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S. B. No. 15 As IntroducedAs Introduced
128th General Assembly | Regular Session | 2009-2010 |
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Cosponsors:
Senators Fedor, Turner, Miller, R., Cafaro, Roberts, Sawyer
A BILL
To amend sections 1739.05, 1751.01, 3923.281,
3923.282, and 3923.51 and to repeal sections
3923.28, 3923.29, and 3923.30 of the Revised Code
to prohibit discrimination in health care
policies, contracts, and agreements in the
coverage provided for the diagnosis and treatment
of mental illnesses and substance abuse or
addiction conditions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.05, 1751.01, 3923.281,
3923.282, and 3923.51 of the Revised Code be amended 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 and substance abuse and addiction conditions;
(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 and
substance abuse
and addiction conditions, 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
medicare 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
medicaid
recipients, or to
the
coverage of participants of the children's
buy-in program, 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 and substance abuse and addiction conditions 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 and
substance abuse and addiction conditions 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 and
substance abuse and addiction conditions 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 and substance abuse and addiction conditions 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 and substance abuse and addiction
conditions 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 and substance abuse and
addiction conditions 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)(f) Home health services;
(i)(g) Prescription drug services;
(k)(i) Services of a dietitian licensed under
Chapter 4759.
of
the Revised Code;
(l)(j) Physical therapy services;
(m)(k) Chiropractic services;
(n)(l) 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 and substance abuse or addiction conditions 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 "Mental illness" means any condition or
disorder involving mental illness as defined by the most recent
edition of the
diagnostic and statistical manual of mental
disorders published by
the American psychiatric association or as
defined by any diagnostic category listed in the mental disorder
section of the most recent edition of the international
classification of diseases.
(E) "Substance abuse or addiction condition" means any
alcohol or drug related disorder as defined by the most recent
edition of the diagnostic and statistical manual of mental
disorders published by the American psychiatric association or as
defined by a diagnostic category listed in the most recent edition
of the international classification of diseases.
(F) "Children's buy-in program" has the same meaning as in
section 5101.5211 of the Revised Code.
(F)(G) "Closed panel plan" means a health care plan that
requires enrollees to use participating providers.
(G)(H) "Compensation" means remuneration for the
provision of
health care services, determined on other than a
fee-for-service
or discounted-fee-for-service basis.
(H)(I) "Contractual
periodic prepayment" means the formula
for
determining the premium rate for all subscribers of a health
insuring
corporation.
(I)(J) "Corporation" means
a corporation formed under Chapter
1701. or 1702. of the
Revised
Code or the similar laws of another
state.
(J)(K) "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.
(K)(L) "Enrollee" means any
natural person who is entitled to
receive health care benefits
provided by a health insuring
corporation.
(L)(M) "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.
(M)(N) "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.
(N)(O) "Health care
services" means basic, supplemental, and
specialty health
care services.
(O)(P) "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.
(P)(Q) "Health insuring
corporation" means a corporation, as
defined in division (I)(J) 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.
(Q)(R) "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.
(R)(S) "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.
(S)(T) "Medicaid" has the same meaning as in section 5111.01
of
the Revised Code.
(T)(U) "Medical record"
means the personal information that
relates to an individual's
physical or mental condition, medical
history, or medical
treatment.
(U)(V) "Medicare" means the program established under Title
XVIII of the "Social Security Act" 49 Stat. 620 (1935), 42 U.S.C.
1395, as amended.
(V)(W)(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.
(W)(X) "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.
(X)(Y) "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.
(Y)(Z) "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.
(Z)(AA) "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.
(AA)(BB) "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.
(BB)(CC) "Provider sponsored
organization" means a
corporation,
as defined in division
(I)(J) 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.
(CC)(DD) "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.
(DD)(EE) "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.
(EE)(FF) "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. 3923.281.
(A) As used in this section:
(1)
"Biologically based mental illness" 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 "Mental illness" means any condition or disorder
involving mental illness as defined by the most recent edition of
the diagnostic and
statistical manual of mental disorders
published by the American
psychiatric association or as defined
by
any diagnostic category listed in the mental disorder section
of
the most recent edition of the international classification of
diseases.
(2)
"Policy of sickness and accident insurance" has the same
meaning as in section 3923.01 of the Revised Code, but excludes
any hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of not longer
than six months, supplemental benefit, or other policy
that
provides coverage for specific diseases or
accidents only; any
policy that provides coverage for workers' compensation claims
compensable pursuant to Chapters 4121. and 4123. of the Revised
Code; any policy that provides coverage to 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, as provided by the Ohio department
of job
and family services under Chapter 5111. of the Revised
Code; and
any policy that provides coverage to beneficiaries
enrolled in
the children's buy-in program established under
sections
5101.5211 to 5101.5216 of the Revised Code.
(3) "Substance abuse or addiction condition" means any
alcohol or drug related disorder as defined by the most recent
edition of the diagnostic and statistical manual of mental
disorders published by the American psychiatric association or as
defined by a diagnostic category listed in the most recent edition
of the international classification of diseases.
(B)
Notwithstanding section 3901.71 of the
Revised
Code,
and
subject to division (E) of this section, every
policy of
sickness
and accident insurance shall provide
benefits
for the
diagnosis
and treatment of biologically based mental illnesses and
substance abuse or addiction conditions on
the same
terms and
conditions as, and
shall provide benefits no
less
extensive than,
those provided
under the policy of sickness
and
accident
insurance
for the
treatment and diagnosis of all
other
physical
diseases and
disorders, if both of the following
apply:
(1)
The biologically based mental illness or substance abuse
or addiction condition is clinically
diagnosed by a physician
authorized under Chapter 4731.
of the
Revised
Code to practice
medicine and
surgery or osteopathic
medicine and surgery; a
psychologist
licensed under Chapter 4732.
of
the Revised
Code; a
professional clinical
counselor,
professional counselor, or
independent social worker
licensed
under Chapter 4757. of
the
Revised
Code; or a clinical nurse
specialist licensed under
Chapter 4723. of the
Revised
Code whose
nursing specialty is
mental health.
(2)
The prescribed treatment is not experimental or
investigational, having proven its clinical effectiveness in
accordance with generally accepted medical standards.
(C)
Division
(B) of this section applies to
all coverages
and
terms and conditions of the policy of sickness
and accident
insurance, including, but not limited to, coverage
of inpatient
hospital services, outpatient services, and
medication; maximum
lifetime benefits; copayments; and
individual and family
deductibles.
(D)
Nothing in this
section shall be construed as
prohibiting
a sickness and
accident insurance company from taking
any of the
following
actions:
(1)
Negotiating separately with mental health care
providers
with regard to reimbursement rates and the delivery of
health care
services;
(2)
Offering policies that provide benefits solely for
the
diagnosis and treatment of biologically based mental illnesses and
substance abuse or addiction conditions;
(3)
Managing the provision of benefits for the diagnosis
or
treatment of biologically based mental illnesses and substance
abuse or addiction conditions through the use
of pre-admission
screening,
by requiring beneficiaries to obtain
authorization
prior to
treatment, or through the use of any other
mechanism
designed to
limit coverage to that treatment determined
to be
necessary;
(4)
Enforcing the terms and conditions of a policy of
sickness and accident insurance.
(E) An insurer that offers any policy of sickness and
accident insurance is not required to provide benefits for the
diagnosis and treatment of biologically based mental illnesses
and substance abuse or addiction conditions pursuant to division
(B) of this section if all of the following
apply:
(1) The insurer 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 and
substance abuse or addiction conditions mental
illnesses for a
period of at least six months independently caused
the insurer's
costs for claims and administrative expenses for the
coverage of
all other physical diseases and disorders to increase
by more
than one per cent per year.
(2) The insurer submits a signed letter from an independent
member of the American academy of actuaries to the superintendent
of insurance opining that the increase described in division
(E)(1) of this section could reasonably justify an increase of
more than one per cent in the annual premiums or rates charged by
the insurer for the coverage of all other physical diseases and
disorders.
(3) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (E)(1) and (2) of this section:
(a) Incurred claims for diagnostic and treatment services for
biologically based mental illnesses and substance abuse or
addiction conditions for a period of at least six
months
independently caused the insurer's costs for claims and
administrative expenses for the coverage of all other physical
diseases and disorders to increase by more than one per cent per
year.
(b) The increase in costs reasonably justifies an increase of
more than one per cent in the annual premiums or rates charged by
the insurer for the coverage of all other physical diseases and
disorders.
Any determination made by the superintendent under this
division is subject to Chapter 119. of the Revised Code.
Sec. 3923.282. (A) As used in this
section:
(1)
"Biologically based mental illness" 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 "Mental illness" means any condition or disorder
involving mental illness as defined by the most recent edition of
the diagnostic and statistical manual of mental disorders
published by the American psychiatric association or as defined by
any diagnostic category listed in the mental disorder section of
the most recent edition of the international classification of
diseases.
(2)
"Plan of health coverage" includes any private or
public
employer group self-insurance plan that provides payment for
health care
benefits for other than specific diseases or
accidents
only, which
benefits are not provided by contract with
a sickness
and accident
insurer or health insuring
corporation.
(3) "Substance abuse or addiction condition" means any
alcohol or drug related disorder as defined by the most recent
edition of the diagnostic and statistical manual of mental
disorders published by the American psychiatric association or as
defined by a diagnostic category listed in the most recent edition
of the international classification of diseases.
(B)
Notwithstanding section 3901.71 of the
Revised
Code, and
subject to division (F) of this section,
each
plan of health
coverage shall provide benefits for the
diagnosis
and treatment
of
biologically based mental illnesses and substance abuse or
addiction conditions on the same terms and conditions as,
and
shall
provide benefits no less extensive than, those provided
under
the plan of health coverage for the treatment and diagnosis
of
all other physical diseases and disorders, if both of the
following apply:
(1)
The biologically based mental illness or substance abuse
or addiction condition is clinically diagnosed by a physician
authorized under Chapter 4731.
of the Revised
Code to practice
medicine and
surgery or osteopathic medicine and surgery; a
psychologist
licensed under Chapter 4732. of
the Revised
Code; a
professional clinical
counselor, professional counselor, or
independent social worker
licensed under Chapter 4757. of
the
Revised
Code; or a clinical nurse
specialist licensed under
Chapter 4723. of the
Revised
Code whose nursing specialty is
mental health.
(2)
The prescribed treatment is not experimental or
investigational, having proven its clinical effectiveness in
accordance with generally accepted medical standards.
(C)
Division
(B) of this section applies to
all coverages
and
terms and conditions of the plan of health
coverage,
including,
but not limited to, coverage of inpatient
hospital
services,
outpatient services, and medication; maximum
lifetime
benefits;
copayments; and individual and family
deductibles.
(D)
This section does
not apply to a plan of health
coverage
if federal
law supersedes, preempts, prohibits, or
otherwise
precludes its
application to such plans. This section does not
apply to long-term care, hospital indemnity, disability income, or
medicare supplement plans of health coverage, or to any other
supplemental benefit plans of health coverage.
(E)
Nothing in this
section shall be construed as
prohibiting
an employer from
taking any of the following actions
in connection
with a plan of
health coverage:
(1)
Negotiating separately with mental health care
providers
with regard to reimbursement rates and the delivery of
health care
services;
(2)
Managing the provision of benefits for the diagnosis
or
treatment of biologically based mental illnesses and substance
abuse or addiction conditions through the use of pre-admission
screening,
by requiring beneficiaries to obtain authorization
prior to
treatment, or through the use of any other mechanism
designed to
limit coverage to that treatment determined to be
necessary;
(3)
Enforcing the terms and conditions of a plan of
health
coverage.
(F) An employer that offers a plan of health coverage is not
required to provide benefits for the diagnosis and treatment of
biologically based mental illnesses and substance abuse or
addiction conditions in combination with benefits for the
treatment and diagnosis of all other physical diseases and
disorders as described in division (B) of this section if both of
the following apply:
(1) The employer 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 and substance abuse or addiction conditions for a period
of at least six months independently caused the employer's costs
for claims and administrative expenses for the coverage of all
other physical diseases and disorders to increase by more than one
per cent per year.
(2) The superintendent of insurance determines from the
documentation and opinion submitted pursuant to division (F) of
this section, that incurred claims for diagnostic and treatment
services for biologically based mental illnesses and substance
abuse or addiction conditions for a period of at least six months
independently caused the employer's costs for claims and
administrative expenses for the coverage of all other physical
diseases and disorders to increase by more than one per cent per
year.
Any determination made by the superintendent under this
division is subject to Chapter 119. of the Revised Code.
Sec. 3923.51. (A) As used in this section, "official
poverty
line" means the poverty line as defined by the United
States
office of management and budget and revised by the
secretary of
health and human services under 95 Stat. 511, 42
U.S.C.A. 9902, as
amended.
(B) Every insurer that is authorized to write sickness and
accident insurance in this state may offer group contracts of
sickness and accident insurance to any charitable foundation that
is certified as exempt from taxation under section 501(c)(3) of
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A.
1, as amended, and that has the sole purpose of issuing
certificates of coverage under these contracts to persons under
the age of nineteen who are members of families that have incomes
that are no greater than three hundred per cent of the official
poverty line.
(C) Contracts offered pursuant to division (B) of this
section are not subject to any of the following:
(1) Sections 3923.122, 3923.24, 3923.28, and 3923.281, and
3923.29
of the
Revised
Code;
(2) Any other sickness and accident insurance coverage
required under this chapter on August 3, 1989.
Any requirement
of
sickness and accident insurance
coverage enacted after that date
applies to this section only if
the subsequent enactment
specifically refers to this section.
(3) Chapter 1751. of the Revised Code.
Section 2. That existing sections 1739.05, 1751.01, 3923.281,
3923.282, and 3923.51 and sections 3923.28, 3923.29, and 3923.30
of the Revised Code are hereby repealed.
Section 3. Section 1751.01 of the Revised Code is
presented
in
this act as a composite of the section as amended by
both Am.
Sub. H.B. 562 and Sub. S.B. 186 of
the 127th General
Assembly.
The General Assembly, applying the
principle stated in
division
(B) of section 1.52 of the Revised
Code that amendments
are to be
harmonized if reasonably capable of
simultaneous
operation, finds
that the composite is the resulting
version of
the section in
effect prior to the effective date of
the section
as presented in
this act.
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