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S. B. No. 381 As IntroducedAs Introduced
129th General Assembly | Regular Session | 2011-2012 |
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Cosponsors:
Senators Balderson, Eklund, Patton, LaRose, Manning
A BILL
To amend sections 1751.01, 3923.281, and 3923.282 of
the Revised Code to include pervasive
developmental disorders in the mental health
insurance parity law.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.01, 3923.281, and 3923.282 of
the Revised Code be amended to read as follows:
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 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 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) 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.
(b) Coverage for diagnostic and treatment services for
biologically based mental illnesses related to pervasive
developmental disorders shall include applied behavior analysis
when provided or supervised by an analyst certified by the
behavior analyst certification board or by a state licensed
physician or psychologist, or a mental health professional, as
defined in division (A)(1)(d) of section 2305.51 of the Revised
Code, so long as the services performed are commensurate with the
physician's, psychologist's, or mental health professional's
training and supervised experience. Such coverage shall include
the services of the personnel who work under the supervision of
the analyst certified by the behavior analyst certification board
or the licensed physician or psychologist or the mental health
professional.
(c) A health insuring corporation may subject coverage for
applied behavior analysis to an annual maximum benefit of fifty
thousand dollars.
(d) On and after January 1, 2014, to the extent that division
(A)(2)(b) of this section results in the state paying the cost of
benefits that exceed the essential health benefits specified under
section 1302(b) of the "Patient Protection and Affordable Care
Act," 42 U.S.C. 18022(b), as amended, those benefits that exceed
the specified essential health benefits shall not be required of
health benefit plans in the individual market or in the small
group market that are offered by a health insuring corporation in
this state either through or outside a health insurance exchange
operated by the state or by the federal government.
(e) "Applied behavior analysis" means the design,
implementation, and evaluation of environmental modifications
using behavioral stimuli and consequences to produce socially
significant improvement in human behavior, that is delivered in a
home or clinic setting to address core deficits resulting from a
medical diagnosis of pervasive developmental disorder. "Applied
behavior analysis" includes the use of direct observation,
measurement, and functional analysis of the relationship between
environment and behavior.
(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, and pervasive developmental
disorders.
(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
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) "Medicaid" has the same meaning as in section 5111.01 of
the Revised Code.
(S) "Medical record" means the personal information that
relates to an individual's physical or mental condition, medical
history, or medical treatment.
(T) "Medicare" means the program established under Title
XVIII of the "Social Security Act" 49 Stat. 620 (1935), 42 U.S.C.
1395, as amended.
(U)(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.
(V) "Osteopathic hospital" means a hospital registered under
section 3701.07 of the Revised Code that advocates osteopathic
principles and the practice and perpetuation of osteopathic
medicine by doing any of the following:
(1) Maintaining a department or service of osteopathic
medicine or a committee on the utilization of osteopathic
principles and methods, under the supervision of an osteopathic
physician;
(2) Maintaining an active medical staff, the majority of
which is comprised of osteopathic physicians;
(3) Maintaining a medical staff executive committee that has
osteopathic physicians as a majority of its members.
(W) "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) "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) "Pervasive developmental disorder" means all of the
following as they are defined in the most recent edition of the
diagnostic and statistical manual of mental disorders as published
by the American psychiatric association:
(3) Pervasive developmental disorder-not otherwise specified;
(5) Childhood disintegrative disorder.
(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 (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.
(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 the most recent edition of the diagnostic and
statistical manual of mental disorders published by the American
psychiatric association, and pervasive developmental disorders.
(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; and 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.
(3) "Applied behavior analysis" means the design,
implementation, and evaluation of environmental modifications
using behavioral stimuli and consequences to produce socially
significant improvement in human behavior, that is delivered in a
home or clinic setting to address core deficits resulting from a
medical diagnosis of pervasive developmental disorder. "Applied
behavior analysis" includes the use of direct observation,
measurement, and functional analysis of the relationship between
environment and behavior.
(4) "Pervasive developmental disorder" means all of the
following as they are defined in the most recent edition of the
diagnostic and statistical manual of mental disorders as published
by the American psychiatric association:
(c) Pervasive developmental disorder-not otherwise specified;
(e) Childhood disintegrative disorder.
(B)(1) 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 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)(a) The biologically based mental illness 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)(b) The prescribed treatment is not experimental or
investigational, having proven its clinical effectiveness in
accordance with generally accepted medical standards.
(2) Coverage for diagnostic and treatment services for
biologically based mental illnesses related to pervasive
developmental disorders shall include applied behavior analysis
when provided or supervised by an analyst certified by the
behavior analyst certification board or by a state licensed
physician or psychologist, or a mental health professional, as
defined under division (A)(1)(d) of section 2305.51 of the Revised
Code, so long as the services performed are commensurate with the
physician's, psychologist's, or mental health professional's
training and supervised experience. Such coverage shall include
the services of the personnel who work under the supervision of
the analyst certified by the behavior analyst certification board
or the licensed physician or psychologist or the mental health
professional.
(3) An insurer may subject coverage for applied behavior
analysis to an annual maximum benefit of fifty thousand dollars.
(4) On and after January 1, 2014, to the extent that the
requirement of division (B)(2) of this section results in the
state paying the cost of benefits that exceed the essential health
benefits specified under section 1302(b) of the "Patient
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as
amended, the specific benefits that exceed the specified essential
health benefits shall not be required of health benefit plans in
the individual market or the small group market that are offered
by a health care insurer in this state either through or outside a
health insurance exchange operated by the state or by the federal
government.
(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;
(3) Managing the provision of benefits for the diagnosis or
treatment of biologically based mental illnesses 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
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 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 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 the most recent edition of the diagnostic and
statistical manual of mental disorders published by the American
psychiatric association, and pervasive developmental disorders.
(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) "Applied behavior analysis" means the design,
implementation, and evaluation of environmental modifications
using behavioral stimuli and consequences to produce socially
significant improvement in human behavior, that is delivered in a
home or clinic setting to address core deficits resulting from a
medical diagnosis of pervasive developmental disorder. "Applied
behavior analysis" includes the use of direct observation,
measurement, and functional analysis of the relationship between
environment and behavior.
(4) "Pervasive developmental disorder" means all of the
following as they are defined in the most recent edition of the
diagnostic and statistical manual of mental disorders as published
by the American psychiatric association:
(c) Pervasive developmental disorder-not otherwise specified;
(e) Childhood disintegrative disorder.
(B)(1) 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 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)(a) The biologically based mental illness 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)(b) The prescribed treatment is not experimental or
investigational, having proven its clinical effectiveness in
accordance with generally accepted medical standards.
(2) Coverage for diagnostic and treatment services for
biologically based mental illnesses related to pervasive
developmental disorders shall include applied behavior analysis
when provided or supervised by an analyst certified by the
behavior analyst certification board or by a state licensed
physician or psychologist, or a mental health professional, as
defined under division (A)(1)(d) of section 2305.51 of the Revised
Code, so long as the services performed are commensurate with the
physician's, psychologist's, or mental health professional's
training and supervised experience. Such coverage shall include
the services of the personnel who work under the supervision of
the analyst certified by the behavior analyst certification board
or the licensed physician or psychologist or the mental health
professional.
(3) An employer may subject coverage for applied behavior
analysis to an annual maximum benefit of fifty thousand dollars.
(4) On and after January 1, 2014, to the extent that the
requirement of division (B)(2) of this section results in the
state paying the cost of benefits that exceed the essential health
benefits specified under section 1302(b) of the "Patient
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as
amended, the specific benefits that exceed the specified essential
health benefits shall not be required of health benefit plans in
the individual market or small group market that are offered by a
health care insurer in this state either through or outside a
health insurance exchange operated by the state or by the federal
government.
(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 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 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 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 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.
Section 2. That existing sections 1751.01, 3923.281, and
3923.282 of the Revised Code are hereby repealed.
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