To enact sections 3959.18, 3964.01 to 3964.09, and 5111.0216 of the Revised Code to establish standards for physician designations by health care insurers.

Section 1.  That sections 3959.18, 3964.01, 3964.02, 3964.03, 3964.04, 3964.05, 3964.06, 3964.07, 3964.08, 3964.09, and 5111.0216 of the Revised Code be enacted to read as follows:

Sec. 3959.18.  Chapter 3964. of the Revised Code applies to an administrator in the same manner that the chapter applies to a health care insurer, as defined in section 3964.01 of the Revised Code.

Sec. 3964.01. As used in this chapter:

(A) "Health care insurer" means an entity that offers a policy, contract, or plan for covering the cost of health care services for individuals who are beneficiaries of or enrolled in the policy, contract, or plan, to the extent that the entity and the policy, contract, or plan are subject to the laws of this state. "Health care insurer" includes all of the following:

(1) A sickness and accident insurance company authorized to do the business of insurance in this state;

(2) A health insuring corporation that holds a certificate of authority issued under Chapter 1751. of the Revised Code;

(3) An entity that offers a multiple employer welfare arrangement, as defined in section 1739.01 of the Revised Code;

(4) The state, a political subdivision, or any other government entity that offers a public employee health benefit plan.

(B) "Medicaid managed care organization" means a managed care organization under contract with the department of job and family services under section 5111.17 of the Revised Code to provide, or arrange for the provision of, health care services to medicaid recipients who are required or permitted to obtain health care services through managed care organizations as part of the care management system established under section 5111.16 of the Revised Code.

(C) "Patient charter" means either the patient charter for physician performance measurement, reporting, and tiering programs, which is developed by the consumer-purchaser disclosure project, or a substantially similar document developed by a successor organization.

(D) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery.

(E) "Physician designation" means a grade, star, tier, or any other rating used by a health care insurer to characterize or represent the insurer's assessment or measurement of a physician's cost efficiency, quality of care, or clinical performance. "Physician designation" does not include either of the following:

(1) Information derived solely from satisfaction surveys or other comments provided by individuals who are beneficiaries of or enrolled in a policy, contract, or plan offered by a health care insurer;

(2) Information for a program established by a health care insurer to assist individuals with estimating a physician's routine fees for providing services.

Sec. 3964.02.  A health care insurer that operates a system for making physician designations shall operate the system in accordance with either of the following:

(A) The criteria identified in the version of the patient charter that is most current at the time the system is being operated;

(B) The criteria identified in another version of the patient charter that was in effect at any time during the twelve-month period immediately preceding the time at which the system is being operated.

Sec. 3964.03. Annually, in accordance with a schedule established by the superintendent of insurance, a health care insurer that operates a system for making physician designations shall submit to the superintendent a certificate from an independent ratings examiner attesting to the examiner's determination that the insurer has been in compliance with section 3964.02 of the Revised Code during the twelve-month period immediately preceding the certificate's submission. The independent ratings examiner that issues the certificate shall be one approved by the superintendent of insurance pursuant to the process established under section 3964.04 of the Revised Code.

The health care insurer shall pay all charges assessed by the independent ratings examiners for the issuance of the certificate.

Sec. 3964.04.  The superintendent of insurance shall establish a process for approving independent ratings examiners that may issue the certificates described in section 3964.03 of the Revised Code. In establishing the approval process, the superintendent is subject to both of the following:

(A) The superintendent may approve only independent rating examiners that are members of at least one nationally recognized, independent, health care quality standard-setting organization.

(B) The superintendent shall approve all entities determined to be eligible by the consumer-purchaser disclosure project or its successor to monitor compliance with the patient charter.

Sec. 3964.05. (A)(1) Subject to division (A)(2) of this section, no health care insurer shall fail to comply with section 3964.02 or 3964.03 of the Revised Code.

(2) Division (A)(1) of this section does not apply to a medicaid managed care organization if the department of job and family services, pursuant to section 5111.0216 of the Revised Code, has extended to the organization the department's operation of a system for making physician designations.

(B) In the case of a health care insurer that is regulated by the department of insurance, a series of violations of this section that, taken together, constitutes a pattern or practice of violating this section shall be considered an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

Sec. 3964.06. Nothing in this chapter shall be construed to deprive any person of any private right of action otherwise available under the law.

Sec. 3964.07. If a provision of a contractual arrangement between a physician and a health care insurer that operates a system for making physician designations does either of the following, the provision is unenforceable:

(A) Limits a right the physician has pursuant to this chapter or the patient charter under which the health care insurer is operating its system pursuant to section 3964.02 of the Revised Code;

(B) Requires the physician or health care insurer to act in a manner that is otherwise contrary to the provisions of this chapter or the applicable patient charter.

Sec. 3964.08.  Neither sections 1333.61 to 1333.69 of the Revised Code nor any other provision of the Revised Code pertaining to trade secrets excuses a health care insurer that is operating a system for making physician designations from complying with any disclosures of information that are required by the patient charter under which the health care insurer is operating its system pursuant to section 3964.02 of the Revised Code.

Sec. 3964.09.  The superintendent of insurance may adopt rules as the superintendent considers necessary to carry out the purposes of this chapter. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

Sec. 5111.0216. (A) As used in this section:

(1) "Patient charter" and "physician" have the same meanings as in section 3964.01 of the Revised Code.

(2) "Physician designation" means a grade, star, tier, or any other rating to characterize or represent an assessment or measurement of a physician's cost efficiency, quality of care, or clinical performance. "Physician designation" does not include either of the following:

(a) Information derived solely from satisfaction surveys or other comments provided by medicaid recipients;

(b) Information established for the medicaid program to assist medicaid recipients with estimating a physician's routine fees for providing services.

(B) The department of job and family services may operate a system for making physician designations for purposes of the medicaid program. If such a system is operated, the department shall extend the system to managed care organizations when contracting with the organizations pursuant to section 5111.17 of the Revised Code.

(C) In operating a system for making physician designations, the department shall operate the system in accordance with either of the following:

(1) The criteria identified in the version of the patient charter that is most current at the time the system is being operated;

(2) The criteria identified in another version of the patient charter that was in effect at any time during the twelve-month period immediately preceding the time at which the system is being operated.

(D) Compliance with division (C) of this section shall be determined by a nationally recognized, independent, health care quality standard-setting organization that is selected by the department.

(E) The department of insurance has no authority over the department of job and family services in the operation of a system for making physician designations.

Section 2. (A) As used in this section, "health care insurer" and "physician designation" have the same meanings as in section 3964.01 of the Revised Code, as enacted by this act.

(B) If, on the effective date of this section, a health care insurer is operating a system for making physician designations and the system has been in operation for at least three months, the first certificate that is required to be submitted under section 3964.03 of the Revised Code, as enacted by this act, is due not later than six months after the effective date of this section. Thereafter, the health care insurer shall annually submit certificates in accordance with the schedule established by the Superintendent of Insurance.