The online versions of legislation provided on this website are not official. Enrolled bills are the final version passed by the Ohio General Assembly and presented to the Governor for signature. The official version of acts signed by the Governor are available from the Secretary of State's Office in the Continental Plaza, 180 East Broad St., Columbus.
|
Sub. S. B. No. 9 As Reported by the Senate Insurance and Financial Institutions CommitteeAs Reported by the Senate Insurance and Financial Institutions Committee
130th General Assembly | Regular Session | 2013-2014 |
| |
Cosponsors: Senators Beagle, Hite, Jones, Seitz, Widener
A BILL
To amend sections 1751.12 and 3905.01 and to enact
sections 3905.47, 3905.471, 3905.472, 3905.473,
and 3905.474 of the Revised Code to specify
licensing and continuing education requirements
for insurance agents involved in selling,
soliciting, or negotiating sickness and accident
insurance through a health benefit exchange and to
make changes to copayments, cost sharing, and
deductibles for health insuring corporations.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.12 and 3905.01 be amended and
sections 3905.47, 3905.471, 3905.472, 3905.473, and 3905.474 of
the Revised Code be enacted to read as follows:
Sec. 1751.12. (A)(1) No contractual periodic prepayment and
no premium rate for nongroup and conversion policies for health
care services, or any amendment to them, may be used by any health
insuring corporation at any time until the contractual periodic
prepayment and premium rate, or amendment, have been filed with
the superintendent of insurance, and shall not be effective until
the expiration of sixty days after their filing unless the
superintendent sooner gives approval. The filing shall be
accompanied by an actuarial certification in the form prescribed
by the superintendent. The superintendent shall disapprove the
filing, if the superintendent determines within the sixty-day
period that the contractual periodic prepayment or premium rate,
or amendment, is not in accordance with sound actuarial principles
or is not reasonably related to the applicable coverage and
characteristics of the applicable class of enrollees. The
superintendent shall notify the health insuring corporation of the
disapproval, and it shall thereafter be unlawful for the health
insuring corporation to use the contractual periodic prepayment or
premium rate, or amendment.
(2) No contractual periodic prepayment for group policies for
health care services shall be used until the contractual periodic
prepayment has been filed with the superintendent. The filing
shall be accompanied by an actuarial certification in the form
prescribed by the superintendent. The superintendent may reject a
filing made under division (A)(2) of this section at any time,
with at least thirty days' written notice to a health insuring
corporation, if the contractual periodic prepayment is not in
accordance with sound actuarial principles or is not reasonably
related to the applicable coverage and characteristics of the
applicable class of enrollees.
(3) At any time, the superintendent, upon at least thirty
days' written notice to a health insuring corporation, may
withdraw the approval given under division (A)(1) of this section,
deemed or actual, of any contractual periodic prepayment or
premium rate, or amendment, based on information that either of
the following applies:
(a) The contractual periodic prepayment or premium rate, or
amendment, is not in accordance with sound actuarial principles.
(b) The contractual periodic prepayment or premium rate, or
amendment, is not reasonably related to the applicable coverage
and characteristics of the applicable class of enrollees.
(4) Any disapproval under division (A)(1) of this section,
any rejection of a filing made under division (A)(2) of this
section, or any withdrawal of approval under division (A)(3) of
this section, shall be effected by a written notice, which shall
state the specific basis for the disapproval, rejection, or
withdrawal and shall be issued in accordance with Chapter 119. of
the Revised Code.
(B) Notwithstanding division (A) of this section, a health
insuring corporation may use a contractual periodic prepayment or
premium rate for policies used for the coverage of beneficiaries
enrolled in medicare pursuant to a medicare risk contract or
medicare cost contract, or for policies used for the coverage of
beneficiaries enrolled in the federal employees health benefits
program pursuant to 5 U.S.C.A. 8905, or for policies used for the
coverage of medicaid recipients, or for policies used for the
coverage of beneficiaries under any other federal health care
program regulated by a federal regulatory body, or for policies
used for the coverage of beneficiaries under any contract covering
officers or employees of the state that has been entered into by
the department of administrative services, if both of the
following apply:
(1) The contractual periodic prepayment or premium rate has
been approved by the United States department of health and human
services, the United States office of personnel management, the
department of job and family services, or the department of
administrative services.
(2) The contractual periodic prepayment or premium rate is
filed with the superintendent prior to use and is accompanied by
documentation of approval from the United States department of
health and human services, the United States office of personnel
management, the department of job and family services, or the
department of administrative services.
(C) The administrative expense portion of all contractual
periodic prepayment or premium rate filings submitted to the
superintendent for review must reflect the actual cost of
administering the product. The superintendent may require that the
administrative expense portion of the filings be itemized and
supported.
(D)(1) Copayments, cost sharing, and deductibles must be
reasonable and must not be a barrier to the necessary utilization
of services by enrollees.
(2) A health insuring corporation, in order to ensure that
copayments, cost sharing, and deductibles are reasonable and not a
barrier to the necessary utilization of basic health care services
by enrollees, may do one of the following:
(a) Impose copayment charges on any single covered basic
health care service that does not exceed forty per cent of the
average cost to the health insuring corporation of providing the
service;
(b) Impose shall impose copayment charges, cost sharing, and
deductible charges that annually do not exceed
twenty forty per
cent of the total annual cost to the health insuring corporation
of providing all covered basic health care services, including
physician office visits, urgent care services, and emergency
health services, when aggregated as to all persons applied to a
standard population expected to be covered under the filed product
in question. In addition, annual copayment charges as to each
enrollee shall not exceed twenty per cent of the total annual cost
to the health insuring corporation of providing all covered basic
health care services, including physician office visits, urgent
care services, and emergency health services, as to such enrollee.
The total annual cost of providing a health care service is the
cost to the health insuring corporation of providing the health
care service to its enrollees as reduced by any applicable
provider discount.
This requirement shall be demonstrated by an
actuary who is a member of the American academy of actuaries and
qualified to provide such certifications as described in the
United States qualification standards promulgated by the American
academy of actuaries pursuant to the code of professional conduct.
(3) To ensure that copayments are reasonable and not a
barrier to the utilization of basic health care services, a health
insuring corporation may not impose, in any contract year, on any
subscriber or enrollee, copayments that exceed two hundred per
cent of the average annual premium rate to subscribers or
enrollees.
(4) For purposes of division (D) of this section, both all of
the following apply:
(a) Copayments imposed by health insuring corporations in
connection with a high deductible health plan that is linked to a
health savings account are reasonable and are not a barrier to the
necessary utilization of services by enrollees.
(b) Divisions Division (D)(2) and (3) of this section do does
not apply to a high deductible health plan that is linked to a
health savings account.
(c) Catastrophic-only plans, as defined under the "Patient
Protection and Affordable Care Act," 124 Stat. 119, 42 U.S.C.
18022 and any related regulations, are not subject to the limits
prescribed in division (D) of this section, provided that such
plans meet all applicable minimum federal requirements.
(E) A health insuring corporation shall not impose lifetime
maximums on basic health care services. However, a health insuring
corporation may establish a benefit limit for inpatient hospital
services that are provided pursuant to a policy, contract,
certificate, or agreement for supplemental health care services.
(F) A health insuring corporation may require that an
enrollee pay an annual deductible that does not exceed one
thousand dollars per enrollee or two thousand dollars per family,
except that:
(1) A health insuring corporation may impose higher
deductibles for high deductible health plans that are linked to
health savings accounts;
(2) The superintendent may adopt rules allowing different
annual copayment, cost sharing, and deductible amounts for plans
with a medical savings account, health reimbursement arrangement,
flexible spending account, or similar account;
(3)(G) A health insuring corporation may impose higher
deductibles copayment, cost sharing, and deductible charges under
health plans if requested by the group contract, policy,
certificate, or agreement holder, or an individual seeking
coverage under an individual health plan. This shall not be
construed as requiring the health insuring corporation to create
customized health plans for group contract holders or individuals.
(G)(H) As used in this section, "health savings account" and
"high deductible health plan" have the same meanings as in the
"Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C. 223, as
amended.
Sec. 3905.01. As used in this chapter:
(A) "Affordable Care Act" means the "Patient Protection and
Affordable Care Act," 124 Stat. 119, 42 U.S.C. 18031 (2011).
(B) "Business entity" means a corporation, association,
partnership, limited liability company, limited liability
partnership, or other legal entity.
(B)(C) "Home state" means the state or territory of the
United States, including the District of Columbia, in which an
insurance agent maintains the insurance agent's principal place of
residence or principal place of business and is licensed to act as
an insurance agent.
(C)(D) "In-person assister" means any entity or person that
receives funding from the centers for medicare and medicaid
services for the purpose of developing and operating an in-person
assistance program within an exchange. The superintendent may, by
rule, apply the requirements of this chapter to any additional
entity or person delineated by the federal government to assist
consumers or participate in exchange activities.
(E) "Insurance" means any of the lines of authority set forth
in Chapter 1739., 1751., or 1761. or Title XXXIX of the Revised
Code, or as additionally determined by the superintendent of
insurance.
(D)(F) "Insurance agent" or "agent" means any person that, in
order to sell, solicit, or negotiate insurance, is required to be
licensed under the laws of this state, including limited lines
insurance agents and surplus line brokers.
(E)(G) "Insurer" has the same meaning as in section 3901.32
of the Revised Code.
(F)(H) "License" means the authority issued by the
superintendent to a person to act as an insurance agent for the
lines of authority specified, but that does not create any actual,
apparent, or inherent authority in the person to represent or
commit an insurer.
(G)(I) "Limited line credit insurance" means credit life,
credit disability, credit property, credit unemployment,
involuntary unemployment, mortgage life, mortgage guaranty,
mortgage disability, guaranteed automobile protection insurance,
or any other form of insurance offered in connection with an
extension of credit that is limited to partially or wholly
extinguishing that credit obligation and that is designated by the
superintendent as limited line credit insurance.
(H)(J) "Limited line credit insurance agent" means a person
that sells, solicits, or negotiates one or more forms of limited
line credit insurance to individuals through a master, corporate,
group, or individual policy.
(I)(K) "Limited lines insurance" means those lines of
authority set forth in divisions (B)(7) to (11) of section 3905.06
of the Revised Code or in rules adopted by the superintendent, or
any lines of authority the superintendent considers necessary to
recognize for purposes of complying with section 3905.072 of the
Revised Code.
(J)(L) "Limited lines insurance agent" means a person
authorized by the superintendent to sell, solicit, or negotiate
limited lines insurance.
(K)(M) "NAIC" means the national association of insurance
commissioners.
(L)(N) "Insurance navigator" means a person selected to
perform the activities and duties identified in division (i) of
section 1311 of the Affordable Care Act that is certified by the
superintendent of insurance under section 3905.471 of the Revised
Code. "Insurance navigator" refers to a navigator specified in
section 1311 of the Affordable Care Act, 42 U.S.C. 13031.
(O) "Negotiate" means to confer directly with, or offer
advice directly to, a purchaser or prospective purchaser of a
particular contract of insurance with respect to the substantive
benefits, terms, or conditions of the contract, provided the
person that is conferring or offering advice either sells
insurance or obtains insurance from insurers for purchasers.
(M)(P) "Person" means an individual or a business entity.
(N)(Q) "Sell" means to exchange a contract of insurance by
any means, for money or its equivalent, on behalf of an insurer.
(O)(R) "Solicit" means to attempt to sell insurance, or to
ask or urge a person to apply for a particular kind of insurance
from a particular insurer.
(P)(S) "Superintendent" or "superintendent of insurance"
means the superintendent of insurance of this state.
(Q)(T) "Terminate" means to cancel the relationship between
an insurance agent and the insurer or to terminate an insurance
agent's authority to transact insurance.
(R)(U) "Uniform application" means the NAIC uniform
application for resident and nonresident agent licensing, as
amended by the NAIC from time to time.
(S)(V) "Uniform business entity application" means the NAIC
uniform business entity application for resident and nonresident
business entities, as amended by the NAIC from time to time.
(W) "Exchange" means a health benefit exchange established by
the state government of Ohio or an exchange established by the
United States department of health and human services in
accordance with the "Patient Protection and Affordable Care Act,"
124 Stat. 119, 42 U.S.C. 18031 (2011).
Sec. 3905.47. (A)(1) No agent shall sell, solicit, or
negotiate insurance through an exchange, or enroll or offer to
enroll a person in a health benefit plan offered through an
exchange, on or after October 1, 2013, without first completing a
training program either required by an exchange or approved by the
superintendent of insurance in accordance with division (B) of
this section.
(2) If an exchange does not require the completion of a
training program pursuant to division (A)(1) of this section, the
superintendent shall establish such a program.
(B) The superintendent shall approve courses to be used for
compliance with division (A) of this section and shall approve
courses established by an exchange, provided that the courses are
in accordance with section 3905.484 of the Revised Code. Any
course the superintendent approves shall consist of topics related
to insurance offered within an exchange, including all of the
following:
(1) The levels of coverage provided in an exchange;
(2) The eligibility requirements for individuals to purchase
insurance through an exchange;
(3) The eligibility requirements for employers to make
insurance available to their employees through a small business
health options program;
(4) Individual eligibility requirements for medicaid;
(5) The use of enrollment forms used in an exchange;
(6) Any other topics as required by the superintendent.
(C) Agents that complete the training program required under
division (A) of this section shall receive continuing education
course credit under sections 3905.481 to 3905.486 of the Revised
Code. All such credit shall count toward satisfying the continuing
education requirement in section 3905.481 of the Revised Code.
Sec. 3905.471. (A) No individual or entity shall act as or
hold itself out to be an insurance navigator or shall receive
insurance navigator funding from the state or an exchange unless
certified as an insurance navigator under this section.
(B) An insurance navigator who complies with the requirements
of this section may do any of the following:
(1) Conduct public education activities to raise awareness of
the availability of qualified health plans;
(2) Distribute fair and impartial general information
concerning enrollment in all qualified health plans offered within
the exchange and the availability of the premium tax credits under
section 36B of the Internal Revenue Code of 1986, 26 U.S.C. 36B,
and cost-sharing reductions under section 1402 of the Affordable
Care Act;
(3) Facilitate enrollment in qualified health plans, without
suggesting that an individual select a particular plan;
(4) Provide referrals to appropriate state agencies for any
enrollee with a grievance, complaint, or question regarding their
health plan, coverage, or a determination under such plan
coverage;
(5) Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population being
served by the exchange.
(C) An insurance navigator shall not do any of the following:
(1) Sell, solicit, or negotiate health insurance;
(2) Provide advice concerning the substantive benefits,
terms, and conditions of a particular health benefit plan or offer
advice about which health benefit plan is better or worse or
suitable for a particular individual or entity;
(3) Recommend a particular health plan or advise consumers
about which health benefit plan to choose;
(4) Provide any information or services related to health
benefit plans or other products not offered in the exchange.
Division (C)(4) of this section shall not be interpreted as
prohibiting an insurance navigator from providing information on
eligibility for medicaid.
(D) An individual shall not act in the capacity of an
insurance navigator, or perform insurance navigator duties on
behalf of an organization serving as an insurance navigator,
unless the individual has applied for certification and the
superintendent finds that the applicant meets all of the following
requirements:
(1) Is at least eighteen years of age;
(2) Has completed and submitted the application and
disclosure form required under division (F)(2) of this section and
has declared, under penalty of refusal, suspension, or revocation
of the insurance navigator's certification, that the statements
made in the form are true, correct, and complete to the best of
the applicant's knowledge and belief;
(3) Has successfully completed a criminal records check under
section 3905.051 of the Revised Code, as required by the
superintendent;
(4) Has successfully completed the certification and training
requirements adopted by the superintendent in accordance with
division (F) of this section;
(5) Has paid all fees required by the superintendent.
(E)(1) A business entity that acts as an insurance navigator,
supervises the activities of individual insurance navigators, or
receives funding to provide insurance navigator services shall
obtain an insurance navigator business entity certification.
(2) Any entity applying for a business entity certification
shall apply in a form specified, and provide any information
required by, the superintendent.
(3) A business entity certified as an insurance navigator
shall, in a manner prescribed by the superintendent, make
available a list of all individual insurance navigators that the
business entity employs, supervises, or with which the business
entity is affiliated.
(F) The superintendent of insurance shall, prior to any
exchange becoming operational in this state, do all of the
following:
(1)(a) Adopt rules to establish a certification and training
program for a prospective insurance navigator and the insurance
navigator's employees that includes screening via a criminal
records check performed in accordance with section 3905.051 of the
Revised Code, initial and continuing education requirements, and
an examination;
(b) The certification and training program shall include
training on compliance with the "Health Insurance Portability and
Accountability Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et
seq., as amended, training on ethics, and training on provisions
of the Affordable Care Act relating to insurance navigators and
exchanges.
(2) Develop an application and disclosure form by which an
insurance navigator may disclose any potential conflicts of
interest, as well as any other information the superintendent
considers pertinent.
(G)(1) The superintendent may suspend, revoke, or refuse to
issue or renew the insurance navigator certification of any
person, or levy a civil penalty against any person, that violates
the requirements of this section or commits any act that would be
a ground for denial, suspension, or revocation of an insurance
agent license, as prescribed in section 3905.14 of the Revised
Code.
(2) The superintendent shall have the power to examine and
investigate the business affairs and records of any insurance
navigator.
(3) The superintendent shall not certify as an insurance
navigator, and shall revoke any existing insurance navigator
certification of, any individual, organization, or business entity
that is receiving financial compensation, including monetary and
in-kind compensation, gifts, or grants, on or after October 1,
2013, from an insurer offering a qualified health benefit plan
through an exchange operating in this state.
(4)(a) If the superintendent finds that a violation of this
section made by an individual insurance navigator was made with
the knowledge of the employing or supervising entity, or that the
employing or supervising entity should reasonably have been aware
of the individual insurance navigator's violation, and the
violation was not reported to the superintendent and no corrective
action was undertaken on a timely basis, then the superintendent
may suspend, revoke, or refuse to renew the insurance navigator
certification of the supervising or employing entity.
(b) In addition to, or in lieu of, any disciplinary action
taken under division (G)(4)(a) of this section, the superintendent
may levy a civil penalty against such an entity.
(H) A business entity that terminates the employment,
engagement, affiliation, or other relationship with an individual
insurance navigator shall notify the superintendent within thirty
days following the effective date of the termination, using a
format prescribed by the superintendent, if the reason for
termination is one of the reasons set forth in section 3905.14 of
the Revised Code, or the entity has knowledge that the insurance
navigator was found by a court or government body to have engaged
in any of the activities in section 3905.14 of the Revised Code.
(I) Insurance navigators are subject to the laws of this
chapter, and any rules adopted pursuant to the chapter, in so far
as such laws are applicable.
(J) The superintendent may deny, suspend, approve, renew, or
revoke the certification of an insurance navigator if the
superintendent determines that doing so would be in the interest
of Ohio insureds or the general public. Such an action is not
subject to Chapter 119. of the Revised Code.
(K) The superintendent may adopt rules in accordance with
Chapter 119. of the Revised Code to implement sections 3905.47 to
3905.473 of the Revised Code.
(L) Any fees collected under this section shall be paid into
the state treasury to the credit of the department of insurance
operating fund created under section 3901.021 of the Revised Code.
Sec. 3905.472. An exchange shall permit an insurer to offer
any health benefit plan that the insurer seeks to offer through
the exchange, so long as the health benefit plan in question is a
qualified health plan under the Affordable Care Act, as approved
by the superintendent of insurance. Nothing in this section shall
be construed to allow the superintendent of insurance to impose
any additional state certification requirements in order to be a
qualified health plan.
Sec. 3905.473. (A) An exchange operating in this state shall
maintain a current list of both of the following:
(1) Licensed insurance agents that have met all of the
requirements necessary to offer or sell insurance through an
exchange;
(2) Individuals and business entities that have been
certified by the superintendent as an insurance navigator.
(B) An exchange shall make available a list of insurance
agents operating near the individual's residence address that are
certified to sell a health benefit plan through an exchange and
insurance navigators that are certified under section 3905.471 of
the Revised Code. An exchange operating in this state shall
maintain a means of communication by which an individual may make
such a request.
(C) Any web site, software application, or other electronic
medium, or an exchange-sanctioned outreach event that enables a
consumer to determine eligibility for and to purchase a qualified
health plan through an exchange shall include information on how
an individual can obtain from an exchange the contact information
of insurance agents operating near the individual's residence
address that are certified to sell health benefit plans through an
exchange and insurance navigators that are certified under section
3905.471 of the Revised Code.
Sec. 3905.474. No person shall act as or hold self out to be
an in-person assister unless that person is either a licensed
insurance agent certified to sell insurance through an exchange
under section 3905.47 of the Revised Code or an insurance
navigator certified under section 3905.471 of the Revised Code.
Section 2. That existing sections 1751.12 and 3905.01 of the
Revised Code are hereby repealed.
|