Section 1. That sections 1739.061, 1751.14, 1751.69, | 22 |
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601, | 23 |
3923.65, 3923.83, 3923.85, 3924.01, 4123.01, 4123.026, and 4123.46 | 24 |
be amended and sections 505.377, 737.082, and 737.222 of the | 25 |
Revised Code be enacted to read as follows: | 26 |
Sec. 505.377. A volunteer firefighter appointed pursuant to | 27 |
this chapter is a bona fide volunteer and not an employee for | 28 |
purposes of section 513 of the "Patient Protection and Affordable | 29 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 30 |
providing those fire protection services, the volunteer receives | 31 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 32 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 33 |
Code. | 34 |
Sec. 737.082. A volunteer firefighter appointed pursuant to | 35 |
this chapter is a bona fide volunteer and not an employee for | 36 |
purposes of section 513 of the "Patient Protection and Affordable | 37 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 38 |
providing those fire protection services, the volunteer receives | 39 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 40 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 41 |
Code. | 42 |
Sec. 737.222. A volunteer firefighter appointed pursuant to | 43 |
this chapter is a bona fide volunteer and not an employee for | 44 |
purposes of section 513 of the "Patient Protection and Affordable | 45 |
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for | 46 |
providing those fire protection services, the volunteer receives | 47 |
any of the benefits provided in Chapter 146., 4121., or 4123. or | 48 |
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised | 49 |
Code. | 50 |
(a) Any program or arrangement covering only accident, | 66 |
credit, dental, disability income, long-term care, hospital | 67 |
indemnity, medicare supplement, medicare, tricare, specified | 68 |
disease, or vision care; coverage under a | 69 |
one-time-limited-duration policy of not longerthat is less than | 70 |
sixtwelve months; coverage issued as a supplement to liability | 71 |
insurance; insurance arising out of workers' compensation or | 72 |
similar law; automobile medical payment insurance; or insurance | 73 |
under which benefits are payable with or without regard to fault | 74 |
and which is statutorily required to be contained in any liability | 75 |
insurance policy or equivalent self-insurance. | 76 |
(1) The standardized identification card or the electronic | 88 |
technology shall be in a format and contain information fields | 89 |
approved by the national council for prescription drug programs or | 90 |
a successor organization, as specified in the council's or | 91 |
successor organization's pharmacy identification card | 92 |
implementation guide in effect on the first day of October most | 93 |
immediately preceding the issuance or required use of the | 94 |
standardized identification card or the electronic technology. | 95 |
(C) If the standardized identification card or the electronic | 113 |
technology issued or required to be used as provided in division | 114 |
(A)(1) of this section is also used for submission and routing of | 115 |
nonpharmacy claims, the designation "Rx" is required to be | 116 |
included as part of the labels identified in divisions (B)(2)(d) | 117 |
and (e) of this section if the issuer's international | 118 |
identification number or the processor's control number is | 119 |
different for medical and pharmacy claims. | 120 |
(E)(1) Except as provided in division (E)(2) of this section, | 127 |
if there is a change in the information contained in the | 128 |
standardized identification card or the electronic technology | 129 |
issued to an individual, the multiple employer welfare arrangement | 130 |
or person under contract with it to issue a standardized | 131 |
identification card or an electronic technology shall issue a new | 132 |
card or electronic technology to the individual. | 133 |
Sec. 1751.14. (A) Notwithstanding section 3901.71 of the | 143 |
Revised Code, any policy, contract, or agreement for health care | 144 |
services authorized by this chapter that is issued, delivered, or | 145 |
renewed in this state and that provides that coverage of an | 146 |
unmarried dependent child will terminate upon attainment of the | 147 |
limiting age for dependent children specified in the policy, | 148 |
contract, or agreement, shall also provide in substance both of | 149 |
the following: | 150 |
Sec. 1751.69. (A) As used in this section, "cost sharing" | 203 |
means the cost to an individual insured under an individual or | 204 |
group health insuring corporation policy, contract, or agreement | 205 |
according to any coverage limit, copayment, coinsurance, | 206 |
deductible, or other out-of-pocket expense requirements imposed by | 207 |
the policy, contract, or agreement. | 208 |
(B) Notwithstanding section 3901.71 of the Revised Code and | 209 |
subject to division (D) of this section, no individual or group | 210 |
health insuring corporation policy, contract, or agreement | 211 |
providing basic health care services or prescription drug services | 212 |
that is delivered, issued for delivery, or renewed in this state, | 213 |
if the policy, contract, or agreement provides coverage for cancer | 214 |
chemotherapy treatment, shall fail to comply with either of the | 215 |
following: | 216 |
(C) Notwithstanding any provision of this section to the | 226 |
contrary, an individual or group health insuring corporation | 227 |
policy, contract, or agreement shall be deemed to be in compliance | 228 |
with this section if the cost sharing imposed under such a policy, | 229 |
contract, or agreement for orally administered cancer treatments | 230 |
does not exceed one hundred dollars per prescription fill. The | 231 |
cost sharing limit of one hundred dollars per prescription fill | 232 |
shall apply to a high deductible plan, as defined in 26 U.S.C. | 233 |
223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only | 234 |
after the deductible has been met. | 235 |
(1)(a) "Administrative expense" means the amount resulting | 275 |
from the following: the amount of premiums earned by the insurer | 276 |
for sickness and accident insurance business plus the amount of | 277 |
losses recovered from reinsurance coverage minus the sum of the | 278 |
amount of claims for losses paid; the amount of losses incurred | 279 |
but not reported; the amount incurred for state fees, federal and | 280 |
state taxes, and reinsurance; and the incurred costs and expenses | 281 |
related, either directly or indirectly, to the payment of | 282 |
commissions, measures to control fraud, and managed care. | 283 |
(b) "Administrative expense" does not include any amounts | 284 |
collected, or administrative expenses incurred, by an insurer for | 285 |
the administration of an employee health benefit plan subject to | 286 |
regulation by the federal "Employee Retirement Income Security Act | 287 |
of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts | 288 |
collected or administrative expenses incurred" means the total | 289 |
amount paid to an administrator for the administration and payment | 290 |
of claims minus the sum of the amount of claims for losses paid | 291 |
and the amount of losses incurred but not reported. | 292 |
(3) "Sickness and accident insurance business" does not | 296 |
include coverage provided by an insurer for specific diseases or | 297 |
accidents only; any hospital indemnity, medicare supplement, | 298 |
long-term care, disability income, one-time-limited-duration | 299 |
policy of no longerthat is less than sixtwelve months, or other | 300 |
policy that offers only supplemental benefits; or coverage | 301 |
provided to individuals who are not residents of this state. | 302 |
(C)(1) Each insurer, on the first day of January or within | 313 |
sixty days thereafter, shall annually prepare, under oath, and | 314 |
deposit in the office of the superintendent of insurance a | 315 |
statement of the aggregate administrative expenses of the insurer, | 316 |
based on the premiums earned in the immediately preceding calendar | 317 |
year on the sickness and accident insurance business of the | 318 |
insurer. The statement shall itemize and separately detail all of | 319 |
the following information with respect to the insurer's sickness | 320 |
and accident insurance business: | 321 |
(E) If the superintendent determines that an insurer has | 346 |
violated this section, the superintendent, pursuant to an | 347 |
adjudication conducted in accordance with Chapter 119. of the | 348 |
Revised Code, may order the suspension of the insurer's license to | 349 |
do the business of sickness and accident insurance in this state | 350 |
until the superintendent is satisfied that the insurer is in | 351 |
compliance with this section. If the insurer continues to do the | 352 |
business of sickness and accident insurance in this state while | 353 |
under the suspension order, the superintendent shall order the | 354 |
insurer to pay one thousand dollars for each day of the violation. | 355 |
(G) The statement of aggregate expenses filed pursuant to | 360 |
this section separately detailing an insurer's individual, small | 361 |
group, and large group business shall be considered work papers | 362 |
resulting from the conduct of a market analysis of an entity | 363 |
subject to examination by the superintendent under division (C) of | 364 |
section 3901.48 of the Revised Code, except that the | 365 |
superintendent may share aggregated market information that | 366 |
identifies the premiums earned as reported under division | 367 |
(C)(1)(a) of this section, the administrative expenses reported | 368 |
under division (C)(1)(i) of this section, the amount of | 369 |
commissions reported under division (C)(1)(f) of this section, the | 370 |
amount of taxes paid as reported under division (C)(1)(d) of this | 371 |
section, the total of the remaining benefit costs as reported | 372 |
under divisions (C)(1)(b) and (c) of this section, and the amount | 373 |
of fraud and managed care expenses reported under divisions | 374 |
(C)(1)(g) and (h) of this section. | 375 |
Sec. 3923.24. (A) Notwithstanding section 3901.71 of the | 376 |
Revised Code, every certificate furnished by an insurer in | 377 |
connection with, or pursuant to any provision of, any group | 378 |
sickness and accident insurance policy delivered, issued for | 379 |
delivery, renewed, or used in this state on or after January 1, | 380 |
1972, every policy of sickness and accident insurance delivered, | 381 |
issued for delivery, renewed, or used in this state on or after | 382 |
January 1, 1972, and every multiple employer welfare arrangement | 383 |
offering an insurance program, which provides that coverage of an | 384 |
unmarried dependent child of a parent or legal guardian will | 385 |
terminate upon attainment of the limiting age for dependent | 386 |
children specified in the contract shall also provide in substance | 387 |
both of the following: | 388 |
(B) Proof of such incapacity and dependence for purposes of | 412 |
division (A)(2) of this section shall be furnished by the | 413 |
policyholder or by the certificate holder to the insurer within | 414 |
thirty-one days of the child's attainment of the limiting age. | 415 |
Upon request, but not more frequently than annually after the | 416 |
two-year period following the child's attainment of the limiting | 417 |
age, the insurer may require proof satisfactory to it of the | 418 |
continuance of such incapacity and dependency. | 419 |
(C) Nothing in this section shall require an insurer to cover | 420 |
a dependent child who is mentally retarded or physically | 421 |
handicapped if the contract is underwritten on evidence of | 422 |
insurability based on health factors set forth in the application, | 423 |
or if such dependent child does not satisfy the conditions of the | 424 |
contract as to any requirement for evidence of insurability or | 425 |
other provision of the contract, satisfaction of which is required | 426 |
for coverage thereunder to take effect. In any such case, the | 427 |
terms of the contract shall apply with regard to the coverage or | 428 |
exclusion of the dependent from such coverage. Nothing in this | 429 |
section shall apply to accidental death or dismemberment benefits | 430 |
provided by any such policy of sickness and accident insurance. | 431 |
(E) This section does not apply to any policies or | 441 |
certificates covering only accident, credit, dental, disability | 442 |
income, long-term care, hospital indemnity, medicare supplement, | 443 |
specified disease, or vision care; coverage under a | 444 |
one-time-limited-duration policy of not longerthat is less than | 445 |
sixtwelve months; coverage issued as a supplement to liability | 446 |
insurance; insurance arising out of a workers' compensation or | 447 |
similar law; automobile medical-payment insurance; or insurance | 448 |
under which benefits are payable with or without regard to fault | 449 |
and that is statutorily required to be contained in any liability | 450 |
insurance policy or equivalent self-insurance. | 451 |
(D) This section does not apply to any public employee | 503 |
benefit plan covering only accident, credit, dental, disability | 504 |
income, long-term care, hospital indemnity, medicare supplement, | 505 |
specified disease, or vision care; coverage under a | 506 |
one-time-limited-duration policy of not longerthat is less than | 507 |
sixtwelve months; coverage issued as a supplement to liability | 508 |
insurance; insurance arising out of a workers' compensation or | 509 |
similar law; automobile medical-payment insurance; or insurance | 510 |
under which benefits are payable with or without regard to fault | 511 |
and which is statutorily required to be contained in any liability | 512 |
insurance policy or equivalent self-insurance. | 513 |
(1) "Biologically based mental illness" means schizophrenia, | 521 |
schizoaffective disorder, major depressive disorder, bipolar | 522 |
disorder, paranoia and other psychotic disorders, | 523 |
obsessive-compulsive disorder, and panic disorder, as these terms | 524 |
are defined in the most recent edition of the diagnostic and | 525 |
statistical manual of mental disorders published by the American | 526 |
psychiatric association. | 527 |
(2) "Policy of sickness and accident insurance" has the same | 528 |
meaning as in section 3923.01 of the Revised Code, but excludes | 529 |
any hospital indemnity, medicare supplement, long-term care, | 530 |
disability income, one-time-limited-duration policy of not longer | 531 |
that is less than sixtwelve months, supplemental benefit, or | 532 |
other policy that provides coverage for specific diseases or | 533 |
accidents only; any policy that provides coverage for workers' | 534 |
compensation claims compensable pursuant to Chapters 4121. and | 535 |
4123. of the Revised Code; and any policy that provides coverage | 536 |
to medicaid recipients. | 537 |
(B) Notwithstanding section 3901.71 of the Revised Code, and | 538 |
subject to division (E) of this section, every policy of sickness | 539 |
and accident insurance shall provide benefits for the diagnosis | 540 |
and treatment of biologically based mental illnesses on the same | 541 |
terms and conditions as, and shall provide benefits no less | 542 |
extensive than, those provided under the policy of sickness and | 543 |
accident insurance for the treatment and diagnosis of all other | 544 |
physical diseases and disorders, if both of the following apply: | 545 |
(1) The biologically based mental illness is clinically | 546 |
diagnosed by a physician authorized under Chapter 4731. of the | 547 |
Revised Code to practice medicine and surgery or osteopathic | 548 |
medicine and surgery; a psychologist licensed under Chapter 4732. | 549 |
of the Revised Code; a professional clinical counselor, | 550 |
professional counselor, or independent social worker licensed | 551 |
under Chapter 4757. of the Revised Code; or a clinical nurse | 552 |
specialist licensed under Chapter 4723. of the Revised Code whose | 553 |
nursing specialty is mental health. | 554 |
(1) The insurer submits documentation certified by an | 585 |
independent member of the American academy of actuaries to the | 586 |
superintendent of insurance showing that incurred claims for | 587 |
diagnostic and treatment services for biologically based mental | 588 |
illnesses for a period of at least six months independently caused | 589 |
the insurer's costs for claims and administrative expenses for the | 590 |
coverage of all other physical diseases and disorders to increase | 591 |
by more than one per cent per year. | 592 |
(B) In determining whether a pre-existing conditions | 624 |
provision applies to a policyholder or dependent, each policy | 625 |
shall credit the time the policyholder or dependent was covered | 626 |
under a previous policy, contract, or plan if the previous | 627 |
coverage was continuous to a date not more than thirty days prior | 628 |
to the effective date of the new coverage, exclusive of any | 629 |
applicable service waiting period under the policy. | 630 |
(d) If the insurer offers coverage in the market through a | 647 |
network plan, the individual no longer resides, lives, or works in | 648 |
the service area, or in an area for which the insurer is | 649 |
authorized to do business; provided, however, that such coverage | 650 |
is terminated uniformly without regard to any health | 651 |
status-related factor of covered individuals. | 652 |
(e) If the coverage is made available in the individual | 653 |
market only through one or more bona fide associations, the | 654 |
membership of the individual in the association, on the basis of | 655 |
which the coverage is provided, ceases; provided, however, that | 656 |
such coverage is terminated under division (C)(2)(e) of this | 657 |
section uniformly without regard to any health status-related | 658 |
factor of covered individuals. | 659 |
An insurer offering coverage to individuals solely through | 660 |
membership in a bona fide association shall not be deemed, by | 661 |
virtue of that offering, to be in the individual market for | 662 |
purposes of sections 3923.58 and 3923.581 of the Revised Code. | 663 |
Such an insurer shall not be required to accept applicants for | 664 |
coverage in the individual market pursuant to sections 3923.58 and | 665 |
3923.581 of the Revised Code unless the insurer also offers | 666 |
coverage to individuals other than through bona fide associations. | 667 |
This section does not apply to any policy that provides | 741 |
coverage for specific diseases or accidents only, or to any | 742 |
hospital indemnity, medicare supplement, long-term care, | 743 |
disability income, one-time-limited-duration policy of no longer | 744 |
that is less than sixtwelve months, or other policy that offers | 745 |
only supplemental benefits. | 746 |
(5) "Pre-existing conditions provision" means a policy | 763 |
provision that excludes or limits coverage for charges or expenses | 764 |
incurred during a specified period following the insured's | 765 |
effective date of coverage as to a condition which, during a | 766 |
specified period immediately preceding the effective date of | 767 |
coverage, had manifested itself in such a manner as would cause an | 768 |
ordinarily prudent person to seek medical advice, diagnosis, care, | 769 |
or treatment or for which medical advice, diagnosis, care, or | 770 |
treatment was recommended or received, or a pregnancy existing on | 771 |
the effective date of coverage. | 772 |
(B) Beginning in January of each year, carriers in the | 773 |
business of issuing health benefit plans to individuals and | 774 |
nonemployer groups, except individual health benefit plans issued | 775 |
pursuant to sections 1751.16 and 3923.122 of the Revised Code, | 776 |
shall accept applicants for open enrollment coverage, as set forth | 777 |
in this division, in the order in which they apply for coverage | 778 |
and subject to the limitation set forth in division (G) of this | 779 |
section. Carriers shall accept for coverage pursuant to this | 780 |
section individuals to whom both of the following conditions | 781 |
apply: | 782 |
(2) The individual is not covered, and is not eligible for | 786 |
coverage, under any other private or public health benefits | 787 |
arrangement, including the medicare program established under | 788 |
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 | 789 |
U.S.C.A. 301, as amended, or any other act of congress or law of | 790 |
this or any other state of the United States that provides | 791 |
benefits comparable to the benefits provided under this section, | 792 |
any medicare supplement policy, or any continuation of coverage | 793 |
policy under state or federal law. | 794 |
A carrier may offer other health benefit plans in addition | 800 |
to, but not in lieu of, the plans required to be offered under | 801 |
this division. A basic health benefit plan shall provide, at a | 802 |
minimum, the coverage provided by the Ohio health care basic plan | 803 |
or any health benefit plan that is substantially similar to the | 804 |
Ohio health care basic plan in benefit plan design and scope of | 805 |
covered services. A standard health benefit plan shall provide, at | 806 |
a minimum, the coverage provided by the Ohio health care standard | 807 |
plan or any health benefit plan that is substantially similar to | 808 |
the Ohio health care standard plan in benefit plan design and | 809 |
scope of covered services. | 810 |
(D)(1) Health benefit plans issued under this section may | 815 |
establish pre-existing conditions provisions that exclude or limit | 816 |
coverage for a period of up to twelve months following the | 817 |
individual's effective date of coverage and that may relate only | 818 |
to conditions during the six months immediately preceding the | 819 |
effective date of coverage. A health insuring corporation may | 820 |
apply a pre-existing condition provision for any basic health care | 821 |
service related to a transplant of a body organ if the transplant | 822 |
occurs within one year after the effective date of an enrollee's | 823 |
coverage under this section except with respect to a newly born | 824 |
child who meets the requirements for coverage under section | 825 |
1751.61 of the Revised Code. | 826 |
(2) In determining whether a pre-existing conditions | 827 |
provision applies to an insured or dependent, each policy shall | 828 |
credit the time the insured or dependent was covered under a | 829 |
previous policy, contract, or plan if the previous coverage was | 830 |
continuous to a date not more than sixty-three days prior to the | 831 |
effective date of the new coverage, exclusive of any applicable | 832 |
service waiting period under the policy. | 833 |
(2) For calendar year 2012 and every year thereafter, an | 840 |
amount that is one and one-half times the base rate for coverage | 841 |
offered to any other individual to which the carrier is currently | 842 |
accepting new business and for which similar copayments and | 843 |
deductibles are applied, unless the superintendent of insurance | 844 |
determines that the amendments by this act to this section and | 845 |
section 3923.581 of the Revised Code, have resulted in the | 846 |
market-wide average medical loss ratio for coverage sold to | 847 |
individual insureds and nonemployer group insureds in this state, | 848 |
including open enrollment insureds, to increase by more than five | 849 |
and one quarter percentage points during calendar year 2010. If | 850 |
the superintendent makes that determination, the premium limit | 851 |
established by division (E)(1) of this section shall remain in | 852 |
effect. The superintendent's determination shall be supported by a | 853 |
signed letter from a member of the American academy of actuaries. | 854 |
(G)(1) A carrier shall not be required to accept new | 859 |
applicants under this section if the total number of the carrier's | 860 |
current insureds with open enrollment coverage issued under this | 861 |
section calculated as of the immediately preceding thirty-first | 862 |
day of December and excluding the carrier's medicare supplement | 863 |
policies and conversion or continuation of coverage policies under | 864 |
state or federal law and any policies described in division (L) of | 865 |
this section meets the following limits: | 866 |
(b) For calendar year 2012 and every year thereafter, eight | 870 |
per cent of the carrier's total number of insured individuals and | 871 |
nonemployer group insureds in this state, unless the | 872 |
superintendent of insurance determines that the amendments by this | 873 |
act to this section and section 3923.581 of the Revised Code, have | 874 |
resulted in the market-wide average medical loss ratio for | 875 |
coverage sold to individual insureds and nonemployer group | 876 |
insureds in this state, including open enrollment insureds, to | 877 |
increase by more than five and one quarter percentage points | 878 |
during calendar year 2010. If the superintendent makes that | 879 |
determination, the enrollment limit established by division | 880 |
(G)(1)(a) of this section shall remain in effect. The | 881 |
superintendent's determination shall be supported by a signed | 882 |
letter from a member of the American academy of actuaries. | 883 |
(2) An officer of the carrier shall certify to the department | 884 |
of insurance when it has met the enrollment limit set forth in | 885 |
division (G)(1) of this section. Upon providing such | 886 |
certification, the carrier shall be relieved of its open | 887 |
enrollment requirement under this section as long as the carrier | 888 |
continues to meet the open enrollment limit. If the total number | 889 |
of the carrier's current insureds with open enrollment coverage | 890 |
issued under this section falls below the enrollment limit, the | 891 |
carrier shall accept new applicants. A carrier may establish a | 892 |
waiting list if the carrier has met the open enrollment limit and | 893 |
shall notify the superintendent if the carrier has a waiting list | 894 |
in effect. | 895 |
(H) A carrier shall not be required to accept under this | 896 |
section applicants who, at the time of enrollment, are confined to | 897 |
a health care facility because of chronic illness, permanent | 898 |
injury, or other infirmity that would cause economic impairment to | 899 |
the carrier if the applicants were accepted. A carrier shall not | 900 |
be required to make the effective date of benefits for individuals | 901 |
accepted under this section earlier than ninety days after the | 902 |
date of acceptance, except that when the individual had prior | 903 |
coverage with a health benefit plan that was terminated by a | 904 |
carrier because the carrier exited the market and the individual | 905 |
was accepted for open enrollment under this section within | 906 |
sixty-three days of that termination, the effective date of | 907 |
benefits shall be the date of enrollment. | 908 |
(I) The requirements of this section do not apply to any | 909 |
carrier that is currently in a state of supervision, insolvency, | 910 |
or liquidation. If a carrier demonstrates to the satisfaction of | 911 |
the superintendent that the requirements of this section would | 912 |
place the carrier in a state of supervision, insolvency, or | 913 |
liquidation, or would otherwise jeopardize the carrier's economic | 914 |
viability overall or in the individual market, the superintendent | 915 |
may waive or modify the requirements of division (B) or (G) of | 916 |
this section. The actions of the superintendent under this | 917 |
division shall be effective for a period of not more than one | 918 |
year. At the expiration of such time, a new showing of need for a | 919 |
waiver or modification by the carrier shall be made before a new | 920 |
waiver or modification is issued or imposed. | 921 |
(J) No hospital, health care facility, or health care | 922 |
practitioner, and no person who employs any health care | 923 |
practitioner, shall balance bill any individual or dependent of an | 924 |
individual for any health care supplies or services provided to | 925 |
the individual or dependent who is insured under a policy issued | 926 |
under this section. The hospital, health care facility, or health | 927 |
care practitioner, or any person that employs the health care | 928 |
practitioner, shall accept payments made to it by the carrier | 929 |
under the terms of the policy or contract insuring or covering | 930 |
such individual as payment in full for such health care supplies | 931 |
or services. | 932 |
As used in this division, "hospital" has the same meaning as | 933 |
in section 3727.01 of the Revised Code; "health care practitioner" | 934 |
has the same meaning as in section 4769.01 of the Revised Code; | 935 |
and "balance bill" means charging or collecting an amount in | 936 |
excess of the amount reimbursable or payable under the policy or | 937 |
health care service contract issued to an individual under this | 938 |
section for such health care supply or service. "Balance bill" | 939 |
does not include charging for or collecting copayments or | 940 |
deductibles required by the policy or contract. | 941 |
(K) A carrier may pay an agent a commission in the amount of | 942 |
not more than five per cent of the premium charged for initial | 943 |
placement or for otherwise securing the issuance of a policy or | 944 |
contract issued to an individual under this section, and not more | 945 |
than four per cent of the premium charged for the renewal of such | 946 |
a policy or contract. The superintendent may adopt, in accordance | 947 |
with Chapter 119. of the Revised Code, such rules as are necessary | 948 |
to enforce this division. | 949 |
(L) This section does not apply to any policy that provides | 950 |
coverage for specific diseases or accidents only, or to any | 951 |
hospital indemnity, medicare supplement, long-term care, | 952 |
disability income, one-time-limited-duration policy of no longer | 953 |
that is less than sixtwelve months, or other policy that offers | 954 |
only supplemental benefits. | 955 |
(a) Any individual or group policy of sickness and accident | 992 |
insurance covering only accident, credit, dental, disability | 993 |
income, long-term care, hospital indemnity, medicare supplement, | 994 |
medicare, tricare, specified disease, or vision care; coverage | 995 |
under a one-time-limited-duration policy of not longerthat is | 996 |
less than sixtwelve months; coverage issued as a supplement to | 997 |
liability insurance; insurance arising out of workers' | 998 |
compensation or similar law; automobile medical payment insurance; | 999 |
or insurance under which benefits are payable with or without | 1000 |
regard to fault and which is statutorily required to be contained | 1001 |
in any liability insurance policy or equivalent self-insurance. | 1002 |
(1) The standardized identification card or the electronic | 1014 |
technology shall be in a format and contain information fields | 1015 |
approved by the national council for prescription drug programs or | 1016 |
a successor organization, as specified in the council's or | 1017 |
successor organization's pharmacy identification card | 1018 |
implementation guide in effect on the first day of October most | 1019 |
immediately preceding the issuance or required use of the | 1020 |
standardized identification card or the electronic technology. | 1021 |
(C) If the standardized identification card or the electronic | 1037 |
technology issued or required to be used as provided in division | 1038 |
(A)(1) of this section is also used for submission and routing of | 1039 |
nonpharmacy claims, the designation "Rx" is required to be | 1040 |
included as part of the labels identified in divisions (B)(2)(d) | 1041 |
and (e) of this section if the issuer's international | 1042 |
identification number or the processor's control number is | 1043 |
different for medical and pharmacy claims. | 1044 |
(B) Every individual or group policy of sickness and accident | 1090 |
insurance that provides hospital, surgical, or medical expense | 1091 |
coverage shall cover emergency services without regard to the day | 1092 |
or time the emergency services are rendered or to whether the | 1093 |
policyholder, the hospital's emergency department where the | 1094 |
services are rendered, or an emergency physician treating the | 1095 |
policyholder, obtained prior authorization for the emergency | 1096 |
services. | 1097 |
(D) This section does not apply to any individual or group | 1106 |
policy of sickness and accident insurance covering only accident, | 1107 |
credit, dental, disability income, long-term care, hospital | 1108 |
indemnity, medicare supplement, medicare, tricare, specified | 1109 |
disease, or vision care; coverage under a one-time limited | 1110 |
duration policy of no longerthat is less than sixtwelve months; | 1111 |
coverage issued as a supplement to liability insurance; insurance | 1112 |
arising out of workers' compensation or similar law; automobile | 1113 |
medical payment insurance; or insurance under which benefits are | 1114 |
payable with or without regard to fault and which is statutorily | 1115 |
required to be contained in any liability insurance policy or | 1116 |
equivalent self-insurance. | 1117 |
(a) Any individual or group policy of insurance covering only | 1134 |
accident, credit, dental, disability income, long-term care, | 1135 |
hospital indemnity, medicare supplement, medicare, tricare, | 1136 |
specified disease, or vision care; coverage under a | 1137 |
one-time-limited-duration policy of not longerthat is less than | 1138 |
sixtwelve months; coverage issued as a supplement to liability | 1139 |
insurance; insurance arising out of workers' compensation or | 1140 |
similar law; automobile medical payment insurance; or insurance | 1141 |
under which benefits are payable with or without regard to fault | 1142 |
and which is statutorily required to be contained in any liability | 1143 |
insurance policy or equivalent self-insurance. | 1144 |
(1) The standardized identification card or the electronic | 1151 |
technology shall be in a format and contain information fields | 1152 |
approved by the national council for prescription drug programs or | 1153 |
a successor organization, as specified in the council's or | 1154 |
successor organization's pharmacy identification card | 1155 |
implementation guide in effect on the first day of October most | 1156 |
immediately preceding the issuance or required use of the | 1157 |
standardized identification card or the electronic technology. | 1158 |
(C) If the standardized identification card or the electronic | 1175 |
technology issued or required to be used as provided in division | 1176 |
(A)(1) of this section is also used for submission and routing of | 1177 |
nonpharmacy claims, the designation "Rx" is required to be | 1178 |
included as part of the labels identified in divisions (B)(2)(d) | 1179 |
and (e) of this section if the issuer's international | 1180 |
identification number or the processor's control number is | 1181 |
different for medical and pharmacy claims. | 1182 |
(D)(1) Except as provided in division (D)(2) of this section, | 1183 |
if there is a change in the information contained in the | 1184 |
standardized identification card or the electronic technology | 1185 |
issued to an insured, the public employee benefit plan or person | 1186 |
under contract with the plan to issue a standardized | 1187 |
identification card or electronic technology shall issue a new | 1188 |
card or electronic technology to the insured. | 1189 |
Sec. 3923.85. (A) As used in this section, "cost sharing" | 1199 |
means the cost to an individual insured under an individual or | 1200 |
group policy of sickness and accident insurance or a public | 1201 |
employee benefit plan according to any coverage limit, copayment, | 1202 |
coinsurance, deductible, or other out-of-pocket expense | 1203 |
requirements imposed by the policy or plan. | 1204 |
(C) Notwithstanding any provision of this section to the | 1220 |
contrary, a policy or plan shall be deemed to be in compliance | 1221 |
with this section if the cost sharing imposed under such a policy | 1222 |
or plan for orally administered cancer treatments does not exceed | 1223 |
one hundred dollars per prescription fill. The cost sharing limit | 1224 |
of one hundred dollars per prescription fill shall apply to a high | 1225 |
deductible plan, as defined in 26 U.S.C. 223, or a catastrophic | 1226 |
plan, as defined in 42 U.S.C. 18022, only after the deductible has | 1227 |
been met. | 1228 |
(A) "Actuarial certification" means a written statement | 1276 |
prepared by a member of the American academy of actuaries, or by | 1277 |
any other person acceptable to the superintendent of insurance, | 1278 |
that states that, based upon the person's examination, a carrier | 1279 |
offering health benefit plans to small employers is in compliance | 1280 |
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial | 1281 |
certification" shall include a review of the appropriate records | 1282 |
of, and the actuarial assumptions and methods used by, the carrier | 1283 |
relative to establishing premium rates for the health benefit | 1284 |
plans. | 1285 |
(D) "Carrier" means any sickness and accident insurance | 1299 |
company or health insuring corporation authorized to issue health | 1300 |
benefit plans in this state or a MEWA. A sickness and accident | 1301 |
insurance company that owns or operates a health insuring | 1302 |
corporation, either as a separate corporation or as a line of | 1303 |
business, shall be considered as a separate carrier from that | 1304 |
health insuring corporation for purposes of sections 3924.01 to | 1305 |
3924.14 of the Revised Code. | 1306 |
(E) "Case characteristics" means, with respect to a small | 1307 |
employer, the geographic area in which the employees work; the age | 1308 |
and sex of the individual employees and their dependents; the | 1309 |
appropriate industry classification as determined by the carrier; | 1310 |
the number of employees and dependents; and such other objective | 1311 |
criteria as may be established by the carrier. "Case | 1312 |
characteristics" does not include claims experience, health | 1313 |
status, or duration of coverage from the date of issue. | 1314 |
(H) "Health benefit plan" means any hospital or medical | 1323 |
expense policy or certificate or any health plan provided by a | 1324 |
carrier, that is delivered, issued for delivery, renewed, or used | 1325 |
in this state on or after the date occurring six months after | 1326 |
November 24, 1995. "Health benefit plan" does not include policies | 1327 |
covering only accident, credit, dental, disability income, | 1328 |
long-term care, hospital indemnity, medicare supplement, specified | 1329 |
disease, or vision care; coverage under a | 1330 |
one-time-limited-duration policy of no longerthat is less than | 1331 |
sixtwelve months; coverage issued as a supplement to liability | 1332 |
insurance; insurance arising out of a workers' compensation or | 1333 |
similar law; automobile medical-payment insurance; or insurance | 1334 |
under which benefits are payable with or without regard to fault | 1335 |
and which is statutorily required to be contained in any liability | 1336 |
insurance policy or equivalent self-insurance. | 1337 |
(I) "Late enrollee" means an eligible employee or dependent | 1338 |
who enrolls in a small employer's health benefit plan other than | 1339 |
during the first period in which the employee or dependent is | 1340 |
eligible to enroll under the plan or during a special enrollment | 1341 |
period described in section 2701(f) of the "Health Insurance | 1342 |
Portability and Accountability Act of 1996," Pub. L. No. 104-191, | 1343 |
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended. | 1344 |
(L) "Pre-existing conditions provision" means a policy | 1355 |
provision that excludes or limits coverage for charges or expenses | 1356 |
incurred during a specified period following the insured's | 1357 |
enrollment date as to a condition for which medical advice, | 1358 |
diagnosis, care, or treatment was recommended or received during a | 1359 |
specified period immediately preceding the enrollment date. | 1360 |
Genetic information shall not be treated as such a condition in | 1361 |
the absence of a diagnosis of the condition related to such | 1362 |
information. | 1363 |
(2) For purposes of division (N)(1) of this section, all | 1378 |
persons treated as a single employer under subsection (b), (c), | 1379 |
(m), or (o) of section 414 of the "Internal Revenue Code of 1986," | 1380 |
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one | 1381 |
employer. In the case of an employer that was not in existence | 1382 |
throughout the preceding calendar year, the determination of | 1383 |
whether the employer is a small or large employer shall be based | 1384 |
on the average number of eligible employees that it is reasonably | 1385 |
expected the employer will employ on business days in the current | 1386 |
calendar year. Any reference in division (N) of this section to an | 1387 |
"employer" includes any predecessor of the employer. Except as | 1388 |
otherwise specifically provided, provisions of sections 3924.01 to | 1389 |
3924.14 of the Revised Code that apply to a small employer that | 1390 |
has a health benefit plan shall continue to apply until the plan | 1391 |
anniversary following the date the employer no longer meets the | 1392 |
requirements of this division. | 1393 |
(a) Every person in the service of the state, or of any | 1400 |
county, municipal corporation, township, or school district | 1401 |
therein, including regular members of lawfully constituted police | 1402 |
and fire departments of municipal corporations and townships, | 1403 |
whether paid or volunteer, and wherever serving within the state | 1404 |
or on temporary assignment outside thereof, and executive officers | 1405 |
of boards of education, under any appointment or contract of hire, | 1406 |
express or implied, oral or written, including any elected | 1407 |
official of the state, or of any county, municipal corporation, or | 1408 |
township, or members of boards of education. | 1409 |
As used in division (A)(1)(a) of this section, the term | 1410 |
"employee" includes the following persons when responding to an | 1411 |
inherently dangerous situation that calls for an immediate | 1412 |
response on the part of the person, regardless of whether the | 1413 |
person is within the limits of the jurisdiction of the person's | 1414 |
regular employment or voluntary service when responding, on the | 1415 |
condition that the person responds to the situation as the person | 1416 |
otherwise would if the person were on duty in the person's | 1417 |
jurisdiction: | 1418 |
(iii) Off-duty first responders, emergency medical | 1424 |
technicians-basic, emergency medical technicians-intermediate, or | 1425 |
emergency medical technicians-paramedic, whether paid or | 1426 |
volunteer,emergency medical workers of an ambulance service | 1427 |
organization or emergency medical service organization pursuant to | 1428 |
Chapter 4765. of the Revised Code. | 1429 |
(b) Every person in the service of any person, firm, or | 1430 |
private corporation, including any public service corporation, | 1431 |
that (i) employs one or more persons regularly in the same | 1432 |
business or in or about the same establishment under any contract | 1433 |
of hire, express or implied, oral or written, including aliens and | 1434 |
minors, household workers who earn one hundred sixty dollars or | 1435 |
more in cash in any calendar quarter from a single household and | 1436 |
casual workers who earn one hundred sixty dollars or more in cash | 1437 |
in any calendar quarter from a single employer, or (ii) is bound | 1438 |
by any such contract of hire or by any other written contract, to | 1439 |
pay into the state insurance fund the premiums provided by this | 1440 |
chapter. | 1441 |
Every person in the service of any independent contractor or | 1488 |
subcontractor who has failed to pay into the state insurance fund | 1489 |
the amount of premium determined and fixed by the administrator of | 1490 |
workers' compensation for the person's employment or occupation or | 1491 |
if a self-insuring employer has failed to pay compensation and | 1492 |
benefits directly to the employer's injured and to the dependents | 1493 |
of the employer's killed employees as required by section 4123.35 | 1494 |
of the Revised Code, shall be considered as the employee of the | 1495 |
person who has entered into a contract, whether written or verbal, | 1496 |
with such independent contractor unless such employees or their | 1497 |
legal representatives or beneficiaries elect, after injury or | 1498 |
death, to regard such independent contractor as the employer. | 1499 |
Any employer may elect to include as an "employee" within | 1511 |
this chapter, any person excluded from the definition of | 1512 |
"employee" pursuant to division (A)(2) of this section. If an | 1513 |
employer is a partnership, sole proprietorship, individual | 1514 |
incorporated as a corporation, or family farm corporation, such | 1515 |
employer may elect to include as an "employee" within this | 1516 |
chapter, any member of such partnership, the owner of the sole | 1517 |
proprietorship, the individual incorporated as a corporation, or | 1518 |
the officers of the family farm corporation. In the event of an | 1519 |
election, the employer shall serve upon the bureau of workers' | 1520 |
compensation written notice naming the persons to be covered, | 1521 |
include such employee's remuneration for premium purposes in all | 1522 |
future payroll reports, and no person excluded from the definition | 1523 |
of "employee" pursuant to division (A)(2) of this section, | 1524 |
proprietor, individual incorporated as a corporation, or partner | 1525 |
shall be deemed an employee within this division until the | 1526 |
employer has served such notice. | 1527 |
For informational purposes only, the bureau shall prescribe | 1528 |
such language as it considers appropriate, on such of its forms as | 1529 |
it considers appropriate, to advise employers of their right to | 1530 |
elect to include as an "employee" within this chapter a sole | 1531 |
proprietor, any member of a partnership, an individual | 1532 |
incorporated as a corporation, the officers of a family farm | 1533 |
corporation, or a person excluded from the definition of | 1534 |
"employee" under division (A)(2) of this section, that they should | 1535 |
check any health and disability insurance policy, or other form of | 1536 |
health and disability plan or contract, presently covering them, | 1537 |
or the purchase of which they may be considering, to determine | 1538 |
whether such policy, plan, or contract excludes benefits for | 1539 |
illness or injury that they might have elected to have covered by | 1540 |
workers' compensation. | 1541 |
(2) Every person, firm, professional employer organization, | 1547 |
and private corporation, including any public service corporation, | 1548 |
that (a) has in service one or more employees or shared employees | 1549 |
regularly in the same business or in or about the same | 1550 |
establishment under any contract of hire, express or implied, oral | 1551 |
or written, or (b) is bound by any such contract of hire or by any | 1552 |
other written contract, to pay into the insurance fund the | 1553 |
premiums provided by this chapter. | 1554 |
All such employers are subject to this chapter. Any member of | 1555 |
a firm or association, who regularly performs manual labor in or | 1556 |
about a mine, factory, or other establishment, including a | 1557 |
household establishment, shall be considered an employee in | 1558 |
determining whether such person, firm, or private corporation, or | 1559 |
public service corporation, has in its service, one or more | 1560 |
employees and the employer shall report the income derived from | 1561 |
such labor to the bureau as part of the payroll of such employer, | 1562 |
and such member shall thereupon be entitled to all the benefits of | 1563 |
an employee. | 1564 |
(4) A condition that pre-existed an injury unless that | 1588 |
pre-existing condition is substantially aggravated by the injury. | 1589 |
Such a substantial aggravation must be documented by objective | 1590 |
diagnostic findings, objective clinical findings, or objective | 1591 |
test results. Subjective complaints may be evidence of such a | 1592 |
substantial aggravation. However, subjective complaints without | 1593 |
objective diagnostic findings, objective clinical findings, or | 1594 |
objective test results are insufficient to substantiate a | 1595 |
substantial aggravation. | 1596 |
(E) "Family farm corporation" means a corporation founded for | 1599 |
the purpose of farming agricultural land in which the majority of | 1600 |
the voting stock is held by and the majority of the stockholders | 1601 |
are persons or the spouse of persons related to each other within | 1602 |
the fourth degree of kinship, according to the rules of the civil | 1603 |
law, and at least one of the related persons is residing on or | 1604 |
actively operating the farm, and none of whose stockholders are a | 1605 |
corporation. A family farm corporation does not cease to qualify | 1606 |
under this division where, by reason of any devise, bequest, or | 1607 |
the operation of the laws of descent or distribution, the | 1608 |
ownership of shares of voting stock is transferred to another | 1609 |
person, as long as that person is within the degree of kinship | 1610 |
stipulated in this division. | 1611 |
(F) "Occupational disease" means a disease contracted in the | 1612 |
course of employment, which by its causes and the characteristics | 1613 |
of its manifestation or the condition of the employment results in | 1614 |
a hazard which distinguishes the employment in character from | 1615 |
employment generally, and the employment creates a risk of | 1616 |
contracting the disease in greater degree and in a different | 1617 |
manner from the public in general. | 1618 |
(G) "Self-insuring employer" means an employer who is granted | 1619 |
the privilege of paying compensation and benefits directly under | 1620 |
section 4123.35 of the Revised Code, including a board of county | 1621 |
commissioners for the sole purpose of constructing a sports | 1622 |
facility as defined in section 307.696 of the Revised Code, | 1623 |
provided that the electors of the county in which the sports | 1624 |
facility is to be built have approved construction of a sports | 1625 |
facility by ballot election no later than November 6, 1997. | 1626 |
(K) "Sexual conduct" means vaginal intercourse between a male | 1633 |
and female; anal intercourse, fellatio, and cunnilingus between | 1634 |
persons regardless of gender; and, without privilege to do so, the | 1635 |
insertion, however slight, of any part of the body or any | 1636 |
instrument, apparatus, or other object into the vaginal or anal | 1637 |
cavity of another. Penetration, however slight, is sufficient to | 1638 |
complete vaginal or anal intercourse. | 1639 |
Sec. 4123.026. (A) The administrator of workers' | 1667 |
compensation, or a self-insuring public employer for the peace | 1668 |
officers, firefighters, and emergency medical workers employed by | 1669 |
or volunteering for that self-insuring public employer, shall pay | 1670 |
the costs of conducting post-exposure medical diagnostic services, | 1671 |
consistent with the standards of medical care existing at the time | 1672 |
of the exposure, to investigate whether an injury or occupational | 1673 |
disease was sustained by a peace officer, firefighter, or | 1674 |
emergency medical worker when coming into contact with the blood | 1675 |
or other body fluid of another person in the course of and arising | 1676 |
out of the peace officer's, firefighter's, or emergency medical | 1677 |
worker's employment, or when responding to an inherently dangerous | 1678 |
situation in the manner described in, and in accordance with the | 1679 |
conditions specified under, division (A)(1)(a) of section 4123.01 | 1680 |
of the Revised Code, through any of the following means: | 1681 |
Sec. 4123.46. (A)(1) Except as provided in division (A)(2) | 1697 |
of this section, the bureau of workers' compensation shall | 1698 |
disburse the state insurance fund to employees of employers who | 1699 |
have paid into the fund the premiums applicable to the classes to | 1700 |
which they belong when the employees have been injured in the | 1701 |
course of their employment, wherever the injuries have occurred, | 1702 |
and provided the injuries have not been purposely self-inflicted, | 1703 |
or to the dependents of the employees in case death has ensued. | 1704 |
(2) As long as injuries have not been purposely | 1705 |
self-inflicted, the bureau shall disburse the surplus fund created | 1706 |
under section 4123.34 of the Revised Code to off-duty peace | 1707 |
officers, firefighters, and emergency medical technicians, and | 1708 |
first respondersworkers, or to their dependents if death ensues, | 1709 |
who are injured while responding to inherently dangerous | 1710 |
situations that call for an immediate response on the part of the | 1711 |
person, regardless of whether the person was within the limits of | 1712 |
the person's jurisdiction when responding, on the condition that | 1713 |
the person responds to the situation as the person otherwise would | 1714 |
if the person were on duty in the person's jurisdiction. | 1715 |
(B) All self-insuring employers, in compliance with this | 1720 |
chapter, shall pay the compensation to injured employees, or to | 1721 |
the dependents of employees who have been killed in the course of | 1722 |
their employment, unless the injury or death of the employee was | 1723 |
purposely self-inflicted, and shall furnish the medical, surgical, | 1724 |
nurse, and hospital care and attention or funeral expenses as | 1725 |
would have been paid and furnished by virtue of this chapter under | 1726 |
a similar state of facts by the bureau out of the state insurance | 1727 |
fund if the employer had paid the premium into the fund. | 1728 |
If any rule or regulation of a self-insuring employer | 1729 |
provides for or authorizes the payment of greater compensation or | 1730 |
more complete or extended medical care, nursing, surgical, and | 1731 |
hospital attention, or funeral expenses to the injured employees, | 1732 |
or to the dependents of the employees as may be killed, the | 1733 |
employer shall pay to the employees, or to the dependents of | 1734 |
employees killed, the amount of compensation and furnish the | 1735 |
medical care, nursing, surgical, and hospital attention or funeral | 1736 |
expenses provided by the self-insuring employer's rules and | 1737 |
regulations. | 1738 |
Section 2. That existing sections 1739.061, 1751.14, 1751.69, | 1742 |
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601, | 1743 |
3923.65, 3923.83, 3923.85, 3924.01, 4123.01, 4123.026, and 4123.46 | 1744 |
of the Revised Code are hereby repealed. | 1745 |
Section 3. Section 1751.14 and division (G) of section | 1746 |
3924.01 of the Revised Code, as amended by this act, apply only to | 1747 |
policies, contracts, and agreements that are delivered, issued for | 1748 |
delivery, or renewed in this state on or after January 1, 2016. | 1749 |
Division (A)(1) of section 3923.24 and division (A)(1) of section | 1750 |
3923.241 of the Revised Code, as amended by this act, apply only | 1751 |
to policies of sickness and accident insurance delivered, issued | 1752 |
for delivery, or renewed in this state and public employee benefit | 1753 |
plans or multiple employer welfare arrangement contracts and | 1754 |
certificates that are established or modified in this state on or | 1755 |
after January 1, 2016. | 1756 |