Bill Text: OH SB15 | 2009-2010 | 128th General Assembly | Introduced

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Bill Title: To prohibit discrimination in health care policies, contracts, and agreements in the coverage provided for the diagnosis and treatment of mental illnesses and substance abuse or addiction conditions.

Spectrum: Partisan Bill (Democrat 7-0)

Status: (Introduced - Dead) 2009-02-10 - To Health, Human Services, & Aging [SB15 Detail]

Download: Ohio-2009-SB15-Introduced.html

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As Introduced

128th General Assembly Regular Session 2009-2010

S. B. No. 15

Senator Miller, D. 

Cosponsors: Senators Fedor, Turner, Miller, R., Cafaro, Roberts, Sawyer 

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A BILL

To amend sections 1739.05, 1751.01, 3923.281,

1

3923.282, and 3923.51 and to repeal sections

2

3923.28, 3923.29, and 3923.30 of the Revised Code

3

to prohibit discrimination in health care

4

policies, contracts, and agreements in the

5

coverage provided for the diagnosis and treatment

6

of mental illnesses and substance abuse or

7

addiction conditions.

8

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That sections 1739.05, 1751.01, 3923.281,	9
3923.282, and 3923.51 of the Revised Code be amended to read as	10
follows:	11

Sec. 1739.05.  (A) A multiple employer welfare arrangement	12
that is created pursuant to sections 1739.01 to 1739.22 of the	13
Revised Code and that operates a group self-insurance program may	14
be established only if any of the following applies:	15

(1) The arrangement has and maintains a minimum enrollment of	16
three hundred employees of two or more employers.	17

(2) The arrangement has and maintains a minimum enrollment of	18
three hundred self-employed individuals.	19

(3) The arrangement has and maintains a minimum enrollment of	20
three hundred employees or self-employed individuals in any	21
combination of divisions (A)(1) and (2) of this section.	22

(B) A multiple employer welfare arrangement that is created	23
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	24
that operates a group self-insurance program shall comply with all	25
laws applicable to self-funded programs in this state, including	26
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	27
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	28
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.80,	29
3924.031, 3924.032, and 3924.27 of the Revised Code.	30

(C) A multiple employer welfare arrangement created pursuant	31
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	32
enrollments only through agents or solicitors licensed pursuant to	33
Chapter 3905. of the Revised Code to sell or solicit sickness and	34
accident insurance.	35

(D) A multiple employer welfare arrangement created pursuant	36
to sections 1739.01 to 1739.22 of the Revised Code shall provide	37
benefits only to individuals who are members, employees of	38
members, or the dependents of members or employees, or are	39
eligible for continuation of coverage under section 1751.53 or	40
3923.38 of the Revised Code or under Title X of the "Consolidated	41
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	42
U.S.C.A. 1161, as amended.	43

Sec. 1751.01.  As used in this chapter:

44

(A)(1) "Basic health care services" means the following	45
services when medically necessary:	46

(a) Physician's services, except when such services are	47
supplemental under division (B) of this section;	48

(b) Inpatient hospital services;

49

(c) Outpatient medical services;

50

(d) Emergency health services;

51

(e) Urgent care services;

52

(f) Diagnostic laboratory services and diagnostic and	53
therapeutic radiologic services;	54

(g) Diagnostic and treatment services, other than	55
prescription drug services, for biologically based mental	56
illnesses and substance abuse and addiction conditions;	57

(h) Preventive health care services, including, but not	58
limited to, voluntary family planning services, infertility	59
services, periodic physical examinations, prenatal obstetrical	60
care, and well-child care;	61

(i) Routine patient care for patients enrolled in an eligible	62
cancer clinical trial pursuant to section 3923.80 of the Revised	63
Code.	64

"Basic health care services" does not include experimental	65
procedures.	66

Except as provided by divisions (A)(2) and (3) of this	67
section in connection with the offering of coverage for diagnostic	68
and treatment services for biologically based mental illnesses and	69
substance abuse and addiction conditions, a health insuring	70
corporation shall not offer coverage for a health care service,	71
defined as a basic health care service by this division, unless	72
it offers coverage for all listed basic health care services.	73
However, this requirement does not apply to the coverage of	74
beneficiaries enrolled in medicare pursuant to a medicare	75
contract, or to the coverage of beneficiaries enrolled in the	76
federal employee health benefits program pursuant to 5 U.S.C.A.	77
8905, or to the coverage of medicaid recipients, or to the	78
coverage of participants of the children's buy-in program, or to	79
the coverage of beneficiaries under any federal health care	80
program regulated by a federal regulatory body, or to the	81
coverage of beneficiaries under any contract covering officers or	82
employees of the state that has been entered into by the	83
department of administrative services.	84

(2) A health insuring corporation may offer coverage for	85
diagnostic and treatment services for biologically based mental	86
illnesses and substance abuse and addiction conditions without	87
offering coverage for all other basic health care services. A	88
health insuring corporation may offer coverage for diagnostic and	89
treatment services for biologically based mental illnesses and	90
substance abuse and addiction conditions alone or in combination	91
with one or more supplemental health care services. However, a	92
health insuring corporation that offers coverage for any other	93
basic health care service shall offer coverage for diagnostic and	94
treatment services for biologically based mental illnesses and	95
substance abuse and addiction conditions in combination with the	96
offer of coverage for all other listed basic health care services.	97

(3) A health insuring corporation that offers coverage for	98
basic health care services is not required to offer coverage for	99
diagnostic and treatment services for biologically based mental	100
illnesses and substance abuse and addiction conditions in	101
combination with the offer of coverage for all other listed basic	102
health care services if all of the following apply:	103

(a) The health insuring corporation submits documentation	104
certified by an independent member of the American academy of	105
actuaries to the superintendent of insurance showing that incurred	106
claims for diagnostic and treatment services for biologically	107
based mental illnesses and substance abuse and addiction	108
conditions for a period of at least six months independently	109
caused the health insuring corporation's costs for claims and	110
administrative expenses for the coverage of basic health care	111
services to increase by more than one per cent per year.	112

(b) The health insuring corporation submits a signed letter	113
from an independent member of the American academy of actuaries to	114
the superintendent of insurance opining that the increase in costs	115
described in division (A)(3)(a) of this section could reasonably	116
justify an increase of more than one per cent in the annual	117
premiums or rates charged by the health insuring corporation for	118
the coverage of basic health care services.	119

(c) The superintendent of insurance makes the following	120
determinations from the documentation and opinion submitted	121
pursuant to divisions (A)(3)(a) and (b) of this section:	122

(i) Incurred claims for diagnostic and treatment services for	123
biologically based mental illnesses and substance abuse and	124
addiction conditions for a period of at least six months	125
independently caused the health insuring corporation's costs for	126
claims and administrative expenses for the coverage of basic	127
health care services to increase by more than one per cent per	128
year.	129

(ii) The increase in costs reasonably justifies an increase	130
of more than one per cent in the annual premiums or rates charged	131
by the health insuring corporation for the coverage of basic	132
health care services.	133

Any determination made by the superintendent under this	134
division is subject to Chapter 119. of the Revised Code.	135

(B)(1) "Supplemental health care services" means any health	136
care services other than basic health care services that a health	137
insuring corporation may offer, alone or in combination with	138
either basic health care services or other supplemental health	139
care services, and includes:	140

(a) Services of facilities for intermediate or long-term	141
care, or both;	142

(b) Dental care services;

143

(c) Vision care and optometric services including lenses and	144
frames;	145

(d) Podiatric care or foot care services;

146

(e) Mental health services, excluding diagnostic and	147
treatment services for biologically based mental illnesses;	148

(f) Short-term outpatient evaluative and crisis-intervention	149
mental health services;	150

(g) Medical or psychological treatment and referral services	151
for alcohol and drug abuse or addiction;	152

(h)(f) Home health services;

153

(i)(g) Prescription drug services;

154

(j)(h) Nursing services;

155

(k)(i) Services of a dietitian licensed under Chapter 4759.	156
of the Revised Code;	157

(l)(j) Physical therapy services;

158

(m)(k) Chiropractic services;

159

(n)(l) Any other category of services approved by the	160
superintendent of insurance.	161

(2) If a health insuring corporation offers prescription	162
drug services under this division, the coverage shall include	163
prescription drug services for the treatment of biologically based	164
mental illnesses and substance abuse or addiction conditions on	165
the same terms and conditions as other physical diseases and	166
disorders.	167

(C) "Specialty health care services" means one of the	168
supplemental health care services listed in division (B) of this	169
section, when provided by a health insuring corporation on an	170
outpatient-only basis and not in combination with other	171
supplemental health care services.	172

(D) "Biologically based mental illnesses" means	173
schizophrenia, schizoaffective disorder, major depressive	174
disorder, bipolar disorder, paranoia and other psychotic	175
disorders, obsessive-compulsive disorder, and panic disorder, as	176
these terms are defined in"Mental illness" means any condition or	177
disorder involving mental illness as defined by the most recent	178
edition of the diagnostic and statistical manual of mental	179
disorders published by the American psychiatric association or as	180
defined by any diagnostic category listed in the mental disorder	181
section of the most recent edition of the international	182
classification of diseases.	183

(E) "Substance abuse or addiction condition" means any	184
alcohol or drug related disorder as defined by the most recent	185
edition of the diagnostic and statistical manual of mental	186
disorders published by the American psychiatric association or as	187
defined by a diagnostic category listed in the most recent edition	188
of the international classification of diseases.	189

(F) "Children's buy-in program" has the same meaning as in	190
section 5101.5211 of the Revised Code.	191

(F)(G) "Closed panel plan" means a health care plan that	192
requires enrollees to use participating providers.	193

(G)(H) "Compensation" means remuneration for the provision of	194
health care services, determined on other than a fee-for-service	195
or discounted-fee-for-service basis.	196

(H)(I) "Contractual periodic prepayment" means the formula	197
for determining the premium rate for all subscribers of a health	198
insuring corporation.	199

(I)(J) "Corporation" means a corporation formed under Chapter	200
1701. or 1702. of the Revised Code or the similar laws of another	201
state.	202

(J)(K) "Emergency health services" means those health care	203
services that must be available on a seven-days-per-week,	204
twenty-four-hours-per-day basis in order to prevent jeopardy to an	205
enrollee's health status that would occur if such services were	206
not received as soon as possible, and includes, where appropriate,	207
provisions for transportation and indemnity payments or service	208
agreements for out-of-area coverage.	209

(K)(L) "Enrollee" means any natural person who is entitled to	210
receive health care benefits provided by a health insuring	211
corporation.	212

(L)(M) "Evidence of coverage" means any certificate,	213
agreement, policy, or contract issued to a subscriber that sets	214
out the coverage and other rights to which such person is	215
entitled under a health care plan.	216

(M)(N) "Health care facility" means any facility, except a	217
health care practitioner's office, that provides preventive,	218
diagnostic, therapeutic, acute convalescent, rehabilitation,	219
mental health, mental retardation, intermediate care, or skilled	220
nursing services.	221

(N)(O) "Health care services" means basic, supplemental, and	222
specialty health care services.	223

(O)(P) "Health delivery network" means any group of providers	224
or health care facilities, or both, or any representative thereof,	225
that have entered into an agreement to offer health care services	226
in a panel rather than on an individual basis.	227

(P)(Q) "Health insuring corporation" means a corporation, as	228
defined in division (I)(J) of this section, that, pursuant to a	229
policy, contract, certificate, or agreement, pays for, reimburses,	230
or provides, delivers, arranges for, or otherwise makes available,	231
basic health care services, supplemental health care services, or	232
specialty health care services, or a combination of basic health	233
care services and either supplemental health care services or	234
specialty health care services, through either an open panel plan	235
or a closed panel plan.	236

"Health insuring corporation" does not include a limited	237
liability company formed pursuant to Chapter 1705. of the Revised	238
Code, an insurer licensed under Title XXXIX of the Revised Code if	239
that insurer offers only open panel plans under which all	240
providers and health care facilities participating receive their	241
compensation directly from the insurer, a corporation formed by or	242
on behalf of a political subdivision or a department, office, or	243
institution of the state, or a public entity formed by or on	244
behalf of a board of county commissioners, a county board of	245
mental retardation and developmental disabilities, an alcohol and	246
drug addiction services board, a board of alcohol, drug addiction,	247
and mental health services, or a community mental health board, as	248
those terms are used in Chapters 340. and 5126. of the Revised	249
Code. Except as provided by division (D) of section 1751.02 of	250
the Revised Code, or as otherwise provided by law, no board,	251
commission, agency, or other entity under the control of a	252
political subdivision may accept insurance risk in providing for	253
health care services. However, nothing in this division shall be	254
construed as prohibiting such entities from purchasing the	255
services of a health insuring corporation or a third-party	256
administrator licensed under Chapter 3959. of the Revised Code.	257

(Q)(R) "Intermediary organization" means a health delivery	258
network or other entity that contracts with licensed health	259
insuring corporations or self-insured employers, or both, to	260
provide health care services, and that enters into contractual	261
arrangements with other entities for the provision of health care	262
services for the purpose of fulfilling the terms of its contracts	263
with the health insuring corporations and self-insured employers.	264

(R)(S) "Intermediate care" means residential care above the	265
level of room and board for patients who require personal	266
assistance and health-related services, but who do not require	267
skilled nursing care.	268

(S)(T) "Medicaid" has the same meaning as in section 5111.01	269
of the Revised Code.	270

(T)(U) "Medical record" means the personal information that	271
relates to an individual's physical or mental condition, medical	272
history, or medical treatment.	273

(U)(V) "Medicare" means the program established under Title	274
XVIII of the "Social Security Act" 49 Stat. 620 (1935), 42 U.S.C.	275
1395, as amended.	276

(V)(W)(1) "Open panel plan" means a health care plan that	277
provides incentives for enrollees to use participating providers	278
and that also allows enrollees to use providers that are not	279
participating providers.	280

(2) No health insuring corporation may offer an open panel	281
plan, unless the health insuring corporation is also licensed as	282
an insurer under Title XXXIX of the Revised Code, the health	283
insuring corporation, on June 4, 1997, holds a certificate of	284
authority or license to operate under Chapter 1736. or 1740. of	285
the Revised Code, or an insurer licensed under Title XXXIX of the	286
Revised Code is responsible for the out-of-network risk as	287
evidenced by both an evidence of coverage filing under section	288
1751.11 of the Revised Code and a policy and certificate filing	289
under section 3923.02 of the Revised Code.	290

(W)(X) "Panel" means a group of providers or health care	291
facilities that have joined together to deliver health care	292
services through a contractual arrangement with a health insuring	293
corporation, employer group, or other payor.	294

(X)(Y) "Person" has the same meaning as in section 1.59 of	295
the Revised Code, and, unless the context otherwise requires,	296
includes any insurance company holding a certificate of authority	297
under Title XXXIX of the Revised Code, any subsidiary and	298
affiliate of an insurance company, and any government agency.	299

(Y)(Z) "Premium rate" means any set fee regularly paid by a	300
subscriber to a health insuring corporation. A "premium rate" does	301
not include a one-time membership fee, an annual administrative	302
fee, or a nominal access fee, paid to a managed health care system	303
under which the recipient of health care services remains solely	304
responsible for any charges accessed for those services by the	305
provider or health care facility.	306

(Z)(AA) "Primary care provider" means a provider that is	307
designated by a health insuring corporation to supervise,	308
coordinate, or provide initial care or continuing care to an	309
enrollee, and that may be required by the health insuring	310
corporation to initiate a referral for specialty care and to	311
maintain supervision of the health care services rendered to the	312
enrollee.	313

(AA)(BB) "Provider" means any natural person or partnership	314
of natural persons who are licensed, certified, accredited, or	315
otherwise authorized in this state to furnish health care	316
services, or any professional association organized under Chapter	317
1785. of the Revised Code, provided that nothing in this chapter	318
or other provisions of law shall be construed to preclude a health	319
insuring corporation, health care practitioner, or organized	320
health care group associated with a health insuring corporation	321
from employing certified nurse practitioners, certified nurse	322
anesthetists, clinical nurse specialists, certified nurse	323
midwives, dietitians, physician assistants, dental assistants,	324
dental hygienists, optometric technicians, or other allied health	325
personnel who are licensed, certified, accredited, or otherwise	326
authorized in this state to furnish health care services.	327

(BB)(CC) "Provider sponsored organization" means a	328
corporation, as defined in division (I)(J) of this section, that	329
is at least eighty per cent owned or controlled by one or more	330
hospitals, as defined in section 3727.01 of the Revised Code, or	331
one or more physicians licensed to practice medicine or surgery	332
or osteopathic medicine and surgery under Chapter 4731. of the	333
Revised Code, or any combination of such physicians and hospitals.	334
Such control is presumed to exist if at least eighty per cent of	335
the voting rights or governance rights of a provider sponsored	336
organization are directly or indirectly owned, controlled, or	337
otherwise held by any combination of the physicians and hospitals	338
described in this division.	339

(CC)(DD) "Solicitation document" means the written materials	340
provided to prospective subscribers or enrollees, or both, and	341
used for advertising and marketing to induce enrollment in the	342
health care plans of a health insuring corporation.	343

(DD)(EE) "Subscriber" means a person who is responsible for	344
making payments to a health insuring corporation for participation	345
in a health care plan, or an enrollee whose employment or other	346
status is the basis of eligibility for enrollment in a health	347
insuring corporation.	348

(EE)(FF) "Urgent care services" means those health care	349
services that are appropriately provided for an unforeseen	350
condition of a kind that usually requires medical attention	351
without delay but that does not pose a threat to the life, limb,	352
or permanent health of the injured or ill person, and may include	353
such health care services provided out of the health insuring	354
corporation's approved service area pursuant to indemnity	355
payments or service agreements.	356

Sec. 3923.281.  (A) As used in this section:

357

(1) "Biologically based mental illness" means schizophrenia,	358
schizoaffective disorder, major depressive disorder, bipolar	359
disorder, paranoia and other psychotic disorders,	360
obsessive-compulsive disorder, and panic disorder, as these terms	361
are defined in"Mental illness" means any condition or disorder	362
involving mental illness as defined by the most recent edition of	363
the diagnostic and statistical manual of mental disorders	364
published by the American psychiatric association or as defined	365
by any diagnostic category listed in the mental disorder section	366
of the most recent edition of the international classification of	367
diseases.	368

(2) "Policy of sickness and accident insurance" has the same	369
meaning as in section 3923.01 of the Revised Code, but excludes	370
any hospital indemnity, medicare supplement, long-term care,	371
disability income, one-time-limited-duration policy of not longer	372
than six months, supplemental benefit, or other policy that	373
provides coverage for specific diseases or accidents only; any	374
policy that provides coverage for workers' compensation claims	375
compensable pursuant to Chapters 4121. and 4123. of the Revised	376
Code; any policy that provides coverage to beneficiaries enrolled	377
in Title XIX of the "Social Security Act," 49 Stat. 620 (1935),	378
42 U.S.C.A. 301, as amended, known as the medical assistance	379
program or medicaid, as provided by the Ohio department of job	380
and family services under Chapter 5111. of the Revised Code; and	381
any policy that provides coverage to beneficiaries enrolled in	382
the children's buy-in program established under sections	383
5101.5211 to 5101.5216 of the Revised Code.	384

(3) "Substance abuse or addiction condition" means any	385
alcohol or drug related disorder as defined by the most recent	386
edition of the diagnostic and statistical manual of mental	387
disorders published by the American psychiatric association or as	388
defined by a diagnostic category listed in the most recent edition	389
of the international classification of diseases.	390

(B) Notwithstanding section 3901.71 of the Revised Code, and	391
subject to division (E) of this section, every policy of	392
sickness and accident insurance shall provide benefits for the	393
diagnosis and treatment of biologically based mental illnesses and	394
substance abuse or addiction conditions on the same terms and	395
conditions as, and shall provide benefits no less extensive than,	396
those provided under the policy of sickness and accident	397
insurance for the treatment and diagnosis of all other physical	398
diseases and disorders, if both of the following apply:	399

(1) The biologically based mental illness or substance abuse	400
or addiction condition is clinically diagnosed by a physician	401
authorized under Chapter 4731. of the Revised Code to practice	402
medicine and surgery or osteopathic medicine and surgery; a	403
psychologist licensed under Chapter 4732. of the Revised Code; a	404
professional clinical counselor, professional counselor, or	405
independent social worker licensed under Chapter 4757. of the	406
Revised Code; or a clinical nurse specialist licensed under	407
Chapter 4723. of the Revised Code whose nursing specialty is	408
mental health.	409

(2) The prescribed treatment is not experimental or	410
investigational, having proven its clinical effectiveness in	411
accordance with generally accepted medical standards.	412

(C) Division (B) of this section applies to all coverages and	413
terms and conditions of the policy of sickness and accident	414
insurance, including, but not limited to, coverage of inpatient	415
hospital services, outpatient services, and medication; maximum	416
lifetime benefits; copayments; and individual and family	417
deductibles.	418

(D) Nothing in this section shall be construed as prohibiting	419
a sickness and accident insurance company from taking any of the	420
following actions:	421

(1) Negotiating separately with mental health care providers	422
with regard to reimbursement rates and the delivery of health care	423
services;	424

(2) Offering policies that provide benefits solely for the	425
diagnosis and treatment of biologically based mental illnesses and	426
substance abuse or addiction conditions;	427

(3) Managing the provision of benefits for the diagnosis or	428
treatment of biologically based mental illnesses and substance	429
abuse or addiction conditions through the use of pre-admission	430
screening, by requiring beneficiaries to obtain authorization	431
prior to treatment, or through the use of any other mechanism	432
designed to limit coverage to that treatment determined to be	433
necessary;	434

(4) Enforcing the terms and conditions of a policy of	435
sickness and accident insurance.	436

(E) An insurer that offers any policy of sickness and	437
accident insurance is not required to provide benefits for the	438
diagnosis and treatment of biologically based mental illnesses	439
and substance abuse or addiction conditions pursuant to division	440
(B) of this section if all of the following apply:	441

(1) The insurer submits documentation certified by an	442
independent member of the American academy of actuaries to the	443
superintendent of insurance showing that incurred claims for	444
diagnostic and treatment services for biologically basedand	445
substance abuse or addiction conditions mental illnesses for a	446
period of at least six months independently caused the insurer's	447
costs for claims and administrative expenses for the coverage of	448
all other physical diseases and disorders to increase by more	449
than one per cent per year.	450

(2) The insurer submits a signed letter from an independent	451
member of the American academy of actuaries to the superintendent	452
of insurance opining that the increase described in division	453
(E)(1) of this section could reasonably justify an increase of	454
more than one per cent in the annual premiums or rates charged by	455
the insurer for the coverage of all other physical diseases and	456
disorders.	457

(3) The superintendent of insurance makes the following	458
determinations from the documentation and opinion submitted	459
pursuant to divisions (E)(1) and (2) of this section:	460

(a) Incurred claims for diagnostic and treatment services for	461
biologically based mental illnesses and substance abuse or	462
addiction conditions for a period of at least six months	463
independently caused the insurer's costs for claims and	464
administrative expenses for the coverage of all other physical	465
diseases and disorders to increase by more than one per cent per	466
year.	467

(b) The increase in costs reasonably justifies an increase of	468
more than one per cent in the annual premiums or rates charged by	469
the insurer for the coverage of all other physical diseases and	470
disorders.	471

Any determination made by the superintendent under this	472
division is subject to Chapter 119. of the Revised Code.	473

Sec. 3923.282. (A) As used in this section:

474

(1) "Biologically based mental illness" means schizophrenia,	475
schizoaffective disorder, major depressive disorder, bipolar	476
disorder, paranoia and other psychotic disorders,	477
obsessive-compulsive disorder, and panic disorder, as these terms	478
are defined in"Mental illness" means any condition or disorder	479
involving mental illness as defined by the most recent edition of	480
the diagnostic and statistical manual of mental disorders	481
published by the American psychiatric association or as defined by	482
any diagnostic category listed in the mental disorder section of	483
the most recent edition of the international classification of	484
diseases.	485

(2) "Plan of health coverage" includes any private or public	486
employer group self-insurance plan that provides payment for	487
health care benefits for other than specific diseases or accidents	488
only, which benefits are not provided by contract with a sickness	489
and accident insurer or health insuring corporation.	490

(3) "Substance abuse or addiction condition" means any	491
alcohol or drug related disorder as defined by the most recent	492
edition of the diagnostic and statistical manual of mental	493
disorders published by the American psychiatric association or as	494
defined by a diagnostic category listed in the most recent edition	495
of the international classification of diseases.	496

(B) Notwithstanding section 3901.71 of the Revised Code, and	497
subject to division (F) of this section, each plan of health	498
coverage shall provide benefits for the diagnosis and treatment of	499
biologically based mental illnesses and substance abuse or	500
addiction conditions on the same terms and conditions as, and	501
shall provide benefits no less extensive than, those provided	502
under the plan of health coverage for the treatment and diagnosis	503
of all other physical diseases and disorders, if both of the	504
following apply:	505

(1) The biologically based mental illness or substance abuse	506
or addiction condition is clinically diagnosed by a physician	507
authorized under Chapter 4731. of the Revised Code to practice	508
medicine and surgery or osteopathic medicine and surgery; a	509
psychologist licensed under Chapter 4732. of the Revised Code; a	510
professional clinical counselor, professional counselor, or	511
independent social worker licensed under Chapter 4757. of the	512
Revised Code; or a clinical nurse specialist licensed under	513
Chapter 4723. of the Revised Code whose nursing specialty is	514
mental health.	515

(2) The prescribed treatment is not experimental or	516
investigational, having proven its clinical effectiveness in	517
accordance with generally accepted medical standards.	518

(C) Division (B) of this section applies to all coverages and	519
terms and conditions of the plan of health coverage, including,	520
but not limited to, coverage of inpatient hospital services,	521
outpatient services, and medication; maximum lifetime benefits;	522
copayments; and individual and family deductibles.	523

(D) This section does not apply to a plan of health coverage	524
if federal law supersedes, preempts, prohibits, or otherwise	525
precludes its application to such plans. This section does not	526
apply to long-term care, hospital indemnity, disability income, or	527
medicare supplement plans of health coverage, or to any other	528
supplemental benefit plans of health coverage.	529

(E) Nothing in this section shall be construed as prohibiting	530
an employer from taking any of the following actions in connection	531
with a plan of health coverage:	532

(1) Negotiating separately with mental health care providers	533
with regard to reimbursement rates and the delivery of health care	534
services;	535

(2) Managing the provision of benefits for the diagnosis or	536
treatment of biologically based mental illnesses and substance	537
abuse or addiction conditions through the use of pre-admission	538
screening, by requiring beneficiaries to obtain authorization	539
prior to treatment, or through the use of any other mechanism	540
designed to limit coverage to that treatment determined to be	541
necessary;	542

(3) Enforcing the terms and conditions of a plan of health	543
coverage.	544

(F) An employer that offers a plan of health coverage is not	545
required to provide benefits for the diagnosis and treatment of	546
biologically based mental illnesses and substance abuse or	547
addiction conditions in combination with benefits for the	548
treatment and diagnosis of all other physical diseases and	549
disorders as described in division (B) of this section if both of	550
the following apply:	551

(1) The employer submits documentation certified by an	552
independent member of the American academy of actuaries to the	553
superintendent of insurance showing that incurred claims for	554
diagnostic and treatment services for biologically based mental	555
illnesses and substance abuse or addiction conditions for a period	556
of at least six months independently caused the employer's costs	557
for claims and administrative expenses for the coverage of all	558
other physical diseases and disorders to increase by more than one	559
per cent per year.	560

(2) The superintendent of insurance determines from the	561
documentation and opinion submitted pursuant to division (F) of	562
this section, that incurred claims for diagnostic and treatment	563
services for biologically based mental illnesses and substance	564
abuse or addiction conditions for a period of at least six months	565
independently caused the employer's costs for claims and	566
administrative expenses for the coverage of all other physical	567
diseases and disorders to increase by more than one per cent per	568
year.	569

Any determination made by the superintendent under this	570
division is subject to Chapter 119. of the Revised Code.	571

Sec. 3923.51.  (A) As used in this section, "official poverty	572
line" means the poverty line as defined by the United States	573
office of management and budget and revised by the secretary of	574
health and human services under 95 Stat. 511, 42 U.S.C.A. 9902, as	575
amended.	576

(B) Every insurer that is authorized to write sickness and	577
accident insurance in this state may offer group contracts of	578
sickness and accident insurance to any charitable foundation that	579
is certified as exempt from taxation under section 501(c)(3) of	580
the "Internal Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A.	581
1, as amended, and that has the sole purpose of issuing	582
certificates of coverage under these contracts to persons under	583
the age of nineteen who are members of families that have incomes	584
that are no greater than three hundred per cent of the official	585
poverty line.	586

(C) Contracts offered pursuant to division (B) of this	587
section are not subject to any of the following:	588

(1) Sections 3923.122, 3923.24, 3923.28,and 3923.281, and	589
3923.29 of the Revised Code;	590

(2) Any other sickness and accident insurance coverage	591
required under this chapter on August 3, 1989. Any requirement of	592
sickness and accident insurance coverage enacted after that date	593
applies to this section only if the subsequent enactment	594
specifically refers to this section.	595

(3) Chapter 1751. of the Revised Code.

596

Section 2. That existing sections 1739.05, 1751.01, 3923.281,	597
3923.282, and 3923.51 and sections 3923.28, 3923.29, and 3923.30	598
of the Revised Code are hereby repealed.	599

Section 3.  Section 1751.01 of the Revised Code is presented	600
in this act as a composite of the section as amended by both Am.	601
Sub. H.B. 562 and Sub. S.B. 186 of the 127th General Assembly.	602
The General Assembly, applying the principle stated in division	603
(B) of section 1.52 of the Revised Code that amendments are to be	604
harmonized if reasonably capable of simultaneous operation, finds	605
that the composite is the resulting version of the section in	606
effect prior to the effective date of the section as presented in	607
this act.	608