
agreements
for out-of-area coverage.
(J) "Enrollee" means any
natural person who is entitled to
receive health care benefits
provided by a health insuring
corporation.
(K) "Evidence of
coverage" means any certificate, agreement,
policy, or contract
issued to a subscriber that sets out the
coverage and other
rights to which such person is entitled under a
health care
plan.
(L) "Health care
facility" means any facility, except a
health care
practitioner's office, that provides preventive,
diagnostic,
therapeutic, acute convalescent, rehabilitation,
mental health,
mental retardation, intermediate care, or skilled
nursing
services.
(M) "Health care
services" means basic, supplemental, and
specialty health
care services.
(N) "Health delivery
network" means any group of providers or
health care facilities,
or both, or any representative thereof,
that have entered into an agreement to
offer health
care services
in a panel rather than on an individual
basis.
(O) "Health insuring
corporation" means a corporation, as
defined in division (H) of this
section, that, pursuant to a
policy, contract,
certificate, or agreement, pays for, reimburses,
or provides,
delivers, arranges for, or otherwise makes available,
basic
health care services, supplemental health care services, or
specialty health care services, or a combination of basic health
care services and either supplemental health care services or
specialty
health care services, through either an open panel plan
or a closed panel
plan.
"Health insuring
corporation" does not include a limited
liability company formed
pursuant to Chapter 1705. of
the Revised
Code,
an insurer licensed under
Title
XXXIX of the
Revised
Code if
that insurer offers
only open panel plans under which all
providers and health care
facilities participating receive their
compensation directly
from the insurer, a corporation formed by
or
on behalf of a political subdivision or a department, office,
or
institution of the state, or a public entity formed by or on
behalf of
a board of county commissioners, a county
board of
mental retardation and developmental disabilities,
an
alcohol and
drug
addiction services board, a board of alcohol, drug addiction,
and mental health services, or a community mental health board,
as
those terms are used in Chapters 340. and 5126. of the
Revised
Code.
Except as provided by division (D)
of section 1751.02 of
the
Revised
Code, or as
otherwise provided by law, no
board,
commission,
agency, or other entity under the control of a
political
subdivision may accept insurance risk in providing for
health
care services. However, nothing in this division shall be
construed as prohibiting such entities from purchasing the
services of a health insuring corporation or a third-party
administrator licensed under Chapter 3959. of the Revised
Code.
(P) "Intermediary
organization" means a health delivery
network or other entity
that contracts with licensed health
insuring corporations or self-insured
employers, or both, to
provide health care services, and that enters into
contractual
arrangements with other entities for the provision
of health care
services for the purpose of fulfilling the terms
of its contracts
with the health insuring corporations and self-insured
employers.
(Q) "Intermediate care"
means residential care above the
level of room and board for
patients who require personal
assistance and health-related
services, but who do not require
skilled nursing care.
(R) "Medical record"
means the personal information that
relates to an individual's
physical or mental condition, medical
history, or medical
treatment.
(S)(1) "Open panel plan" means a health care plan that
provides
incentives for enrollees to use participating providers
and that also allows
enrollees to use providers that are not
participating providers.
(2) No health insuring corporation may offer an open
panel
plan, unless the health insuring corporation is also
licensed as
an insurer under Title XXXIX of the
Revised Code, the health
insuring corporation, on June 4,
1997,
holds a certificate of
authority or license to
operate under Chapter 1736. or 1740. of
the Revised Code, or an insurer licensed under
Title XXXIX of the
Revised Code is
responsible for the out-of-network risk as
evidenced by both an evidence of
coverage filing under section
1751.11
of the Revised Code and a policy and
certificate filing
under section 3923.02 of the
Revised Code.
(T) "Panel" means a group of providers or health care
facilities that have joined together to deliver health care
services through a contractual arrangement with a health
insuring
corporation, employer group, or other payor.
(U) "Person" has the same meaning as in section 1.59 of the
Revised Code, and, unless the context otherwise requires,
includes
any insurance company holding a certificate of authority under
Title XXXIX of the Revised Code, any
subsidiary and affiliate of
an insurance company, and any government
agency.
(V) "Premium rate" means any set fee
regularly paid by a
subscriber to a health insuring corporation. A "premium
rate" does
not include a one-time membership fee, an annual
administrative
fee, or a nominal access fee, paid to a managed
health care system
under which the recipient of health care
services remains solely
responsible for any charges accessed for
those services by the
provider or health care facility.
(W) "Primary care
provider" means a provider that is
designated by a health
insuring corporation to supervise,
coordinate, or provide
initial care or continuing care to an
enrollee, and that may be
required by the health insuring
corporation to initiate a
referral for specialty care and to
maintain supervision of the
health care services rendered to the
enrollee.
(X) "Provider" means any
natural person or partnership of
natural persons who are
licensed, certified, accredited, or
otherwise authorized in this
state to furnish health care
services, or any professional
association organized under Chapter
1785. of the Revised
Code, provided that nothing in
this chapter
or other provisions of law shall be construed to
preclude a health
insuring corporation, health care
practitioner, or organized
health care group associated with a
health insuring corporation
from employing certified nurse practitioners,
certified nurse
anesthetists, clinical nurse specialists, certified nurse
midwives, dietitians, physician assistants, dental assistants,
dental
hygienists, optometric technicians, or other allied health
personnel who are licensed, certified, accredited, or otherwise
authorized in this state to furnish health care services.
(Y) "Provider sponsored
organization" means a corporation, as
defined in division
(H) of this section, that is at least eighty
per cent owned or
controlled
by one or more hospitals, as defined
in section 3727.01 of the
Revised Code, or one or more physicians
licensed
to practice medicine or surgery or osteopathic medicine
and
surgery under Chapter 4731. of the Revised
Code, or any
combination of such physicians and
hospitals. Such control is
presumed to exist if at least eighty per cent
of the voting rights
or governance rights of a provider
sponsored organization are
directly or indirectly owned,
controlled, or otherwise held by any
combination of the
physicians and hospitals described in this
division.
(Z) "Solicitation document" means the written materials
provided
to prospective subscribers or enrollees, or both, and
used for advertising and
marketing to induce enrollment in the
health care plans of a
health insuring corporation.
(AA) "Subscriber" means a
person who is responsible for
making payments to a health
insuring corporation for participation
in a health care plan, or
an enrollee whose employment or other
status is the basis of
eligibility for enrollment in a health
insuring corporation.
(BB) "Urgent care
services" means those health care services
that are
appropriately provided for an unforeseen condition of a
kind
that usually requires medical attention without delay but
that
does not pose a threat to the life, limb, or permanent health
of
the injured or ill person,
and may include such health care
services provided
out of the health insuring corporation's
approved service area
pursuant to indemnity payments or service
agreements.
Sec. 3923.80. (A) 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.
Section 2. That existing sections 1739.05 and 1751.01 of the
Revised Code are hereby repealed.
Section 3. Section 3923.80 of the Revised Code, as enacted by
this act, shall take effect sixty days after the effective date of
this act and shall apply only to plans of health coverage that
are
delivered, issued for delivery, or renewed in this state on
or
after that delayed effective date.
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