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Am. S. B. No. 99 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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Senators Oelslager, Tavares
Cosponsors:
Senators Brown, Cafaro, Gardner, Hite, Kearney, Lehner, Schiavoni, Smith, Turner, LaRose, Manning, Skindell, Gentile, Burke, Eklund, Hughes, Jones, Obhof, Sawyer, Uecker
Representatives Wachtmann, Antonio, Barnes, Bishoff, Brown, Carney, Hagan, R., Hottinger, Johnson, Schuring
A BILL
To amend sections 1739.05 and 5162.20 and to enact
sections 1751.69, 3923.85, and 5164.09 of the
Revised Code regarding insurance and Medicaid
coverage for orally administered cancer
medications.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1739.05 and 5162.20 be amended and
sections 1751.69, 3923.85, and 5164.09 of the Revised Code be
enacted to read as follows:
Sec. 1739.05. (A) A multiple employer welfare arrangement
that is created pursuant to sections 1739.01 to 1739.22 of the
Revised Code and that operates a group self-insurance program may
be established only if any of the following applies:
(1) The arrangement has and maintains a minimum enrollment of
three hundred employees of two or more employers.
(2) The arrangement has and maintains a minimum enrollment of
three hundred self-employed individuals.
(3) The arrangement has and maintains a minimum enrollment of
three hundred employees or self-employed individuals in any
combination of divisions (A)(1) and (2) of this section.
(B) A multiple employer welfare arrangement that is created
pursuant to sections 1739.01 to 1739.22 of the Revised Code and
that operates a group self-insurance program shall comply with all
laws applicable to self-funded programs in this state, including
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,
3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63,
3923.80, 3923.85, 3924.031, 3924.032, and 3924.27 of the Revised
Code.
(C) A multiple employer welfare arrangement created pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall solicit
enrollments only through agents or solicitors licensed pursuant to
Chapter 3905. of the Revised Code to sell or solicit sickness and
accident insurance.
(D) A multiple employer welfare arrangement created pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall provide
benefits only to individuals who are members, employees of
members, or the dependents of members or employees, or are
eligible for continuation of coverage under section 1751.53 or
3923.38 of the Revised Code or under Title X of the "Consolidated
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29
U.S.C.A. 1161, as amended.
Sec. 1751.69. (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.
(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. 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.
(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. 5162.20. (A) The department of medicaid shall institute
cost-sharing requirements for the medicaid program. The department
shall not institute cost-sharing requirements in a manner that
disproportionately does either of the following:
(1) Disproportionately impacts the ability of medicaid
recipients with chronic illnesses to obtain medically necessary
medicaid services;
(2) Violates section 5164.09 of the Revised Code.
(B)(1) No provider shall refuse to provide a service to a
medicaid recipient who is unable to pay a required copayment for
the service.
(2) Division (B)(1) of this section shall not be considered
to do either of the following with regard to a medicaid recipient
who is unable to pay a required copayment:
(a) Relieve the medicaid recipient from the obligation to pay
a copayment;
(b) Prohibit the provider from attempting to collect an
unpaid copayment.
(C) Except as provided in division (F) of this section, no
provider shall waive a medicaid recipient's obligation to pay the
provider a copayment.
(D) No provider or drug manufacturer, including the
manufacturer's representative, employee, independent contractor,
or agent, shall pay any copayment on behalf of a medicaid
recipient.
(E) If it is the routine business practice of a provider to
refuse service to any individual who owes an outstanding debt to
the provider, the provider may consider an unpaid copayment
imposed by the cost-sharing requirements as an outstanding debt
and may refuse service to a medicaid recipient who owes the
provider an outstanding debt. If the provider intends to refuse
service to a medicaid recipient who owes the provider an
outstanding debt, the provider shall notify the recipient of the
provider's intent to refuse service.
(F) In the case of a provider that is a hospital, the
cost-sharing program shall permit the hospital to take action to
collect a copayment by providing, at the time services are
rendered to a medicaid recipient, notice that a copayment may be
owed. If the hospital provides the notice and chooses not to take
any further action to pursue collection of the copayment, the
prohibition against waiving copayments specified in division (C)
of this section does not apply.
(G) The department of medicaid may collaborate with a state
agency that is administering, pursuant to a contract entered into
under section 5162.35 of the Revised Code, one or more components,
or one or more aspects of a component, of the medicaid program as
necessary for the state agency to apply the cost-sharing
requirements to the components or aspects of a component that the
state agency administers.
Sec. 5164.09. (A) Except as provided in division (C) of this
section, the medicaid program shall cover prescribed, orally
administered cancer medications on at least the same basis that it
covers intraveneously administered or injected cancer medications.
In implementing this section, the department of medicaid shall not
institute cost-sharing requirements under section 5162.20 of the
Revised Code for prescribed, orally administered cancer
medications that are greater than any cost-sharing requirements
instituted under that section for intraveneously administered or
injected cancer medications.
(B) Division (A) of this section does not preclude the
department from requiring a medicaid recipient to obtain prior
authorization before a prescribed, orally administered cancer
medication is dispensed to the recipient.
(C) This section shall not be implemented during a fiscal
year if the medicaid director determines that this section's
implementation would cause the costs of the medicaid program's
coverage of prescribed drugs to increase by more than one per cent
over such costs for the most recent previous fiscal year for which
the amount of such costs is known.
Section 2. That existing sections 1739.05 and 5162.20 of the
Revised Code are hereby repealed.
Section 3. Sections 5162.20 and 5164.09 of the Revised Code
as amended or enacted by this act shall take effect January 1,
2015.
Section 4. This act shall be known as the "Robert L. Schuler
Act" in honor of the late Robert L. Schuler who served in both the
Ohio House of Representatives and the Ohio Senate.
Section 5. Sections 1739.05 and 1751.69 of the Revised Code,
as amended or enacted 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, 2015. Section
3923.85 of the Revised Code, as enacted by this act, applies only
to policies of sickness and accident insurance delivered, issued
for delivery, or renewed in this state and public employee benefit
plans that are established or modified in this state on or after
January 1, 2015.
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