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H. B. No. 310 As IntroducedAs Introduced
128th General Assembly | Regular Session | 2009-2010 |
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Representatives Garland, Driehaus
Cosponsors:
Representatives Murray, Hagan, Chandler, Okey, Stewart, Celeste, Harris, Harwood, Domenick, Fende, Brown, Yuko, Letson, Williams, B., Phillips, Pillich, Ujvagi
A BILL
To amend section 1739.05 and to enact sections
1751.69 and 3923.85
of the Revised Code to
require health insurers to
provide coverage for
prostheses.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That section 1739.05 be amended and sections
1751.69 and 3923.85 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,
3923.85,
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. 1751.69. As used in this section, "prosthesis" means an
artificial leg, arm, or eye,
including a replacement if required
because of a change in the
patient's physical condition.
(B) Notwithstanding section 3901.71 of the Revised Code, each
individual or group health insuring corporation policy, contract,
or agreement providing basic health care services that is
delivered, issued for delivery, or renewed in this state shall
provide coverage for benefits for a
prosthesis that at least
equals the coverage provided under the
federal medicare program
pursuant to Title XVIII of the "Social
Security Act," 79 Stat.
286 (1965), 42 U.S.C. 1395, as amended.
(C) The policy, contract, or agreement may require prior
authorization for
a prosthesis in the same manner that prior
authorization is
required for any other covered benefit.
(D) The policy, contract, or agreement may impose a
copayment,
coinsurance, or both, on a prosthesis, not to exceed
the copayment
or coinsurance amounts imposed under part B of the
medicare fee
for service program. The policy, contract, or
agreement shall reimburse for a
prosthesis at an amount not less
than the fee schedule amount for
the prosthesis under federal
medicare reimbursement schedule.
(E) Covered benefits are limited to the most appropriate
model that adequately meets the medical needs of the patient as
determined by the enrollee's treating physician.
(F) The policy, contract, or agreement also shall provide
coverage for
benefits for the repair or replacement of a
prosthesis under this section if the
insured's treating physician
determines the repair or replacement
is appropriate.
(G) The policy, contract, or agreement shall not impose any
annual or
lifetime dollar maximum on coverage for prostheses
other than an
annual or lifetime dollar maximum that applies in
the aggregate to
all terms and services covered under the policy,
contract, or agreement.
Sec. 3923.85. As used in this section, "prosthesis" means an
artificial leg, arm, or eye,
including a replacement if required
because of a change in the
patient's physical condition.
(B) Notwithstanding section 3901.71 of the Revised Code, each
individual or group policy of sickness and accident insurance that
is delivered, issued for delivery, or renewed in this state and
each public employee benefit plan that is established or modified
in this state shall provide coverage for benefits for a
prosthesis that at least equals the coverage provided under the
federal medicare program pursuant to Title XVIII of the "Social
Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1395, as amended.
(C) The policy or plan may require prior authorization for
a
prosthesis in the same manner that prior authorization is
required for any other covered benefit.
(D) The policy or plan may impose a copayment,
coinsurance,
or both, on a prosthesis, not to exceed the copayment
or
coinsurance amounts imposed under part B of the medicare fee
for
service program. The policy or plan shall reimburse for a
prosthesis at an amount not less than the fee schedule amount for
the prosthesis under federal medicare reimbursement schedule.
(E) Covered benefits are limited to the most appropriate
model that adequately meets the medical needs of the patient as
determined by the insured's or plan member's treating physician.
(F) The policy or plan also shall provide coverage for
benefits for the repair or replacement of a prosthesis under this
section if the
insured's treating physician determines the repair
or replacement
is appropriate.
(G) The policy or plan shall not impose any annual or
lifetime dollar maximum on coverage for prostheses other than an
annual or lifetime dollar maximum that applies in the aggregate to
all terms and services covered under the policy or plan.
(H) This section does not apply to the offer or renewal of
any individual or group policy of sickness and accident insurance
that provides coverage for specific diseases or accidents only, or
to any hospital indemnity, medicare supplement, medicare, tricare,
long-term care, disability income, one-time limited duration
policy of not longer than six months, or other policy that offers
only supplemental benefits.
Section 2. That existing section 1739.05 of the Revised Code
is hereby repealed.
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