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S. B. No. 88 As IntroducedAs Introduced
130th General Assembly | Regular Session | 2013-2014 |
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Cosponsors:
Senators Turner, Tavares
A BILL
To amend sections 124.14 and 3924.01 and to enact
sections 3965.01 to 3965.14 of the Revised Code to
establish the Ohio Health Benefit Exchange Agency
and to establish the Ohio Health Benefit Exchange
Program consisting of an exchange for individual
coverage and a Small Business Health Options
Program.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 124.14 and 3924.01 be amended and
sections 3965.01, 3965.02, 3965.03, 3965.04, 3965.05, 3965.06,
3965.07, 3965.08, 3965.09, 3965.10, 3965.11, 3965.12, 3965.13, and
3965.14 of the Revised Code be enacted to read as follows:
Sec. 124.14. (A)(1) The director of administrative services
shall establish, and may modify or rescind, by rule, a job
classification plan for all positions, offices, and employments
the salaries of which are paid in whole or in part by the state.
The director shall group jobs within a classification so that the
positions are similar enough in duties and responsibilities to be
described by the same title, to have the same pay assigned with
equity, and to have the same qualifications for selection applied.
The director shall, by rule, assign a classification title to each
classification within the classification plan. However, the
director shall consider in establishing classifications, including
classifications with parenthetical titles, and assigning pay
ranges such factors as duties performed only on one shift, special
skills in short supply in the labor market, recruitment problems,
separation rates, comparative salary rates, the amount of training
required, and other conditions affecting employment. The director
shall describe the duties and responsibilities of the class,
establish the qualifications for being employed in each position
in the class, and file with the secretary of state a copy of
specifications for all of the classifications. The director shall
file new, additional, or revised specifications with the secretary
of state before they are used.
The director shall, by rule, assign each classification,
either on a statewide basis or in particular counties or state
institutions, to a pay range established under section 124.15 or
section 124.152 of the Revised Code. The director may assign a
classification to a pay range on a temporary basis for a period of
six months. The director may establish, by rule adopted under
Chapter 119. of the Revised Code, experimental classification
plans for some or all employees paid directly by warrant of the
director of budget and management. The rule shall include
specifications for each classification within the plan and shall
specifically address compensation ranges, and methods for
advancing within the ranges, for the classifications, which may be
assigned to pay ranges other than the pay ranges established under
section 124.15 or 124.152 of the Revised Code.
(2) The director of administrative services may reassign to a
proper classification those positions that have been assigned to
an improper classification. If the compensation of an employee in
such a reassigned position exceeds the maximum rate of pay for the
employee's new classification, the employee shall be placed in pay
step X and shall not receive an increase in compensation until the
maximum rate of pay for that classification exceeds the employee's
compensation.
(3) The director may reassign an exempt employee, as defined
in section 124.152 of the Revised Code, to a bargaining unit
classification if the director determines that the bargaining unit
classification is the proper classification for that employee.
Notwithstanding Chapter 4117. of the Revised Code or instruments
and contracts negotiated under it, these placements are at the
director's discretion.
(4) The director shall, by rule, assign related
classifications, which form a career progression, to a
classification series. The director shall, by rule, assign each
classification in the classification plan a five-digit number, the
first four digits of which shall denote the classification series
to which the classification is assigned. When a career progression
encompasses more than ten classifications, the director shall, by
rule, identify the additional classifications belonging to a
classification series. The additional classifications shall be
part of the classification series, notwithstanding the fact that
the first four digits of the number assigned to the additional
classifications do not correspond to the first four digits of the
numbers assigned to other classifications in the classification
series.
(B) Division (A) of this section and sections 124.15 and
124.152 of the Revised Code do not apply to the following persons,
positions, offices, and employments:
(2) Legislative employees, employees of the legislative
service commission, employees in the office of the governor,
employees who are in the unclassified civil service and exempt
from collective bargaining coverage in the office of the secretary
of state, auditor of state, treasurer of state, and attorney
general, and employees of the supreme court;
(3) Any position for which the authority to determine
compensation is given by law to another individual or entity;
(4) Employees of the bureau of workers' compensation whose
compensation the administrator of workers' compensation
establishes under division (B) of section 4121.121 of the Revised
Code;
(5) Employees of the Ohio health benefit exchange program
whose compensation the board of the Ohio health benefit exchange
agency establishes under division (H) of section 3965.03 of the
Revised Code.
(C) The director may employ a consulting agency to aid and
assist the director in carrying out this section.
(D)(1) When the director proposes to modify a classification
or the assignment of classes to appropriate pay ranges, the
director shall send written notice of the proposed rule to the
appointing authorities of the affected employees thirty days
before a hearing on the proposed rule. The appointing authorities
shall notify the affected employees regarding the proposed rule.
The director also shall send those appointing authorities notice
of any final rule that is adopted within ten days after adoption.
(2) When the director proposes to reclassify any employee in
the service of the state so that the employee is adversely
affected, the director shall give to the employee affected and to
the employee's appointing authority a written notice setting forth
the proposed new classification, pay range, and salary. Upon the
request of any classified employee in the service of the state who
is not serving in a probationary period, the director shall
perform a job audit to review the classification of the employee's
position to determine whether the position is properly classified.
The director shall give to the employee affected and to the
employee's appointing authority a written notice of the director's
determination whether or not to reclassify the position or to
reassign the employee to another classification. An employee or
appointing authority desiring a hearing shall file a written
request for the hearing with the state personnel board of review
within thirty days after receiving the notice. The board shall set
the matter for a hearing and notify the employee and appointing
authority of the time and place of the hearing. The employee, the
appointing authority, or any authorized representative of the
employee who wishes to submit facts for the consideration of the
board shall be afforded reasonable opportunity to do so. After the
hearing, the board shall consider anew the reclassification and
may order the reclassification of the employee and require the
director to assign the employee to such appropriate classification
as the facts and evidence warrant. As provided in division (A)(1)
of section 124.03 of the Revised Code, the board may determine the
most appropriate classification for the position of any employee
coming before the board, with or without a job audit. The board
shall disallow any reclassification or reassignment classification
of any employee when it finds that changes have been made in the
duties and responsibilities of any particular employee for
political, religious, or other unjust reasons.
(E)(1) Employees of each county department of job and family
services shall be paid a salary or wage established by the board
of county commissioners. The provisions of section 124.18 of the
Revised Code concerning the standard work week apply to employees
of county departments of job and family services. A board of
county commissioners may do either of the following:
(a) Notwithstanding any other section of the Revised Code,
supplement the sick leave, vacation leave, personal leave, and
other benefits of any employee of the county department of job and
family services of that county, if the employee is eligible for
the supplement under a written policy providing for the
supplement;
(b) Notwithstanding any other section of the Revised Code,
establish alternative schedules of sick leave, vacation leave,
personal leave, or other benefits for employees not inconsistent
with the provisions of a collective bargaining agreement covering
the affected employees.
(2) Division (E)(1) of this section does not apply to
employees for whom the state employment relations board
establishes appropriate bargaining units pursuant to section
4117.06 of the Revised Code, except in either of the following
situations:
(a) The employees for whom the state employment relations
board establishes appropriate bargaining units elect no
representative in a board-conducted representation election.
(b) After the state employment relations board establishes
appropriate bargaining units for such employees, all employee
organizations withdraw from a representation election.
(F)(1) Notwithstanding any contrary provision of sections
124.01 to 124.64 of the Revised Code, the board of trustees of
each state university or college, as defined in section 3345.12 of
the Revised Code, shall carry out all matters of governance
involving the officers and employees of the university or college,
including, but not limited to, the powers, duties, and functions
of the department of administrative services and the director of
administrative services specified in this chapter. Officers and
employees of a state university or college shall have the right of
appeal to the state personnel board of review as provided in this
chapter.
(2) Each board of trustees shall adopt rules under section
111.15 of the Revised Code to carry out the matters of governance
described in division (F)(1) of this section. Until the board of
trustees adopts those rules, a state university or college shall
continue to operate pursuant to the applicable rules adopted by
the director of administrative services under this chapter.
(G)(1) Each board of county commissioners may, by a
resolution adopted by a majority of its members, establish a
county personnel department to exercise the powers, duties, and
functions specified in division (G) of this section. As used in
division (G) of this section, "county personnel department" means
a county personnel department established by a board of county
commissioners under division (G)(1) of this section.
(2)(a) Each board of county commissioners, by a resolution
adopted by a majority of its members, may designate the county
personnel department of the county to exercise the powers, duties,
and functions specified in sections 124.01 to 124.64 and Chapter
325. of the Revised Code with regard to employees in the service
of the county, except for the powers and duties of the state
personnel board of review, which powers and duties shall not be
construed as having been modified or diminished in any manner by
division (G)(2) of this section, with respect to the employees for
whom the board of county commissioners is the appointing authority
or co-appointing authority.
(b) Nothing in division (G)(2) of this section shall be
construed to limit the right of any employee who possesses the
right of appeal to the state personnel board of review to continue
to possess that right of appeal.
(c) Any board of county commissioners that has established a
county personnel department may contract with the department of
administrative services, in accordance with division (H) of this
section, another political subdivision, or an appropriate public
or private entity to provide competitive testing services or other
appropriate services.
(3) After the county personnel department of a county has
been established as described in division (G)(2) of this section,
any elected official, board, agency, or other appointing authority
of that county, upon written notification to the county personnel
department, may elect to use the services and facilities of the
county personnel department. Upon receipt of the notification by
the county personnel department, the county personnel department
shall exercise the powers, duties, and functions as described in
division (G)(2) of this section with respect to the employees of
that elected official, board, agency, or other appointing
authority.
(4) Each board of county commissioners, by a resolution
adopted by a majority of its members, may disband the county
personnel department.
(5) Any elected official, board, agency, or appointing
authority of a county may end its involvement with a county
personnel department upon actual receipt by the department of a
certified copy of the notification that contains the decision to
no longer participate.
(6) A county personnel department, in carrying out its
duties, shall adhere to merit system principles with regard to
employees of county departments of job and family services, child
support enforcement agencies, and public child welfare agencies so
that there is no threatened loss of federal funding for these
agencies, and the county is financially liable to the state for
any loss of federal funds due to the action or inaction of the
county personnel department.
(H) County agencies may contract with the department of
administrative services for any human resources services,
including, but not limited to, establishment and modification of
job classification plans, competitive testing services, and
periodic audits and reviews of the county's uniform application of
the powers, duties, and functions specified in sections 124.01 to
124.64 and Chapter 325. of the Revised Code with regard to
employees in the service of the county. Nothing in this division
modifies the powers and duties of the state personnel board of
review with respect to employees in the service of the county.
Nothing in this division limits the right of any employee who
possesses the right of appeal to the state personnel board of
review to continue to possess that right of appeal.
(I) The director of administrative services shall establish
the rate and method of compensation for all employees who are paid
directly by warrant of the director of budget and management and
who are serving in positions that the director of administrative
services has determined impracticable to include in the state job
classification plan. This division does not apply to elected
officials, legislative employees, employees of the legislative
service commission, employees who are in the unclassified civil
service and exempt from collective bargaining coverage in the
office of the secretary of state, auditor of state, treasurer of
state, and attorney general, employees of the courts, employees of
the bureau of workers' compensation whose compensation the
administrator of workers' compensation establishes under division
(B) of section 4121.121 of the Revised Code, or employees of an
appointing authority authorized by law to fix the compensation of
those employees.
(J) The director of administrative services shall set the
rate of compensation for all intermittent, seasonal, temporary,
emergency, and casual employees in the service of the state who
are not considered public employees under section 4117.01 of the
Revised Code. Those employees are not entitled to receive employee
benefits. This rate of compensation shall be equitable in terms of
the rate of employees serving in the same or similar
classifications. This division does not apply to elected
officials, legislative employees, employees of the legislative
service commission, employees who are in the unclassified civil
service and exempt from collective bargaining coverage in the
office of the secretary of state, auditor of state, treasurer of
state, and attorney general, employees of the courts, employees of
the bureau of workers' compensation whose compensation the
administrator establishes under division (B) of section 4121.121
of the Revised Code, or employees of an appointing authority
authorized by law to fix the compensation of those employees.
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 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 than six 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, until January 1, 2016, 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 and, on
and after January 1, 2016, an employer that employed an average of
not more than one hundred employees during the preceding calendar
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. 3965.01. (A) The purpose of this chapter is to provide
for the establishment of an Ohio health benefit exchange agency
and an Ohio health benefit exchange program to facilitate the
purchase and sale of qualified health plans in the individual
market in this state, and to provide for the establishment of a
small business health options program as a part of the Ohio health
benefit exchange program to assist qualified small employers in
this state in facilitating the enrollment of their employees in
qualified health plans offered in the small group market.
(B) The Ohio general assembly declares that the following
objectives are to be served by this chapter:
(1) Extend access to high quality, affordable health plans to
all Ohioans;
(2) Reduce the number of uninsured Ohioans by creating a
cost-effective, user-friendly, and transparent marketplace to help
consumers and employers select high quality, affordable health
plans and claim available federal tax credits and cost-sharing
subsidies;
(3) Strengthen the health care delivery system;
(4) Guarantee the availability and renewability of health
care coverage through the private health insurance market to
qualified individuals and qualified small employers;
(5) Require that health care service plans and health
insurers issuing coverage in the individual and small employer
markets compete on the basis of price, quality, and service, not
on risk selection;
(6) Meet the requirements of the federal act and applicable
federal guidance and regulations.
Sec. 3965.02. As used in this chapter:
(A) "Carrier" means any sickness and accident insurance
company or health insuring corporation authorized to issue health
benefit plans in this state.
(B) "Exchange" or "exchange program" means the Ohio health
benefit exchange program established in section 3965.05 of the
Revised Code.
(C) "Exchange agency" means the Ohio health benefit exchange
agency established in section 3965.03 of the Revised Code.
(D) "Federal act" means the federal "Patient Protection and
Affordable Care Act of 2010," 124 Stat. 119, as amended by the
federal "Health Care and Education Reconciliation Act of 2010,"
124 Stat. 1029, and any amendments to those acts, or regulations
or guidance issued under those acts.
(E) "Health benefit plan" means a policy, contract,
certificate, or agreement offered or issued by a carrier to
provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services. "Health benefit plan" does not
include any of the following:
(1) Policies covering only accident or disability income;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability
insurance and automobile liability insurance;
(4) Workers' compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for on-site medical clinics;
(8) Other similar insurance coverage under which benefits for
health care services are secondary or incidental to other
insurance benefits;
(9) Any plan offering the benefits or coverage described in
division (D) of section 3965.06 of the Revised Code.
(F) "Qualified dental plan" means a limited scope dental plan
that has been certified in accordance with section 3965.07 of the
Revised Code.
(G) "Qualified employer" means a small employer that meets
the criteria for a qualified employer established in section
3965.11 of the Revised Code.
(H) "Qualified health plan" means a health benefit plan that
has been certified pursuant to section 3965.06 of the Revised
Code.
(I) "Qualified individual" means an individual who meets the
criteria for a qualified individual established in section 3965.10
of the Revised Code.
(J) "Secretary" means the secretary of the United States
department of health and human services.
(K) "SHOP exchange" means the small business health options
program established in section 3965.11 of the Revised Code.
(L)(1) "Small employer" means, until January 1, 2016, an
employer that employed an average of not more than fifty employees
during the preceding calendar year and, on and after January 1,
2016, an employer that employed an average of not more than one
hundred employees during the preceding calendar year.
(2) For the purposes of division (L)(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. 1, as amended, shall be treated as a
single employer. Any reference in division (L) of this section to
an "employer" includes any predecessor of the 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 the employer is reasonably expected to
employ on business days in the current calendar year. All
employees shall be counted, including part-time employees and
employees who are not eligible for coverage through the employer.
Sec. 3965.03. (A) The Ohio health benefit exchange agency is
hereby created. The agency shall have a board of directors
consisting of the following members:
(1) The following individuals, as part of their appointed
roles:
(a) The superintendent of insurance, or the superintendant's
designee;
(b) The director of medicaid, or the director's designee;
(c) The director of health, or the director's designee.
(2) The following members appointed by the governor following
the nomination process described in section 3965.04 of the Revised
Code. Not more than half shall be members of the same political
party, none shall have been employed by or worked as an insurance
agent or health care provider in the three years prior to
appointment, and all shall be residents of this state. At least
one of the six appointed members of the board shall have knowledge
of best practices used to address disparities in quality, access,
and affordability of health care.
(a) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as a union representative;
(b) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as a consumer representative;
(c) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as a small business representative;
(d) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as an actuary;
(e) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as an economist;
(f) One individual who, on account of the individual's
present or previous vocation, employment, or affiliations, can be
classified as an employee benefits specialist.
(B) The board shall not include health care providers or
their representatives, or insurers or their representatives,
brokers, or agents.
(C)(1) Of the initial appointments made to the board under
division (A)(2) of this section, the governor shall appoint two
members to a term ending on June 30, 2014, two members to a term
ending on June 30, 2015, and two members to a term ending on June
30, 2016. Thereafter, terms of office shall be for three years,
with each term ending on the same day of the same month as did the
term that it succeeds. Each member shall hold office from the date
of the member's appointment until the end of the term for which
the member was appointed.
(2) The governor shall not appoint any person to more than
two full terms of office on the board. This restriction does not
prevent the governor from appointing a person to fill a vacancy
caused by the death, resignation, or removal of a board member and
also appointing that person twice to full terms on the board, or
from appointing a person previously appointed to fill less than a
full term twice to full terms on the board.
(3) Vacancies shall be filled in accordance with division (F)
of section 3965.04 of the Revised Code. Any member appointed to
fill a vacancy occurring prior to the expiration date of the term
for which the member's predecessor was appointed shall hold office
as a member for the remainder of that term. A member shall
continue in office subsequent to the expiration date of the
member's term until a successor takes office or until a period of
sixty days has elapsed, whichever occurs first.
(D) All members of the board shall receive their reasonable
and necessary expenses pursuant to section 126.31 of the Revised
Code while engaged in the performance of their duties as members
and all members described in division (A)(2) of this section also
shall receive an annual salary not to exceed sixty thousand
dollars in total, payable on the following basis:
(1) Except as provided in division (D)(2) of this section, a
member shall receive five thousand dollars during a month in which
the member attends one or more meetings of the board and shall
receive no payment during a month in which the member attends no
meeting of the board.
(2) A member may receive not more than sixty thousand dollars
per year to compensate the member for attending meetings of the
board, regardless of the number of meetings held by the board
during a year or the number of meetings in excess of twelve within
a year that the member attends.
(E) The board shall set meeting dates as necessary to perform
the duties of the board under this chapter. The board shall meet
at least twelve times per year. A majority of the members shall
constitute a quorum.
(F) Before entering the duties of office, each appointed
member to the board described in division (A)(2) of this section
shall take an oath of office as required by sections 3.22 and 3.23
of the Revised Code.
(G) The board may appoint an advisory committee to the board
that shall consist of ten, eleven, or twelve individuals who
represent stakeholders, but who shall not vote on the matters
before the board. The advisory committee may include all of the
following individuals:
(1) Representatives of health insuring corporations;
(3) Health care providers;
(4) Consumers, including persons with disabilities;
(5) Small business owners;
(6) Representatives of organizations or community members
that represent ethnic, racial, and rural communities;
(7) Others as the board sees fit.
(H) The board is responsible for the effective operation of
all exchange agency responsibilities and the compliance of the
exchange agency and the exchange program with all federal and
state rules and regulations. The board shall do all of the
following:
(1) Exercise all powers reasonably necessary to carry out and
comply with the duties, responsibilities, and requirements of this
chapter and the federal act;
(2) Hire an executive director who shall be in the
unclassified civil service. The executive director shall be
responsible for the operation of the exchange program.
(3) Set the salaries for staff hired by the executive
director pursuant to section 3965.05 of the Revised Code that are
in amounts reasonably necessary to attract and retain individuals
of superior qualifications, publish those salaries in the board's
annual budget, and post the board's annual budget on the web site
of the exchange agency.
(4) Consult with stakeholders relevant to carrying out the
activities applicable to the board under this chapter, including
all of the following:
(a) Health care consumers who are enrolled in health plans;
(b) Individuals and entities with experience in facilitating
enrollment in health plans;
(c) Representatives of small businesses and self-employed
individuals;
(d) Advocates for enrolling hard-to-reach populations.
(5) Develop standardized quality measures to evaluate health
benefit plans pursuant to division (A)(7)(g) of section 3965.06 of
the Revised Code;
(6) Establish a navigator program in accordance with section
3965.09 of the Revised Code and select individuals and entities
for the navigator program using the criteria listed in that
section;
(7) Develop privacy policies in accordance with relevant
federal and state law, rule, and regulation to protect sensitive
applicant and enrollee information;
(8) Adopt bylaws for the regulation of its affairs and the
conduct of its business.
(I) The board may sue and be sued in the name of the exchange
agency.
Sec. 3965.04. (A) There is hereby created an exchange agency
board of directors nominating council consisting of the following
individuals:
(1) The chief executive officer of AARP, or that officer's
designee;
(2) The executive director of the Ohio developmental
disabilities council, or the executive director's designee;
(3) The director or equivalent representative of the Ohio
small business council of the Ohio chamber of commerce, or the
director or equivalent representative's designee;
(4) The chairperson of the board of directors of the council
of smaller enterprises, or the chairperson's designee;
(5) The executive director of the universal health care
action network of Ohio, or the executive director's designee;
(6) The president of the Ohio AFL-CIO, or the president's
designee;
(7) The president or equivalent representative of the largest
public employee organization in this state, or the president or
equivalent representative's designee;
(8) The president of the health policy institute of Ohio, or
the president's designee;
(9) The executive director of the Ohio commission on minority
health, or the executive director's designee;
(10) The chairperson of the department of economics at the
Ohio state university, or the chairperson's designee;
(11) The president of the Ohio association of health plans,
or the president's designee;
(12) The president of the Ohio state medical association, or
the president's designee;
(13) The chief executive officer of the Ohio hospital
association, or that officer's designee;
(14) An individual selected by the president of the senate;
(15) An individual selected by the speaker of the house of
representatives.
(B) At its first meeting each calendar year, the council
shall select from among its members a chairperson and secretary.
The council may adopt bylaws governing its proceedings.
(C) The council shall keep a record of its proceedings.
Special meetings may be called by the chairperson, and shall be
called by the chairperson upon receipt of a written request for a
meeting signed by two or more members of the council. Written
notice of the time and place of each meeting shall be sent to each
member of the council. Eight members, or their alternates,
constitute a quorum.
(1) Review and evaluate possible appointees for the office of
exchange board director of the Ohio health benefit exchange
agency;
(2) Consistent with section 3965.03 of the Revised Code, not
more than eighty-five nor less than sixty days prior to the
expiration of the term of an exchange board director or not more
than thirty days after the death of, resignation of, or
termination of service by, an exchange board director, provide the
governor with a list of four individuals who are, in the judgment
of the council, the most fully qualified to accede to the office
of exchange board director. The council shall not include the name
of an individual upon the list, if the appointment of that
individual by the governor would result in more than three
appointed members of the board of directors belonging to or being
affiliated with the same political party.
(E) In reviewing and evaluating possible appointees for the
office of exchange board director, the council may accept comments
from, cooperate with, and request information from any person. The
council may make recommendations to the general assembly
concerning changes in legislation to assist the council in the
performance of its duties.
(F) Within thirty days of receipt of the council's
recommendations, the governor shall fill a vacancy occurring in
the office of exchange board director by appointment of one of the
persons recommended by the council. Nothing in this section shall
prevent the governor in the governor's discretion from rejecting
all of the nominees of the council and reconvening the council in
order to select four additional nominees. However, when the
governor has reconvened the council and the council has provided
the governor with a second list of four names, the governor shall
make the appointment from one of the names on the first list or
the second list. Each appointment by the governor shall be subject
to the advice and consent of the senate.
(G) Members of the council shall be compensated on a per diem
basis pursuant to the procedures set forth in section 124.14 of
the Revised Code plus reasonable travel expenses. All the expenses
of the nominating council shall be paid from moneys appropriated
to the exchange agency for that purpose.
Sec. 3965.05. (A) There is hereby created the Ohio health
benefit exchange program within the Ohio health benefit exchange
agency consisting of an exchange for individual coverage and a
SHOP exchange. The executive director of the exchange agency shall
be responsible for operating the exchange and shall hire all
necessary staff to meet the responsibilities of the executive
director as described in this section. All staff hired by the
executive director shall be in the classified civil service.
(B) The executive director shall do all of the following:
(1) Make qualified health plans available to qualified
individuals and qualified employers beginning on January 1, 2014;
(2) Establish procedures by rule for the certification,
recertification, and decertification of health benefit plans as
qualified health plans pursuant to section 3965.06 of the Revised
Code and consistent with guidelines developed by the secretary
under section 1311(c) of the federal act;
(3) Provide for the operation of a toll-free telephone
hotline to respond to requests for assistance regarding the
exchange;
(4) Establish enrollment periods, consistent with the
requirements of section 1311(c)(6) of the federal act;
(5) Maintain a web site through which individuals can enroll
in qualified health plans, and through which enrollees and
applicants can obtain standardized comparative information on such
plans;
(6) Assign a rating to each qualified health plan offered
through the exchange in accordance with the criteria developed by
the secretary under section 1311(c)(3) of the federal act, and
determine the level of coverage of each qualified health plan in
accordance with regulations issued by the secretary under section
1302(d)(2)(A) of the federal act;
(7) Ensure that throughout the state a choice of qualified
health plans are provided at the catastrophic, bronze, silver,
gold, and platinum levels of coverage as those levels are
described in sections 1302(d) and (e) of the federal act. A
particular plan may be available in one region of the state and
not others so long as throughout the state there is a comparable
selection of options at each coverage level.
(8) Use a standardized format for presenting health benefit
options in the exchange, including the use of the uniform outline
of coverage established under section 2715 of the "Public Health
Service Act," 124 Stat. 132, 42 U.S.C. 300gg-15 (2010);
(9) Inform individuals of eligibility requirements for the
programs listed in division (B) of section 3965.10 of the Revised
Code and enroll all eligible individuals in those programs;
(10) Grant certifications attesting that individuals are
exempt from the individual responsibility requirement and penalty
under section 5000A of the "Internal Revenue Code of 1986," 124
Stat. 1215, if individuals meet the criteria listed in division
(C) of section 3965.10 of the Revised Code;
(11) Establish and make available by electronic means a
calculator to determine the actual cost of coverage after
application of any premium tax credit under section 36B of the
"Internal Revenue Code of 1986," 125 Stat. 168, and any
cost-sharing reduction under section 1402 of the federal act;
(12) Transfer to the United States secretary of the treasury
all of the following:
(a) A list of the individuals who are issued a certification
under division (B)(10) of this section, including the name and
taxpayer identification number of each individual;
(b) The name and taxpayer identification number of each
individual who was an employee of an employer but who was
determined to be eligible for the premium tax credit under section
36B of the "Internal Revenue Code of 1986," 125 Stat. 168, because
of either of the following reasons:
(i) The employer did not provide minimum essential coverage.
(ii) The employer provided the minimum essential coverage,
but it was determined under section 36B(c)(2)(C) of the "Internal
Revenue Code of 1986," 125 Stat. 168, to either be unaffordable to
the employee or not to provide the required minimum actuarial
value.
(c) The name and taxpayer identification number of both of
the following:
(i) Each individual who notifies the executive director
pursuant to section 1411(b)(4) of the federal act that the
individual has changed employers;
(ii) Each individual who ceases coverage under a qualified
health plan during a plan year and the effective date of that
cessation.
(13) Provide to each employer the name of each employee of
the employer described in division (B)(12)(c)(ii) of this section
who ceases coverage under a qualified health plan during a plan
year and the effective date of the cessation;
(14) Review the rate of premium growth within the exchange
and outside the exchange, and consider the information in making
recommendations to the board of the exchange agency on whether to
continue limiting qualified employer status to small employers;
(15) Meet the following financial integrity requirements:
(a) Keep an accurate accounting of all activities, receipts,
and expenditures, and annually submit to the secretary an
accounting report as required by section 1313 of the federal act;
(b) Conduct an annual fiscal audit;
(c) Annually prepare a written report on the implementation
and performance of the exchange functions during the preceding
fiscal year, including, at a minimum, the manner in which funds
were expended and the progress toward, and the achievement of, the
requirements of this chapter. This report shall be transmitted to
the general assembly and the governor and shall be made available
to the public on the web site of the exchange.
(d) Fully cooperate with any investigation conducted by the
secretary pursuant to the secretary's authority under the federal
act and allow the secretary, in coordination with the inspector
general of the United States department of health and human
services, to do all of the following:
(i) Investigate the affairs of the exchange;
(ii) Examine the properties and records of the exchange;
(iii) Require periodic reports in relation to the activities
undertaken by the exchange.
(e) In carrying out the activities of the exchange under this
chapter, not use any funds intended for the administrative and
operational expenses of the exchange for staff retreats,
promotional giveaways, excessive executive compensation, or
promotion of federal or state legislative and regulatory
modifications.
(16) Provide referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman
established under section 2793 of the "Public Health Service Act,"
124 Stat. 138, 42 U.S.C. 300gg-93 (2010), or the department of
insurance for any enrollee with a grievance, complaint, or
question regarding the enrollee's health plan, coverage, or a
determination under that plan or coverage;
(17) Market and publicize the availability of health care
coverage and federal subsidies through the exchange including
efforts to reach hard-to-reach populations;
(18) Before January 1, 2019, conduct an ongoing study of
exchange activities and the enrollees in qualified health plans
offered through the exchange, including all of the following:
(a) A survey of the cost and affordability of insurance
provided under both the exchange for individual coverage and the
SHOP exchange;
(b) The number of physicians by area and specialty who are
not taking or accepting new patients who are enrolled in qualified
health plans through the exchange;
(c) The adequacy of provider networks of qualified health
plans.
(19) Collaborate with agencies and departments of this state,
including the department of job and family services and the
department of insurance, to allow an individual to remain enrolled
with the individual's carrier and provider network if the
individual loses eligibility for premium tax credits and becomes
eligible for medicaid, or loses eligibility for medicaid and
becomes eligible for premium tax credits through the exchange;
(20) Ensure that the privacy of applicants and enrollees in
the exchange is protected by enforcing the privacy policies
developed by the board of the exchange agency pursuant to division
(H)(7) of section 3965.03 of the Revised Code.
(C) The executive director may do any of the following:
(1) Contract with an eligible entity for any of the functions
of the exchange described in this chapter, including the
department of job and family services or an entity that has
experience in individual and small group health insurance, benefit
administration or other experience relevant to the
responsibilities to be assumed by the entity. A carrier or an
affiliate of a carrier is not an eligible entity.
(2) Enter into information-sharing agreements with federal
and state agencies and departments and other state health benefit
exchange agencies to carry out the responsibilities of the
exchange under this chapter, provided those agreements include
adequate protections with respect to the confidentiality of the
information to be shared and comply with all state and federal
laws, rules, and regulations.
(3) Make available supplemental coverage for enrollees of the
exchange to the extent permitted by the federal act, provided that
funds in the Ohio health benefit exchange operating fund
established in section 3965.12 of the Revised Code are not used to
pay the cost of that coverage. Any supplemental coverage offered
in the exchange shall be subject to the charge imposed on
qualified health plans under section 3965.12 of the Revised Code.
(D) Neither the executive director nor any carrier offering a
health benefit plan through the exchange shall do either of the
following:
(1) Make available on the exchange any health plan that is
not a qualified health plan;
(2) Charge an individual a fee or penalty for termination of
coverage if the individual enrolls in another type of minimum
essential coverage because the individual has become newly
eligible for that coverage or because the individual's
employer-sponsored coverage has become affordable under the
standards of section 36B(c)(2)(C) of the "Internal Revenue Code of
1986," 125 Stat. 168.
(E) All data collection performed by the executive director
pursuant to this chapter shall include demographic information,
including racial and ethnic information as specified by the
executive director in rules adopted in accordance with section
3965.13 of the Revised Code.
Sec. 3965.06. (A) The executive director of the exchange may
certify a health benefit plan as a qualified health plan if all of
the following conditions are met:
(1) The plan provides the essential health benefits package
described in section 1302(a) of the federal act, except that the
plan is not required to provide essential benefits that duplicate
the minimum benefits of qualified dental plans, as provided in
section 3965.07 of the Revised Code, if both of the following are
true:
(a) The executive director has determined that at least one
qualified dental plan is available to supplement the qualified
health plan's coverage.
(b) The carrier makes prominent disclosure at the time it
offers the plan, in a form approved by the executive director,
that the plan does not provide the full range of essential
pediatric benefits, and that qualified dental plans providing
those benefits and other dental benefits not covered by the plan
are offered through the exchange.
(2) The premium rates and contract language have been
approved by the superintendent of insurance.
(3) The plan provides at least a bronze level of coverage, as
determined pursuant to division (B)(6) of section 3965.05 of the
Revised Code unless the plan is certified as a qualified
catastrophic plan, which will only be offered to individuals
eligible for catastrophic coverage.
(4) The plan's cost-sharing requirements do not exceed the
limits established under section 1302(c)(1) of the federal act,
and, if the plan is offered through the SHOP exchange, the plan's
deductible does not exceed the limits established under section
1302(c)(2) of the federal act.
(5) The carrier offering the plan meets all of the following
criteria:
(a) The carrier is licensed and in good standing to offer
health insurance coverage in this state.
(b) The carrier offers at least one qualified catastrophic
health plan, at least one qualified health plan in the bronze
level, at least one qualified health plan in the silver level, at
least one qualified health plan in the gold level, and at least
one qualified health plan in the platinum level, as determined by
the executive director pursuant to division (B)(6) of section
3965.05 of the Revised Code, through the SHOP exchange or the
exchange for individual coverage or both if the carrier
participates in both the SHOP exchange and the exchange for
individual coverage.
(c) The carrier charges the same premium rate for each
qualified health plan without regard to whether the plan is
offered through the exchange and without regard to whether the
plan is offered directly from the carrier or through an insurance
agent.
(d) The carrier does not charge any fee or penalty for
termination of coverage in violation of division (D)(2) of section
3965.05 of the Revised Code.
(e) The carrier complies with the regulations developed by
the secretary under section 1311(d) of the federal act and such
other requirements as the executive director may establish.
(6) The plan meets the requirements of certification as
established by rule pursuant to division (B)(2) of section 3965.05
of the Revised Code and by the secretary under section 1311(c) of
the federal act.
(7) The executive director determines that making the plan
available through the exchange is in the interest of qualified
individuals and qualified employers in this state. In making such
a determination, the executive director shall consider all of the
following:
(a) Plans should not make use of marketing practices that
would discourage enrollment by people with significant health
needs.
(b) Plans must provide a sufficient choice of providers and,
where available, must include essential community providers that
serve low-income, medically underserved individuals.
(c) Plans must be accredited by a recognized accreditation
organization, or achieve accreditation from a recognized
accreditation organization within a time period defined by the
board of the exchange agency, based on a review of their clinical
quality, patient experience, access, utilization management,
quality assurance, provider credentialing, complaints and appeals
processes, network adequacy and access, and patient information
programs.
(d) Plans must have a quality improvement strategy.
(e) Plans must use a uniform enrollment form for individuals
and small employers.
(f) Plans must use a standard format for presenting plan
options.
(g) Plans must provide information about their performance on
standardized quality measures as determined by the board of the
exchange agency under division (H)(5) of section 3965.03 of the
Revised Code to enrollees and prospective enrollees.
(h) Plans must report annually to the federal government on
the quality of their pediatric care.
(8) The plan does not offer benefits or coverage described in
division (D) of this section.
(B) The executive director shall not exclude a health benefit
plan from certification for any of the following reasons:
(1) On the basis that the plan is a fee-for-service plan;
(2) Through the imposition of premium price controls by the
exchange;
(3) On the basis that the health benefit plan provides
treatments necessary to prevent patients' deaths in circumstances
the executive director determines are inappropriate or too costly.
(C) The executive director shall require each carrier seeking
certification of a plan as a qualified health plan to do all of
the following:
(1) Submit a justification to the executive director for any
premium increase before implementation of that increase;
(2) Prominently post any information regarding a premium
increase on its web site. The executive director shall take this
information, along with the information and the recommendations
provided to the exchange by the secretary under section 2794(b) of
the "Public Health Service Act," 124 Stat. 139, 42 U.S.C. 300gg-94
(2010), into consideration when determining whether to allow the
carrier to make plans available through the exchange.
(3) Make available to the public, in language that the
intended audience, including individuals with limited English
proficiency, can readily understand, and submit to the exchange,
the secretary, and the superintendent of insurance, accurate and
timely disclosure of all of the following information:
(a) Claims payment policies and practices;
(b) Periodic financial disclosures;
(c) Data on enrollment, disenrollment, the number of claims
that are denied, and rating practices;
(d) Information on cost-sharing and payments with respect to
any out-of-network coverage;
(e) Information on enrollee and participant rights under
Title I of the federal act;
(f) Other information as determined appropriate by the
secretary pursuant to section 1303 of the federal act.
(4) Permit individuals to learn, in a timely manner upon the
request of the individual, the amount of cost-sharing, including
deductibles, copayments, and coinsurance, under the individual's
plan or coverage that the individual would be responsible for
paying with respect to the furnishing of a specific item or
service by a participating provider. At a minimum, this
information shall be made available to the individual through a
web site and through other means for individuals without access to
the internet.
(D) The executive director shall not consider any health
benefit plan for certification as a qualified health plan if the
health benefit plan includes any of the following:
(1) Any of the following benefits if they are provided under
a separate policy, certificate, or contract of insurance or are
otherwise not an integral part of the plan:
(a) Limited scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home
health care, or community-based care;
(c) Other similar, limited benefits specified in federal
regulations issued pursuant to the "Health Insurance Portability
and Accountability Act of 1996," 110 Stat. 1936 (1996).
(2) Either of the following benefits if the benefits are
provided under a separate policy, certificate, or contract of
insurance, there is no coordination between the provision of the
benefits and any exclusion of benefits under any health benefit
plan maintained by the same carrier, and the benefits are paid
with respect to an event without regard to whether benefits are
provided with respect to such an event under any health benefit
plan maintained by the same carrier:
(a) Coverage only for a specified disease or illness;
(b) Hospital indemnity or other fixed indemnity insurance.
(3) Any of the following if offered as a separate policy,
certificate, or contract of insurance:
(a) Medicare supplemental health insurance as defined under
section 1882(g)(1) of the "Social Security Act," 124 Stat. 460, 42
U.S.C. 1395ss (2010);
(b) Coverage supplemental to the coverage provided under
chapter 55 of Title 10 of the United States Code;
(c) Similar supplemental coverage provided to coverage under
a group health plan.
(E) The executive director shall not exempt any carrier
seeking certification of a qualified health plan, regardless of
the type or size of the carrier, from state licensure or solvency
requirements and shall apply the criteria of this section in a
manner that assures a level playing field between or among
carriers participating in the exchange.
Sec. 3965.07. (A) The executive director may certify a
dental plan as a qualified dental plan if all of the following
conditions are met:
(1) The plan provides limited scope dental benefits that are
offered separately from any qualified health plan.
(2) The plan does not substantially duplicate the benefits
typically offered by health benefit plans without dental coverage.
(3) The plan includes, at a minimum, the essential pediatric
dental benefits prescribed by the secretary pursuant to section
1302(b)(1)(J) of the federal act, and such other dental benefits
as the executive director or the secretary may specify by rule or
regulation.
(B) The provisions of this chapter that are applicable to
qualified health plans shall also apply to qualified dental plans
to the extent relevant with the following exceptions:
(1) A carrier that is licensed to offer dental coverage need
not be licensed to offer other health benefits.
(2) Carriers may jointly offer a comprehensive plan through
the exchange in which the dental benefits are provided by a
carrier through a qualified dental plan and the other benefits are
provided by a carrier through a qualified health plan, provided
that the plans are priced separately and are also made available
for purchase separately at the same price.
(C) The executive director may adopt additional rules
concerning qualified dental health plans.
Sec. 3965.08. (A) Health plans that are certified as
qualified health plans pursuant to section 3965.06 of the Revised
Code and dental plans that are certified as qualified dental plans
pursuant to section 3965.07 of the Revised Code may bid to
participate in the exchange for individual coverage and the SHOP
exchange. Bidding plans will be scored by the executive director
of the exchange based on the following criteria:
(1) The cost of the plan to individuals in terms of premiums
and typical out-of-pocket expenses;
(2) The carrier's overall offering and plan design. Preferred
features of health benefit plans include the following:
(a) Use of a select, high-performance network;
(b) Centers of excellence for complex conditions or
procedures;
(c) Innovative pharmacy management;
(d) Active consumer engagement;
(e) Wellness incentives and management;
(f) Preventive and flex benefits for chronic conditions.
(3) Use of multilingual community outreach or nontraditional
media outlets to reach hard-to-reach communities for marketing
purposes;
(4) The ability of the plan to confirm its compliance with
various program rules and reporting requirements;
(5) The design of the plan's enrollment process, including
the following considerations:
(a) Level of burden to the consumer;
(b) Ease of use with regard to populations that may
experience barriers to enrollment such as the disabled and those
with limited English language proficiency.
(6) A determination of whether including a given plan in the
exchange will encourage a robust system of regional plans.
(B) After consideration of the criteria listed in division
(A) of this section, the executive director shall select qualified
health plans and qualified dental plans to participate in the
exchange. There shall not be a set minimum or maximum number of
qualified health or dental plans that are required to exist in the
exchange.
(C) In the course of selectively contracting for health care
coverage, the executive director shall do both of the following:
(a) Seek to contract with carriers so as to provide health
care coverage choices that offer the optimal combination of
choice, value, quality, and service;
(b) Maintain a robust system of regional plans.
Sec. 3965.09. (A) The board of the exchange agency shall
establish a navigator program in accordance with section 1311(i)
of the federal act, designed to advise individual consumers and
employers on the use of the exchange.
(B) The board shall select individuals and entities to be
part of the navigator program. To be considered for a grant under
the navigator program, an individual or entity shall meet all of
the following criteria:
(1) The individual or entity shall demonstrate to the board
that the individual or entity has existing relationships or could
readily establish relationships with consumers, employers and
employees, or self-employed individuals, likely to be qualified to
enroll in a qualified health plan;
(2) The individual or entity shall not be a health insurance
issuer or receive any compensation, either directly or indirectly,
from any health insurance issuer in connection with the enrollment
of any qualified individuals or employees of a qualified employer
in a qualified health plan;
(3) The individual or entity shall be capable of carrying out
the duties listed in division (C) of this section.
(C) Navigators shall do all of the following:
(1) Conduct public education activities to raise awareness of
the availability of qualified health plans;
(2) Distribute fair and impartial information concerning
enrollment in qualified health plans, and the availability of
premium tax credits under section 36B of the "Internal Revenue
Code of 1986," 125 Stat. 168, and cost-sharing reductions under
section 1402 of the federal act;
(3) Facilitate enrollment in qualified health plans;
(4) Provide referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman
established under section 2793 of the "Public Health Service Act,"
124 Stat. 138, 42 U.S.C. 300gg-93 (2010), or the department of
insurance, for any enrollee with a grievance, complaint, or
question regarding their health benefit plan or coverage or a
determination under that plan or coverage;
(5) Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population being
served by the exchange.
(D) The board shall award grants to individuals and entities
approved by the board to perform work as navigators in order to
fund the required duties described in division (C) of this
section. Funds for grants shall be withdrawn from the Ohio health
benefit exchange operating fund established in section 3965.12 of
the Revised Code.
Sec. 3965.10. (A) Only qualified individuals shall be
permitted to purchase health insurance through the exchange. A
qualified individual is an individual, including a minor, who
meets all of the following criteria:
(1) The individual is seeking to enroll in a qualified health
plan offered to individuals through the exchange.
(2) The individual resides in this state.
(3) The individual is not incarcerated at the time of
enrollment, other than incarceration pending the disposition of
charges.
(4) The individual is, and is reasonably expected to be, for
the entire period for which enrollment is sought, a citizen or
national of the United States, or an alien lawfully present in the
United States.
(B) If the executive director of the exchange program
determines that an individual seeking to purchase health insurance
through the exchange is eligible for the medicaid program under
Title XIX of the "Social Security Act," 124 Stat. 328, 42 U.S.C.
1396 (2010), the children's health insurance program under Title
XXI of the "Social Security Act," 111 Stat. 552, 42 U.S.C. 1397aa
(1997), or any applicable state or local public program, the
executive director shall enroll the individual in that program.
(C) An individual shall be exempt from the individual
responsibility requirement under section 5000A of the "Internal
Revenue Code of 1986," 124 Stat. 1215, or from the penalty imposed
by that section for either of the following reasons:
(1) There is no affordable qualified health plan available
through the exchange, or the individual's employer, covering the
individual.
(2) The individual meets the requirements for any other such
exemption from the individual responsibility requirement or
penalty.
Sec. 3965.11. (A) As a part of the exchange there shall
exist a SHOP exchange through which qualified employers may access
coverage for their employees, and that shall enable any qualified
employer to specify a level of coverage so that any of its
employees may enroll in any qualified health plan offered through
the SHOP exchange at the specified level of coverage.
(B) Only qualified employers shall be permitted to
participate in the SHOP exchange. A qualified employer is a small
employer that elects to make its full-time employees eligible for
one or more qualified health plans offered through the SHOP
exchange, and at the option of the employer, some or all of its
part-time employees, provided that the employer meets either of
the following criteria:
(1) The employer has its principal place of business in this
state and elects to provide coverage through the SHOP exchange to
all of its eligible employees, wherever employed;
(2) The employer elects to provide coverage through the SHOP
exchange to all of its eligible employees who are principally
employed in this state.
(C) If an employer that makes enrollment in qualified health
plans available to its employees through the SHOP exchange would
cease to be a small employer by reason of an increase in the
number of its employees, the employer shall continue to be treated
as a small employer for purposes of this chapter as long as it
continuously makes enrollment through the SHOP exchange available
to its employees.
Sec. 3965.12. (A)(1) The exchange agency may charge
assessments or user fees to carriers or otherwise may generate
funding necessary to support its operations and the operations of
the exchange.
(2) All funds collected by the exchange agency pursuant to
division (A)(1) of this section shall be paid into the state
treasury to the credit of the Ohio health benefit exchange
operating fund, which is hereby created.
(B) The exchange agency shall publish the average costs of
licensing, regulatory fees, and any other payments required by the
exchange agency and the exchange, and the administrative costs of
the exchange agency and the exchange, on a web site to educate
consumers on such costs. This information shall include
information on monies lost to waste, fraud, and abuse.
Sec. 3965.13. The board of the exchange agency and the
executive director of the exchange may adopt rules to implement
the provisions of this chapter. Rules adopted pursuant to this
section shall not conflict with or prevent the application of
regulations promulgated by the secretary under the federal act.
Sec. 3965.14. Nothing in this chapter, and no action taken
by the board of the exchange agency or the executive director of
the exchange pursuant to this chapter, shall be construed to
preempt or supersede the authority of the superintendent of
insurance to regulate the business of insurance within this state.
Except as expressly provided to the contrary in this chapter, all
carriers offering qualified health plans in this state shall
comply fully with all applicable health insurance laws of this
state and rules adopted and orders issued by the superintendent.
Section 2. That existing sections 124.14 and 3924.01 of the
Revised Code are hereby repealed.
Section 3. Within ninety days after the effective date of
this act, the exchange agency board of directors nominating
council established in section 3965.04 of the Revised Code as
enacted in this act shall produce two, three, or four nominees for
each position described in division (A)(2) of section 3965.03 of
the Revised Code. Following nomination, the Governor shall appoint
the members described in that division to the board of the Ohio
Health Benefit Exchange Agency in accordance with division (F) of
section 3965.04 of the Revised Code as enacted in this act. At the
time of appointment, the Governor shall determine which members of
the board shall serve the terms described in division (C)(1) of
section 3965.03 of the Revised Code. For each subsequent
nomination period, the nominating council shall produce four
nominees for each position as required by division (D)(2) of
section 3965.04 of the Revised Code.
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