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Sub. S. B. No. 54 As Reported by the House Health and Aging CommitteeAs Reported by the House Health and Aging Committee
130th General Assembly | Regular Session | 2013-2014 |
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Cosponsors:
Senators Cafaro, Gentile, Smith, Sawyer, Tavares, Schiavoni, Turner, Lehner, Jones, Bacon, Balderson, Beagle, Burke, Coley, Faber, Gardner, Hite, Hughes, LaRose, Manning, Obhof, Oelslager, Patton, Peterson, Schaffer, Seitz, Skindell, Uecker, Widener
Representatives Wachtmann, Brown
A BILL
To amend sections 1739.061, 1751.14, 1751.69,
3923.022, 3923.24, 3923.241, 3923.281, 3923.57,
3923.58, 3923.601, 3923.65, 3923.83, 3923.85,
3924.01, 4729.291, and 4729.541 and to enact
sections 505.377, 737.082, 737.222, 3702.40, and
4731.056 of the Revised Code to require a
mammography facility to include certain
information in the mammography report summary sent
to a patient under federal law if the patient's
mammogram demonstrates the presence of dense
breast tissue; to establish requirements regarding
controlled substances containing buprenorphine
used for the purpose of treating drug dependence
or addiction; to clarify the status of volunteer
firefighters for purposes of the Patient
Protection and Affordable Care Act; to make
changes regarding coverage for a dependent child
under a parent's health insurance plan and the
hours of work needed to qualify for coverage under
a small employer health benefit plan; to increase
the duration of the health insurance considered to
be short-term under certain insurance laws; and to
make changes to the chemotherapy parity law.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.061, 1751.14, 1751.69,
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601,
3923.65, 3923.83, 3923.85, 3924.01, 4729.291, and 4729.541 be
amended and sections 505.377, 737.082, 737.222, 3702.40, and
4731.056 of the Revised Code be enacted to read as follows:
Sec. 505.377. A volunteer firefighter appointed pursuant to
this chapter is a bona fide volunteer and not an employee for
purposes of section 513 of the "Patient Protection and Affordable
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for
providing those fire protection services, the volunteer receives
any of the benefits provided in Chapter 146., 4121., or 4123. or
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised
Code.
Sec. 737.082. A volunteer firefighter appointed pursuant to
this chapter is a bona fide volunteer and not an employee for
purposes of section 513 of the "Patient Protection and Affordable
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for
providing those fire protection services, the volunteer receives
any of the benefits provided in Chapter 146., 4121., or 4123. or
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised
Code.
Sec. 737.222. A volunteer firefighter appointed pursuant to
this chapter is a bona fide volunteer and not an employee for
purposes of section 513 of the "Patient Protection and Affordable
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for
providing those fire protection services, the volunteer receives
any of the benefits provided in Chapter 146., 4121., or 4123. or
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised
Code.
Sec. 1739.061. (A)(1) This section applies to both of the
following:
(a) A multiple employer welfare arrangement that issues or
requires the use of a standardized identification card or an
electronic technology for submission and routing of prescription
drug claims;
(b) A person or entity that a multiple employer welfare
arrangement contracts with to issue a standardized identification
card or an electronic technology described in division (A)(1)(a)
of this section.
(2) Notwithstanding division (A)(1) of this section, this
section does not apply to the issuance or required use of a
standardized identification card or an electronic technology for
the submission and routing of prescription drug claims in
connection with any of the following:
(a) Any program or arrangement covering only accident,
credit, dental, disability income, long-term care, hospital
indemnity, medicare supplement, medicare, tricare, specified
disease, or vision care; coverage under a
one-time-limited-duration policy of not longer that is less than
six twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of workers' compensation or
similar law; automobile medical payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
(b) Coverage provided under the medicaid program.
(c) Coverage provided under an employer's self-insurance plan
or by any of its administrators, as defined in section 3959.01 of
the Revised Code, to the extent that federal law supersedes,
preempts, prohibits, or otherwise precludes the application of
this section to the plan and its administrators.
(B) A standardized identification card or an electronic
technology issued or required to be used as provided in division
(A)(1) of this section shall contain uniform prescription drug
information in accordance with either division (B)(1) or (2) of
this section.
(1) The standardized identification card or the electronic
technology shall be in a format and contain information fields
approved by the national council for prescription drug programs or
a successor organization, as specified in the council's or
successor organization's pharmacy identification card
implementation guide in effect on the first day of October most
immediately preceding the issuance or required use of the
standardized identification card or the electronic technology.
(2) If the multiple employer welfare arrangement or person
under contract with it to issue a standardized identification card
or an electronic technology requires the information for the
submission and routing of a claim, the standardized identification
card or the electronic technology shall contain any of the
following information:
(a) The name of the multiple employer welfare arrangement;
(b) The individual's name, group number, and identification
number;
(c) A telephone number to inquire about pharmacy-related
issues;
(d) The issuer's international identification number, labeled
as "ANSI BIN" or "RxBIN";
(e) The processor's control number, labeled as "RxPCN";
(f) The individual's pharmacy benefits group number if
different from the insured's medical group number, labeled as
"RxGrp."
(C) If the standardized identification card or the electronic
technology issued or required to be used as provided in division
(A)(1) of this section is also used for submission and routing of
nonpharmacy claims, the designation "Rx" is required to be
included as part of the labels identified in divisions (B)(2)(d)
and (e) of this section if the issuer's international
identification number or the processor's control number is
different for medical and pharmacy claims.
(D) Each multiple employer welfare arrangement described in
division (A) of this section shall annually file a certificate
with the superintendent of insurance certifying that it or any
person it contracts with to issue a standardized identification
card or electronic technology for submission and routing of
prescription drug claims complies with this section.
(E)(1) Except as provided in division (E)(2) of this section,
if there is a change in the information contained in the
standardized identification card or the electronic technology
issued to an individual, the multiple employer welfare arrangement
or person under contract with it to issue a standardized
identification card or an electronic technology shall issue a new
card or electronic technology to the individual.
(2) A multiple employer welfare arrangement or person under
contract with it is not required under division (E)(1) of this
section to issue a new card or electronic technology to an
individual more than once during a twelve-month period.
(F) Nothing in this section shall be construed as requiring a
multiple employer welfare arrangement to produce more than one
standardized identification card or one electronic technology for
use by individuals accessing health care benefits provided under a
multiple employer welfare arrangement.
Sec. 1751.14. (A) Notwithstanding section 3901.71 of the
Revised Code, any policy, contract, or agreement for health care
services authorized by this chapter that is issued, delivered, or
renewed in this state and that provides that coverage of an
unmarried dependent child will terminate upon attainment of the
limiting age for dependent children specified in the policy,
contract, or agreement, shall also provide in substance both of
the following:
(1) Once an unmarried child has attained the limiting age for
dependent children, as provided in the policy, contract, or
agreement, upon the request of the subscriber, the health insuring
corporation shall offer to cover the unmarried child until the
child attains twenty-eight twenty-six years of age if all of the
following are true:
(a) The child is the natural child, stepchild, or adopted
child of the subscriber.
(b) The child is a resident of this state or a full-time
student at an accredited public or private institution of higher
education.
(c) The child is not employed by an employer that offers any
health benefit plan under which the child is eligible for
coverage.
(d) The child is not eligible for coverage under the medicaid
program or the medicare program.
(2) That attainment of the limiting age for dependent
children shall not operate to terminate the coverage of a
dependent child if the child is and continues to be both of the
following:
(a) Incapable of self-sustaining employment by reason of
mental retardation or physical handicap;
(b) Primarily dependent upon the subscriber for support and
maintenance.
(B) Proof of incapacity and dependence for purposes of
division (A)(2) of this section shall be furnished to the health
insuring corporation within thirty-one days of the child's
attainment of the limiting age. Upon request, but not more
frequently than annually, the health insuring corporation may
require proof satisfactory to it of the continuance of such
incapacity and dependency.
(C) Nothing in this section shall do any of the following:
(1) Require that any policy, contract, or agreement offer
coverage for dependent children or provide coverage for an
unmarried dependent child's children as dependents on the policy,
contract, or agreement;
(2) Require an employer to pay for any part of the premium
for an unmarried dependent child that has attained the limiting
age for dependents, as provided in the policy, contract, or
agreement;
(3) Require an employer to offer health insurance coverage to
the dependents of any employee.
(D) This section does not apply to any health insuring
corporation policy, contract, or agreement offering only
supplemental health care services or specialty health care
services.
(E) As used in this section, "health benefit plan" has the
same meaning as in section 3924.01 of the Revised Code and also
includes both of the following:
(1) A public employee benefit plan;
(2) A health benefit plan as regulated under the "Employee
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.
Sec. 1751.69. (A) As used in this section, "cost sharing"
means the cost to an individual insured under an individual or
group health insuring corporation policy, contract, or agreement
according to any coverage limit, copayment, coinsurance,
deductible, or other out-of-pocket expense requirements imposed by
the policy, contract, or agreement.
(B) Notwithstanding section 3901.71 of the Revised Code and
subject to division (D) of this section, no individual or group
health insuring corporation policy, contract, or agreement
providing basic health care services or prescription drug services
that is delivered, issued for delivery, or renewed in this state,
if the policy, contract, or agreement provides coverage for cancer
chemotherapy treatment, shall fail to comply with either of the
following:
(1) The policy, contract, or agreement shall not provide
coverage or impose cost sharing for a prescribed, orally
administered cancer medication on a less favorable basis than the
coverage it provides or cost sharing it imposes for intraveneously
administered or injected cancer medications.
(2) The policy, contract, or agreement shall not comply with
division (B)(1) of this section by imposing an increase in cost
sharing solely for orally administered, intravenously
administered, or injected cancer medications.
(C) Notwithstanding any provision of this section to the
contrary, an individual or group health insuring corporation
policy, contract, or agreement shall be deemed to be in compliance
with this section if the cost sharing imposed under such a policy,
contract, or agreement for orally administered cancer treatments
does not exceed one hundred dollars per prescription fill. The
cost sharing limit of one hundred dollars per prescription fill
shall apply to a high deductible plan, as defined in 26 U.S.C.
223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only
after the deductible has been met.
(D) The prohibitions in division (B) of this section do not
preclude an individual or group health insuring corporation
policy, contract, or agreement from requiring an enrollee to
obtain prior authorization before orally administered cancer
medication is dispensed to the enrollee.
(E) A health insuring corporation that offers coverage for
basic health care services is not required to comply with division
(B) of this section if all of the following apply:
(1) The health insuring corporation submits documentation
certified by an independent member of the American academy of
actuaries to the superintendent of insurance showing that
compliance with division (B)(1) of this section 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.
(2) 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 (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 health insuring corporation for
the coverage of basic health care services.
(3)(a) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (E)(1) and (2) of this section:
(i) Compliance with division (B)(1) of this section 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 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.
(b) Any determination made by the superintendent under
division (E)(3) of this section is subject to Chapter 119. of the
Revised Code.
Sec. 3702.40. (A) As used in this section, "mammogram" and
"facility" have the same meanings as in section 263b(a) of the
"Mammography Quality Standards Act of 1992," 106 Stat. 3547
(1992), 42 U.S.C. 263b(a), as amended.
(B) As required by 21 C.F.R. 900.12(c)(2), a facility shall
send to each patient who has a mammogram at the facility a summary
of the written report containing the results of the patient's
mammogram. If, based on the breast imaging reporting and data
system established by the American college of radiology, the
patient's mammogram demonstrates that the patient has dense breast
tissue, the summary shall include the following statement:
"Your mammogram demonstrates that you have dense breast
tissue, which could hide abnormalities. Dense breast tissue, in
and of itself, is a relatively common condition. Therefore, this
information is not provided to cause undue concern; rather, it is
to raise your awareness and promote discussion with your health
care provider regarding the presence of dense breast tissue in
addition to other risk factors."
As required by 21 C.F.R. 900.12(c)(3), the facility shall
send to the patient's health care provider, if known, a copy of
the written report containing the results of the patient's
mammogram not later than thirty days after the mammogram was
performed.
(C) This section does not do either of the following:
(1) Create a new cause of action or substantive legal right
against a person, facility, or other entity.
(2) Create a standard of care, obligation, or duty for a
person, facility, or other entity that would provide the basis for
a cause of action or substantive legal right, other than the duty
to send the summary and written report described in division (B)
of this section.
Sec. 3923.022. (A) As used in this section:
(1)(a) "Administrative expense" means the amount resulting
from the following: the amount of premiums earned by the insurer
for sickness and accident insurance business plus the amount of
losses recovered from reinsurance coverage minus the sum of the
amount of claims for losses paid; the amount of losses incurred
but not reported; the amount incurred for state fees, federal and
state taxes, and reinsurance; and the incurred costs and expenses
related, either directly or indirectly, to the payment of
commissions, measures to control fraud, and managed care.
(b) "Administrative expense" does not include any amounts
collected, or administrative expenses incurred, by an insurer for
the administration of an employee health benefit plan subject to
regulation by the federal "Employee Retirement Income Security Act
of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts
collected or administrative expenses incurred" means the total
amount paid to an administrator for the administration and payment
of claims minus the sum of the amount of claims for losses paid
and the amount of losses incurred but not reported.
(2) "Insurer" means any insurance company authorized under
Title XXXIX of the Revised Code to do the business of sickness and
accident insurance in this state.
(3) "Sickness and accident insurance business" does not
include coverage provided by an insurer for specific diseases or
accidents only; any hospital indemnity, medicare supplement,
long-term care, disability income, one-time-limited-duration
policy of no longer that is less than six twelve months, or other
policy that offers only supplemental benefits; or coverage
provided to individuals who are not residents of this state.
(4) "Individual business" includes both individual sickness
and accident insurance and sickness and accident insurance made
available by insurers in the individual market to individuals,
with or without family members or dependents, through group
policies issued to one or more associations or entities.
(B) Notwithstanding section 3941.14 of the Revised Code, each
insurer shall have aggregate administrative expenses of no more
than twenty per cent of the premium income of the insurer, based
on the premiums earned in that year on the sickness and accident
insurance business of the insurer.
(C)(1) Each insurer, on the first day of January or within
sixty days thereafter, shall annually prepare, under oath, and
deposit in the office of the superintendent of insurance a
statement of the aggregate administrative expenses of the insurer,
based on the premiums earned in the immediately preceding calendar
year on the sickness and accident insurance business of the
insurer. The statement shall itemize and separately detail all of
the following information with respect to the insurer's sickness
and accident insurance business:
(a) The amount of premiums earned by the insurer both before
and after any costs related to the insurer's purchase of
reinsurance coverage;
(b) The total amount of claims for losses paid by the insurer
both before and after any reimbursement from reinsurance coverage;
(c) The amount of any losses incurred by the insurer but not
reported by the insurer in the current or prior year;
(d) The amount of costs incurred by the insurer for state
fees and federal and state taxes;
(e) The amount of costs incurred by the insurer for
reinsurance coverage;
(f) The amount of costs incurred by the insurer that are
related to the insurer's payment of commissions;
(g) The amount of costs incurred by the insurer that are
related to the insurer's fraud prevention measures;
(h) The amount of costs incurred by the insurer that are
related to managed care; and
(i) Any other administrative expenses incurred by the
insurer.
(2) The statement also shall include all of the information
required under division (C)(1) of this section separately detailed
for the insurer's individual business, small group business, and
large group business.
(D) No insurer shall fail to comply with this section.
(E) If the superintendent determines that an insurer has
violated this section, the superintendent, pursuant to an
adjudication conducted in accordance with Chapter 119. of the
Revised Code, may order the suspension of the insurer's license to
do the business of sickness and accident insurance in this state
until the superintendent is satisfied that the insurer is in
compliance with this section. If the insurer continues to do the
business of sickness and accident insurance in this state while
under the suspension order, the superintendent shall order the
insurer to pay one thousand dollars for each day of the violation.
(F) Any money collected by the superintendent under division
(E) of this section shall be deposited by the superintendent into
the state treasury to the credit of the department of insurance
operating fund.
(G) The statement of aggregate expenses filed pursuant to
this section separately detailing an insurer's individual, small
group, and large group business shall be considered work papers
resulting from the conduct of a market analysis of an entity
subject to examination by the superintendent under division (C) of
section 3901.48 of the Revised Code, except that the
superintendent may share aggregated market information that
identifies the premiums earned as reported under division
(C)(1)(a) of this section, the administrative expenses reported
under division (C)(1)(i) of this section, the amount of
commissions reported under division (C)(1)(f) of this section, the
amount of taxes paid as reported under division (C)(1)(d) of this
section, the total of the remaining benefit costs as reported
under divisions (C)(1)(b) and (c) of this section, and the amount
of fraud and managed care expenses reported under divisions
(C)(1)(g) and (h) of this section.
Sec. 3923.24. (A) Notwithstanding section 3901.71 of the
Revised Code, every certificate furnished by an insurer in
connection with, or pursuant to any provision of, any group
sickness and accident insurance policy delivered, issued for
delivery, renewed, or used in this state on or after January 1,
1972, every policy of sickness and accident insurance delivered,
issued for delivery, renewed, or used in this state on or after
January 1, 1972, and every multiple employer welfare arrangement
offering an insurance program, which provides that coverage of an
unmarried dependent child of a parent or legal guardian will
terminate upon attainment of the limiting age for dependent
children specified in the contract shall also provide in substance
both of the following:
(1) Once an unmarried child has attained the limiting age for
dependent children, as provided in the policy, upon the request of
the insured, the insurer shall offer to cover the unmarried child
until the child attains twenty-eight twenty-six years of age if
all of the following are true:
(a) The child is the natural child, stepchild, or adopted
child of the insured.
(b) The child is a resident of this state or a full-time
student at an accredited public or private institution of higher
education.
(c) The child is not employed by an employer that offers any
health benefit plan under which the child is eligible for
coverage.
(d) The child is not eligible for the medicaid program or the
medicare program.
(2) That attainment of the limiting age for dependent
children shall not operate to terminate the coverage of a
dependent child if the child is and continues to be both of the
following:
(a) Incapable of self-sustaining employment by reason of
mental retardation or physical handicap;
(b) Primarily dependent upon the policyholder or certificate
holder for support and maintenance.
(B) Proof of such incapacity and dependence for purposes of
division (A)(2) of this section shall be furnished by the
policyholder or by the certificate holder to the insurer within
thirty-one days of the child's attainment of the limiting age.
Upon request, but not more frequently than annually after the
two-year period following the child's attainment of the limiting
age, the insurer may require proof satisfactory to it of the
continuance of such incapacity and dependency.
(C) Nothing in this section shall require an insurer to cover
a dependent child who is mentally retarded or physically
handicapped if the contract is underwritten on evidence of
insurability based on health factors set forth in the application,
or if such dependent child does not satisfy the conditions of the
contract as to any requirement for evidence of insurability or
other provision of the contract, satisfaction of which is required
for coverage thereunder to take effect. In any such case, the
terms of the contract shall apply with regard to the coverage or
exclusion of the dependent from such coverage. Nothing in this
section shall apply to accidental death or dismemberment benefits
provided by any such policy of sickness and accident insurance.
(D) Nothing in this section shall do any of the following:
(1) Require that any policy offer coverage for dependent
children or provide coverage for an unmarried dependent child's
children as dependents on the policy;
(2) Require an employer to pay for any part of the premium
for an unmarried dependent child that has attained the limiting
age for dependents, as provided in the policy;
(3) Require an employer to offer health insurance coverage to
the dependents of any employee.
(E) This section does not apply to any policies or
certificates covering only accident, credit, dental, disability
income, long-term care, hospital indemnity, medicare supplement,
specified disease, or vision care; coverage under a
one-time-limited-duration policy of not longer that is less than
six twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of a workers' compensation or
similar law; automobile medical-payment insurance; or insurance
under which benefits are payable with or without regard to fault
and that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
(F) As used in this section, "health benefit plan" has the
same meaning as in section 3924.01 of the Revised Code and also
includes both of the following:
(1) A public employee benefit plan;
(2) A health benefit plan as regulated under the "Employee
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.
Sec. 3923.241. (A) Notwithstanding section 3901.71 of the
Revised Code, any public employee benefit plan that provides that
coverage of an unmarried dependent child will terminate upon
attainment of the limiting age for dependent children specified in
the plan shall also provide in substance both of the following:
(1) Once an unmarried child has attained the limiting age for
dependent children, as provided in the plan, upon the request of
the employee, the public employee benefit plan shall offer to
cover the unmarried child until the child attains twenty-eight
twenty-six years of age if all of the following are true:
(a) The child is the natural child, stepchild, or adopted
child of the employee.
(b) The child is a resident of this state or a full-time
student at an accredited public or private institution of higher
education.
(c) The child is not employed by an employer that offers any
health benefit plan under which the child is eligible for
coverage.
(d) The child is not eligible for the medicaid program or the
medicare program.
(2) That attainment of the limiting age for dependent
children shall not operate to terminate the coverage of a
dependent child if the child is and continues to be both of the
following:
(a) Incapable of self-sustaining employment by reason of
mental retardation or physical handicap;
(b) Primarily dependent upon the plan member for support and
maintenance.
(B) Proof of incapacity and dependence for purposes of
division (A)(2) of this section shall be furnished to the public
employee benefit plan within thirty-one days of the child's
attainment of the limiting age. Upon request, but not more
frequently than annually, the public employee benefit plan may
require proof satisfactory to it of the continuance of such
incapacity and dependency.
(C) Nothing in this section shall do any of the following:
(1) Require that any public employee benefit plan offer
coverage for dependent children or provide coverage for an
unmarried dependent child's children as dependents on the public
employee benefit plan;
(2) Require an employer to pay for any part of the premium
for an unmarried dependent child that has attained the limiting
age for dependents, as provided in the plan;
(3) Require an employer to offer health insurance coverage to
the dependents of any employee.
(D) This section does not apply to any public employee
benefit plan covering only accident, credit, dental, disability
income, long-term care, hospital indemnity, medicare supplement,
specified disease, or vision care; coverage under a
one-time-limited-duration policy of not longer that is less than
six twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of a workers' compensation or
similar law; automobile medical-payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
(E) As used in this section, "health benefit plan" has the
same meaning as in section 3924.01 of the Revised Code and also
includes both of the following:
(1) A public employee benefit plan;
(2) A health benefit plan as regulated under the "Employee
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.
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.
(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
that is less than six twelve 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 medicaid recipients.
(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 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 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 licensed professional clinical counselor,
licensed professional counselor, independent social worker, or
independent marriage and family therapist licensed under Chapter
4757. of the Revised Code; or a clinical nurse specialist or
certified nurse practitioner 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;
(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. 3923.57. Notwithstanding any provision of this chapter,
every individual policy of sickness and accident insurance that is
delivered, issued for delivery, or renewed in this state is
subject to the following conditions, as applicable:
(A) Pre-existing conditions provisions shall not exclude or
limit coverage for a period beyond twelve months following the
policyholder's effective date of coverage and may only relate to
conditions during the six months immediately preceding the
effective date of coverage.
(B) In determining whether a pre-existing conditions
provision applies to a policyholder or dependent, each policy
shall credit the time the policyholder or dependent was covered
under a previous policy, contract, or plan if the previous
coverage was continuous to a date not more than thirty days prior
to the effective date of the new coverage, exclusive of any
applicable service waiting period under the policy.
(C)(1) Except as otherwise provided in division (C) of this
section, an insurer that provides an individual sickness and
accident insurance policy to an individual shall renew or continue
in force such coverage at the option of the individual.
(2) An insurer may nonrenew or discontinue coverage of an
individual in the individual market based only on one or more of
the following reasons:
(a) The individual failed to pay premiums or contributions in
accordance with the terms of the policy or the insurer has not
received timely premium payments.
(b) The individual performed an act or practice that
constitutes fraud or made an intentional misrepresentation of
material fact under the terms of the policy.
(c) The insurer is ceasing to offer coverage in the
individual market in accordance with division (D) of this section
and the applicable laws of this state.
(d) If the insurer offers coverage in the market through a
network plan, the individual no longer resides, lives, or works in
the service area, or in an area for which the insurer is
authorized to do business; provided, however, that such coverage
is terminated uniformly without regard to any health
status-related factor of covered individuals.
(e) If the coverage is made available in the individual
market only through one or more bona fide associations, the
membership of the individual in the association, on the basis of
which the coverage is provided, ceases; provided, however, that
such coverage is terminated under division (C)(2)(e) of this
section uniformly without regard to any health status-related
factor of covered individuals.
An insurer offering coverage to individuals solely through
membership in a bona fide association shall not be deemed, by
virtue of that offering, to be in the individual market for
purposes of sections 3923.58 and 3923.581 of the Revised Code.
Such an insurer shall not be required to accept applicants for
coverage in the individual market pursuant to sections 3923.58 and
3923.581 of the Revised Code unless the insurer also offers
coverage to individuals other than through bona fide associations.
(3) An insurer may cancel or decide not to renew the coverage
of a dependent of an individual if the dependent has performed an
act or practice that constitutes fraud or made an intentional
misrepresentation of material fact under the terms of the coverage
and if the cancellation or nonrenewal is not based, either
directly or indirectly, on any health status-related factor in
relation to the dependent.
(D)(1) If an insurer decides to discontinue offering a
particular type of health insurance coverage offered in the
individual market, coverage of such type may be discontinued by
the insurer if the insurer does all of the following:
(a) Provides notice to each individual provided coverage of
this type in such market of the discontinuation at least ninety
days prior to the date of the discontinuation of the coverage;
(b) Offers to each individual provided coverage of this type
in such market, the option to purchase any other individual health
insurance coverage currently being offered by the insurer for
individuals in that market;
(c) In exercising the option to discontinue coverage of this
type and in offering the option of coverage under division
(D)(1)(b) of this section, acts uniformly without regard to any
health status-related factor of covered individuals or of
individuals who may become eligible for such coverage.
(2) If an insurer elects to discontinue offering all health
insurance coverage in the individual market in this state, health
insurance coverage may be discontinued by the insurer only if both
of the following apply:
(a) The insurer provides notice to the department of
insurance and to each individual of the discontinuation at least
one hundred eighty days prior to the date of the expiration of the
coverage.
(b) All health insurance delivered or issued for delivery in
this state in such market is discontinued and coverage under that
health insurance in that market is not renewed.
(3) In the event of a discontinuation under division (D)(2)
of this section in the individual market, the insurer shall not
provide for the issuance of any health insurance coverage in the
market and this state during the five-year period beginning on the
date of the discontinuation of the last health insurance coverage
not so renewed.
(E) Notwithstanding divisions (C) and (D) of this section, an
insurer may, at the time of coverage renewal, modify the health
insurance coverage for a policy form offered to individuals in the
individual market if the modification is consistent with the law
of this state and effective on a uniform basis among all
individuals with that policy form.
(F) Such policies are subject to sections 2743 and 2747 of
the "Health Insurance Portability and Accountability Act of 1996,"
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and
300gg-47, as amended.
(G) Sections 3924.031 and 3924.032 of the Revised Code shall
apply to sickness and accident insurance policies offered in the
individual market in the same manner as they apply to health
benefit plans offered in the small employer market.
In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of
this section also apply to all group sickness and accident
insurance policies that are not sold in connection with an
employment-related group health plan and that provide more than
short-term, limited duration coverage.
In applying divisions (C) to (G) of this section with respect
to health insurance coverage that is made available by an insurer
in the individual market to individuals only through one or more
associations, the term "individual" includes the association of
which the individual is a member.
For purposes of this section, any policy issued pursuant to
division (C) of section 3923.13 of the Revised Code in connection
with a public or private college or university student health
insurance program is considered to be issued to a bona fide
association.
As used in this section, "bona fide association" has the same
meaning as in section 3924.03 of the Revised Code, and "health
status-related factor" and "network plan" have the same meanings
as in section 3924.031 of the Revised Code.
This section does not apply to any policy that provides
coverage for specific diseases or accidents only, or to any
hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer
that is less than six twelve months, or other policy that offers
only supplemental benefits.
Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 of
the Revised Code:
(1) "Base rate" means, as to any health benefit plan that is
issued by a carrier in the individual market, the lowest premium
rate for new or existing business prescribed by the carrier for
the same or similar coverage under a plan or arrangement covering
any individual with similar case characteristics.
(2) "Carrier," "health benefit plan," and "MEWA" have the
same meanings as in section 3924.01 of the Revised Code.
(3) "Network plan" means a health benefit plan of a carrier
under which the financing and delivery of medical care, including
items and services paid for as medical care, are provided, in
whole or in part, through a defined set of providers under
contract with the carrier.
(4) "Ohio health care basic and standard plans" means those
plans established under section 3924.10 of the Revised Code.
(5) "Pre-existing conditions provision" means a policy
provision that excludes or limits coverage for charges or expenses
incurred during a specified period following the insured's
effective date of coverage as to a condition which, during a
specified period immediately preceding the effective date of
coverage, had manifested itself in such a manner as would cause an
ordinarily prudent person to seek medical advice, diagnosis, care,
or treatment or for which medical advice, diagnosis, care, or
treatment was recommended or received, or a pregnancy existing on
the effective date of coverage.
(B) Beginning in January of each year, carriers in the
business of issuing health benefit plans to individuals and
nonemployer groups, except individual health benefit plans issued
pursuant to sections 1751.16 and 3923.122 of the Revised Code,
shall accept applicants for open enrollment coverage, as set forth
in this division, in the order in which they apply for coverage
and subject to the limitation set forth in division (G) of this
section. Carriers shall accept for coverage pursuant to this
section individuals to whom both of the following conditions
apply:
(1) The individual is not applying for coverage as an
employee of an employer, as a member of an association, or as a
member of any other group.
(2) The individual is not covered, and is not eligible for
coverage, under any other private or public health benefits
arrangement, including the medicare program established under
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, or any other act of congress or law of
this or any other state of the United States that provides
benefits comparable to the benefits provided under this section,
any medicare supplement policy, or any continuation of coverage
policy under state or federal law.
(C) A carrier shall offer to any individual accepted under
this section the Ohio health care basic and standard plans or
health benefit plans that are substantially similar to the Ohio
health care basic and standard plans in benefit plan design and
scope of covered services.
A carrier may offer other health benefit plans in addition
to, but not in lieu of, the plans required to be offered under
this division. A basic health benefit plan shall provide, at a
minimum, the coverage provided by the Ohio health care basic plan
or any health benefit plan that is substantially similar to the
Ohio health care basic plan in benefit plan design and scope of
covered services. A standard health benefit plan shall provide, at
a minimum, the coverage provided by the Ohio health care standard
plan or any health benefit plan that is substantially similar to
the Ohio health care standard plan in benefit plan design and
scope of covered services.
For purposes of this division, the superintendent of
insurance shall determine whether a health benefit plan is
substantially similar to the Ohio health care basic and standard
plans in benefit plan design and scope of covered services.
(D)(1) Health benefit plans issued under this section may
establish pre-existing conditions provisions that exclude or limit
coverage for a period of up to twelve months following the
individual's effective date of coverage and that may relate only
to conditions during the six months immediately preceding the
effective date of coverage. A health insuring corporation may
apply a pre-existing condition provision for any basic health care
service related to a transplant of a body organ if the transplant
occurs within one year after the effective date of an enrollee's
coverage under this section except with respect to a newly born
child who meets the requirements for coverage under section
1751.61 of the Revised Code.
(2) In determining whether a pre-existing conditions
provision applies to an insured or dependent, each policy shall
credit the time the insured or dependent was covered under a
previous policy, contract, or plan if the previous coverage was
continuous to a date not more than sixty-three days prior to the
effective date of the new coverage, exclusive of any applicable
service waiting period under the policy.
(E) Premiums charged to individuals under this section may
not exceed the amounts specified below:
(1) For calendar years 2010 and 2011, an amount that is two
times the base rate for coverage offered to any other individual
to which the carrier is currently accepting new business, and for
which similar copayments and deductibles are applied;
(2) For calendar year 2012 and every year thereafter, an
amount that is one and one-half times the base rate for coverage
offered to any other individual to which the carrier is currently
accepting new business and for which similar copayments and
deductibles are applied, unless the superintendent of insurance
determines that the amendments by this act to this section and
section 3923.581 of the Revised Code, have resulted in the
market-wide average medical loss ratio for coverage sold to
individual insureds and nonemployer group insureds in this state,
including open enrollment insureds, to increase by more than five
and one quarter percentage points during calendar year 2010. If
the superintendent makes that determination, the premium limit
established by division (E)(1) of this section shall remain in
effect. The superintendent's determination shall be supported by a
signed letter from a member of the American academy of actuaries.
(F) In offering health benefit plans under this section, a
carrier may require the purchase of health benefit plans that
condition the reimbursement of health services upon the use of a
specific network of providers.
(G)(1) A carrier shall not be required to accept new
applicants under this section if the total number of the carrier's
current insureds with open enrollment coverage issued under this
section calculated as of the immediately preceding thirty-first
day of December and excluding the carrier's medicare supplement
policies and conversion or continuation of coverage policies under
state or federal law and any policies described in division (L) of
this section meets the following limits:
(a) For calendar years 2010 and 2011, four per cent of the
carrier's total number of individual or nonemployer group insureds
in this state;
(b) For calendar year 2012 and every year thereafter, eight
per cent of the carrier's total number of insured individuals and
nonemployer group insureds in this state, unless the
superintendent of insurance determines that the amendments by this
act to this section and section 3923.581 of the Revised Code, have
resulted in the market-wide average medical loss ratio for
coverage sold to individual insureds and nonemployer group
insureds in this state, including open enrollment insureds, to
increase by more than five and one quarter percentage points
during calendar year 2010. If the superintendent makes that
determination, the enrollment limit established by division
(G)(1)(a) of this section shall remain in effect. The
superintendent's determination shall be supported by a signed
letter from a member of the American academy of actuaries.
(2) An officer of the carrier shall certify to the department
of insurance when it has met the enrollment limit set forth in
division (G)(1) of this section. Upon providing such
certification, the carrier shall be relieved of its open
enrollment requirement under this section as long as the carrier
continues to meet the open enrollment limit. If the total number
of the carrier's current insureds with open enrollment coverage
issued under this section falls below the enrollment limit, the
carrier shall accept new applicants. A carrier may establish a
waiting list if the carrier has met the open enrollment limit and
shall notify the superintendent if the carrier has a waiting list
in effect.
(H) A carrier shall not be required to accept under this
section applicants who, at the time of enrollment, are confined to
a health care facility because of chronic illness, permanent
injury, or other infirmity that would cause economic impairment to
the carrier if the applicants were accepted. A carrier shall not
be required to make the effective date of benefits for individuals
accepted under this section earlier than ninety days after the
date of acceptance, except that when the individual had prior
coverage with a health benefit plan that was terminated by a
carrier because the carrier exited the market and the individual
was accepted for open enrollment under this section within
sixty-three days of that termination, the effective date of
benefits shall be the date of enrollment.
(I) The requirements of this section do not apply to any
carrier that is currently in a state of supervision, insolvency,
or liquidation. If a carrier demonstrates to the satisfaction of
the superintendent that the requirements of this section would
place the carrier in a state of supervision, insolvency, or
liquidation, or would otherwise jeopardize the carrier's economic
viability overall or in the individual market, the superintendent
may waive or modify the requirements of division (B) or (G) of
this section. The actions of the superintendent under this
division shall be effective for a period of not more than one
year. At the expiration of such time, a new showing of need for a
waiver or modification by the carrier shall be made before a new
waiver or modification is issued or imposed.
(J) No hospital, health care facility, or health care
practitioner, and no person who employs any health care
practitioner, shall balance bill any individual or dependent of an
individual for any health care supplies or services provided to
the individual or dependent who is insured under a policy issued
under this section. The hospital, health care facility, or health
care practitioner, or any person that employs the health care
practitioner, shall accept payments made to it by the carrier
under the terms of the policy or contract insuring or covering
such individual as payment in full for such health care supplies
or services.
As used in this division, "hospital" has the same meaning as
in section 3727.01 of the Revised Code; "health care practitioner"
has the same meaning as in section 4769.01 of the Revised Code;
and "balance bill" means charging or collecting an amount in
excess of the amount reimbursable or payable under the policy or
health care service contract issued to an individual under this
section for such health care supply or service. "Balance bill"
does not include charging for or collecting copayments or
deductibles required by the policy or contract.
(K) A carrier may pay an agent a commission in the amount of
not more than five per cent of the premium charged for initial
placement or for otherwise securing the issuance of a policy or
contract issued to an individual under this section, and not more
than four per cent of the premium charged for the renewal of such
a policy or contract. The superintendent may adopt, in accordance
with Chapter 119. of the Revised Code, such rules as are necessary
to enforce this division.
(L) This section does not apply to any policy that provides
coverage for specific diseases or accidents only, or to any
hospital indemnity, medicare supplement, long-term care,
disability income, one-time-limited-duration policy of no longer
that is less than six twelve months, or other policy that offers
only supplemental benefits.
(M) If a carrier offers a health benefit plan in the
individual market through a network plan, the carrier may do both
of the following:
(1) Limit the individuals that may apply for such coverage to
those who live, work, or reside in the service area of the network
plan;
(2) Within the service area of the network plan, deny the
coverage to individuals if the carrier has demonstrated both of
the following to the superintendent:
(a) The carrier will not have the capacity to deliver
services adequately to any additional individuals because of the
carrier's obligations to existing group contract holders and
individuals.
(b) The carrier is applying division (M)(2) of this section
uniformly to all individuals without regard to any health
status-related factors of those individuals.
(N) A carrier that, pursuant to division (M)(2) of this
section, denies coverage to an individual in the service area of a
network plan, shall not offer coverage in the individual market
within that service area for at least one hundred eighty days
after the date the carrier denies the coverage.
Sec. 3923.601. (A)(1) This section applies to both of the
following:
(a) A sickness and accident insurer that issues or requires
the use of a standardized identification card or an electronic
technology for submission and routing of prescription drug claims
pursuant to a policy, contract, or agreement for health care
services;
(b) A person that a sickness and accident insurer contracts
with to issue a standardized identification card or an electronic
technology described in division (A)(1)(a) of this section.
(2) Notwithstanding division (A)(1) of this section, this
section does not apply to the issuance or required use of a
standardized identification card or an electronic technology for
the submission and routing of prescription drug claims in
connection with any of the following:
(a) Any individual or group policy of sickness and accident
insurance covering only accident, credit, dental, disability
income, long-term care, hospital indemnity, medicare supplement,
medicare, tricare, specified disease, or vision care; coverage
under a one-time-limited-duration policy of not longer that is
less than six
twelve months; coverage issued as a supplement to
liability insurance; insurance arising out of workers'
compensation or similar law; automobile medical payment insurance;
or insurance under which benefits are payable with or without
regard to fault and which is statutorily required to be contained
in any liability insurance policy or equivalent self-insurance.
(b) Coverage provided under the medicaid program.
(c) Coverage provided under an employer's self-insurance plan
or by any of its administrators, as defined in section 3959.01 of
the Revised Code, to the extent that federal law supersedes,
preempts, prohibits, or otherwise precludes the application of
this section to the plan and its administrators.
(B) A standardized identification card or an electronic
technology issued or required to be used as provided in division
(A)(1) of this section shall contain uniform prescription drug
information in accordance with either division (B)(1) or (2) of
this section.
(1) The standardized identification card or the electronic
technology shall be in a format and contain information fields
approved by the national council for prescription drug programs or
a successor organization, as specified in the council's or
successor organization's pharmacy identification card
implementation guide in effect on the first day of October most
immediately preceding the issuance or required use of the
standardized identification card or the electronic technology.
(2) If the insurer or person under contract with the insurer
to issue a standardized identification card or an electronic
technology requires the information for the submission and routing
of a claim, the standardized identification card or the electronic
technology shall contain any of the following information:
(b) The insured's name, group number, and identification
number;
(c) A telephone number to inquire about pharmacy-related
issues;
(d) The issuer's international identification number, labeled
as "ANSI BIN" or "RxBIN";
(e) The processor's control number, labeled as "RxPCN";
(f) The insured's pharmacy benefits group number if different
from the insured's medical group number, labeled as "RxGrp."
(C) If the standardized identification card or the electronic
technology issued or required to be used as provided in division
(A)(1) of this section is also used for submission and routing of
nonpharmacy claims, the designation "Rx" is required to be
included as part of the labels identified in divisions (B)(2)(d)
and (e) of this section if the issuer's international
identification number or the processor's control number is
different for medical and pharmacy claims.
(D) Each sickness and accident insurer described in division
(A) of this section shall annually file a certificate with the
superintendent of insurance certifying that it or any person it
contracts with to issue a standardized identification card or
electronic technology for submission and routing of prescription
drug claims complies with this section.
(E)(1) Except as provided in division (E)(2) of this section,
if there is a change in the information contained in the
standardized identification card or the electronic technology
issued to an insured, the insurer or person under contract with
the insurer to issue a standardized identification card or an
electronic technology shall issue a new card or electronic
technology to the insured.
(2) An insurer or person under contract with the insurer is
not required under division (E)(1) of this section to issue a new
card or electronic technology to an insured more than once during
a twelve-month period.
(F) Nothing in this section shall be construed as requiring
an insurer to produce more than one standardized identification
card or one electronic technology for use by insureds accessing
health care benefits provided under a policy of sickness and
accident insurance.
Sec. 3923.65. (A) As used in this section:
(1) "Emergency medical condition" means a medical condition
that manifests itself by such acute symptoms of sufficient
severity, including severe pain, that a prudent layperson with
average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in any of the
following:
(a) Placing the health of the individual or, with respect to
a pregnant woman, the health of the woman or her unborn child, in
serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.
(2) "Emergency services" means the following:
(a) A medical screening examination, as required by federal
law, that is within the capability of the emergency department of
a hospital, including ancillary services routinely available to
the emergency department, to evaluate an emergency medical
condition;
(b) Such further medical examination and treatment that are
required by federal law to stabilize an emergency medical
condition and are within the capabilities of the staff and
facilities available at the hospital, including any trauma and
burn center of the hospital.
(B) Every individual or group policy of sickness and accident
insurance that provides hospital, surgical, or medical expense
coverage shall cover emergency services without regard to the day
or time the emergency services are rendered or to whether the
policyholder, the hospital's emergency department where the
services are rendered, or an emergency physician treating the
policyholder, obtained prior authorization for the emergency
services.
(C) Every individual policy or certificate furnished by an
insurer in connection with any sickness and accident insurance
policy shall provide information regarding the following:
(1) The scope of coverage for emergency services;
(2) The appropriate use of emergency services, including the
use of the 9-1-1 system and any other telephone access systems
utilized to access prehospital emergency services;
(3) Any copayments for emergency services.
(D) This section does not apply to any individual or group
policy of sickness and accident insurance covering only accident,
credit, dental, disability income, long-term care, hospital
indemnity, medicare supplement, medicare, tricare, specified
disease, or vision care; coverage under a one-time limited
duration policy of no longer that is less than six twelve months;
coverage issued as a supplement to liability insurance; insurance
arising out of workers' compensation or similar law; automobile
medical payment insurance; or insurance under which benefits are
payable with or without regard to fault and which is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance.
Sec. 3923.83. (A)(1) This section applies to both of the
following:
(a) A public employee benefit plan that issues or requires
the use of a standardized identification card or an electronic
technology for submission and routing of prescription drug claims
pursuant to a policy, contract, or agreement for health care
services;
(b) A person or entity that a public employee benefit plan
contracts with to issue a standardized identification card or an
electronic technology described in division (A)(1)(a) of this
section.
(2) Notwithstanding division (A)(1) of this section, this
section does not apply to the issuance or required use of a
standardized identification card or an electronic technology for
the submission and routing of prescription drug claims in
connection with either of the following:
(a) Any individual or group policy of insurance covering only
accident, credit, dental, disability income, long-term care,
hospital indemnity, medicare supplement, medicare, tricare,
specified disease, or vision care; coverage under a
one-time-limited-duration policy of not longer that is less than
six twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of workers' compensation or
similar law; automobile medical payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
(b) Coverage provided under the medicaid program.
(B) A standardized identification card or an electronic
technology issued or required to be used as provided in division
(A)(1) of this section shall contain uniform prescription drug
information in accordance with either division (B)(1) or (2) of
this section.
(1) The standardized identification card or the electronic
technology shall be in a format and contain information fields
approved by the national council for prescription drug programs or
a successor organization, as specified in the council's or
successor organization's pharmacy identification card
implementation guide in effect on the first day of October most
immediately preceding the issuance or required use of the
standardized identification card or the electronic technology.
(2) If the public employee benefit plan or person under
contract with the plan to issue a standardized identification card
or an electronic technology requires the information for the
submission and routing of a claim, the standardized identification
card or the electronic technology shall contain any of the
following information:
(b) The insured's name, group number, and identification
number;
(c) A telephone number to inquire about pharmacy-related
issues;
(d) The issuer's international identification number, labeled
as "ANSI BIN" or "RxBIN";
(e) The processor's control number, labeled as "RxPCN";
(f) The insured's pharmacy benefits group number if different
from the insured's medical group number, labeled as "RxGrp."
(C) If the standardized identification card or the electronic
technology issued or required to be used as provided in division
(A)(1) of this section is also used for submission and routing of
nonpharmacy claims, the designation "Rx" is required to be
included as part of the labels identified in divisions (B)(2)(d)
and (e) of this section if the issuer's international
identification number or the processor's control number is
different for medical and pharmacy claims.
(D)(1) Except as provided in division (D)(2) of this section,
if there is a change in the information contained in the
standardized identification card or the electronic technology
issued to an insured, the public employee benefit plan or person
under contract with the plan to issue a standardized
identification card or electronic technology shall issue a new
card or electronic technology to the insured.
(2) A public employee benefit plan or person under contract
with the plan is not required under division (D)(1) of this
section to issue a new card or electronic technology to an insured
more than once during a twelve-month period.
(E) Nothing in this section shall be construed as requiring a
public employee benefit plan to produce more than one standardized
identification card or one electronic technology for use by
insureds accessing health care benefits provided under a health
benefit plan.
Sec. 3923.85. (A) As used in this section, "cost sharing"
means the cost to an individual insured under an individual or
group policy of sickness and accident insurance or a public
employee benefit plan according to any coverage limit, copayment,
coinsurance, deductible, or other out-of-pocket expense
requirements imposed by the policy or plan.
(B) Notwithstanding section 3901.71 of the Revised Code and
subject to division (D) of this section, no individual or group
policy of sickness and accident insurance that is delivered,
issued for delivery, or renewed in this state and no public
employee benefit plan that is established or modified in this
state shall fail to comply with either of the following:
(1) The policy or plan shall not provide coverage or impose
cost sharing for a prescribed, orally administered cancer
medication on a less favorable basis than the coverage it provides
or cost sharing it imposes for intraveneously administered or
injected cancer medications.
(2) The policy or plan shall not comply with division (B)(1)
of this section by imposing an increase in cost sharing solely for
orally administered, intravenously administered, or injected
cancer medications.
(C) Notwithstanding any provision of this section to the
contrary, a policy or plan shall be deemed to be in compliance
with this section if the cost sharing imposed under such a policy
or plan for orally administered cancer treatments does not exceed
one hundred dollars per prescription fill. The cost sharing limit
of one hundred dollars per prescription fill shall apply to a high
deductible plan, as defined in 26 U.S.C. 223, or a catastrophic
plan, as defined in 42 U.S.C. 18022, only after the deductible has
been met.
(D)(1) The prohibitions in division (B) of this section do
not preclude an individual or group policy of sickness and
accident insurance or public employee benefit plan from requiring
an insured or plan member to obtain prior authorization before
orally administered cancer medication is dispensed to the insured
or plan member.
(2) Division (B) of 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,
disability income, or other policy that offers only supplemental
benefits.
(E) An insurer that offers any sickness and accident
insurance or any public employee benefit plan that offers coverage
for basic health care services is not required to comply with
division (B) of this section if all of the following apply:
(1) The insurer or plan submits documentation certified by an
independent member of the American academy of actuaries to the
superintendent of insurance showing that compliance with division
(B)(1) of this section for a period of at least six months
independently caused the insurer or plan'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.
(2) The insurer or plan 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 (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 or plan for the coverage
of basic health care services.
(3)(a) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (E)(1) and (2) of this section:
(i) Compliance with division (B)(1) of this section for a
period of at least six months independently caused the insurer or
plan's costs for claims and administrative expenses for the
coverage of basic health care services to increase 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 insurer or plan for the coverage of basic health care
services.
(b) Any determination made by the superintendent under
division (E)(3) of this section is subject to Chapter 119. of the
Revised Code.
Sec. 3924.01. As used in sections 3924.01 to 3924.14 of the
Revised Code:
(A) "Actuarial certification" means a written statement
prepared by a member of the American academy of actuaries, or by
any other person acceptable to the superintendent of insurance,
that states that, based upon the person's examination, a carrier
offering health benefit plans to small employers is in compliance
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial
certification" shall include a review of the appropriate records
of, and the actuarial assumptions and methods used by, the carrier
relative to establishing premium rates for the health benefit
plans.
(B) "Adjusted average market premium price" means the average
market premium price as determined by the board of directors of
the Ohio health reinsurance program either on the basis of the
arithmetic mean of all carriers' premium rates for an OHC plan
sold to groups with similar case characteristics by all carriers
selling OHC plans in the state, or on any other equitable basis
determined by the board.
(C) "Base premium rate" means, as to any health benefit plan
that is issued by a carrier and that covers at least two but no
more than fifty employees of a small employer, the lowest premium
rate for a new or existing business prescribed by the carrier for
the same or similar coverage under a plan or arrangement covering
any small employer with similar case characteristics.
(D) "Carrier" means any sickness and accident insurance
company or health insuring corporation authorized to issue health
benefit plans in this state or a MEWA. A sickness and accident
insurance company that owns or operates a health insuring
corporation, either as a separate corporation or as a line of
business, shall be considered as a separate carrier from that
health insuring corporation for purposes of sections 3924.01 to
3924.14 of the Revised Code.
(E) "Case characteristics" means, with respect to a small
employer, the geographic area in which the employees work; the age
and sex of the individual employees and their dependents; the
appropriate industry classification as determined by the carrier;
the number of employees and dependents; and such other objective
criteria as may be established by the carrier. "Case
characteristics" does not include claims experience, health
status, or duration of coverage from the date of issue.
(F) "Dependent" means the spouse or child of an eligible
employee, subject to applicable terms of the health benefits plan
covering the employee.
(G) "Eligible employee" means an employee who works a normal
work week of twenty-five thirty or more hours. "Eligible employee"
does not include a temporary or substitute employee, or a seasonal
employee who works only part of the calendar year on the basis of
natural or suitable times or circumstances.
(H) "Health benefit plan" means any hospital or medical
expense policy or certificate or any health plan provided by a
carrier, that is delivered, issued for delivery, renewed, or used
in this state on or after the date occurring six months after
November 24, 1995. "Health benefit plan" does not include policies
covering only accident, credit, dental, disability income,
long-term care, hospital indemnity, medicare supplement, specified
disease, or vision care; coverage under a
one-time-limited-duration policy of no longer that is less than
six twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of a workers' compensation or
similar law; automobile medical-payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
(I) "Late enrollee" means an eligible employee or dependent
who enrolls in a small employer's health benefit plan other than
during the first period in which the employee or dependent is
eligible to enroll under the plan or during a special enrollment
period described in section 2701(f) of the "Health Insurance
Portability and Accountability Act of 1996," Pub. L. No. 104-191,
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended.
(J) "MEWA" means any "multiple employer welfare arrangement"
as defined in section 3 of the "Federal Employee Retirement Income
Security Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended,
except for any arrangement which is fully insured as defined in
division (b)(6)(D) of section 514 of that act.
(K) "Midpoint rate" means, for small employers with similar
case characteristics and plan designs and as determined by the
applicable carrier for a rating period, the arithmetic average of
the applicable base premium rate and the corresponding highest
premium rate.
(L) "Pre-existing conditions provision" means a policy
provision that excludes or limits coverage for charges or expenses
incurred during a specified period following the insured's
enrollment date as to a condition for which medical advice,
diagnosis, care, or treatment was recommended or received during a
specified period immediately preceding the enrollment date.
Genetic information shall not be treated as such a condition in
the absence of a diagnosis of the condition related to such
information.
For purposes of this division, "enrollment date" means, with
respect to an individual covered under a group health benefit
plan, the date of enrollment of the individual in the plan or, if
earlier, the first day of the waiting period for such enrollment.
(M) "Service waiting period" means the period of time after
employment begins before an employee is eligible to be covered for
benefits under the terms of any applicable health benefit plan
offered by the small employer.
(N)(1) "Small employer" means, in connection with a group
health benefit plan and with respect to a calendar year and a plan
year, an employer who employed an average of at least two but no
more than fifty eligible employees on business days during the
preceding calendar year and who employs at least two employees on
the first day of the plan year.
(2) For purposes of division (N)(1) of this section, all
persons treated as a single employer under subsection (b), (c),
(m), or (o) of section 414 of the "Internal Revenue Code of 1986,"
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one
employer. In the case of an employer that was not in existence
throughout the preceding calendar year, the determination of
whether the employer is a small or large employer shall be based
on the average number of eligible employees that it is reasonably
expected the employer will employ on business days in the current
calendar year. Any reference in division (N) of this section to an
"employer" includes any predecessor of the employer. Except as
otherwise specifically provided, provisions of sections 3924.01 to
3924.14 of the Revised Code that apply to a small employer that
has a health benefit plan shall continue to apply until the plan
anniversary following the date the employer no longer meets the
requirements of this division.
(O) "OHC plan" means an Ohio health care plan, which is the
basic, standard, or carrier reimbursement plan for small employers
and individuals established in accordance with section 3924.10 of
the Revised Code.
Sec. 4729.291. (A) When a licensed health professional
authorized to prescribe drugs personally furnishes drugs to a
patient pursuant to division (B) of section 4729.29 of the Revised
Code, the prescriber shall ensure that the drugs are labeled and
packaged in accordance with state and federal drug laws and any
rules and regulations adopted pursuant to those laws. Records of
purchase and disposition of all drugs personally furnished to
patients shall be maintained by the prescriber in accordance with
state and federal drug statutes and any rules adopted pursuant to
those statutes.
(B) When personally furnishing to a patient RU-486
(mifepristone), a prescriber is subject to section 2919.123 of the
Revised Code. A prescription for RU-486 (mifepristone) shall be in
writing and in accordance with section 2919.123 of the Revised
Code.
(C)(1) Except as provided in division (D) of this section, a
prescriber may shall not do either of the following:
(a) In any thirty-day period, personally furnish to or for
patients, taken as a whole, controlled substances in an amount
that exceeds a total of two thousand five hundred dosage units;
(b) In any seventy-two-hour period, personally furnish to or
for a patient an amount of a controlled substance that exceeds the
amount necessary for the patient's use in a seventy-two-hour
period.
(2) The state board of pharmacy may impose a fine of not more
than five thousand dollars on a prescriber who fails to comply
with the limits established under division (C)(1) of this section.
A separate fine may be imposed for each instance of failing to
comply with the limits. In imposing the fine, the board's actions
shall be taken in accordance with Chapter 119. of the Revised
Code.
(D)(1) None of the following shall be counted in determining
whether the amounts specified in division (C)(1) of this section
have been exceeded:
(a) Methadone provided to patients for the purpose of
treating drug dependence or addiction, if the prescriber meets the
conditions specified in 21 C.F.R. 1306.07;
(b) Buprenorphine provided to patients for the purpose of
treating drug dependence or addiction, if the prescriber is exempt
from separate registration with the United States drug enforcement
administration as part of an opioid treatment program that is the
subject of a current, valid certification from the substance abuse
and mental health services administration of the United States
department of health and human services pursuant to 21 42 C.F.R.
1301.28 8.11 and distributes both buprenorphine and methadone;
(c) Controlled substances provided to research subjects by a
facility conducting clinical research in studies approved by a
hospital-based institutional review board or an institutional
review board accredited by the association for the accreditation
of human research protection programs.
(2) Division (C)(1) of this section does not apply to a
prescriber who is a veterinarian.
Sec. 4729.541. (A) Except as provided in divisions (B) and
(C) of this section, a business entity described in division
(B)(1)(j) or (k) of section 4729.51 of the Revised Code may
possess, have custody or control of, and distribute the dangerous
drugs in category I, category II, and category III, as defined in
section 4729.54 of the Revised Code, without holding a terminal
distributor of dangerous drugs license issued under that section.
(B) If a business entity described in division (B)(1)(j) or
(k) of section 4729.51 of the Revised Code is a pain management
clinic or is operating a pain management clinic, the entity shall
hold a license as a terminal distributor of dangerous drugs with a
pain management clinic classification issued under section
4729.552 of the Revised Code.
(C) Beginning April 1, 2015, a business entity described in
division (B)(1)(j) or (k) of section 4729.51 of the Revised Code
shall hold a license as a terminal distributor of dangerous drugs
in order to possess, have custody or control of, and distribute
dangerous either of the following:
(1) Dangerous drugs that are compounded or used for the
purpose of compounding;
(2) Controlled substances containing buprenorphine that are
used for the purpose of treating drug dependence or addiction.
Sec. 4731.056. (A) As used in this section:
(1) "Controlled substance," "schedule III," "schedule IV,"
and "schedule V" have the same meanings as in section 3719.01 of
the Revised Code.
(2) "Physician" means an individual authorized by this
chapter to practice medicine and surgery or osteopathic medicine
and surgery.
(B) The state medical board shall adopt rules in accordance
with Chapter 119. of the Revised Code that establish standards and
procedures to be followed by physicians in the use of controlled
substances in schedule III, IV, or V to treat opioid dependence or
addiction. The board may limit the application of the rules to
treatment provided through an office-based practice or other
practice type or location specified by the board.
Section 2. That existing sections 1739.061, 1751.14,
1751.69, 3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58,
3923.601, 3923.65, 3923.83, 3923.85, 3924.01, 4729.291, and
4729.541 of the Revised Code are hereby repealed.
Section 3. Section 1751.14 and division (G) of section
3924.01 of the Revised Code, as amended by this act, apply only to
policies, contracts, and agreements that are delivered, issued for
delivery, or renewed in this state on or after January 1, 2016.
Division (A)(1) of section 3923.24 and division (A)(1) of section
3923.241 of the Revised Code, as amended by this act, apply only
to policies of sickness and accident insurance delivered, issued
for delivery, or renewed in this state and public employee benefit
plans or multiple employer welfare arrangement contracts and
certificates that are established or modified in this state on or
after January 1, 2016.
Section 4. The General Assembly declares that the amendments
made to section 3923.58 of the Revised Code by this act are not to
supersede the suspension of the operation of this section enacted
by Section 3 of Sub. S.B. 9 of the 130th General Assembly. Rather,
it is the intent of the General Assembly to ensure consistency in
Ohio Insurance Law should this suspension be nullified.
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