Chapter 3923 | Sickness And Accident Insurance

Section 3923.01 | Policy of sickness and accident insurance defined.

• Effective: November 24, 1995
• Latest Legislation: Senate Bill 150 - 121st General Assembly

As used in this chapter, "policy of sickness and accident insurance" includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.

Section 3923.011 | Sickness and accident insurance definitions.

• Effective: January 9, 1961
• Latest Legislation: House Bill 1 - 104th General Assembly

As used in any policy of sickness and accident insurance delivered, issued for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto:

(A) "Total disability" means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment.

(B) "Confinement to house" includes the activities of a convalescent not able to be gainfully employed.

(C) "Accidental death" means death by accident exclusively and independently of all other causes.

Section 3923.02 | Form of policy filed with superintendent.

• Effective: July 1, 1955
• Latest Legislation: House Bill 881 - 101st General Assembly

No certificate shall be furnished by any insurer in connection with, or pursuant to any provision of, any group sickness and accident insurance policy delivered, issued for delivery, or used in this state, and no policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state, nor shall any indorsement, rider, or application which becomes or which is designed to become a part of any such policy or certificate be delivered, issued for delivery, or used in this state, until a copy of the form of such policy, certificate, indorsement, rider, or application and of the premium rates and of the classification of risks pertaining thereto has been filed with the superintendent of insurance. No such policy, certificate, indorsement, rider or application shall be delivered, issued for delivery, or used until the expiration of thirty days after the form of such policy, certificate, indorsement, rider, or application has been filed with the superintendent, unless he has previously given to the insurer his written approval thereto. If the superintendent finds that any such form of policy, certificate, indorsement, rider, or application which has been filed with him by an insurer contains any provision which is contrary to the law of this state, or contains inconsistent provisions, or contains any question, provision, title, heading, backing, or other indication of its contents, which is ambiguous, misleading, or deceptive, or likely to mislead or deceive the policyholder, certificate holder or applicant, he shall give written notice of his finding to the insurer which has filed such form, and thereafter no insurer which has filed such form shall deliver, issue for delivery, or use such form in this state.

After the expiration of thirty days from the filing of any such form, or at any time after the superintendent has given written approval thereof, the superintendent may, after a hearing of which at least twenty days' written notice has been given to the insurer issuing such form, withdraw approval on any ground stated in this section. Such disapproval shall be effected by written order of the superintendent which shall state the ground for disapproval and the date, not less than thirty days after such hearing, when the withdrawal of approval shall become effective. After the date when the withdrawal of approval of any such form becomes effective, such form shall not be delivered, issued for delivery, or used in this state. The form of any certificate furnished by any insurer to a resident of this state in connection with, or pursuant to any provisions of, any group sickness and accident insurance policy which policy is not delivered, issued for delivery, or used in this state but which insures residents of this state shall, upon request of the superintendent, be filed with the superintendent.

Section 3923.021 | Approval or disapproval of premium rates.

• Effective: January 1, 2021
• Latest Legislation: House Bill 339 - 133rd General Assembly

(A) As used in this section:

(1) "Benefits provided are not unreasonable in relation to the premium charged" means the rates were calculated in accordance with sound actuarial principles.

(2) "Individual policy of sickness and accident insurance" includes sickness and accident insurance made available by insurers in the individual market to individuals, with or without family members or dependents, through group policies issued to one or more associations or entities.

(B) With respect to any filing, made pursuant to section 3923.02 of the Revised Code, of any premium rates for any individual policy of sickness and accident insurance or certificates made available by an insurer to individuals in the individual market through a group policy or for any indorsement or rider pertaining thereto, the superintendent of insurance may, within thirty days after filing:

(1) Disapprove such filing after finding that the benefits provided are unreasonable in relation to the premium charged. Such disapproval shall be effected by written order of the superintendent, a copy of which shall be mailed to the insurer that has made the filing. In the order, the superintendent shall specify the reasons for the disapproval and state that a hearing will be held within fifteen days after requested in writing by the insurer. If a hearing is so requested, the superintendent shall also give such public notice as the superintendent considers appropriate. The superintendent, within fifteen days after the commencement of any hearing, shall issue a written order, a copy of which shall be mailed to the insurer that has made the filing, either affirming the prior disapproval or approving such filing after finding that the benefits provided are not unreasonable in relation to the premium charged.

(2) Set a date for a public hearing to commence no later than forty days after the filing. The superintendent shall give the insurer making the filing twenty days' written notice of the hearing and shall give such public notice as the superintendent considers appropriate. The superintendent, within twenty days after the commencement of a hearing, shall issue a written order, a copy of which shall be mailed to the insurer that has made the filing, either approving such filing if the superintendent finds that the benefits provided are not unreasonable in relation to the premium charged, or disapproving such filing if the superintendent finds that the benefits provided are unreasonable in relation to the premium charged. This division does not apply to any insurer organized or transacting the business of insurance under Chapter 3907. or 3909. of the Revised Code.

(3) Take no action, in which case such filing shall be deemed to be approved and shall become effective upon the thirty-first day after such filing, unless the superintendent has previously given to the insurer a written approval.

(C) At any time after any filing has been approved pursuant to this section, the superintendent may, after a hearing of which at least twenty days' written notice has been given to the insurer that has made such filing and for which such public notice as the superintendent considers appropriate has been given, withdraw approval of such filing after finding that the benefits provided are unreasonable in relation to the premium charged. Such withdrawal of approval shall be effected by written order of the superintendent, a copy of which shall be mailed to the insurer that has made the filing, which shall state the ground for such withdrawal and the date, not less than forty days after the date of such order, when the withdrawal of approval shall become effective.

(D) The superintendent may retain at the insurer's expense such attorneys, actuaries, accountants, and other experts not otherwise a part of the superintendent's staff as shall be reasonably necessary to assist in the preparation for and conduct of any public hearing under this section. The expense for retaining such experts and the expenses of the department of insurance incurred in connection with such public hearing shall be assessed against the insurer in an amount not to exceed one one-hundredth of one per cent of the sum of premiums earned plus net realized investment gain or loss of such insurer as reflected in the most current annual statement on file with the superintendent. Any person retained shall be under the direction and control of the superintendent and shall act in a purely advisory capacity.

Section 3923.022 | Maximum aggregate administrative expenses.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A) As used in this section:

(1)(a) "Administrative expense" means the amount resulting from the following: the amount of premiums earned by the insurer for sickness and accident insurance business plus the amount of losses recovered from reinsurance coverage minus the sum of the amount of claims for losses paid; the amount of losses incurred but not reported; the amount incurred for state fees, federal and state taxes, and reinsurance; and the incurred costs and expenses related, either directly or indirectly, to the payment of commissions, measures to control fraud, and managed care.

(b) "Administrative expense" does not include any amounts collected, or administrative expenses incurred, by an insurer for the administration of an employee health benefit plan subject to regulation by the federal "Employee Retirement Income Security Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts collected or administrative expenses incurred" means the total amount paid to an administrator for the administration and payment of claims minus the sum of the amount of claims for losses paid and the amount of losses incurred but not reported.

(2) "Insurer" means any insurance company authorized under Title XXXIX of the Revised Code to do the business of sickness and accident insurance in this state.

(3) "Sickness and accident insurance business" does not include coverage provided by an insurer for specific diseases or accidents only; any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy that is less than twelve months, or other policy that offers only supplemental benefits; or coverage provided to individuals who are not residents of this state.

(4) "Individual business" includes both individual sickness and accident insurance and sickness and accident insurance made available by insurers in the individual market to individuals, with or without family members or dependents, through group policies issued to one or more associations or entities.

(B) Notwithstanding section 3941.14 of the Revised Code, each insurer shall have aggregate administrative expenses of no more than twenty per cent of the premium income of the insurer, based on the premiums earned in that year on the sickness and accident insurance business of the insurer.

(C)(1) Each insurer, on the first day of January or within sixty days thereafter, shall annually prepare, under oath, and deposit in the office of the superintendent of insurance a statement of the aggregate administrative expenses of the insurer, based on the premiums earned in the immediately preceding calendar year on the sickness and accident insurance business of the insurer. The statement shall itemize and separately detail all of the following information with respect to the insurer's sickness and accident insurance business:

(a) The amount of premiums earned by the insurer both before and after any costs related to the insurer's purchase of reinsurance coverage;

(b) The total amount of claims for losses paid by the insurer both before and after any reimbursement from reinsurance coverage;

(c) The amount of any losses incurred by the insurer but not reported by the insurer in the current or prior year;

(d) The amount of costs incurred by the insurer for state fees and federal and state taxes;

(e) The amount of costs incurred by the insurer for reinsurance coverage;

(f) The amount of costs incurred by the insurer that are related to the insurer's payment of commissions;

(g) The amount of costs incurred by the insurer that are related to the insurer's fraud prevention measures;

(h) The amount of costs incurred by the insurer that are related to managed care; and

(i) Any other administrative expenses incurred by the insurer.

(2) The statement also shall include all of the information required under division (C)(1) of this section separately detailed for the insurer's individual business, small group business, and large group business.

(D) No insurer shall fail to comply with this section.

(E) If the superintendent determines that an insurer has violated this section, the superintendent, pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code, may order the suspension of the insurer's license to do the business of sickness and accident insurance in this state until the superintendent is satisfied that the insurer is in compliance with this section. If the insurer continues to do the business of sickness and accident insurance in this state while under the suspension order, the superintendent shall order the insurer to pay one thousand dollars for each day of the violation.

(F) Any money collected by the superintendent under division (E) of this section shall be deposited by the superintendent into the state treasury to the credit of the department of insurance operating fund.

(G) The statement of aggregate expenses filed pursuant to this section separately detailing an insurer's individual, small group, and large group business shall be considered work papers resulting from the conduct of a market analysis of an entity subject to examination by the superintendent under division (C) of section 3901.48 of the Revised Code, except that the superintendent may share aggregated market information that identifies the premiums earned as reported under division (C)(1)(a) of this section, the administrative expenses reported under division (C)(1)(i) of this section, the amount of commissions reported under division (C)(1)(f) of this section, the amount of taxes paid as reported under division (C)(1)(d) of this section, the total of the remaining benefit costs as reported under divisions (C)(1)(b) and (c) of this section, and the amount of fraud and managed care expenses reported under divisions (C)(1)(g) and (h) of this section.

Last updated November 23, 2021 at 3:53 PM

Section 3923.03 | Necessary provisions.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

No policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state unless all the following requirements are complied with:

(A) The entire money and other considerations therefor are expressed therein.

(B) The time at which insurance takes effect and terminates is expressed therein.

(C) It purports to insure only one person, except that a policy may be issued to the head of a family, who for this purpose may be the husband or the wife and who is considered the policyholder, covering any two or more members of any one family, including husband, wife, dependent children, any children under the age of nineteen, and other dependents living with the family.

(D) Every printed portion of the text matter and of any indorsements or attached papers shall be printed in uniform type of which the face shall be not less than ten point, the "text" to include all printed matter except the name and address of the insurer, name and title of the policy, captions, subcaptions, and form number. The superintendent of insurance shall not disapprove any such policy on the ground that every printed portion of its text matter or of any indorsement or attached paper is not printed in uniform type if it is shown that the type used is required to conform to the laws of another state in which the insurer is licensed.

(E) The exceptions and reductions of indemnity are adequately captioned and clearly set forth in the policy.

(F) Every such policy, including riders and indorsements, shall be identified by a form number in the lower left-hand corner of its first page.

Section 3923.04 | Policy standard provisions.

• Effective: January 1, 2021
• Latest Legislation: House Bill 339 - 133rd General Assembly

Except as provided in section 3923.07 of the Revised Code, every policy of sickness and accident insurance delivered, issued for delivery, or used in this state shall contain the standard provisions specified in this section in the words in which the same appear in this section. Such standard provisions shall be preceded individually by the caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the superintendent of insurance may approve.

(A) A provision as follows: Entire contract; changes. This policy, including the indorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be indorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.

No statement made by an applicant for a policy of sickness and accident insurance not included therein shall avoid the policy or be used to deny any claim thereunder or be used in any legal proceeding thereunder.

(B) A provision in two parts as follows: Time limit on certain defenses.

(1) After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for this policy shall be used to void this policy or to deny a claim for loss incurred or disability (as defined in this policy) commencing after the expiration of such two -year period.

The policy provision in division (B)(1) of this section shall not be so construed as to affect any legal requirements for avoidance of a policy or denial of a claim during such initial two-year period, nor to limit the application of divisions (A), (B), (C), (D), and (E) of section 3923.05 of the Revised Code in the event of misstatement with respect to age, occupation, or other insurance.

A policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty, or a policy issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue, may contain, in lieu of the foregoing policy provision in division (B)(1) of this section, a provision, from which the clause in parentheses may be omitted at the insurer's option, under the caption Incontestable, as follows: After this policy has been in force for a period of two years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.

(2) No claim for loss incurred or disability (as defined in this policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.

No chronic disease or chronic physical condition may be excluded from the coverage of a policy of sickness insurance or from the sickness insurance coverage of a policy of sickness and accident insurance except by name or specific description.

(C) A provision as follows: Grace period. A grace period of __________ days will be granted for the payment of each premium falling due after the first premium, during which grace period this policy shall continue in force.

The insurer shall insert in the blank space in the policy provision in division (C) of this section a number not smaller than seven for weekly premium policies or ten for monthly premium policies or thirty-one for all other policies.

A policy in which the insurer reserves the right to refuse any renewal shall contain a provision, at the beginning of the policy provision in division (C) of this section, as follows: Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to the insured's last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted. Each such policy, other than an accident insurance only policy, shall provide in substance, in a provision thereof or in an indorsement thereon or in a rider attached thereto, that the insurer may not refuse renewal of the policy before the first anniversary, or between anniversaries, of its date of issue, and that any non-renewal of the policy by the insurer or insured shall be without prejudice to any claim originating prior to the effective date of non-renewal.

(D) A provision as follows: Reinstatement. If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate this policy. If the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, this policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under this policy immediately before the due date of the defaulted premium, subject to any provisions indorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement.

The last sentence of the policy provision in division (D) of this section may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or from any policy issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue.

(E) A provision as follows: Notice of claim. Written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by this policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at ________ or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.

The insurer shall insert in the blank space in the policy provision in division (E) of this section the location of such office as it may desire to designate for the purpose of notice.

In a policy providing a loss of time benefit which may be payable for at least two years, an insurer may insert, between the first and second sentences of the policy provision in division (E) of this section, a provision as follows:

Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, the insured shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.

(F) A provision as follows: Claim forms. The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in this policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

(G) A provision as follows: Proofs of loss. Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.

(H) A provision as follows: Time of payment of claims. Indemnities payable under this policy for any loss, other than loss for which this policy provides any periodic payment, will be paid immediately upon, or within thirty days after, receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ________ and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

The insurer shall insert in the blank space in the provision in division (H) of this section a period for payment which must not be less frequently than monthly. The insurer may at its option omit from the provision in division (H) of this section ", or within thirty days after,".

(I) A provision as follows: Payment of claims. Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.

The insurer may at its option add at the end of the provision in division (I) of this section, the following provisions or either of the following provisions:

(1) If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding ________ dollars, to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.

(2) Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the services be rendered by a particular hospital or person.

The insurer shall insert in the blank space in the policy provision in division (I)(1) of this section an amount which shall not exceed one thousand dollars.

(J) A provision as follows: Physical examination and autopsy. The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

(K) A provision as follows: Legal actions. No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.

(L) A provision as follows: Change of beneficiary. Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.

The insurer may at its option omit from the provision in division (L) of this section the following: Unless the insured makes an irrevocable designation of beneficiary.

(M) A provision, which shall be contained in the policy or in an indorsement thereon or in a rider attached thereto, as follows: Cancellation by the insured. Non-cancellation by the insurer. The insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. The earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when this policy was issued. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation. The insurer may not cancel this policy. This provision nullifies any other provision, contained in this policy or in any indorsement hereon or in any rider attached hereto, which provides for cancellation of this policy by the insurer or by the insured.

Section 3923.041 | Policies with prior authorization requirement provisions.

• Effective: September 29, 2017
• Latest Legislation: House Bill 49 - 132nd General Assembly

(A) As used in this section:

(1) "Chronic condition" means a medical condition that has persisted after reasonable efforts have been made to relieve or cure its cause and has continued, either continuously or episodically, for longer than six continuous months.

(2) "Clinical peer" means a health care practitioner in the same or in a similar, specialty that typically manages the medical condition, procedure, or treatment under review.

(3) "Covered person" means a person receiving coverage for health services under a policy of sickness and accident insurance or a public employee benefit plan.

(4) "Emergency service" has the same meaning as in section 1753.28 of the Revised Code.

(5) "Fraudulent or materially incorrect information" means any type of intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the covered person in question.

(6) "Health care practitioner" has the same meaning as in section 3701.74 of the Revised Code.

(7) "NCPDP SCRIPT standard" means the national council for prescription drug programs SCRIPT standard version 201310 or the most recent standard adopted by the United States department of health and human services.

(8) "Prior authorization requirement" means any practice implemented by either a sickness and accident insurer or a public employee benefit plan in which coverage of a health care service, device, or drug is dependent upon a covered person or a health care practitioner obtaining approval from the insurer or plan prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.

(9) "Urgent care services" means a medical care or other service for a condition where application of the timeframe for making routine or non-life threatening care determinations is either of the following:

(a) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient's psychological state;

(b) In the opinion of a practitioner with knowledge of the patient's medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(10) "Utilization review" and "utilization review organization" have the same meanings as in section 1751.77 of the Revised Code.

(B) If a policy issued by a sickness and accident insurer or a public employee benefit plan contains a prior authorization requirement, then all of the following apply:

(1) For policies issued on or after January 1, 2018, the insurer or plan shall permit health care practitioners to access the prior authorization form through the applicable electronic software system.

(2)(a) For policies issued on or after January 1, 2018, the insurer or plan, or other payer acting on behalf of the insurer or plan, to accept prior authorization requests through a secure electronic transmission.

(b) For policies issued on or after January 1, 2018, the insurer or plan, a pharmacy benefit manager responsible for handling prior authorization requests, or other payer acting on behalf of the insurer or plan shall accept and respond to prior prescription benefit authorization requests through a secure electronic transmission using NCPDP SCRIPT standard ePA transactions, and for prior medical benefit authorization requests through a secure electronic transmission using standards established by the council for affordable quality health care on operating rules for information exchange or its successor.

(c) For purposes of division (B)(2) of this section, neither of the following shall be considered a secure electronic transmission:

(i) A facsimile;

(ii) A proprietary payer portal for prescription drug requests that does not use NCPDP SCRIPT standard.

(3) For policies issued on or after January 1, 2018, a health care practitioner and an insurer or plan may enter into a contractual arrangement under which the insurer or plan agrees to process prior authorization requests that are not submitted electronically because of the financial hardship that electronic submission of prior authorization requests would create for the health care practitioner or if internet connectivity is limited or unavailable where the health care practitioner is located.

(4)(a) For policies issued on or after January 1, 2018, if the health care practitioner submits the request for prior authorization electronically as described in divisions (B)(1) and (2) of this section, the insurer or plan shall respond to all prior authorization requests within forty-eight hours for urgent care services, or ten calendar days for any prior authorization request that is not for an urgent care service, of the time the request is received by the insurer or plan. Division (B)(4) of this section does not apply to emergency services.

(b) The response required under division (B)(4)(a) of this section shall indicate whether the request is approved or denied. If the prior authorization is denied, the insurer or plan shall provide the specific reason for the denial.

(c) If the prior authorization request is incomplete, the insurer or plan shall indicate the specific additional information that is required to process the request.

(5)(a) For policies issued on or after January 1, 2018, if a health care practitioner submits a prior authorization request as described in divisions (B)(1) and (2) of this section, the insurer or plan shall provide an electronic receipt to the health care practitioner acknowledging that the prior authorization request was received.

(b) For policies issued on or after January 1, 2018, if an issuer or plan requests additional information that is required to process a prior authorization request as described in division (B)(4)(c) of this section, the health care practitioner shall provide an electronic receipt to the issuer or plan acknowledging that the request for additional information was received.

(6)(a) For policies issued on or after January 1, 2017, for a prior approval related to a chronic condition, the insurer or plan shall honor a prior authorization approval for an approved drug for the lesser of the following from the date of the approval:

(i) Twelve months;

(ii) The last day of the covered person's eligibility under the policy or plan.

(b) The duration of all other prior authorization approvals shall be dictated by the policy or plan.

(c) An insurer or plan, in relation to prior approval under division (B)(6)(a) of this section, may require a health care practitioner to submit information to the insurer or plan indicating that the patient's chronic condition has not changed.

(i) The request for information by the insurer or plan and the response by the health care practitioner shall be in an electronic format, which may be by electronic mail or other electronic communication.

(ii) The frequency of the submission of requested information shall be consistent with medical or scientific evidence, as defined in section 3922.01 of the Revised Code, but shall not be required more frequently than quarterly.

(iii) If the health care practitioner does not respond within five calendar days from the date the request was received, the insurer or plan may terminate the twelve-month approval.

(d) A twelve-month approval provided under division (B)(6)(a) of this section is no longer valid and automatically terminates if there are changes to federal or state laws or federal regulatory guidance or compliance information prescribing that the drug in question is no longer approved or safe for the intended purpose.

(e) A twelve-month approval provided under division (B)(6)(a) of this section does not apply to and is not required for any of the following:

(i) Medications that are prescribed for a non-maintenance condition;

(ii) Medications that have a typical treatment of less than one year;

(iii) Medications that require an initial trial period to determine effectiveness and tolerability, beyond which a one-year, or greater, prior authorization period will be given;

(iv) Medications where there is medical or scientific evidence as defined in section 3922.01 of the Revised Code that do not support a twelve-month prior approval;

(v) Medications that are a schedule I or II controlled substance or any opioid analgesic or benzodiazepine, as defined in section 3719.01 of the Revised Code;

(vi) Medications that are not prescribed by an in-network provider as part of the care management program.

(7) For policies issued on or after January 1, 2017, an insurer or plan may, but is not required to, provide the twelve-month approval prescribed in division (B)(6)(a) of this section for a prescription drug that meets either of the following:

(a) The drug is prescribed or administered to treat a rare medical condition and pursuant to medical or scientific evidence as defined in section 3922.01 of the Revised Code.

(b) Medications that are controlled substances not included in division (B)(6)(e)(v) of this section.

For purposes of division (B)(7) of this section, "rare medical condition" means any disease or condition that affects fewer than two hundred thousand individuals in the United States.

(8) Nothing in division (B)(6) or (7) of this section prohibits the substitution, in accordance with section 4729.38 of the Revised Code, of any drug that has received a twelve-month approval under division (B)(6)(a) of this section when there is a release of either of the following:

(a) A United States food and drug administration approved comparable brand product or a generic counterpart of a brand product that is listed as therapeutically equivalent in the United States food and drug administration's publication titled approved drug products with therapeutic equivalence evaluations;

(b) An interchangeable biological product, as defined in section 3715.01 of the Revised Code.

(9)(a) For policies issued on or after January 1, 2017, upon written request, an insurer or plan shall permit a retrospective review for a claim that is submitted for a service where prior authorization was required but not obtained if the service in question meets all of the following:

(i) The service is directly related to another service for which prior approval has already been obtained and that has already been performed.

(ii) The new service was not known to be needed at the time the original prior authorized service was performed.

(iii) The need for the new service was revealed at the time the original authorized service was performed.

(b) Once the written request and all necessary information is received, the insurer or plan shall review the claim for coverage and medical necessity. The insurer or plan shall not deny a claim for such a new service based solely on the fact that a prior authorization approval was not received for the new service in question.

(10)(a) For policies issued on or after January 1, 2017, the insurer or plan shall disclose to all participating health care practitioners any new prior authorization requirement at least thirty days prior to the effective date of the new requirement.

(b) The notice may be sent via electronic mail or standard mail and shall be conspicuously entitled "Notice of Changes to Prior Authorization Requirements." The notice is not required to contain a complete listing of all changes made to the prior authorization requirements, but shall include specific information on where the health care practitioner may locate the information on the insurer or plan's web site or, if applicable, the insurer's or plan's portal.

(c) All participating health care practitioners shall promptly notify the insurer or plan of any changes to the health care practitioner's electronic mail or standard mail address.

(11)(a) For policies issued on or after January 1, 2017, the insurer or plan shall make available to all participating health care practitioners on its web site or provider portal a listing of its prior authorization requirements, including specific information or documentation that a practitioner must submit in order for the prior authorization request to be considered complete.

(b) The insurer or plan shall make available on its web site information about the policies, contracts, or agreements offered by the insurer or plan that clearly identifies specific services, drugs, or devices to which a prior authorization requirement exists.

(12) For policies issued on or after January 1, 2018, the insurer or plan shall establish a streamlined appeal process relating to adverse prior authorization determinations that shall include all of the following:

(a) For urgent care services, the appeal shall be considered within forty-eight hours after the insurer or plan receives the appeal.

(b) For all other matters, the appeal shall be considered within ten calendar days after the insurer or plan receives the appeal.

(c) The appeal shall be between the health care practitioner requesting the service in question and a clinical peer.

(d) If the appeal does not resolve the disagreement, either the covered person or an authorized representative as defined in section 3922.01 of the Revised Code may request an external review under Chapter 3922. of the Revised Code to the extent Chapter 3922. of the Revised Code is applicable.

(C) For policies issued on or after January 1, 2017, except in cases of fraudulent or materially incorrect information, an insurer or plan shall not retroactively deny a prior authorization for a health care service, drug, or device when all of the following are met:

(1) The health care practitioner submits a prior authorization request to the insurer or plan for a health care service, drug, or device;

(2) The insurer or plan approves the prior authorization request after determining that all of the following are true:

(a) The patient is eligible under the health benefit plan.

(b) The health care service, drug, or device is covered under the patient's health benefit plan.

(c) The health care service, drug, or device meets the insurer's or plan's standards for medical necessity and prior authorization.

(3) The health care practitioner renders the health care service, drug, or device pursuant to the approved prior authorization request and all of the terms and conditions of the health care practitioner's contract with the insurer or plan;

(4) On the date the health care practitioner renders the prior approved health care service, drug, or device, all of the following are true:

(a) The patient is eligible under the health benefit plan.

(b) The patient's condition or circumstances related to the patient's care has not changed.

(c) The health care practitioner submits an accurate claim that matches the information submitted by the health care practitioner in the approved prior authorization request.

(5) If the health care practitioner submits a claim that includes an unintentional error and the error results in a claim that does not match the information originally submitted by the health care practitioner in the approved prior authorization request, upon receiving a denial of services from the insurer or plan, the health care practitioner may resubmit the claim pursuant to division (C) of this section with the information that matches the information included in the approved prior authorization.

(D) Any provision of a contractual arrangement entered into between an insurer or plan and a health care practitioner or beneficiary that is contrary to divisions (A) to (C) of this section is unenforceable.

(E) For policies issued on or after January 1, 2017, committing a series of violations of this section that, taken together, constitute a practice or pattern shall be considered an unfair and deceptive practice under sections 3901.19 to 3901.26 of the Revised Code.

(F) The superintendent of insurance may adopt rules in accordance with Chapter 119. of the Revised Code as necessary to implement the provisions of this section.

(G) This section does not apply to any of the following types of coverage: a policy, contract, certificate, or agreement that covers only a specified accident, accident only, credit, dental, disability income, long-term care, hospital indemnity, supplemental coverage as described in section 3923.37 of the Revised Code, specified disease, or vision care; a dental benefit that is offered as a part of a policy of sickness and accident insurance or a public employee benefit plan; coverage issued as a supplement to liability insurance; insurance arising out of workers' compensation or similar law; automobile medical payment insurance; insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance; a medicare supplement policy of insurance as defined by the superintendent of insurance by rule; coverage under a plan through medicare or the federal employees benefit program; or any coverage issued under Chapter 55 of Title 10 of the United States Code and any coverage issued as a supplement to that coverage.

Section 3923.05 | Provisions to conform to prescribed wording.

• Effective: April 7, 2009
• Latest Legislation: House Bill 493 - 127th General Assembly

Except as provided in section 3923.07 of the Revised Code, no policy of sickness and accident insurance delivered, issued for delivery, or used in this state shall contain provisions respecting the matters set forth in this section unless such provisions are in the words in which the same appear in this section. Any such provisions in any such policy shall be preceded by the appropriate caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the superintendent of insurance may approve.

(A) A provision as follows: Change of occupation. If the insured be injured or contract sickness after having changed the insured's occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes the insured's occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification for occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to the date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.

(B) A provision as follows: Misstatement of age. If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.

(C) A provision as follows:

(1) Other insurance in this insurer. If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for _______________ in excess of _________ dollars, the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to the insured's estate.

The insurer shall insert the type of coverage or coverages in the first blank space in the provision in division (C)(1) of this section and the maximum limit of indemnity or indemnities in the second blank space in the provision in division (C)(1) of this section.

(2) In lieu of the foregoing provision in division (C)(1) of this section, a provision as follows: Other insurance in this insurer. Insurance effective at any time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, the insured's beneficiary or the insured's estate, as the case may be, and the insurer will return all premiums paid for all other such policies.

(D) A provision as follows: Insurance with other insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.

If the provision in division (D) of this section is included in a policy of sickness and accident insurance which also contains the provision in division (E) of this section, the insurer shall add to the caption of the provision in division (D) of this section the following: Expense incurred benefits.

The insurer may at its option include in the provision in division (D) of this section a definition of "other valid coverage" approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the superintendent. In the absence of such definition in the provision in division (D) of this section, "other valid coverage" as used in such provision shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations.

For the purpose of applying the provision in division (D) of this section with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, whether provided by governmental agency or otherwise, shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice.

In applying the provision in division (D) of this section no third party liability coverage shall be included as "other valid coverage."

(E) A provision as follows: Insurance with other insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which the insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined.

If the provision in division (E) of this section is included in a policy of sickness and accident insurance which also contains the provision in division (D) of this section, the insurer shall add to the caption of the provision in division (E) of this section the following: Other benefits.

The insurer may at its option include in the provision in division (E) of this section a definition of "other valid coverage" approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada, and to any other coverage the inclusion of which may be approved by the superintendent. In the absence of such definition in the provision in division (E) of this section, "other valid coverage" as used in such provision shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations.

For the purpose of applying the provision in division (E) of this section with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, whether provided by a governmental agency or otherwise, shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice.

In applying the provision in division (E) of this section no third party liability coverage shall be included as "other valid coverage."

(F) A provision as follows: Relation of earnings to insurance. If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or the insured's average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall this operate to reduce benefits other than those payable for loss of time.

The provision in division (F) of this section may be placed only in a policy of sickness and accident insurance which the insured has a right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or in a policy of sickness and accident insurance issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue.

The insurer may at its option include in the provision in division (F) of this section a definition of "valid loss of time coverage" approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada or to any other coverage the inclusion of which may be approved by the superintendent or any combination of such coverages. In the absence of such definition in the provision in division (F) of this section "valid loss of time coverage" as used in such provision shall not include any coverage provided for such insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, whether provided by a governmental agency or otherwise, or benefits provided by union welfare plans or by employer or employee benefit organizations.

(G) A provision as follows: Unpaid premium. Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.

(H) A provision as follows: Conformity with state statutes. Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.

(I) A provision as follows: Illegal occupation. The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.

Section 3923.06 | Order of presentation of policy provisions.

• Effective: July 1, 1955
• Latest Legislation: House Bill 881 - 101st General Assembly

The policy provisions set forth in sections 3923.04 and 3923.05 of the Revised Code or any corresponding policy provisions used in lieu thereof in accordance with section 3923.07 of the Revised Code shall be printed in each policy of sickness and accident insurance in the order in which such policy provisions are set forth in sections 3923.04 and 3923.05 of the Revised Code or, at the option of the insurer, any such policy provision may be printed as a unit in any part of any such policy along with other policy provisions to which such policy provision may be logically related, provided the resulting policy shall not be wholly or partly unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom such policy is offered, delivered, or issued.

As used in sections 3923.01, 3923.04, 3923.05, 3923.06, 3923.07, 3923.10, 3923.13, 3923.15, 3923.19 and 3923.20 of the Revised Code, "insured" shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy of sickness and accident insurance covering the insured or from being entitled under such policy to any indemnities, benefits, and rights provided therein.

Any policy of sickness and accident insurance may contain a provision for paying not exceeding two hundred dollars as an extended disability benefit upon the insured's death from any cause, which benefit shall not be construed as life insurance.

If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to the right of cancellation by the insured until the end of the period for which premium has been accepted. The insurer may not refuse to accept any premium due before the first anniversary, or between anniversaries, of the date of issue of any policy other than an accident insurance only policy. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

Any such policy may contain a provision making any portion of the charter, constitution, or bylaws of the insurer a part of the policy, but such portion of the charter, constitution, or bylaws shall be set forth in full in the policy, provided that this provision shall not apply to any statement of rates or classification of risks or short rate table filed with the superintendent of insurance.

Section 3923.061 | Interest on proceeds payable due to death by sickness or accident.

• Effective: July 23, 2002
• Latest Legislation: House Bill 345 - 124th General Assembly

(A) On and after January 1, 2003, any insurance company authorized to do business in this state shall pay interest, in accordance with division (B) of this section and subject to division (C) of this section, on any proceeds that become due pursuant to the terms of a policy of sickness and accident insurance due to the death of the insured by sickness or accident.

(B) The interest payable pursuant to division (A) of this section shall be computed from the date of the death of the insured to the date of the payment of the proceeds and shall be at whichever of the following rates is greater:

(1) The annual short-term applicable federal rate for purposes of section 1274(d) of the Internal Revenue Code, as defined in section 5747.01 of the Revised Code, in effect for the month in which the insured died;

(2) The current rate of interest on proceeds left on deposit with the company under an interest settlement option contained in the policy of sickness and accident insurance.

(C) Division (A) or (B) of this section does not require the payment of interest unless the insured was a resident of this state on the date of the insured's death and unless the beneficiary under the policy of sickness and accident insurance elects in writing to receive, or a written election has been made for the beneficiary to receive, the proceeds of the policy by means of a lump sum payment.

Section 3923.07 | Omission or substitution of provisions.

• Effective: October 14, 1953
• Latest Legislation: Senate Bill 268 - 100th General Assembly

If any policy provision set forth in section 3923.04 or 3923.05 of the Revised Code is in whole or in part inapplicable or inconsistent with the coverage provided by a policy of sickness and accident insurance, the insurer shall, with the approval of the superintendent of insurance, omit from such policy any inapplicable provision or part of a provision and shall, with the approval of the superintendent, modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

In any such policy an insurer may at its option substitute for, or use in lieu of, anyone or more of the policy provisions set forth in sections 3923.04 and 3923.05 of the Revised Code a corresponding policy provision or corresponding policy provisions of different wording approved by the superintendent which is not less favorable in any respect to the insured or the beneficiary.

No policy provision not subject to sections 3923.04 and 3923.05 of the Revised Code shall make any policy of sickness and accident insurance or any part of any such policy less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to such sections.

Section 3923.071 | Policies, applications, riders or indorsements issued prior to 10-1-53.

• Effective: October 14, 1953
• Latest Legislation: Senate Bill 268 - 100th General Assembly

Any policy of sickness and accident insurance, indorsement, rider, or application which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be delivered, issued for delivery, or used in this state until January 1, 1956, without being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

A copy of the form of any policy of sickness and accident insurance, indorsement, rider, or application which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be filed with and approved by the superintendent at any time after October 1, 1953, for subsequent delivery, issuance for delivery, and use in this state until January 1, 1956, without being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

A copy of the form of any rider or indorsement which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be filed with and approved by the superintendent at any time after October 1, 1953, for subsequent delivery, issuance for delivery, or use in this state at any time after October 1, 1953, in connection with and as a part of policies of sickness and accident insurance issued before January 1, 1956, on any policy form which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, regardless of when such policy form was filed with and approved by the superintendent, without such rider or indorsement being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

Section 3923.08 | Nonconflicting provisions permitted in policy.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

Any foreign or alien insurer authorized to do business in this state may, with the approval of the superintendent of insurance, insert in any policy of sickness and accident insurance, delivered, issued for delivery, or used in this state, any provision required by the laws of the state or the country in which such insurer is domiciled, if such provision is not substantially in conflict with any law of this state.

Any domestic insurer may insert in any such policy issued for delivery in another state or foreign country, and governed by the laws thereof, any provision required by the laws of such other state or country applicable to such policy.

Section 3923.09 | Validity of nonconforming policy.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

A policy of sickness and accident insurance issued in violation of sections 3923.01 to 3923.22, inclusive, of the Revised Code, is valid but shall be construed as provided by such sections, and when any provision in such policy is in conflict with such sections, the rights, duties, and obligations of the insurer, the policyholder, and the beneficiary shall be governed by such sections.

Section 3923.10 | Industrial sickness and accident insurance.

• Effective: July 1, 1955
• Latest Legislation: House Bill 881 - 101st General Assembly

Industrial sickness and accident insurance is that form of sickness and accident insurance under individual policies for which the premium is payable weekly, and includes any such policy which covers sickness only or accident only.

Any insurer authorized to make, transact, or issue sickness and accident insurance in this state may make, transact, or issue industrial sickness and accident insurance in this state.

No policy of industrial sickness and accident insurance may be delivered, issued for delivery, or used in this state unless it has printed thereon the words "industrial policy."

Each such policy shall be subject to sections 3923.01 to 3923.22, inclusive, of the Revised Code. Such policy may contain a provision that, upon proper written request, a named beneficiary shall be designated in or by indorsement on the policy to receive the proceeds thereof on the death of the insured, and there shall be reserved to the insured the power to change the beneficiary at any time by written notice to the insurer at its home office, accompanied by the policy for indorsement of the change thereon by the insurer. The insurer may refuse to designate a beneficiary if evidence satisfactory to the company of such beneficiary's insurable interest in the life of the insured is not furnished on request. Any such policy may provide in substance that any payment thereunder may be made to the insured or the insured's estate, or to any relative by blood or connection by marriage of the insured, or to the extent of such portion of any payment under the policy as may reasonably appear to the insurer to be due to such person, or to any other person equitably entitled thereto by reason of having incurred expense occasioned by the maintenance, illness, or burial of the insured. If the policy is in force at the death of the insured, the proceeds thereof shall be payable to the named beneficiary if he is living, but upon the expiration of fifteen days after the death of the insured, unless proof of claim in the manner and form required by the policy, accompanied by the policy for surrender, has previously been made by such beneficiary, the insurer may pay said proceeds to any other person permitted by the policy.

Section 3923.11 | Sickness and accident insurance on a franchise plan.

• Effective: October 16, 2009
• Latest Legislation: House Bill 1 - 128th General Assembly

(A) Sickness and accident insurance on a franchise plan is that form of sickness and accident insurance issued to either of the following:

(1) Five or more or, with respect to long-term care or disability income insurance, two or more employees of any corporation, copartnership, or individual employer, or of any governmental corporation or agency or a department thereof;

(2) Ten or more or, with respect to long-term care or disability income insurance, two or more members of any trade or professional association, or labor union, or any other association having had an active existence for at least two years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance.

(B) In order that such sickness and accident insurance be considered as issued on a franchise plan, such employees or such members, with or without one or more of their dependents and members of their immediate families, must be issued the same form of an individual policy, varying only as to amounts and kinds of coverage applied for by such employees or such members, under an arrangement by which the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association for its members, or by some designated person acting on behalf of such employer or association.

Section 3923.12 | Group sickness and accident insurance.

• Effective: April 11, 1991
• Latest Legislation: House Bill 737 - 118th General Assembly

(A) Group sickness and accident insurance is that form of sickness and accident insurance covering any group of two or more employees, members, or other persons, with or without one or more of their dependents and members of their immediate families. Such insurance may be offered to groups without regard to the purpose or type of group or the occupation of the employees, members, or other persons insured under the policy.

(B) As used in this section:

(1) "Employees" includes the officers, managers, and employees of the employer, the partners, if the employer is a partnership, the officers, managers, and employees of subsidiary or affiliated corporations of a corporation employer, and the individual proprietors, partners, and employees of individuals and firms, the business of which is controlled by the insured employer through stock ownership, contract, or otherwise.

(2) "Employer" includes any municipal or governmental corporation, unit, agency, or department thereof, as well as private individuals, partnerships, and corporations.

(C) Each such policy shall contain in substance the following provisions:

(1) A provision that the policy, the application of the policyholder, if the application or copy thereof is attached to the policy, and the individual applications submitted in connection with the policy by the employees or members, shall constitute the entire contract between the parties, and that all statements, in the absence of fraud, made by any applicant shall be deemed representations and not warranties, and that no such statement shall avoid the insurance or reduce benefits thereunder unless contained in a written application;

(2) A provision that the insurer will furnish to the policyholder, for delivery to each employee or member of the insured group, an individual certificate setting forth in summary form a statement of the essential features of the insurance coverage of the employee or member and to whom benefits thereunder are payable. If dependents or members of the immediate family of the employee or member are included in the coverage, only one certificate need be issued for each family unit.

(3) A provision that to the group originally insured may be added from time to time eligible new employees or members, their dependents, or members of their immediate families, in accordance with the terms of the policy.

(D) Each such policy together with any application in connection therewith shall be available for inspection at all reasonable times at the place of business or principal residence of the policyholder where the policy is on file, by any beneficiary thereunder, or by an authorized representative of the beneficiary.

Section 3923.121 | Association of insurers to provide basic medical coverage to persons 65 or older.

• Effective: September 1, 2002
• Latest Legislation: Senate Bill 129 - 124th General Assembly

(A) As used in this section:

(1) "Association" means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide sickness and accident insurance in accordance with this section.

(2) "Insurer" means any insurance company authorized to do the business of sickness and accident insurance in this state.

(3) "Insured" means a person covered under a group policy issued pursuant to this section.

(B) Any insurer may join with one or more other insurers, in an association, to offer, sell, and issue to a policyholder selected by the association a policy of group insurance against major financial loss from sickness and accident covering residents of this state who are sixty-five years of age or older and the spouses of such residents. The insurance shall be offered, issued, and administered in the name of the association. Membership in the association shall be open to any insurer and each insurer which participates shall be liable for a specified percentage of the risks. The policy may be executed on behalf of the association by a duly authorized person and need not be countersigned by an agent.

(C) The persons eligible for coverage under the policy shall be all residents of this state who are sixty-five years of age or older and their spouses, subject to reasonable underwriting restrictions to be set forth in the plan of the association. The policy may provide basic hospital and surgical coverage, basic medical coverage, major medical coverage, and any combination of these; provided that it shall not be required as a condition for obtaining major medical coverage that any basic coverage be taken.

(D) The association shall file with the superintendent of insurance any policy, contract, certificate, or other evidence of insurance, application, or other forms pertaining to such insurance together with the premium rates to be charged therefor. The superintendent may approve, disapprove, and withdraw approval of the forms in accordance with section 3923.02 of the Revised Code, or the premium rates if by reasonable assumptions such rates are excessive in relation to the benefits provided. In determining whether such rates by reasonable assumptions are excessive in relation to the benefits provided the superintendent shall give due consideration to past and prospective claim experience, within and outside this state, and to fluctuations in such claim experience, to a reasonable risk charge, to contribution to surplus and contingency funds, to past and prospective expenses, both within and outside this state, and to all other relevant factors within and outside this state, including any differing operating methods of the insurers joining in the issuance of the policy. In reviewing the forms the superintendent shall not be bound by the requirements of sections 3923.04 to 3923.07 of the Revised Code with respect to standard provisions to be included in sickness and accident policies or forms.

(E) The association may enroll eligible persons for coverage under the policy through any insurance agent licensed to sell sickness and accident insurance pursuant to Chapter 3905. of the Revised Code or section 3941.02 of the Revised Code.

(F) The association shall file annually with the superintendent on such date and in such form as the superintendent may prescribe, a financial summary of its operations.

(G) The association may sue and be sued in its associate name and for such purposes only shall be treated as a domestic corporation. Service of process against the association made upon a managing agent, any member thereof, or any agent authorized by appointment to receive service of process, shall have the same force and effect as if the service had been made upon all members of the association.

(H) Under any policy issued as provided in this section, the policyholder, or such person as the policyholder shall designate, shall alone be a member of each domestic mutual insurance company joining in the issue of the policy and shall be entitled to one vote by virtue of such policy at the meetings of each such mutual insurance company. Notice of the annual meetings of each such mutual insurance company may be given by written notice to the policyholder or as otherwise prescribed in the policy.

Section 3923.122 | [Suspended eff. 1/1/2014 to 1/1/2026, per Section 3 of S.B. 9 of the 130th General Assembly, as amended] Option for conversion from group policy to individual policy.

• Effective: October 16, 2009
• Latest Legislation: House Bill 1 - 128th General Assembly

(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1976, shall include a provision giving each insured the option to convert to the following:

(1) In the case of an individual who is not a federally eligible individual, any of the individual policies of hospital, surgical, or medical expense insurance then being issued by the insurer with benefit limits not to exceed those in effect under the group policy;

(2) In the case of a federally eligible individual, a basic or standard plan established in accordance with section 3924.10 of the Revised Code or plans substantially similar to the basic and standard plan in benefit design and scope of covered services. For purposes of division (A)(2) of this section, the superintendent of insurance shall determine whether a plan is substantially similar to the basic or standard plan in benefit design and scope of covered services.

(B) An option for conversion to an individual policy shall be available without evidence of insurability to every insured, including any person eligible under division (D) of this section, who terminates employment or membership in the group holding the policy after having been continuously insured thereunder for at least one year.

Upon receipt of the insured's written application and upon payment of at least the first quarterly premium not later than thirty-one days after the termination of coverage under the group policy, the insurer shall issue a converted policy on a form then available for conversion. The premium shall be in accordance with the insurer's table of premium rates in effect on the later of the following dates:

(1) The effective date of the converted policy;

(2) The date of application therefor; and shall be applicable to the class of risk to which each person covered belongs and to the form and amount of the policy at the person's then attained age. However, premiums charged federally eligible individuals may not exceed the amounts specified below:

(a) For calendar years 2010 and 2011, an amount that is two times the base rate charged any other individual of a group to which the insurer is currently accepting new business and for which similar copayments and deductibles are applied;

(b) For calendar year 2012 and every year thereafter, an amount that is one and one-half times the base rate charged any other individual of a group to which the insurer is currently accepting new business and for which similar copayments and deductibles are applied, unless the superintendent of insurance determines that the amendments by this act to sections 3923.58 and 3923.581 of the Revised Code, have resulted in the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the premium limit established by division (B)(2)(a) of this section shall remain in effect.

At the election of the insurer, a separate converted policy may be issued to cover any dependent of an employee or member of the group.

Except as provided in division (H) of this section, any converted policy shall become effective as of the day following the date of termination of insurance under the group policy.

Any probationary or waiting period set forth in the converted policy is deemed to commence on the effective date of the insured's coverage under the group policy.

(C) No insurer shall be required to issue a converted policy to any person who is, or is eligible to be, covered for benefits at least comparable to the group policy under:

(1) Title XVIII of the Social Security Act, as amended or superseded;

(2) Any act of congress or law under this or any other state of the United States that duplicates coverage offered under division (C)(1) of this section;

(3) Any policy that duplicates coverage offered under division (C)(1) of this section;

(4) Any other group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only.

(D) The option for conversion shall be available:

(1) Upon the death of the employee or member, to the surviving spouse with respect to such of the spouse and dependents as are then covered by the group policy;

(2) To a child solely with respect to the child upon attaining the limiting age of coverage under the group policy while covered as a dependent thereunder;

(3) Upon the divorce, dissolution, or annulment of the marriage of the employee or member, to the divorced spouse, or former spouse in the event of annulment, of such employee or member, or upon the legal separation of the spouse from such employee or member, to the spouse.

Persons possessing the option for conversion pursuant to this division shall be considered members for the purposes of division (H) of this section.

(E) If coverage is continued under a group policy on an employee following retirement prior to the time the employee is, or is eligible to be, covered by Title XVIII of the Social Security Act, the employee may elect, in lieu of the continuance of group insurance, to have the same conversion rights as would apply had the employee's insurance terminated at retirement by reason of termination of employment.

(F) If the insurer and the group policyholder agree upon one or more additional plans of benefits to be available for converted policies, the applicant for the converted policy may elect such a plan in lieu of a converted policy.

(G) The converted policy may contain provisions for avoiding duplication of benefits provided pursuant to divisions (C)(1), (2), (3), and (4) of this section or provided under any other insured or noninsured plan or program.

(H) If an employee or member becomes entitled to obtain a converted policy pursuant to this section, and if the employee or member has not received notice of the conversion privilege at least fifteen days prior to the expiration of the thirty-one-day conversion period provided in division (B) of this section, then the employee or member has an additional period within which to exercise the privilege. This additional period shall expire fifteen days after the employee or member receives notice, but in no event shall the period extend beyond sixty days after the expiration of the thirty-one-day conversion period.

Written notice presented to the employee or member, or mailed by the policyholder to the last known address of the employee or member as indicated on its records, constitutes notice for the purpose of this division. In the case of a person who is eligible for a converted policy under division (D)(2) or (D)(3) of this section, a policyholder shall not be responsible for presenting or mailing such notice, unless such policyholder has actual knowledge of the person's eligibility for a converted policy.

If an additional period is allowed by an employee or member for the exercise of a conversion privilege, and if written application for the converted policy, accompanied by at least the first quarterly premium, is made after the expiration of the thirty-one-day conversion period, but within the additional period allowed an employee or member in accordance with this division, the effective date of the converted policy shall be the date of application.

(I) The converted policy may provide that any hospital, surgical, or medical expense benefits otherwise payable with respect to any person may be reduced by the amount of any such benefits payable under the group policy for the same loss after termination of coverage.

(J) The converted policy may contain:

(1) Any exclusion, reduction, or limitation contained in the group policy or customarily used in individual policies issued by the insurer;

(2) Any provision permitted in this section;

(3) Any other provision not prohibited by law.

Any provision required or permitted in this section may be made a part of any converted policy by means of an endorsement or rider.

(K) The time limit specified in a converted policy for certain defenses with respect to any person who was covered by a group policy shall commence on the effective date of such person's coverage under the group policy.

(L) No insurer shall use deterioration of health as the basis for refusing to renew a converted policy.

(M) No insurer shall use age or health status as the basis for refusing to renew a converted policy.

(N) A converted policy made available pursuant to this section shall, if delivery of the policy is to be made in this state, comply with this section. If delivery of a converted policy is to be made in another state, it may be on a form offered by the insurer in the jurisdiction where the delivery is to be made and which provides benefits substantially in compliance with those required in a policy delivered in this state.

(O) As used in this section:

(1) "Base rate" means, as to any health benefit plan that is issued by an insurer in the individual market, the lowest premium rate for new or existing business prescribed by the insurer for the same or similar coverage under a plan or arrangement covering any individual of a group with similar case characteristics.

(2) "Federally eligible individual" means an eligible individual as defined in 45 C.F.R. 148.103.

Last updated March 23, 2022 at 10:27 AM

Section 3923.123 | Association of insurers to provide group health coverage to qualified unemployed persons.

• Effective: June 4, 1997
• Latest Legislation: Senate Bill 67 - 122nd General Assembly

(A) As used in this section:

(1) "Association" means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide health coverage in accordance with this section.

(2) "Insurer" includes any insurance company authorized to do the business of sickness and accident insurance in this state and any health insuring corporation holding a certificate of authority under Chapter 1751. of the Revised Code.

(3) "Insured" means a person covered under a group policy or contract issued pursuant to this section.

(4) "Qualified unemployed person" means one who became unemployed while a resident of this state from employment or self-employment and has since been continuously unemployed or is employed only so that the person does not have, or have a right to purchase, group health coverage. An individual who is, or who becomes, covered by medicare is not a qualified unemployed person. A person eligible for coverage under this section, who is also eligible for continuation of coverage under section 1751.53 or 3923.38 of the Revised Code, may elect either coverage, but not both. A person who elects continuation of coverage under either of such sections may, upon the termination of the continuation of coverage, elect any coverage available under this section.

(B) Any insurer may join with one or more other insurers, in an association, to offer, sell, and issue to a policyholder or subscriber selected by the association a policy or contract of group health coverage, covering residents of this state who are qualified unemployed persons and the spouses or dependents of such residents. The coverage shall be offered, issued, and administered in the name of the association. Membership in the association shall be open to any insurer and each insurer which participates shall be liable for a specified percentage of the risks. The policy or contract may be executed on behalf of the association by a duly authorized person.

(C) The persons eligible for coverage under the policy or contract shall be all residents of this state who are qualified unemployed persons and their spouses and dependents, subject to reasonable underwriting restrictions to be set forth in the plan of the association. The policy or contract may provide basic hospital and surgical coverage, basic medical coverage, major medical coverage, and any combination of these; provided that it shall not be required as a condition for obtaining major medical coverage that any basic coverage be taken.

(D) The association shall file with the superintendent of insurance any policy, contract, certificate, or other evidence of coverage, application, or other forms pertaining to such insurance together with the premium rates to be charged therefor. The superintendent may approve, disapprove, and withdraw approval of the forms in accordance with section 3923.02 of the Revised Code, or the premium rates if by reasonable assumptions such rates are excessive in relation to the benefits provided. In determining whether such rates by reasonable assumptions are excessive in relation to the benefits provided, the superintendent shall give due consideration to past and prospective claim experience, within and outside this state, and to fluctuations in such claim experience, to a reasonable risk charge, to contribution to surplus and contingency funds, to past and prospective expenses, both within and outside this state, and to all other relevant factors within and outside this state, including any differing operating methods of the insurers joining in the issuance of the policy or contract. In reviewing the forms the superintendent shall not be bound by the requirements of sections 3923.04 to 3923.07 of the Revised Code with respect to standard provisions to be included in sickness and accident policies or forms.

(E) The association may enroll eligible persons for coverage under the policy or contract through any person licensed by, or authorized under the law of, this state to sell the policies or contracts, or to enroll persons in the health plans, of any of the insurers participating in the association.

(F) The association shall file annually with the superintendent on such date and in such form as the superintendent may prescribe, a financial summary of its operations.

(G) The association may sue and be sued in its associate name and for such purposes only shall be treated as a domestic corporation. Service of process against such association made upon a managing agent, any member thereof, or any agent authorized by appointment to receive service of process, shall have the same force and effect as if such service had been made upon all members of the association.

(H) Under any policy issued as provided in this section, the policyholder, or such person as the policyholder shall designate, shall alone be a member of each domestic mutual insurance company joining in the issue of the policy and shall be entitled to one vote by virtue of such policy at the meetings of each such mutual insurance company. Notice of the annual meetings of each such mutual insurance company may be given by written notice to the policyholder or as otherwise prescribed in said policy.

Section 3923.13 | Blanket sickness and accident insurance.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

Blanket sickness and accident insurance is that form of sickness and accident insurance covering special groups of persons as enumerated in one of the following divisions:

(A) Under a policy issued to any common carrier, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on such common carrier;

(B) Under a policy issued to an employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment;

(C) Under a policy issued to a college, school, or other institution of learning, or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or teachers;

(D) Under a policy issued in the name of any volunteer fire department or first aid or other similar volunteer group, which shall be deemed the policyholder, covering all of the members of such department or group;

(E) Under a policy issued to any other substantially similar group which, in the discretion of the superintendent of insurance, may be subject to the issuance of a blanket sickness and accident policy.

An individual application is not required from a person covered under a blanket sickness or accident policy, nor is it necessary for the insurer to furnish each person a certificate.

All benefits under any blanket sickness and accident policy shall be payable to the person insured, or to his designated beneficiary, or to his estate, except that if the person insured is a minor, such benefits may be made payable to his parent, guardian, or other person actually supporting him.

This section does not affect the legal liability of policyholders for the death of, or injury to, any member of any such group.

Section 3923.14 | False statement in application - alteration of written application.

• Effective: July 1, 1955
• Latest Legislation: House Bill 881 - 101st General Assembly

The falsity of any statement in the application for any policy of sickness and accident insurance shall not bar the right to recovery thereunder, or be used in evidence at any trial to recover upon such policy, unless it is clearly proved that such false statement is willfully false, that it was fraudulently made, that it materially affects either the acceptance of the risk or the hazard assumed by the insurer, that it induced the insurer to issue the policy, and that but for such false statement the policy would not have been issued.

No alteration of any written application for any such policy, by erasure, insertion, or otherwise, shall be made by any person other than the applicant without the written consent of said applicant, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not be ascribed to the applicant.

Section 3923.141 | Agent of the insurer.

• Effective: July 1, 1955
• Latest Legislation: House Bill 1 - 101st General Assembly

Any person who solicits an application for, or for reinstatement of, a policy of sickness and accident insurance to insure any other person shall be considered the agent of the insurer and not of the insured in any controversy between the insured or his beneficiary and the insurer issuing or reinstating a policy upon such application or accepting or making a renewal of such policy.

Section 3923.15 | Unfair discrimination prohibited.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

No insurer doing the business of sickness and accident insurance in this state shall make or permit any unfair discrimination between individuals of substantially the same hazard in the amount of premium rates charged for any policy or contract of such insurance or in the benefits payable thereunder. This section does not prohibit different premium rates, different benefits, or different underwriting procedure for individuals insured under group, franchise, or blanket plans of insurance, or for individuals insured under a policy issued to the head of a family as provided in section 3923.03.

Section 3923.16 | Misleading or deceptive advertising prohibited.

• Effective: July 1, 1955
• Latest Legislation: House Bill 881 - 101st General Assembly

No insurer doing business in this state, and no insurance agent, solicitor, or broker, shall use in connection with the solicitation of sickness and accident insurance any advertising copy, advertising practice, or plan of solicitation which is materially misleading or deceptive. An advertising copy, advertising practice, or plan of solicitation is materially misleading or deceptive if, by implication or otherwise, it transmits information in such manner or of such substance that a prospective applicant for sickness and accident insurance may be led thereby to his material damage.

If, after due notice and hearing, the superintendent of insurance finds that any such advertising copy, advertising practice, or plan of solicitation is materially misleading or deceptive, he shall order the insurer, agent, solicitor, or broker using such copy, practice, or plan to cease such use. Upon making such a finding the superintendent may also, by order, suspend the certificate of authority of such insurer to transact business within this state, or suspend the license issued to such agent, solicitor, or broker, for a period of not more than ninety days.

If the superintendent finds, after due notice and hearing, that any authorized insurer, licensed insurance agent, licensed insurance solicitor, or licensed insurance broker has willfully violated any such order to cease, he may suspend or revoke the certificate of authority of such insurer, or the license issued to such agent, solicitor, or broker.

Section 3923.161 | Describing cancellability and renewability provisions clearly and with prominence or emphasis.

• Effective: January 1, 1980
• Latest Legislation: House Bill 43 - 113th General Assembly

(A) No insurer doing business in this state, and no insurance agent, solicitor, or broker, shall, in connection with any advertising copy, advertising practice, or plan of solicitation, refer to noncancellation provisions of a sickness and accident insurance policy without successively describing the cancellability and the renewability provisions of the policy clearly and with equal prominence or emphasis.

(B) Violation of this section is an unfair and deceptive act or practice under section 3923.16 and sections 3901.19 to 3901.22 of the Revised Code.

(C) As used in this section, "advertising copy," "advertising practice," or "plan of solicitation" includes oral or written representations.

Section 3923.17 | Prohibition of rebates not to prohibit commissions or dividends.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

The laws of this state prohibiting rebates do not prohibit any of the following:

(A) The payment of a commission or other compensation to any licensed agent or broker;

(B) Any insurer from allowing or returning to its participating policyholders dividends, savings, or unused premium deposits;

(C) Any insurer from returning or otherwise abating, in full or in part, the premiums of its policyholders out of surplus accumulated from nonparticipating insurance;

(D) The taking of a bona fide obligation, with interest at a rate not exceeding six per cent per annum, in the payment of any premium.

Section 3923.18 | Rights of insurer in defense of claim not waived.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

The acknowledgment by an insurer of the receipt of notice given under any policy of sickness and accident insurance, or the furnishing by him of forms for filing proofs of loss, or his acceptance of such proofs, or his investigation of any claim thereunder, shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

Section 3923.19 | Benefits exempt from legal process - exception.

• Effective: September 30, 2008
• Latest Legislation: Senate Bill 281 - 127th General Assembly

(A) Benefits under all policies of sickness and accident insurance are not liable to attachment or other process, or to be taken, appropriated, or applied by any legal or equitable process or by operation of law, either before or after payment of the benefits, to pay any liabilities of the person insured under any such policy to the extent that the benefits are reasonably necessary for the support of the debtor and any dependents of the debtor.

When a policy provides for a lump sum payment because of a dismemberment or other loss insured, the payment is exempt from execution by the insured's creditors.

(B)(1) A payment under a stock bonus, pension, profitsharing, annuity, or similar plan or contract on account of illness, disability, death, age, or length of service, to the extent reasonably necessary for the support of the person who is the beneficiary of the plan or party to the contract and any dependents of the person, is not liable to attachment or other process, or to be taken, appropriated, or applied by any legal or equitable process or by operation of law, either before or after payment of the benefits, to pay any liabilities of the person unless all of the following apply:

(a) The plan or contract was established by or under the auspices of an insider that employed the person at the time the person's rights under the plan or contract arose.

(b) The payment is on account of age or length of service.

(c) The plan or contract does not qualify under section 401(a), 403(a), 403(b), or 408 of the Internal Revenue Code of 1986, 100 Stat. 2085, 26 U.S.C. 1, as amended.

(2) When a plan or contract provides for a lump sum payment because of a dismemberment or other loss covered by the plan or contract, the payment is exempt from execution by the person's creditors.

Section 3923.20 | Exemptions for certain insurance policies.

• Effective: August 30, 1955
• Latest Legislation: Senate Bill 294 - 101st General Assembly

Sections 3923.01 to 3923.22, inclusive, of the Revised Code, do not apply to or affect:

(A)(1) Any policy of liability insurance, with or without supplementary expense coverage therein;

(2) Any policy of motor vehicle liability insurance with supplementary coverage protecting the insured against loss where said insured has secured a judgment against a party for bodily injury or death as a result of a motor vehicle accident and where said judgment remains unsatisfied.

(3) Any policy of motor vehicle liability insurance with supplementary coverage which insures against the hazards which arise out of a motor vehicle accident as defined in section 4509.01 (J) of the Revised Code.

(B) Any life insurance, endowment, or annuity policy or contract, or any contract supplemental thereto, which contains only such provisions relating to sickness and accident insurance as:

(1) Provide additional benefits in case of death or dismemberment by accident;

(2) Operate to safeguard such policy or contract against lapse, or to give a special surrender value or special benefit or annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the policy, contract, or supplemental contract.

Sections 3923.03 to 3923.07, inclusive, of the Revised Code, do not apply to those forms of sickness and accident policies enumerated in sections 3923.12 and 3923.13 of the Revised Code, provided that no such policy shall contain any provision relative to notice or proof of loss, or the time for paying benefits, or the time within which suit may be brought upon the policy, which in the opinion of the superintendent of insurance is less favorable to the insured than would be permitted by the standard provisions set forth in section 3923.04 of the Revised Code.

Section 3923.21 | Prohibition against delivery of policy on disapproved insurance form.

• Effective: September 29, 1955
• Latest Legislation: Senate Bill 365 - 101st General Assembly

If, after notice and hearing, the superintendent of insurance finds that any insurer, insurance agent, solicitor, or broker has delivered or issued for delivery or use in this state any policy of sickness and accident insurance on a form which has been disapproved by the superintendent of insurance or has violated sections 3923.01 to 3923.22, inclusive, of the Revised Code, or an order of the superintendent made in accordance with such sections, the superintendent may suspend the authority of such insurer to transact business within this state for a period of not more than ninety days. In the case of an agent, solicitor, or broker the superintendent may suspend the license issued to such agent, solicitor, or broker for a period of not more than ninety days.

If the superintendent finds that any such insurer, insurance agent, solicitor, or broker has willfully done any of the acts referred to in the preceding paragraph he may revoke the license of such insurer, agent, solicitor, or broker for any such willful violation.

Section 3923.22 | Appeal - applicability of administrative procedure sections.

• Effective: October 1, 1953
• Latest Legislation: House Bill 1 - 100th General Assembly

Any person, partnership, or corporation adversely affected by an order, finding, or determination of the superintendent of insurance may appeal to the court of common pleas of Franklin county in accordance with sections 119.01 to 119.13, inclusive, of the Revised Code. Said sections are also applicable to sections 3923.01 to 3923.22 inclusive, of the Revised Code.

Section 3923.23 | Reimbursement for services of licensed osteopath, optometrist, chiropractor or podiatrist.

• Effective: July 1, 1980
• Latest Legislation: House Bill 569 - 113th General Assembly

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, optometry, chiropractic, or podiatry, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed.

Section 3923.231 | Reimbursement for services of licensed psychologist.

• Effective: July 1, 1980
• Latest Legislation: House Bill 569 - 113th General Assembly

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a person licensed in this state as a psychologist as defined in division (A) of section 4732.01 of the Revised Code, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed who has received a doctorate of psychology or has a minimum of five years clinical experience.

Section 3923.232 | Reimbursement for services of licensed dentist.

• Effective: July 1, 1980
• Latest Legislation: House Bill 569 - 113th General Assembly

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a person licensed in this state for the practice of dentistry, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed.

Section 3923.233 | Reimbursement for services of certified nurse-midwife performing service in collaboration with licensed physician.

• Effective: April 6, 2017
• Latest Legislation: House Bill 216 - 131st General Assembly

Notwithstanding any provision of any certificate furnished by an insurer in connection with or pursuant to any group sickness and accident insurance policy delivered, issued, renewed, or used, in or outside this state, on or after January 1, 1985, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed, or used, in or outside this state, on or after January 1, 1985, whenever the policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code and is designated as a certified nurse-midwife in accordance with section 4723.42 of the Revised Code, reimbursement under the policy or certificate shall not be denied to a certified nurse-midwife performing the service in collaboration with a licensed physician. The collaborating physician shall be identified on an insurance claim form.

The cost of collaboration with a certified nurse-midwife by a licensed physician as required under section 4723.43 of the Revised Code is a reimbursable expense.

The division of any reimbursement payment for services performed by a certified nurse-midwife between the certified nurse-midwife and the certified nurse-midwife's collaborating physician shall be determined and mutually agreed upon by the certified nurse-midwife and the physician. The division of fees shall not be considered a violation of division (B)(17) of section 4731.22 of the Revised Code. In no case shall the total fees charged exceed the fee the physician would have charged had the physician provided the entire service.

Section 3923.234 | Reimbursement for services of certified mechanotherapist.

• Effective: April 30, 1992
• Latest Legislation: House Bill 454 - 119th General Assembly

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed, or used, in or outside this state, on or after July 20, 1988, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed, or used, in or outside this state, on or after July 20, 1988, whenever the policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a mechanotherapist, who was issued a certificate as a mechanotherapist under section 4731.15 of the Revised Code and practices in accordance with rules adopted under section 4731.151 of the Revised Code, reimbursement under the policy or certificate shall not be denied when the service is rendered by a person so registered, but only if that person completed educational requirements in mechanotherapy on or before November 3, 1975.

As used in this section, "educational requirements" has the same meaning as in section 4731.151 of the Revised Code.

Section 3923.24 | Continuing coverage for dependent children.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, every certificate furnished by an insurer in connection with, or pursuant to any provision of, any group sickness and accident insurance policy delivered, issued for delivery, renewed, or used in this state on or after January 1, 1972, every policy of sickness and accident insurance delivered, issued for delivery, renewed, or used in this state on or after January 1, 1972, and every multiple employer welfare arrangement offering an insurance program, which provides that coverage of an unmarried dependent child of a parent or legal guardian will terminate upon attainment of the limiting age for dependent children specified in the contract shall also provide in substance both of the following:

(1) Once an unmarried child has attained the limiting age for dependent children, as provided in the policy, upon the request of the insured, the insurer shall offer to cover the unmarried child until the child attains twenty-six years of age if all of the following are true:

(a) The child is the natural child, stepchild, or adopted child of the insured.

(b) The child is a resident of this state or a full-time student at an accredited public or private institution of higher education.

(c) The child is not employed by an employer that offers any health benefit plan under which the child is eligible for coverage.

(d) The child is not eligible for the medicaid program or the medicare program.

(2) That attainment of the limiting age for dependent children shall not operate to terminate the coverage of a dependent child if the child is and continues to be both of the following:

(a) Incapable of self-sustaining employment by reason of an intellectual disability or physical disability;

(b) Primarily dependent upon the policyholder or certificate holder for support and maintenance.

(B) Proof of such incapacity and dependence for purposes of division (A)(2) of this section shall be furnished by the policyholder or by the certificate holder to the insurer within thirty-one days of the child's attainment of the limiting age. Upon request, but not more frequently than annually after the two-year period following the child's attainment of the limiting age, the insurer may require proof satisfactory to it of the continuance of such incapacity and dependency.

(C) Nothing in this section shall require an insurer to cover a dependent child who has an intellectual disability or physical disability if the contract is underwritten on evidence of insurability based on health factors set forth in the application, or if such dependent child does not satisfy the conditions of the contract as to any requirement for evidence of insurability or other provision of the contract, satisfaction of which is required for coverage thereunder to take effect. In any such case, the terms of the contract shall apply with regard to the coverage or exclusion of the dependent from such coverage. Nothing in this section shall apply to accidental death or dismemberment benefits provided by any such policy of sickness and accident insurance.

(D) Nothing in this section shall do any of the following:

(1) Require that any policy offer coverage for dependent children or provide coverage for an unmarried dependent child's children as dependents on the policy;

(2) Require an employer to pay for any part of the premium for an unmarried dependent child that has attained the limiting age for dependents, as provided in the policy;

(3) Require an employer to offer health insurance coverage to the dependents of any employee.

(E)(1) This section does not apply to any policies or certificates covering only accident, credit, disability income, long-term care, hospital indemnity, medicare supplement, or specified disease; coverage under a one-time-limited-duration policy that is less than twelve months; coverage issued as a supplement to liability insurance; insurance arising out of a workers' compensation or similar law; automobile medical-payment insurance; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(2) This section applies to policies or certificates providing coverage for dental care or vision care services that are issued, renewed, or amended on or after January 1, 2024.

(F) As used in this section, "health benefit plan" has the same meaning as in section 3924.01 of the Revised Code and also includes both of the following:

(1) A public employee benefit plan;

(2) A health benefit plan as regulated under the "Employee Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.

Last updated October 3, 2023 at 12:29 PM

Section 3923.241 | Public employee benefit plans - continuing coverage for dependent children.

• Effective: October 3, 2023
• Latest Legislation: House Bill 33 - 135th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, any public employee benefit plan that provides that coverage of an unmarried dependent child will terminate upon attainment of the limiting age for dependent children specified in the plan shall also provide in substance both of the following:

(1) Once an unmarried child has attained the limiting age for dependent children, as provided in the plan, upon the request of the employee, the public employee benefit plan shall offer to cover the unmarried child until the child attains twenty-six years of age if all of the following are true:

(a) The child is the natural child, stepchild, or adopted child of the employee.

(b) The child is a resident of this state or a full-time student at an accredited public or private institution of higher education.

(c) The child is not employed by an employer that offers any health benefit plan under which the child is eligible for coverage.

(d) The child is not eligible for the medicaid program or the medicare program.

(2) That attainment of the limiting age for dependent children shall not operate to terminate the coverage of a dependent child if the child is and continues to be both of the following:

(a) Incapable of self-sustaining employment by reason of an intellectual disability or physical disability;

(b) Primarily dependent upon the plan member for support and maintenance.

(B) Proof of incapacity and dependence for purposes of division (A)(2) of this section shall be furnished to the public employee benefit plan within thirty-one days of the child's attainment of the limiting age. Upon request, but not more frequently than annually, the public employee benefit plan may require proof satisfactory to it of the continuance of such incapacity and dependency.

(C) Nothing in this section shall do any of the following:

(1) Require that any public employee benefit plan offer coverage for dependent children or provide coverage for an unmarried dependent child's children as dependents on the public employee benefit plan;

(2) Require an employer to pay for any part of the premium for an unmarried dependent child that has attained the limiting age for dependents, as provided in the plan;

(3) Require an employer to offer health insurance coverage to the dependents of any employee.

(D)(1) This section does not apply to any public employee benefit plan covering only accident, credit, disability income, long-term care, hospital indemnity, medicare supplement, or specified disease; coverage under a one-time-limited-duration policy that is less than twelve months; coverage issued as a supplement to liability insurance; insurance arising out of a workers' compensation or similar law; automobile medical-payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(2) This section applies to public employee benefit plans providing coverage for dental care or vision care services that are issued, renewed, or amended on or after January 1, 2024.

(E) As used in this section, "health benefit plan" has the same meaning as in section 3924.01 of the Revised Code and also includes both of the following:

(1) A public employee benefit plan;

(2) A health benefit plan as regulated under the "Employee Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.

Last updated October 3, 2023 at 12:29 PM

Section 3923.25 | Kidney dialysis benefits.

• Effective: April 3, 1972
• Latest Legislation: Senate Bill 326 - 109th General Assembly

Every certificate furnished by an insurer in connection with, or pursuant to any provision of any group sickness and accident insurance policy delivered, issued for delivery, renewed, or used in this state, provided such policy was delivered, issued for delivery, or renewed on or after July 1, 1972, and every policy of sickness and accident insurance delivered, issued for delivery, renewed, or used in this state, provided such policy was delivered, issued for delivery, or renewed on or after July 1, 1972, which provides for kidney dialysis benefits, shall be deemed to include such benefits on an equal basis if the dialysis is performed on an out-patient basis. For purposes of this section, "out-patient basis" includes care rendered at any location whether or not at a hospital, upon approval by the attending physician.

Section 3923.26 | Coverage for newly born children from the moment of birth.

• Effective: June 30, 1997
• Latest Legislation: House Bill 374 - 122nd General Assembly

Every group policy or certificate of sickness and accident insurance delivered, issued for delivery, or renewed in this state providing coverage on an expense-incurred basis, and every individual policy of sickness and accident insurance delivered, issued for delivery, or renewed in this state which provides coverage on an expense-incurred basis, either of which makes coverage available for family members of the insured, shall, as to such family members' coverage, also provide that any sickness and accident insurance benefits applicable for children shall be payable with respect to a newly born child of the insured from the moment of birth.

The coverage for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

If payment of a specific premium is required to provide coverage for an additional child, the certificate or policy may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer within thirty-one days after the date of birth in order to have the coverage continue beyond such period.

The requirements of this section apply to all such individual or group sickness and accident insurance policies delivered or issued for delivery in this state on or after January 1, 1975, and all such individual or group sickness and accident insurance policies renewed in this state on or after January 1, 1978.

Section 3923.27 | Hospitalization coverage for mental illness.

• Effective: September 29, 2005
• Latest Legislation: House Bill 66 - 126th General Assembly

No policy of sickness and accident insurance delivered, issued for delivery, or renewed in this state after August 26, 1976, including both individual and group policies, that provides hospitalization coverage for mental illness shall exclude such coverage for the reason that the insured is hospitalized in an institution or facility receiving tax support from the state, any municipal corporation, county, or joint county board, whether such institution or facility is deemed charitable or otherwise, provided the institution or facility or portion thereof is fully accredited by the joint commission on accreditation of hospitals or certified under Titles XVIII and XIX of the "Social Security Act of 1935," 79 Stat. 291, 42 U.S.C.A. 1395, as amended. The insurance coverage shall provide payment amounting to the lesser of either the full amount of the statutory charge for the cost of the services pursuant to section 5121.33 of the Revised Code or the benefits payable for the services under the applicable insurance policy. Insurance benefits for the coverage shall be paid so long as patients and their liable relatives retain their statutory liability pursuant to section 5121.33 of the Revised Code. Only that portion or per cent of the benefits shall be payable that has been assigned, or ordered to be paid, to the state or other appropriate provider for services rendered by the institution or facility.

Section 3923.28 | Outpatient coverage for mental or emotional disorders.

• Effective: July 10, 2014
• Latest Legislation: House Bill 232 - 130th General Assembly

(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, and that provides coverage for mental or emotional disorders, shall provide benefits for services on an outpatient basis for each eligible person under the policy who resides in this state for mental or emotional disorders, or for evaluations, that are at least equal to five hundred fifty dollars in any calendar year or twelve-month period.

(1) The services shall be legally performed by or under the clinical supervision of any of the following:

(a) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;

(b) A psychologist licensed under Chapter 4732. of the Revised Code;

(c) A licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code;

(d) A clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

(2) The services may be performed in an office, in a hospital, or in a community mental health facility so long as the hospital or community mental health facility is approved by the joint commission, the council on accreditation, or the commission on accreditation of rehabilitation facilities.

(B) Outpatient benefits offered under division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five-hundred-fifty-dollar outpatient benefit for services under all contracts.

(C) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services.

(D) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.

(E)(1) Services performed under the clinical supervision of a health care professional identified in division (A)(1) of this section, in order to be reimbursable under the coverage required in division (A) of this section, shall meet both of the following requirements:

(a) The services shall be performed in accordance with a treatment plan that describes the expected duration, frequency, and type of services to be performed;

(b) The plan shall be reviewed and approved by the health care professional every three months.

(2) Payment of benefits for services reimbursable under division (E)(1) of this section shall not be restricted to services described in the treatment plan or conditioned upon standards of clinical supervision that are more restrictive than standards of a health care professional described in division (A)(1) of this section, which at least equal the requirements of division (E)(1) of this section.

(F) The benefits provided by this section for mental and emotional disorders shall not be reduced by the cost of benefits provided pursuant to section 3923.281 of the Revised Code for diagnostic and treatment services for biologically based mental illnesses. This section does not apply to benefits for diagnostic and treatment services for biologically based mental illnesses.

Section 3923.281 | Sickness and accident policies - biologically based mental illness.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A) As used in this section:

(1) "Biologically based mental illness" means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.

(2) "Policy of sickness and accident insurance" has the same meaning as in section 3923.01 of the Revised Code, but excludes any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy that is less than twelve months, supplemental benefit, or other policy that provides coverage for specific diseases or accidents only; any policy that provides coverage for workers' compensation claims compensable pursuant to Chapters 4121. and 4123. of the Revised Code; and any policy that provides coverage to medicaid recipients.

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

(1) The biologically based mental illness is clinically diagnosed by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

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

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

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

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

(2) Offering policies that provide benefits solely for the diagnosis and treatment of biologically based mental illnesses;

(3) Managing the provision of benefits for the diagnosis or treatment of biologically based mental illnesses through the use of pre-admission screening, by requiring beneficiaries to obtain authorization prior to treatment, or through the use of any other mechanism designed to limit coverage to that treatment determined to be necessary;

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

(E) An insurer that offers any policy of sickness and accident insurance is not required to provide benefits for the diagnosis and treatment of biologically based mental illnesses pursuant to division (B) of this section if all of the following apply:

(1) The insurer submits documentation certified by an independent member of the American academy of actuaries to the superintendent of insurance showing that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the insurer's costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

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

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

(a) Incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the insurer's costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

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

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

Section 3923.282 | Health coverage plans - biologically based mental illness.

• Effective: July 10, 2014
• Latest Legislation: House Bill 232 - 130th General Assembly

(A) As used in this section:

(1) "Biologically based mental illness" means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.

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

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

(1) The biologically based mental illness is clinically diagnosed by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

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

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

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

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

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

(2) Managing the provision of benefits for the diagnosis or treatment of biologically based mental illnesses through the use of pre-admission screening, by requiring beneficiaries to obtain authorization prior to treatment, or through the use of any other mechanism designed to limit coverage to that treatment determined to be necessary;

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

(F) An employer that offers a plan of health coverage is not required to provide benefits for the diagnosis and treatment of biologically based mental illnesses in combination with benefits for the treatment and diagnosis of all other physical diseases and disorders as described in division (B) of this section if both of the following apply:

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

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

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

Section 3923.29 | Outpatient, inpatient, and intermediate primary care benefits for alcoholism.

• Effective: July 10, 2014
• Latest Legislation: House Bill 232 - 130th General Assembly

(A)(1) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, shall provide for each eligible person under the policy who resides in this state, outpatient, inpatient, and intermediate primary care benefits for alcoholism that are at least equal to five hundred fifty dollars in any calendar year or twelve-month period.

(2) The services shall be legally performed by or under the clinical supervision of any of the following:

(a) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;

(b) A psychologist licensed under Chapter 4732. of the Revised Code;

(c) A licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code whose practice includes chemical dependency counseling;

(d) An independent chemical dependency counselor licensed under Chapter 4758. of the Revised Code;

(e) A clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

(3) The services may be performed in an office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility so long as the hospital, community mental health facility, or alcoholism treatment facility is approved by the joint commission, the council on accreditation, or the commission on accreditation of rehabilitation facilities or certified by the department of mental health and addiction services.

(B) The benefits mandated by division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five hundred fifty dollar benefit for services under all contracts.

(C) For an eligible person, who receives treatment for alcoholism from an approved or certified alcoholism treatment facility, to remain entitled to the benefits mandated by division (A) of this section, a health care professional identified in division (A)(2) of this section shall every three months certify that such person needs to continue utilizing such treatment.

(D) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services. Such person or facility shall also have in effect a program of rehabilitation or a program of rehabilitation and detoxification.

(E) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.

Section 3923.30 | Requiring provision of coverage of treatment of mental or nervous disorders and alcoholism.

• Effective: July 10, 2014
• Latest Legislation: House Bill 232 - 130th General Assembly

Every person, the state and any of its instrumentalities, any county, township, school district, or other political subdivisions and any of its instrumentalities, and any municipal corporation and any of its instrumentalities, which provides payment for health care benefits for any of its employees resident in this state, which benefits are not provided by contract with an insurer qualified to provide sickness and accident insurance, or a health insuring corporation, shall include the following benefits in its plan of health care benefits commencing on or after January 1, 1979:

(A) If such plan of health care benefits provides payment for the treatment of mental or nervous disorders, then such plan shall provide benefits for services on an outpatient basis for each eligible employee and dependent for mental or emotional disorders, or for evaluations, that are at least equal to the following:

(1) Payments not less than five hundred fifty dollars in a twelve-month period, for services legally performed by or under the clinical supervision of any of the following:

(a) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;

(b) A psychologist licensed under Chapter 4732. of the Revised Code;

(c) A licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code;

(d) An independent chemical dependency counselor licensed under Chapter 4758. of the Revised Code;

(e) A clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

The services may be performed in an office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility so long as the hospital, community mental health facility, or alcoholism treatment facility is approved by the joint commission, the council on accreditation, or the commission on accreditation of rehabilitation facilities or certified by the department of mental health and addiction services;

(2) Such benefit shall be subject to reasonable limitations, and may be subject to reasonable deductibles and co-insurance costs.

(3) In order to qualify for participation under this division, every facility specified in this division shall have in effect a plan for utilization review and a plan for peer review and every person specified in this division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services.

(4) Such payment for benefits shall not be greater than usual, customary, and reasonable.

(5)(a) Services performed by or under the clinical supervision of a health care professional identified in division (A)(1) of this section, in order to be reimbursable under the coverage required in division (A) of this section, shall meet both of the following requirements:

(i) The services shall be performed in accordance with a treatment plan that describes the expected duration, frequency, and type of services to be performed;

(ii) The plan shall be reviewed and approved by the health care professional every three months.

(b) Payment of benefits for services reimbursable under division (A)(5)(a) of the section shall not be restricted to services described in the treatment plan or conditioned upon standards of a licensed physician or licensed psychologist, which at least equal the requirements of division (A)(5)(a) of this section.

(B) Payment for benefits for alcoholism treatment for outpatient, inpatient, and intermediate primary care for each eligible employee and dependent that are at least equal to the following:

(1) Payments not less than five hundred fifty dollars in a twelve-month period for services legally performed by or under the clinical supervision of a health care professional identified in division (A)(1) of this section, whether performed in an office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility so long as the hospital, community mental health facility, or alcoholism treatment facility is approved by the joint commission, the council on accreditation, or the commission on accreditation of rehabilitation facilities or certified by the department of mental health and addiction services;

(2) The benefits provided under this division shall be subject to reasonable limitations and may be subject to reasonable deductibles and co-insurance costs.

(3) A health care professional shall every three months certify a patient's need for continued services performed by such facilities.

(4) In order to qualify for participation under this division, every facility specified in this division shall have in effect a plan for utilization review and a plan for peer review and every person specified in this division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and efficient utilization of available health facilities and services. Such person or facilities shall also have in effect a program of rehabilitation or a program of rehabilitation and detoxification.

(5) Nothing in this section shall be construed to require reimbursement for benefits which is greater than usual, customary, and reasonable.

(C) The benefits provided by division (A) of this section for mental and emotional disorders shall not be reduced by the cost of benefits provided pursuant to section 3923.282 of the Revised Code for diagnostic and treatment services for biologically based mental illness. This section does not apply to benefits for diagnostic and treatment services for biologically based mental illnesses.

Section 3923.301 | Requiring provision of coverage for services of certified nurse-midwife performing service in collaboration with licensed physician.

• Effective: April 6, 2017
• Latest Legislation: House Bill 216 - 131st General Assembly

Every person, the state and any of its instrumentalities, any county, township, school district, or other political subdivision and any of its instrumentalities, and any municipal corporation and any of its instrumentalities that provides payment for health care benefits for any of its employees resident in this state, which benefits are not provided by contract with an insurer qualified to provide sickness and accident insurance or a health insuring corporation, and that includes reimbursement for any service that may be legally performed by an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723. of the Revised Code and is designated as a certified nurse-midwife in accordance with section 4723.42 of the Revised Code, shall not deny reimbursement to a certified nurse-midwife performing the service if the service is performed in collaboration with a licensed physician. The collaborating physician shall be identified on the claim form.

The cost of collaboration with a certified nurse-midwife by a licensed physician as required under section 4723.43 of the Revised Code is a reimbursable expense.

The division of any reimbursement payment for services performed by a certified nurse-midwife between the certified nurse-midwife and the certified nurse-midwife's collaborating physician shall be determined and mutually agreed upon by the certified nurse-midwife and the physician. The division of fees shall not be considered a violation of division (B)(17) of section 4731.22 of the Revised Code. In no case shall the total fees charged exceed the fee the physician would have charged had the physician provided the entire service.

Section 3923.31 | Right to rescind individual policy of sickness and accident insurance.

• Effective: July 1, 1980
• Latest Legislation: House Bill 494 - 113th General Assembly

(A)(1) A policyholder has the right to rescind an individual policy of sickness and accident insurance delivered or issued for delivery in this state at least until midnight of the tenth day after the date on which the policyholder receives the policy, by returning the policy to the insurer or an agent of the insurer. No reason need be stated for the return or the rescission.

(2) The policy may provide that the coverage shall be in force during any period prior to its return, and that a pro rata portion of the premium is chargeable for the coverage. The charge shall be apportioned on a per diem basis only, and may not be loaded or weighted in any way to require the policyholder to pay, or penalize the policyholder, for exercising the right of rescission under this section. A policy that provides for such pro rata coverage may also provide that the right of rescission terminates if, prior to exercising such right, the policyholder makes a claim for benefits. A policy that does not provide for such coverage is void from the beginning when returned. Any premium paid by a policyholder who returns a policy under this section, in excess of a charge permitted under this division, shall be promptly refunded to the policyholder.

(B) The policy is deemed returned, if, within the period of time specified by the insurer in accordance with division (A) of this section, the policyholder mails the policy to the insurer or agent, or delivers, or causes the delivery of, the policy to the insurer or agent.

(C) A notice of the policyholder's rights under this section shall be printed prominently on the first page of the policy or attached thereto. The notice shall specify how and where the policyholder may return the policy.

(D) This section does not apply to any single-premium nonrenewable policy.

Section 3923.32 | Right of family member to continue coverage after subscriber's death or upon change in marital relation to subscriber.

• Effective: October 6, 1980
• Latest Legislation: House Bill 45 - 113th General Assembly

(A) Every individual family sickness and accident insurance policy that provides hospital, surgical, and medical expense benefits or hospital confinement indemnity benefits, and that is delivered or issued for delivery in this state on or after January 1, 1981, shall provide covered family members the right to continue such coverage upon the death of the named insured and upon the divorce, the annulment or dissolution of marriage, or the legal separation of the spouse from the named insured. Such right shall not exist with respect to any covered family member who is eligible for medicare or any other similar federal or state health insurance program, or in the event the coverage terminates for nonpayment of premium, nonrenewal of the policy, or the expiration of the term for which the policy is issued.

(B) In the case of the divorce, annulment, or dissolution of marriage, or legal separation of the spouse from the named insured, the insurer shall satisfy the right to the continuation of coverage under this section by issuing either a converted or separate policy with the person who exercises the conversion right designated as the named insured. In the case of the death of the named insured, the insurer may satisfy the right to the continuation of coverage under this section by continuing the original policy with the person who exercises the right of continuation designated as the named insured or by issuing either a converted or separate policy with the person who exercises the conversion right designated as the named insured. Where continuation of coverage or conversion is made in the name of the spouse of the named insured, such coverage may, at the option of the spouse, include covered dependent children for whom the spouse has responsibility for care and support.

(C) Coverage continued through the issuance of a converted or separate policy shall consist of a form of coverage then being offered by the insurer as a conversion policy in the jurisdiction where the person exercising the conversion right resides that most nearly approximates the coverage of the policy from which conversion is exercised. Continued and converted coverages shall contain renewal provisions that are not less favorable to the insured than those contained in the policy from which the conversion is made, except that the person who exercises the right of conversion is not entitled to have included a right to renew the coverage after the attainment of the age of eligibility for medicare or any other similar federal or state health insurance program.

(D) The eligible covered family member exercising the continuation or conversion right must notify the insurer and make payment of the applicable premium within thirty-one days following the date such coverage otherwise terminates as specified in the policy or contract from which continuation or conversion is being exercised.

(E) Coverage shall be provided through continuation or conversion without additional evidence of insurability, and shall not impose any preexisting condition limitations or other contractual time limitations other than those remaining unexpired under the policy or contract from which continuation or conversion is exercised.

(F) Benefits otherwise payable under a converted or separate policy may be reduced:

(1) So they are not, during the first policy year of the converted or separate policy, in excess of those that would have been payable had the coverage under the policy from which conversion is exercised not terminated; and

(2) By the amount of benefits, if any, payable as to the same loss under the policy from which conversion is exercised.

(G) Any probationary or waiting period set forth in the converted or separate policy is deemed to commence on the effective date of the applicant's coverage under the original policy.

Section 3923.33 | Medicare supplement policy definitions.

• Effective: June 4, 1997
• Latest Legislation: Senate Bill 67 - 122nd General Assembly

As used in section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code:

(A) "Applicant" means:

(1) In the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits; and

(2) In the case of a group medicare supplement policy, the proposed certificate holder.

(B) "Certificate" means, for purposes of section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code, any certificate delivered or issued for delivery in this state under a group medicare supplement policy.

(C) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer.

(D) "Direct response insurance policy" means a medicare supplement policy or certificate marketed without the direct involvement of an insurance agent.

(E) "Issuer" includes insurance companies, fraternal benefit societies, health insuring corporations, and any other entities delivering or issuing for delivery in this state medicare supplement policies or certificates.

(F) "Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, 79 Stat. 291, 42 U.S.C.A. 1395, as then constituted or later amended.

(G) "Medicare supplement policy" means a group or individual policy of sickness and accident insurance or a subscriber contract of health insuring corporations or any other issuers, other than a policy issued pursuant to a contract under section 1876 of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A., 1395mm, as amended, or an issued policy under any demonstration project specified in 42 U.S.C.A. 1395ss(g)(1), which is advertised, marketed, or designed primarily as a supplement to reimbursements under medicare for the hospital, medical, or surgical expenses of persons eligible for medicare.

(H) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

Section 3923.331 | Statutes applicable to medicare supplement policies.

• Effective: March 3, 1996
• Latest Legislation: House Bill 374 - 121st General Assembly

(A) Except as otherwise provided in the Revised Code, section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code shall apply to:

(1) All medicare supplement policies delivered or issued for delivery in this state on or after the effective date of this amendment; and

(2) All certificates issued under group medicare supplement policies, which certificates are delivered or issued for delivery in this state on or after the effective date of this amendment.

(B) Section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

(C) Except as otherwise provided in division (D) of section 3923.334 of the Revised Code, section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code are not intended to prohibit or apply to insurance policies or health care benefit plans, including group conversion policies, provided to medicare eligible persons, which policies are not marketed or held to be medicare supplement policies or benefit plans.

Section 3923.332 | Standards for policy provisions of medicare supplement policies and certificates.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

(A) No medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by medicare.

(B) Notwithstanding section 3923.04 of the Revised Code or any other provision of law of this state, a medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

(C) The superintendent of insurance shall adopt reasonable rules to establish specific standards for policy provisions of medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state, including sections 3923.03 to 3923.09 of the Revised Code. No requirement in Title XVII or XXXIX of the Revised Code relating to minimum required policy benefits, other than the minimum standards contained in section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code, shall apply to medicare supplement policies and certificates. The standards may cover, but are not limited to:

(1) Terms of renewability;

(2) Initial and subsequent conditions of eligibility;

(3) Nonduplication of coverage;

(4) Probationary periods;

(5) Benefit limitations, exceptions, and reductions;

(6) Elimination periods;

(7) Requirements for replacement;

(8) Recurrent conditions; and

(9) Definitions of terms.

(D) The superintendent shall adopt reasonable rules to establish minimum standards for benefits, claims payment, advertising and marketing practices and compensation arrangements, and reporting practices, for medicare supplement policies and certificates.

(E) The superintendent may adopt from time to time such reasonable rules as are necessary to conform medicare supplement policies and certificates to the requirements of federal law and regulations promulgated thereunder, including but not limited to:

(1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements;

(2) Establishing a uniform methodology for calculating and reporting loss ratios;

(3) Assuring public access to policies, premiums, and loss ratio information of issuers of medicare supplement insurance;

(4) Establishing a process for approving or disapproving policy forms and certificate forms and proposed premium increases;

(5) Establishing a policy for holding public hearings prior to approval of premium increases; and

(6) Establishing standards for medicare select policies and certificates.

(F) The superintendent may adopt reasonable rules that specify prohibited policy provisions not otherwise specifically authorized by any provision in the Revised Code that, in the opinion of the superintendent, are unjust, unfair, or unfairly discriminatory to any person insured or proposed to be insured under a medicare supplement policy or certificate.

Section 3923.333 | Benefits to be reasonable in relation to premium charged.

• Effective: June 4, 1997
• Latest Legislation: Senate Bill 67 - 122nd General Assembly

Medicare supplement policies shall return to policyholders benefits that are reasonable in relation to the premium charged. The superintendent of insurance shall issue reasonable rules to establish minimum standards for loss ratios of medicare supplement policies on the basis of incurred claims experience, or incurred health care expenses where coverage is provided by a health insuring corporation on a service rather than reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.

Section 3923.334 | Outline of coverage delivered at time application is made.

• Effective: March 3, 1996
• Latest Legislation: House Bill 374 - 121st General Assembly

(A) In order to provide for full and fair disclosure in the sale of medicare supplement policies, no medicare supplement policy or certificate shall be delivered in this state, unless an outline of coverage is delivered to the applicant at the time application is made.

(B) The superintendent of insurance shall prescribe the format and content of the outline of coverage required by division (A) of this section. For purposes of this section, "format" means style, arrangements and overall appearance, including such items as the size, color and prominence of type, and arrangement of text and captions. The outline of coverage shall include:

(1) A description of the principal benefits and coverage provided in the policy;

(2) A statement of the renewal provisions, including any reservation by the issuer of a right to change premiums, and disclosure of the existence of any automatic renewal premium increases based on the age of the policyholder or certificate holder;

(3) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

(C) The superintendent may prescribe by rule a standard form and the contents of an informational brochure for persons eligible for medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of medicare. Except in the case of direct response insurance policies, the superintendent may require by rule that the informational brochure be provided to any prospective insureds eligible for medicare concurrently with delivery of the outline of coverage. With respect to direct response insurance policies, the superintendent may require by rule that the prescribed brochure be provided upon request to any prospective insureds eligible for medicare, but in no event later than the time of policy delivery.

(D) The superintendent may adopt rules for captions or notice requirements, determined to be in the public interest and designed to inform prospective insureds that particular insurance coverages are not medicare supplement coverages, for all sickness and accident insurance policies and subscriber contracts sold to persons eligible for medicare, other than:

(1) Medicare supplement policies; or

(2) Disability income policies.

(E) The superintendent may adopt reasonable rules to govern the full and fair disclosure of information in connection with the replacement of sickness and accident insurance policies, subscriber contracts, or certificates by persons eligible for medicare.

Section 3923.335 | Right to return policy or certificate and have premium refunded.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

Section 3923.336 | Review and approval of advertisement by superintendent.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

(A) Each issuer of medicare supplement policies or certificates in this state shall provide a copy of any medicare supplement advertisement intended for use in this state, whether through written or electronic media, to the superintendent of insurance for review and approval.

(B) The superintendent shall adopt rules to carry out the purposes of this section.

Section 3923.337 | Rules.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

All rules adopted pursuant to section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code shall be subject to Chapter 119. of the Revised Code.

Section 3923.338 | Orders of superintendent.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

In addition to any other applicable penalties for violations of Title XVII or XXXIX of the Revised Code, the superintendent of insurance, pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code, may issue an order requiring issuers violating any provision of section 3923.33 or sections 3923.331 to 3923.339 of the Revised Code or rules adopted pursuant to those sections to do either or both of the following:

(A) Cease marketing any medicare supplement policy or certificate in this state that is related directly or indirectly to the violation;

(B) Take such actions as are necessary to comply with section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code.

Section 3923.339 | Severability.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

If any provision of section 3923.33 or sections 3923.331 to 3923.339 of the Revised Code or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code and the application of such remainder to other persons or circumstances shall not be affected thereby.

Section 3923.36 | Excluding coverage of illness or injury covered by workers' compensation.

• Effective: October 13, 1983
• Latest Legislation: House Bill 340 - 115th General Assembly

No sickness and accident insurance policy shall be construed to exclude illness or injury upon the ground that the insured might have elected to have such illness or injury covered by workers' compensation under division (A)(3) of section 4123.01 of the Revised Code unless the policy clearly excludes work or occupational related illness or injury or the policy, or a separate writing signed by the insured, informs the insured that such coverage is excluded and may be available to the subscriber under workers' compensation as the sole proprietor of a business, a member of a partnership, or an officer of a family farm corporation.

Section 3923.37 | Prohibiting exclusion or reduction of benefits because of benefits payable under supplemental policy.

• Effective: October 13, 1983
• Latest Legislation: House Bill 340 - 115th General Assembly

(A) No individual or group sickness and accident insurance policy shall be delivered, issued for delivery, or renewed in this state that excludes or reduces the benefits payable to or on behalf of an insured because benefits are also payable or have been paid under a supplemental sickness and accident policy to which all of the following apply:

(1) The policy covers a specified disease or a limited plan of coverage.

(2) The policy is specifically designed, advertised, represented, and sold as a supplement to other basic sickness and accident insurance coverage.

(3) The entire premium for the policy is paid by the insured, the insured's family, or the insured's guardian.

(B) This section applies to supplemental sickness and accident policies irrespective of the mode or channel of premium payment to the insurer or of any reduction in the premium by virtue of the insured's membership in any organization or the insured's status as an employee.

Section 3923.38 | Continuing policy upon termination of employment.

• Effective: April 1, 2009
• Latest Legislation: House Bill 2 - 128th General Assembly

(A) As used in this section:

(1) "Group policy" includes any group sickness and accident policy or contract delivered, issued for delivery, or renewed in this state on or after June 28, 1984, and any private or public employer self-insurance plan or other plan that provides, or provides payment for, health care benefits for employees resident in this state other than through an insurer or health insuring corporation, to which both of the following apply:

(a) The policy insures employees for hospital, surgical, or major medical insurance on an expense incurred or service basis, other than for specified diseases or for accidental injuries only.

(b) The policy is in effect and covers an eligible employee at the time the employee's employment is terminated.

(2) "Eligible employee" includes only an employee to whom all of the following apply:

(a) The employee has been continuously insured under a group policy or under the policy and any prior similar group coverage replaced by the policy, during the entire three-month period preceding the termination of the employee's employment.

(b) The employee did not voluntarily terminate the employee's employment and the termination of employment is not a result of any gross misconduct on the part of the employee.

(c) The employee is not, and does not become, covered by or eligible for coverage by medicare under Title XVIII of the Social Security Act, as amended.

(d) The employee is not, and does not become, covered by or eligible for coverage by any other insured or uninsured arrangement that provides hospital, surgical, or medical coverage for individuals in a group and under which the person was not covered immediately prior to such termination. A person eligible for continuation of coverage under this section, who is also eligible for coverage under section 3923.123 of the Revised Code, may elect either coverage, but not both. A person who elects continuation of coverage may elect any coverage available under section 3923.123 of the Revised Code upon the termination of the continuation of coverage.

(3) "Group rate" means, in the case of an employer self-insurance or other health benefits plan, the average monthly cost per employee, over a period of at least twelve months, of the operation of the plan that would represent a group insurance rate if the same coverage had been provided under a group sickness and accident insurance policy.

(B) A group policy shall provide that any eligible employee may continue the employee's hospital, surgical, and medical insurance under the policy, for the employee and the employee's eligible dependents, for a period of twelve months after the date that the insurance coverage would otherwise terminate by reason of the termination of the employee's employment. Each certificate of coverage, or other notice of coverage, issued to employees under the policy shall include a notice of the employee's privilege of continuation.

(C) All of the following apply to the continuation of coverage required under division (B) of this section:

(1) Continuation need not include dental, vision care, or any other benefits provided under the policy in addition to its hospital, surgical, or major medical benefits.

(2) The employer shall notify the employee of the right of continuation at the time the employer notifies the employee of the termination of employment. The notice shall inform the employee of the amount of contribution required by the employer under division (C)(4) of this section.

(3) The employee shall file a written election of continuation with the employer and pay the employer the first contribution required under division (C)(4) of this section. The request and payment must be received by the employer no later than the earlier of any of the following dates:

(a) Thirty-one days after the date on which the employee's coverage would otherwise terminate;

(b) Ten days after the date on which the employee's coverage would otherwise terminate, if the employer has notified the employee of the right of continuation prior to such date;

(c) Ten days after the employer notifies the employee of the right of continuation, if the notice is given after the date on which the employee's coverage would otherwise terminate.

(4) The employee must pay to the employer, on a monthly basis, in advance, the amount of contribution required by the employer. The amount required shall not exceed the group rate for the insurance being continued under the policy on the due date of each payment.

(5) The employee's privilege to continue coverage and the coverage under any continuation ceases if any of the following occurs:

(a) The employee ceases to be an eligible employee under division (A)(2)(c) or (d) of this section;

(b) A period of twelve months expires after the date that the employee's insurance under the policy would otherwise have terminated because of the termination of employment;

(c) The employee fails to make a timely payment of a required contribution, in which event the coverage shall cease at the end of the coverage for which contributions were made;

(d) The policy is terminated, or the employer terminates participation under the policy, unless the employer replaces the coverage by similar coverage under another group policy or other group health arrangement.

If the employer replaces the policy with similar group health coverage, all of the following apply:

(i) The member shall be covered under the replacement coverage, for the balance of the period that the member would have remained covered under the terminated coverage if it had not been terminated.

(ii) The minimum level of benefits under the replacement coverage shall be the applicable level of benefits of the policy replaced reduced by any benefits payable under the policy replaced.

(iii) The policy replaced shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.

(D) This section does not apply to an employer's self-insurance plan if federal law supersedes, preempts, prohibits, or otherwise precludes its application to such plans.

(E) An employer shall notify the insurer if the employee elects continuation of coverage under this section. The insurer may require the employer to provide documentation if the employee elects continuation of coverage and is seeking premium assistance for the continuation of coverage under the "American Recovery and Investment Act of 2009," Pub. L. No. 111-5, 123 Stat. 115. The director of insurance shall publish guidance for employers and insurers regarding the contents of such documentation.

Section 3923.381 | Continuing coverage under group policy when reservist is called or ordered to active duty.

• Effective: September 18, 1997
• Latest Legislation: Senate Bill 130 - 122nd General Assembly

(A) As used in this section:

(1) "Eligible person" means any person who, at the time a reservist is called or ordered to active duty, is covered under a group policy and is either of the following:

(a) An employee who is a reservist called or ordered to active duty;

(b) The spouse or a dependent child of an employee described in division (A)(1)(a) of this section.

(2) "Group policy" includes any group sickness and accident insurance policy that satisfies all of the following:

(a) The policy is delivered, issued for delivery, or renewed in this state on or after April 17, 1991.

(b) The policy covers employees for hospital, surgical, or major medical insurance on an expense incurred or service basis, other than for specified diseases or accidental injuries only.

(c) The policy is in effect and covers an eligible person at the time a reservist is called or ordered to active duty.

(3) "Reservist" means a member of a reserve component of the armed forces of the United States. "Reservist" includes a member of the Ohio national guard.

(B) Every group policy shall provide that any eligible person may continue the coverage under the policy for a period of eighteen months after the date on which the coverage would otherwise terminate because the reservist is called or ordered to active duty.

(C)(1) An eligible person may extend the eighteen-month period of continuation of coverage to a thirty-six-month period of continuation of coverage, if any of the following occurs during the eighteen-month period:

(a) The death of the reservist;

(b) The divorce or separation of a reservist from the reservist's spouse;

(c) The cessation of dependency of a child pursuant to the terms of the policy.

(2) The thirty-six-month period of continuation of coverage is deemed to begin on the date on which the coverage would otherwise terminate because the reservist is called or ordered to active duty.

(3) The employer may begin the thirty-six-month period on the date of any occurrence described in division (C)(1) of this section.

(D) All of the following apply to any continuation of coverage, or the extension of any continuation of coverage, provided under division (B) or (C) of this section:

(1) The continuation of coverage shall provide the same benefits as those provided to any similarly situated eligible person who is covered under the same group policy and an employee who has not been called or ordered to active duty.

(2) An employer shall notify each employee of the right of continuation of coverage at the time of employment. At the time the reservist is called or ordered to active duty, the employer shall notify each eligible person of the requirements for the continuation of coverage.

(3) Each certificate of coverage issued by an insurer to an employee under the group policy shall include a notice of the eligible person's right of continuation of coverage.

(4) An eligible person shall file a written election of continuation of coverage with the employer and pay the employer the first contribution required under division (D)(5) of this section. The written election and payment must be received by the employer no later than thirty-one days after the date on which the eligible person's coverage would otherwise terminate. If the employer notifies the eligible person of the right of continuation of coverage after the date on which the eligible person's coverage would otherwise terminate, the written election and payment must be received by the employer no later than thirty-one days after the date of the notification.

(5)(a) Except as provided in division (D)(5)(b) or (c) of this section, the eligible person shall pay to the employer, on a monthly basis and in advance, the amount of contribution required by the employer. The amount shall not exceed one hundred two per cent of the group rate for the coverage being continued under the group policy on the due date of each payment.

(b) The employer may pay a portion or all of the eligible person's contribution.

(c) A reservist called or ordered to active duty for less than thirty-one days shall not be required to pay more than the eligible person's contribution, if any, for the coverage.

(E) The eligible person's right to any continuation of coverage, or the extension of any continuation of coverage, provided under division (B) or (C) of this section ceases on the date on which any of the following occurs:

(1) The eligible person, whether as an employee or otherwise, enrolls in another group policy or other group health plan or arrangement that does not contain any exclusion or limitation with respect to any preexisting condition of that eligible person. For purposes of division (E)(1) of this section, a group policy or other group health plan or arrangement does not include the civilian health and medical program of the uniformed services as defined in Public Law 99-661, 100 Stat. 3898 (1986), 10 U.S.C.A. 1072.

(2) The period of either eighteen months provided under division (B) of this section or thirty-six months provided under division (C) of this section expires.

(3) The eligible person fails to make a timely payment of a required contribution, in which case the coverage ceases at the end of the period of coverage for which contributions were made.

(4) The group policy, or participation under the group policy, is terminated, unless the employer, in accordance with division (F) of this section, replaces the coverage with similar coverage under another group policy or other group health plan or arrangement.

(F) If the employer replaces the group policy with similar coverage as described in division (E)(4) of this section, both of the following apply:

(1) The eligible person is covered under the replacement coverage for the balance of the period that the eligible person would have remained covered under the terminated coverage if it had not been terminated.

(2) The level of benefits under the replacement coverage is the same as the level of benefits provided to any similarly situated eligible person who is covered under the group policy and an employee who has not been called or ordered to active duty.

(G) Upon the reservist's release from active duty and return to employment for the employer by whom the reservist was employed at the time of being called or ordered to active duty, both of the following apply:

(1) Every eligible person is entitled, without any waiting period, to coverage under the employer's group policy that is in effect at the time of the reservist's return to employment.

(2) Every eligible person is entitled to all benefits under the group policy described in division (G)(1) of this section from the date of the original coverage under the policy.

(H)(1) No insurer shall fail to provide for a continuation of coverage, or an extension of a continuation of coverage, in a group policy as required by and in accordance with the terms and conditions set forth under this section.

(2) No insurer shall fail to issue a certificate of coverage in compliance with division (D)(3) of this section.

(3) No employer shall fail to provide an employee or eligible person with notice of the right to a continuation of coverage under a group policy in accordance with division (D)(2) of this section.

(I) Whoever violates division (H)(1), (2), or (3) of this section is deemed to have engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

Section 3923.382 | Continuing coverage under group plan when reservist is called or ordered to active duty.

• Effective: September 18, 1997
• Latest Legislation: Senate Bill 130 - 122nd General Assembly

(A) As used in this section:

(1) "Eligible person" means any person who, at the time a reservist is called or ordered to active duty, is covered under a group plan and is either of the following:

(a) An employee who is a reservist called or ordered to active duty;

(b) The spouse or a dependent child of an employee described in division (A)(1)(a) of this section.

(2) "Group plan" includes any private or public employer self-insurance plan that satisfies all of the following:

(a) The plan is established or modified in this state on or after April 17, 1991.

(b) The plan provides, or provides payment for, health benefits for employees resident in this state other than through an insurer or health insuring corporation.

(c) The plan is in effect and covers an eligible person at the time a reservist is called or ordered to active duty.

(3) "Group rate" means the average monthly cost per employee, over a period of at least twelve months of the operation of a group plan, that would represent a group insurance rate if the same coverage had been provided under a group sickness and accident insurance policy.

(4) "Reservist" means a member of a reserve component of the armed forces of the United States. "Reservist" includes a member of the Ohio national guard.

(B) Every group plan shall provide that any eligible person may continue the coverage under the plan for a period of eighteen months after the date on which the coverage would otherwise terminate because the reservist is called or ordered to active duty.

(C)(1) An eligible person may extend the eighteen-month period of continuation of coverage to a thirty-six-month period of continuation of coverage, if any of the following occurs during the eighteen-month period:

(a) The death of the reservist;

(b) The divorce or separation of a reservist from the reservist's spouse;

(c) The cessation of dependency of a child pursuant to the terms of the plan.

(2) The thirty-six-month period of continuation of coverage is deemed to begin on the date on which the coverage would otherwise terminate because the reservist is called or ordered to active duty.

(3) The employer may begin the thirty-six-month period on the date of any occurrence described in division (C)(1) of this section.

(D) All of the following apply to any continuation of coverage, or the extension of any continuation of coverage, provided under division (B) or (C) of this section:

(1) The continuation of coverage shall provide the same benefits as those provided to any similarly situated eligible person who is covered under the same group plan and an employee who has not been called or ordered to active duty.

(2) An employer shall notify each employee of the right of continuation of coverage at the time of employment. At the time the reservist is called or ordered to active duty, the employer shall notify each eligible person of the requirements for the continuation of coverage.

(3) Each certificate or other evidence of coverage issued by an employer to an employee under the group plan shall include a notice of the eligible person's right of continuation of coverage.

(4) An eligible person shall file a written election of continuation of coverage with the employer and pay the employer the first contribution required under division (D)(5) of this section. The written election and payment must be received by the employer no later than thirty-one days after the date on which the eligible person's coverage would otherwise terminate. If the employer notifies the eligible person of the right of continuation of coverage after the date on which the eligible person's coverage would otherwise terminate, the written election and payment must be received by the employer no later than thirty-one days after the date of the notification.

(5)(a) Except as provided in division (D)(5)(b) or (c) of this section, the eligible person shall pay to the employer, on a monthly basis and in advance, the amount of contribution required by the employer. The amount shall not exceed one hundred two per cent of the group rate for the coverage being continued under the group plan on the due date of each payment.

(b) The employer may pay a portion or all of the eligible person's contribution.

(c) A reservist called or ordered to active duty for less than thirty-one days shall not be required to pay more than the eligible person's contribution if any, for the coverage.

(E) The eligible person's right to any continuation of coverage, or the extension of any continuation of coverage, provided under division (B) or (C) of this section ceases on the date on which any of the following occurs:

(1) The eligible person, whether as an employee or otherwise, enrolls in another group plan or other group health plan or arrangement that does not contain any exclusion or limitation with respect to any preexisting condition of that eligible person. For purposes of division (E)(1) of this section, a group plan or other group health plan or arrangement does not include the civilian health and medical program of the uniformed services as defined in Public Law 99-661, 100 Stat. 3898 (1986), 10 U.S.C.A. 1072.

(2) The period of either eighteen months provided under division (B) of this section or thirty-six months provided under division (C) of this section expires.

(3) The eligible person fails to make a timely payment of a required contribution, in which case the coverage ceases at the end of the period of coverage for which contributions were made.

(4) The group plan, or participation under the group plan, is terminated, unless the employer, in accordance with division (F) of this section, replaces the coverage with similar coverage under another group plan or other group health plan or arrangement.

(F) If the employer replaces the group plan with similar coverage as described in division (E)(4) of this section, both of the following apply:

(1) The eligible person is covered under the replacement coverage for the balance of the period that the person would have remained covered under the terminated coverage if it had not been terminated.

(2) The level of benefits under the replacement coverage is the same as the level of benefits provided to any similarly situated eligible person who is covered under the group plan and an employee who has not been called or ordered to active duty.

(G) Upon the reservist's release from active duty and the reservist's return to employment for the employer by whom the reservist was employed at the time the reservist was called or ordered to active duty, both of the following apply:

(1) Every eligible person is entitled, without any waiting period, to coverage under the employer's group plan that is in effect at the time of the reservist's return to employment.

(2) Every eligible person is entitled to all benefits under the group plan described in division (G)(1) of this section from the date of the original coverage under the plan.

(H)(1) No employer shall fail to provide for a continuation of coverage, or an extension of a continuation of coverage, in a group plan as required by and in accordance with the terms and conditions set forth under this section.

(2) No employer shall fail to issue a certificate or other evidence of coverage in compliance with division (D)(3) of this section.

(3) No employer shall fail to provide an employee or eligible person with notice of the right to a continuation of coverage under a group plan in accordance with division (D)(2) of this section.

(I) Whoever violates division (H)(1), (2), or (3) of this section is deemed to have engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

(J) This section does not apply to a group plan that is superseded, preempted, prohibited, or otherwise precluded by federal law.

Section 3923.39 | Consolidated corporation cancelling individual policy for nonpayment.

• Effective: October 1, 1987
• Latest Legislation: Senate Bill 124 - 117th General Assembly

(A) As used in this section:

(1) "Consolidated corporation" means any mutual insurance company that merged or consolidated with a hospital service association.

(2) "Individual policy" means a policy other than a policy issued pursuant to section 3923.11, 3923.12, or 3923.13 of the Revised Code.

(3) "Individual policyholder" means a person who is an insured under an individual policy.

(4) "Cancel" means any cancellation, denial of renewal, lapse, or other termination of coverage of an individual policyholder of a consolidated corporation on the ground of nonpayment of a policy payment.

(5) "Notice of cancellation" means a notice by a consolidated corporation of an intention to cancel an individual policy on the ground of nonpayment of a policy payment.

(6) "Extenuating circumstances" means circumstances that excuse an individual policyholder's failure to pay a policy payment after the mailing of a notice of cancellation under this section and include, but are not limited to, any of the following:

(a) Hospitalization;

(b) Incapacity or incompetency;

(c) Continuous absence from the address to which the notice was addressed for a period of time, including the date on which the notice was delivered to the address, of not more than sixty days from the date on which the notice was mailed.

(7) "Medicare supplement policy" has the same meaning as in section 3923.33 of the Revised Code.

(B) If a consolidated corporation does not receive a policy payment due from a policyholder on an individual policy on or before the due date shown on a billing mailed to the policyholder, the consolidated corporation may cancel the policyholder's coverage by mailing a notice of cancellation to the policyholder at his last known address.

No cancellation for nonpayment of a policy payment shall take effect until not less than fifteen days have passed since the date of mailing of a notice of cancellation.

An individual policyholder whose coverage is terminated for nonpayment may apply for reinstatement of coverage within sixty days after the date the notice of cancellation is mailed. The consolidated corporation shall reinstate the coverage, continuous from the date of cancellation, if it determines that the policyholder's failure to pay was due to extenuating circumstances, and the policyholder pays the payment required for reinstatement of coverage. A consolidated corporation shall establish an appeals procedure that will enable the policyholder to present the reasons why the consolidated corporation should reconsider the cancellation and reinstate the coverage.

The notice of cancellation shall advise the policyholder of the policyholder's rights to appeal the cancellation of coverage and of the amount of payment that will be required to reinstate the coverage.

(C) No individual policyholder of a consolidated corporation shall be billed either by a hospital or the consolidated corporation for rendered health care services adjudged unnecessary by a utilization review mechanism recognized by the consolidated corporation or the hospital, provided such individual policyholder has acted in good faith. The contract between the consolidated corporation and the hospital may specify the conditions under which the consolidated corporation or the hospital shall sustain the loss of revenue.

(D) Notwithstanding the provisions of section 3941.47 of the Revised Code, a medicare supplement policy issued or renewed by a consolidated corporation to an individual policyholder may not provide for the denial or reduction of benefits under such policy when services are provided at or by a hospital which does not have a contractual relationship with such consolidated corporation.

Section 3923.40 | Coverage of adopted children.

• Effective: June 30, 1997
• Latest Legislation: House Bill 374 - 122nd General Assembly

No individual or group policy of sickness and accident insurance that makes family coverage available may be delivered, issued for delivery, or renewed in this state on or after January 1, 1989, unless the policy covers adopted children of the insured on the same basis as other dependents.

The coverage required by this section is subject to the requirements and restrictions set forth in section 3924.51 of the Revised Code.

Section 3923.41 | Long-term care insurance definitions.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

As used in sections 3923.41 to 3923.48 of the Revised Code:

(A) "Long-term care insurance" means any insurance policy or rider advertised, marketed, offered, or designed to provide coverage for not less than one year for each covered person on an expense incurred, indemnity, prepaid, or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital. "Long-term care insurance" includes group and individual annuities and life insurance policies or riders that provide directly or supplement long-term care benefits, and policies or riders that provide for payment of benefits based on cognitive impairment or the loss of functional capacity. "Long-term care insurance" includes group and individual policies or riders whether issued by insurers, fraternal benefit societies, or health insuring corporations. "Long-term care insurance" includes qualified long-term care insurance contracts. "Long-term care insurance" does not include any insurance policy that is offered primarily to provide basic medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage.

With regard to life insurance, "long-term care insurance" does not include life insurance policies that accelerate the death benefits specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement; that provide the option of a lump sum payment for those benefits; and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.

Notwithstanding any other provision contained in sections 3923.41 to 3923.48 of the Revised Code, any product advertised, marketed, or offered as long-term care insurance shall be subject to sections 3923.41 to 3923.48 of the Revised Code.

(B) "Applicant" means either of the following:

(1) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits;

(2) In the case of a group long-term care insurance policy, the proposed certificate holder.

(C) "Certificate" means any certificate issued under a group long-term care insurance policy that has been delivered, issued for delivery, or used in or outside this state.

(D) "Group long-term care insurance" means a long-term care insurance policy that is delivered or issued for delivery in this state to any of the following:

(1) One or more employers or labor organizations, or a trust or the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, established for either of the following:

(a) Employees or former employees or a combination thereof;

(b) Members of the labor organization, or former members of the labor organization, or a combination thereof.

(2) Any professional, trade, or occupational association for its members or former or retired members, or a combination thereof, if the association satisfies both of the following requirements:

(a) It is composed of individuals all of whom are or were actively engaged in the same profession, trade, or occupation.

(b) It is maintained in good faith for purposes other than obtaining insurance.

(3) An association or trust of the trustees of a fund established, created, or maintained for the benefit of members of one or more associations that meets the requirements of section 3923.43 of the Revised Code;

(4) A group other than as described in divisions (D)(1), (2), and (3) of this section about whom the superintendent of insurance finds that all of the following are true:

(a) The issuance of the group policy is not contrary to the best interest of the public.

(b) The issuance of the group policy would result in economies of acquisition or administration.

(c) The benefits of the group policy are reasonable in relation to the premiums charged.

(E) "Policy" means any policy, contract, rider, or endorsement delivered, issued for delivery, or used in or outside this state by an insurer, fraternal benefit society, or health insuring corporation.

(F)(1) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" means an individual or group insurance contract of which all of the following are true pursuant to division (b) of section 7702B of the "Internal Revenue Code of 1986," 26 U.S.C. 7702B, as amended:

(a) The only insurance protection provided under the contract is coverage of qualified long-term care services including payments made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.

(b) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the "Social Security Act," 42 U.S.C. 1395 et seq., as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The contract may pay or reimburse expenses that are reimbursable under Title XVIII of the Social Security Act as a secondary payer. A contract may allow payments to be made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.

(c) The contract is guaranteed renewable, within the meaning of division (b)(1)(C) of section 7702B of the "Internal Revenue Code of 1986," 26 U.S.C. 7702B, as amended.

(d) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in division (F)(1)(e) of this section.

(e) All refunds of premiums, and all policy holder dividends or similar amounts, under the contract shall be applied to a reduction in future premiums or to increase future benefits, except that a refund in the event of death of the insured or in the event of a complete surrender or cancellation of the contract shall not exceed the aggregate premiums paid under the contract.

(f) The contract meets the consumer protection provisions set forth in division (g) of section 7702B of the "Internal Revenue Code of 1986," 26 U.S.C. 7702B, as amended.

(2) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" also means the portion of a life insurance contract that provides long-term care insurance coverage by a rider or as part of the contract and that satisfies the requirements of divisions (b) and (e) of section 7702B of the Internal Revenue Code of 1986, 26 U.S.C 7702B, as amended.

(G) "State long-term care partnership program" or "partnership program" means a program established under division (b) of section 1917 of the "Social Security Act," 42 U.S.C. 1396p, as amended.

(H) "Insurance agent" or "agent" means a person licensed under Chapter 3905. of the Revised Code to sell, solicit, or negotiate insurance.

(I) "Insurer" means any person authorized under Title XXXIX of the Revised Code to engage in the business of insurance in this state or any health insuring corporation authorized under Chapter 1751. of the Revised Code to do business in this state that issues long-term care insurance policies or certificates.

Section 3923.42 | Citing provisions - applicability.

• Effective: January 31, 1992
• Latest Legislation: House Bill 490 - 119th General Assembly

(A) Sections 3923.41 to 3923.48 of the Revised Code may be cited as the "long-term care insurance act."

(B) Sections 3923.41 to 3923.48 of the Revised Code do not supersede the obligations of entities subject to these sections to comply with the substance of other applicable insurance laws insofar as they do not conflict with these sections, except that section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code and rules intended to apply to medicare supplement insurance policies do not apply to long-term care insurance. A policy that is not advertised, marketed, or offered as long-term care insurance need not meet the requirements of sections 3923.41 to 3923.48 of the Revised Code.

Section 3923.43 | Evidence to be filed by long-term care insurance association.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

(A) Prior to advertising, marketing, or offering a policy within this state, the association or the insurer of the association described in division (D)(3) of section 3923.41 of the Revised Code, shall file evidence with the superintendent of insurance that the association has at the outset a minimum of one hundred persons and has been organized and maintained in good faith for purposes other than that of obtaining insurance, has been in active existence for at least one year, and has a constitution and bylaws that provide all of the following:

(1) The association holds regular meetings not less than annually to further the purposes of the members;

(2) Except for credit unions, the association collects dues or solicits contributions from members;

(3) The association's members have voting privileges and representation on the governing board and committees of the association.

(B) Thirty days after the evidence filing, the association is deemed to satisfy the organizational requirements listed in division (A) of this section unless the superintendent makes a specific finding that the association does not satisfy the organizational requirements.

Section 3923.44 | Standards for full and fair disclosure for sale of long-term care insurance policies.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

(A) The superintendent of insurance, pursuant to Chapter 119. of the Revised Code, may adopt rules that include standards for full and fair disclosure setting forth the manner, content, and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of coverage, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions, and definitions of terms. Such rules may include provisions related to the state long-term care partnership program, including, but not limited to, requirements related to offers to exchange partnership program policies for previously issued policies and for consumer disclosures related to the state long-term care partnership program.

(B) No long-term care insurance policy shall:

(1) Be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;

(2) Contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder;

(3) Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care;

(4) Use a definition of "preexisting condition" that is more restrictive than the following: "Preexisting condition" means a condition for which medical advice or treatment was recommended by, or received from, a provider of health care services, within six months preceding the effective date of coverage of an insured person.

(5) Exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured person.

(C) The superintendent may extend the limitation periods set forth in divisions (B)(4) and (5) of this section as to specific age group categories in specific policy forms upon findings that the extension is in the best interest of the public.

(D) "Preexisting condition" does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer's established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in division (B)(5) of this section expires. No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in division (B)(5) of this section.

(E)(1) No long-term care insurance policy shall do any of the following:

(a) Condition eligibility for any institutional benefits on a requirement of prior hospitalization;

(b) Condition eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care;

(c) Condition eligibility for any institutional benefits, other than waiver of premium or post-confinement, post-acute care, or recuperative benefits, on a requirement of prior institutionalization.

(2) Every long-term care insurance policy that conditions eligibility for noninstitutional benefits on the prior receipt of institutional care is subject to both of the following:

(a) The policy shall not require a prior institutional stay of more than thirty days.

(b) The policy shall provide that eligibility for noninstitutional benefits shall be established by the alternative of a period of hospitalization of not more than three days.

(3) No long-term care insurance policy, except for the policy described in division (E)(2) of this section, shall condition eligibility for noninstitutional benefits on the requirement of prior hospitalization.

(4) No long-term care insurance policy that provides benefits only following institutionalization shall condition the benefits upon admission to a facility for the same or related conditions within a period of less than thirty days after discharge from the institution.

(F) A long-term care insurance policy that provides post-confinement, post-acute care, or recuperative benefits shall state any limitations or conditions on eligibility for benefits, including any required period of prior institutionalization as permitted in division (E)(1)(c) of this section, in a separate paragraph of the policy or certificate and shall label that paragraph "Limitations or Conditions on Eligibility for Benefits."

(G) The superintendent, pursuant to Chapter 119. of the Revised Code, may adopt rules establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the rule.

(H)(1) A person insured under a long-term care insurance policy may return the policy or certificate in accordance with the procedures and requirements provided for individual policyholders under section 3923.31 of the Revised Code, except that the person has thirty days from the date of delivery to return the policy or certificate and have the premium refunded.

(2) A notice of the policyholder's or certificate holder's rights under division (H)(1) of this section and section 3923.31 of the Revised Code shall be printed prominently on the first page of the policy or certificate or attached to the policy or certificate.

(I) Except as provided in division (M) of this section, an outline of coverage and a notice that consumer information is available from the department of insurance under section 3923.49 of the Revised Code shall be delivered to a prospective applicant for long-term care insurance at the time of the initial solicitation through means that prominently direct the attention of the prospective applicant to the outline of coverage, the purpose of the outline of coverage, and the notice. In the case of agent solicitations, the agent shall deliver the outline of coverage and notice prior to the presentation of an application or enrollment form. In the case of direct response solicitations, the insurer shall deliver the outline of coverage and notice in conjunction with any application or enrollment form. The superintendent shall prescribe by rule the content and format of the outline of coverage and notice, including the style, overall appearance, size, color and prominence of type, and the arrangement of text and captions. The outline of coverage shall include all of the following:

(1) A description of the principal benefits and coverage provided in the policy;

(2) A statement of the principal exclusions, reductions, and limitations contained in the policy;

(3) A statement of the terms under which the individual policy or certificate or the group policy or certificate may be renewed and the terms under which cancellation is permitted, including any reservation in the policy of a right to change premiums. Continuation or conversion provisions of group long-term care insurance shall be specifically described.

(4) A description of the terms under which the policy or certificate may be returned and the premium refunded;

(5) A brief description of the relationship of the cost of care and benefits;

(6) A statement that the outline of coverage is a summary of the policy issued or applied for, and that the policy or group master policy should be consulted to determine governing contractual provisions;

(7) A statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract.

(J) A certificate issued pursuant to a group long-term care insurance policy that is delivered, issued for delivery, or used in or outside this state shall include all of the following:

(1) A description of the principal benefits and coverage provided in the policy;

(2) A statement of the principal exclusions, reductions, and limitations contained in the policy;

(3) A statement that the group master policy determines governing contractual provisions.

(K) If an individual life insurance policy provides long-term care benefits within the policy or by rider, a policy summary shall be delivered to an applicant for the policy at the time of policy delivery. In the case of direct response solicitations, the insurer shall deliver the policy summary to the applicant upon the applicant's request. If no such request is made, the insurer shall deliver the policy summary no later than at the time of policy delivery. In addition to any other information required by this section, the policy summary shall include all of the following:

(1) A statement that explains how the terms of the policy that provide benefits for long-term care insurance affect the other terms of the policy, including how the payment of these benefits would reduce the death benefits payable by the policy;

(2) A description of the amount of benefits for long-term care insurance that is available under the policy, the length of time these benefits could be paid by the policy, and any guaranteed lifetime benefits provided by the policy, for each insured under the policy;

(3) A statement of the exclusions, reductions, and limitations on benefits for long-term care insurance that are contained in the policy;

(4) A statement of the effects of exercising other rights under the policy;

(5) A statement of the guarantees, if any, with respect to the policy costs of providing benefits for long-term care insurance;

(6) A statement of all current and projected maximum lifetime benefits;

(7) A statement of whether long-term care inflation protection is available under the policy.

(L) During the time when a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, the insurer shall provide a monthly report to the policyholder. The report shall include all of the following:

(1) A description of all benefits for long-term care insurance that were paid by the policy during that month;

(2) An explanation of any changes in the policy, including death benefits or cash values due to the payout of long-term care benefits;

(3) A statement of the amount of benefits for long-term care insurance that is still available under the policy.

(M) In case of a policy issued to a group defined in division (D)(1) of section 3923.41 of the Revised Code, an outline of coverage shall not be required to be delivered, provided that the information described in division (I) of this section is contained in other materials relating to enrollment and, upon request, these other materials are made available to the superintendent.

(N)(1) Policies that are intended to qualify under the state long-term care partnership program shall comply with all state and federal requirements applicable to policies issued in connection with the state long-term care partnership program.

(2)(a) For policies intended to qualify under the state long-term care partnership program, the agent or insurer shall deliver to the applicant a long-term care partnership policy disclosure form along with the outline of coverage specified in division (I) of this section.

(b) In the case of a policy issued to a group where an outline of coverage is not delivered, the long-term care partnership policy disclosure form is delivered with enrollment forms.

(c) In the case of a life insurance policy that offers long-term care insurance within the policy or as a rider, the disclosure form is provided with the policy summary.

(O) No insurer shall issue a policy intended to qualify as a state partnership program policy that fails to satisfy the following inflation protection requirements:

(1) For a person who is less than sixty-one years of age as of the date of purchase of the policy, the policy provides annual inflation protection of at least three per cent compounded annually per year or a rate, compounded annually, that is equal to the annual consumer price index.

(2) For a person who is at least sixty-one years of age but less than seventy-six years of age as of the date of purchase of the policy, the policy provides annual inflation protection of at least three per cent simple or a rate equal to the annual consumer price index.

(3) For a person who is at least seventy-six years of age as of the date of purchase of the policy, the policy may provide inflation protection.

(P) As used in this section, "consumer price index" means consumer price index for all urban consumers, U.S. city average, all items, as determined by the bureau of labor statistics of the United States department of labor.

(Q) For purposes of division (O) of this section, the superintendent may approve an alternative index to be used in place of the consumer price index.

(R) The superintendent shall prescribe by rule pursuant to Chapter 119. of the Revised Code the content and format of the state long-term care partnership program policy disclosure form required by division (N)(2) of this section.

(S) No policy may be advertised, marketed, or offered as long-term care insurance unless it complies with sections 3923.41 to 3923.48 of the Revised Code.

(T) The superintendent may adopt rules in accordance with Chapter 119. of the Revised Code to establish minimum standards for marketing practices, agent compensation, agent testing, and reporting practices for long-term care insurance.

Section 3923.441 | Rescission of long-term care policy for misrepresentation.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

(A) Except as otherwise provided in division (C) of this section and notwithstanding division (B) of section 3923.04 of the Revised Code, no insurer shall rescind a long-term care insurance policy or certificate or deny an otherwise valid claim based upon a misrepresentation by the applicant without adhering to one of the following:

(1) For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the insurer can demonstrate that the insured misrepresented facts that were material to the insurer's offer of coverage to the insured.

(2) For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the insurer can demonstrate that the insured misrepresented facts that were both material to the insurer's offer of coverage to the insured and that pertain to the condition for which the insured sought benefits.

(3) After a policy or certificate has been in force for at least two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the insurer can demonstrate that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health in the insured's application for the policy.

(B) No insurer shall recover from the insured benefits that were paid under a long-term care insurance policy or certificate prior to the rescission of the policy or certificate pursuant to this section.

(C) In the event of the death of the insured, the remaining death benefits under a life insurance policy that accelerates benefits for long-term care are governed by section 3923.04 of the Revised Code.

Section 3923.442 | Offer of nonforfeiture benefit option with long-term care policy.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

(A)(1) Except as provided in division (B) of this section, no insurer shall deliver or issue for delivery a long-term care insurance policy or certificate in this state without offering the policyholder or certificate holder the option of purchasing a nonforfeiture benefit.

(2) An insurer's offer of a nonforfeiture benefit pursuant to this section may be in the form of a rider that is attached to the policy.

(3) If the policyholder or certificate holder declines the nonforfeiture benefit offered pursuant to this section, the insurer shall provide a contingent benefit upon lapse that shall be available for a period of time specified in the policy or certificate following a substantial increase in premium rates.

(B)(1) For a group long-term care insurance policy, the insurer shall make the offer required by division (A) of this section to the group policyholder.

(2) For a group long-term care insurance policy as defined by division (D)(4) of section 3923.41 of the Revised Code, other than to a continuing care retirement community or other similar entity, the insurer shall make the offer required by division (A) of this section to each proposed certificate holder.

(C) The superintendent of insurance may adopt rules specifying the type of nonforfeiture benefits insurers may offer as part of long-term care insurance policies and certificates, the standards for nonforfeiture benefits, and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as described in division (A) of this section.

Section 3923.443 | Training required for agents selling long-term care policies.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

(A)(1) No agent shall sell, solicit, or negotiate long-term care insurance on or after September 1, 2008, without completing an initial eight-hour partnership program training course as described in division (B) of this section.

(2)(a) Any agent that sells, solicits, or negotiates any long-term care insurance shall complete at least four hours of continuing education in every twenty-four-month period commencing on the first day of January of the year immediately following the year of the issuance of the agent's license.

(b) No agent shall fail to complete the continuing education requirements in division (A)(2)(a) of this section in the twenty-four-month period described in that division.

(B) The initial training course and continuing education required under division (A) of this section may be approved by the superintendent of insurance as continuing education courses under sections 3905.481 to 3905.486 of the Revised Code and shall consist of combined topics related to long-term care insurance, long-term care services, and state long-term care insurance partnership programs, including all of the following:

(1) State and federal regulations and requirements and the relationship between state long-term care insurance partnership programs and other public and private coverage of long-term care services, including medicaid;

(2) Available long-term care services and providers;

(3) Changes or improvements in long-term care services or providers;

(4) Alternatives to the purchase of private long-term care insurance;

(5) The effect of inflation on benefits and the importance of inflation protection;

(6) Consumer suitability standards and guidelines;

(7) Any other topics required by the superintendent.

(C) The initial training and continuing education required by division (A) of this section shall not include training that is specific to a particular insurer or company product or that includes any sales or marketing information, materials, or training other than those required by state or federal law.

(D) A resident agent shall satisfy the training and continuing education required by division (A) of this section by completing long-term care courses that are approved by the superintendent. A nonresident agent may satisfy the training and continuing education required by division (A) of this section by completing the training requirements in any other state, provided that the course is approved for credit by the insurance department of that state prior to the agent taking the course.

(E) Each insurer shall obtain records of the initial training and continuing education completed by agents of that insurer pursuant to division (A) of this section as well as the training completed by the insurer's agents concerning the distribution of the insurer's partnership program policies and shall make those records available to the superintendent upon request.

(F) Each insurer shall maintain records with respect to the training of its agents concerning the distribution of the insurer's partnership program policies. Each insurer shall provide documentation to the superintendent that will allow the superintendent to provide assurance to the medicaid director that agents have received the training required by this section and that agents have demonstrated an understanding of the partnership program policies and their relationship to public and private coverage of long-term care in this state, including medicaid. The superintendent may audit each insurer's records annually to verify that the insurer is maintaining the records required by this division. The superintendent shall make the records provided to the superintendent pursuant to division (E) of this section available to the director.

Section 3923.444 | Compensation of agents selling long-term care policies.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

(A) No agent or third-party administrator shall field issue a long-term care insurance policy or certificate if the compensation to the agent or third-party administrator is not based on the number of policies or certificates issued.

(B) As used in this section, "field issue" means to issue a policy or certificate pursuant to the underwriting authority granted to an agent or third-party administrator by an insurer using the insurer's underwriting guidelines.

Section 3923.45 | Forms.

• Effective: September 14, 1988
• Latest Legislation: House Bill 611 - 117th General Assembly

The form of all long-term care insurance policies and applications shall be filed and approved in accordance with section 3923.02 of the Revised Code.

Section 3923.46 | Rates for individual policy.

• Effective: September 14, 1988
• Latest Legislation: House Bill 611 - 117th General Assembly

Premium rates for any individual policy of long-term care insurance shall be filed in accordance with section 3923.021 of the Revised Code.

Section 3923.47 | Rules.

• Effective: September 10, 2007
• Latest Legislation: House Bill 100 - 127th General Assembly

The superintendent of insurance shall, pursuant to Chapter 119. of the Revised Code, adopt rules to carry out the purposes of sections 3923.41 to 3923.48 of the Revised Code including rules related to the state long-term care partnership program.

Section 3923.48 | Violation is unfair and deceptive insurance practice.

• Effective: August 14, 1992
• Latest Legislation: House Bill 216 - 119th General Assembly

Any violation of sections 3923.44 to 3923.46 of the Revised Code is an unfair and deceptive insurance practice under sections 3901.19 to 3901.23 of the Revised Code.

Section 3923.49 | Establishing outreach program to educate consumers.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

The department of insurance shall establish an outreach program to educate consumers about the following:

(A) The need for long-term care insurance;

(B) Mechanisms for financing long-term care;

(C) The availability of long-term care insurance;

(D) The resource protection provided by the Ohio long-term care insurance program under section 5164.86 of the Revised Code;

(E) That a consumer who purchased a long-term care insurance policy that does not meet the requirements of section 3923.50 of the Revised Code may purchase a policy that meets those requirements.

The department shall develop and make available to consumers information to assist them in choosing long-term care insurance coverage.

Section 3923.50 | Notifying department of job and family services of long-term care insurance policies that comply with insurance department requirements.

• Effective: September 29, 2013
• Latest Legislation: House Bill 59 - 130th General Assembly

For the purposes of the Ohio long-term care insurance program established under section 5164.86 of the Revised Code, the department of insurance shall notify the department of medicaid of all long-term care insurance policies that meet all of the following requirements:

(A) Comply with sections 3923.41 to 3923.48 of the Revised Code and the rules adopted under section 3923.47 of the Revised Code;

(B) Provide benefits for home and community-based services in addition to nursing home care;

(C) Include case management services in its coverage of home and community-based services;

(D) Provide five per cent inflation protection compounded annually;

(E) Provide for the keeping of records and explanation-of-benefit reports on insurance payments that count toward resource exclusion for the medicaid program;

(F) Provide the information the medicaid director determines is necessary to document the extent of resource exclusion and to evaluate the Ohio long-term care insurance program;

(G) Comply with other requirements established in rules adopted under this section.

The superintendent of insurance shall adopt rules in accordance with Chapter 119. of the Revised Code establishing requirements under division (G) of this section that policies must meet to qualify under the Ohio long-term care insurance program. The superintendent shall consult with the departments of aging and medicaid in adopting those rules.

Section 3923.51 | Group contracts of sickness and accident insurance persons under nineteen who are members of impoverished families.

• Effective: March 30, 2007
• Latest Legislation: Senate Bill 116 - 126th General Assembly

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

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

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

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

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

(3) Chapter 1751. of the Revised Code.

Section 3923.52 | Screening mammography and cytologic screening benefits.

• Effective: September 23, 2022
• Latest Legislation: House Bill 371 - 134th General Assembly

(A) As used in this section and section 3923.53 of the Revised Code:

(1) "Screening mammography" means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in asymptomatic women and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. "Screening mammography" includes digital breast tomosynthesis. "Screening mammography" includes two views for each breast. The term also includes the professional interpretation of the film.

"Screening mammography" does not include diagnostic mammography.

(2) "Supplemental breast cancer screening" means any additional screening method deemed medically necessary by a treating health care provider for proper breast cancer screening in accordance with applicable American college of radiology guidelines, including magnetic resonance imaging, ultrasound, or molecular breast imaging.

(B) Notwithstanding section 3901.71 of the Revised Code, every policy of individual or group sickness and accident insurance that is delivered, issued for delivery, or renewed in this state shall provide benefits for the expenses of all of the following:

(1) To detect the presence of breast cancer in adult women, screening mammography;

(2) To detect the presence of breast cancer in adult women meeting either of the conditions described in division (C)(2) of this section, supplemental breast cancer screening;

(3) To detect the presence of cervical cancer, cytologic screening.

(C)(1) The benefits provided under division (B)(1) of this section shall cover expenses for one screening mammography every year, including digital breast tomosynthesis.

(2) The benefits provided under division (B)(2) of this section shall cover expenses for supplemental breast cancer screening for an adult woman who meets either of the following conditions:

(a) The woman's screening mammography demonstrates, based on the breast imaging reporting and data system established by the American college of radiology, that the woman has dense breast tissue;

(b) The woman is at an increased risk of breast cancer due to family history, prior personal history of breast cancer, ancestry, genetic predisposition, or other reasons as determined by the woman's health care provider.

(D) As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection.

(1) Subject to divisions (D)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section or a component of the supplemental breast cancer screening benefit in division (B)(2) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component.

(2) Regardless of whether separate payments are made for the benefit provided under division (B)(1) or (2) of this section, the total benefit for a screening mammography or supplemental breast cancer screening shall not exceed one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography or supplemental breast cancer screening. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography or supplemental breast cancer screening or a component of supplemental breast cancer screening, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state.

(3) The benefit paid in accordance with division (D)(1) of this section shall constitute full payment. No provider, hospital, or other health care facility shall seek or receive compensation in excess of the payment made in accordance with division (D)(1) of this section, except for approved deductibles and copayments.

(E) The benefits provided under division (B)(1) or (2) of this section shall be provided only for screening mammographies or supplemental breast cancer screenings that are performed in a facility or mobile mammography screening unit that is accredited under the American college of radiology mammography accreditation program or in a hospital as defined in section 3727.01 of the Revised Code.

(F) The benefits provided under division (B)(3) of this section shall be provided only for cytologic screenings that are processed and interpreted in a laboratory certified by the college of American pathologists or in a hospital as defined in section 3727.01 of the Revised Code.

(G) This section does not apply to any policy that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, or other policy that offers only supplemental benefits.

Last updated July 14, 2022 at 3:05 PM

Section 3923.53 | Public employee benefit plan - breast cancer and cervical cancer screening.

• Effective: September 23, 2022
• Latest Legislation: House Bill 371 - 134th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, every public employee benefit plan that is established or modified in this state shall provide benefits for the expenses of all of the following:

(1) To detect the presence of breast cancer in adult women, screening mammography;

(2) To detect the presence of breast cancer in adult women meeting any of the conditions described in division (B)(2) of this section, supplemental breast cancer screening;

(3) To detect the presence of cervical cancer, cytologic screening.

(B)(1) The benefits provided under division (A)(1) of this section shall cover expenses for one screening mammography every year, including digital breast tomosynthesis.

(2) The benefits provided under division (A)(2) of this section shall cover expenses for supplemental breast cancer screening for an adult woman who meets any of the following conditions:

(a) The woman's screening mammography demonstrates, based on the breast imaging reporting and data system established by the American college of radiology, that the woman has dense breast tissue;

(b) The woman is at an increased risk of breast cancer due to family history, prior personal history of breast cancer, ancestry, genetic predisposition, or other reasons as determined by the woman's health care provider.

(C) As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection.

(1) Subject to divisions (C)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (A)(1) of this section or a component of the supplemental breast cancer screening benefit in division (A)(2) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component.

(2) Regardless of whether separate payments are made for the benefit provided under division (A)(1) or (2) of this section, the total benefit for a screening mammography or supplemental breast cancer screening shall not exceed one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography or supplemental breast cancer screening. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography or supplemental breast cancer screening or a component of supplemental breast cancer screening, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state.

(3) The benefit paid in accordance with division (C)(1) of this section shall constitute full payment. No provider, hospital, or other health care facility shall seek or receive compensation in excess of the payment made in accordance with division (C)(1) of this section, except for approved deductibles and copayments.

(D) The benefits provided under division (A)(1) or (2) of this section shall be provided only for screening mammographies or supplemental breast cancer screenings that are performed in a facility or mobile mammography screening unit that is accredited under the American college of radiology mammography accreditation program or in a hospital as defined in section 3727.01 of the Revised Code.

(E) The benefits provided under division (A)(3) of this section shall be provided only for cytologic screenings that are processed and interpreted in a laboratory certified by the college of American pathologists or in a hospital as defined in section 3727.01 of the Revised Code.

Last updated October 31, 2022 at 5:16 PM

Section 3923.54 | Employee health care benefit plan.

• Effective: March 22, 2005
• Latest Legislation: House Bill 331 - 125th General Assembly

(A) As used in this section, "screening mammography" means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in asymptomatic women and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. "Screening mammography" includes two views for each breast. The term also includes the professional interpretation of the film.

"Screening mammography" does not include diagnostic mammography.

(B) Each employer in this state that provides, in whole or in part, health care benefits for its employees under a policy of sickness and accident insurance issued in accordance with Chapter 3923. of the Revised Code shall also provide to its employees benefits for the expenses of both of the following:

(1) Screening mammography to detect the presence of breast cancer in adult women;

(2) Cytologic screening for the presence of cervical cancer.

(C) An employer may comply with division (B) of this section in any of the following ways:

(1) By providing the benefits under a health insuring corporation contract issued in accordance with Chapter 1751. of the Revised Code or a policy of sickness and accident insurance issued in accordance with Chapter 3923. of the Revised Code;

(2) By reimbursing the employee for the direct health care provider charges associated with receipt of the covered service;

(3) By making any other arrangement that provides the benefits described in division (B) of this section.

(D) The benefits provided under division (B)(1) of this section shall cover expenses in accordance with all of the following:

(1) If a woman is at least thirty-five years of age but under forty years of age, one screening mammography;

(2) If a woman is at least forty years of age but under fifty years of age, either of the following:

(a) One screening mammography every two years;

(b) If a licensed physician has determined that the woman has risk factors to breast cancer, one screening mammography every year.

(3) If a woman is at least fifty years of age but under sixty-five years of age, one screening mammography every year.

(E) As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection.

(1) Subject to divisions (E)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component.

(2) Regardless of whether separate payments are made for the benefit provided under division (B)(1) of this section, the total benefit for a screening mammography need not exceed one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state.

(3) The benefit paid in accordance with division (E)(1) of this section shall constitute full payment. No provider, hospital, or other health care facility shall seek or receive compensation in excess of the payment made in accordance with division (E)(1) of this section, except for approved deductibles and copayments.

(F) The benefits provided under division (B)(1) of this section shall be provided only for screening mammographies that are performed in a facility or mobile mammography screening unit that is accredited under the American college of radiology mammography accreditation program or in a hospital as defined in section 3727.01 of the Revised Code.

(G) The benefits provided under division (B)(2) of this section shall be provided only for cytologic screenings that are processed and interpreted in a laboratory certified by the college of American pathologists or in a hospital as defined in section 3727.01 of the Revised Code.

Section 3923.55 | Policy to include benefits for child health supervision services from moment of birth until age nine.

• Effective: August 1, 2002
• Latest Legislation: House Bill 150 - 124th General Assembly

(A) As used in this section and section 3923.56 of the Revised Code:

(1) "Child health supervision services" means periodic review of a child's physical and emotional status performed by a physician, by a health care professional under the supervision of a physician, or, in the case of hearing screening, by an individual acting in accordance with section 3701.505 of the Revised Code.

(2) "Periodic review" means a review performed in accordance with the recommendations of the American academy of pediatrics and includes a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations, and laboratory tests.

(3) "Physician" means a person authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(B) Notwithstanding section 3901.71 of the Revised Code, each policy of individual or group sickness and accident insurance delivered, issued for delivery, or renewed in this state on or after the effective date of this amendment, that provides coverage for family members of the insured shall provide, with respect to that coverage, that any benefits applicable for children shall include benefits for child health supervision services from the moment of birth until age nine.

(C) A policy that provides the benefits described in division (B) of this section may limit the benefits to cover only the expenses of child health supervision services that are performed by one physician or by a health care professional under the supervision of one physician during the course of any one visit.

(D) Copayments and deductibles shall be reasonable and shall not be a barrier to the necessary utilization of child health supervision services by covered persons.

(E) Benefits for child health supervision services that are provided to a child during the period from birth to age one shall not exceed a maximum limit of five hundred dollars, including benefits for the hearing screening required by the program established under section 3701.504 of the Revised Code. The benefits for the hearing screening shall not exceed a maximum limit of seventy-five dollars. Benefits for child health supervision services that are provided to a child during any year thereafter shall not exceed a maximum limit of one hundred fifty dollars per year.

(F) This section does not apply to any policy that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, or other policy that offers only supplemental benefits.

Section 3923.56 | Plan to include benefits for child health supervision services from moment of birth until age nine.

• Effective: August 1, 2002
• Latest Legislation: House Bill 150 - 124th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, each employee benefit plan established or maintained in this state on or after the effective date of this amendment that provides coverage for family members of the employee shall provide, with respect to that coverage, that any benefits applicable for children shall include benefits for child health supervision services from the moment of birth until age nine.

(B) A plan that provides the benefits described in division (A) of this section may limit the benefits to cover only the expenses of child health supervision services that are performed by one physician or by a health care professional under the supervision of one physician during the course of any one visit.

(C) Copayments and deductibles shall be reasonable and shall not be a barrier to the necessary utilization of child health supervision services by covered persons.

(D) Benefits for child health supervision services that are provided to a child during the period from birth to age one shall not exceed a maximum limit of five hundred dollars, including benefits for the hearing screening required by the program established under section 3701.504 of the Revised Code. The benefits for the hearing screening shall not exceed a maximum limit of seventy-five dollars. Benefits for child health supervision services that are provided to a child during any year thereafter shall not exceed a maximum limit of one hundred fifty dollars per year.

Section 3923.57 | Pre-existing conditions provisions.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

Notwithstanding any provision of this chapter, every individual policy of sickness and accident insurance that is delivered, issued for delivery, or renewed in this state is subject to the following conditions, as applicable:

(A) Pre-existing conditions provisions shall not exclude or limit coverage for a period beyond twelve months following the policyholder's effective date of coverage and may only relate to conditions during the six months immediately preceding the effective date of coverage.

(B) In determining whether a pre-existing conditions provision applies to a policyholder or dependent, each policy shall credit the time the policyholder or dependent was covered under a previous policy, contract, or plan if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable service waiting period under the policy.

(C)(1) Except as otherwise provided in division (C) of this section, an insurer that provides an individual sickness and accident insurance policy to an individual shall renew or continue in force such coverage at the option of the individual.

(2) An insurer may nonrenew or discontinue coverage of an individual in the individual market based only on one or more of the following reasons:

(a) The individual failed to pay premiums or contributions in accordance with the terms of the policy or the insurer has not received timely premium payments.

(b) The individual performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the policy.

(c) The insurer is ceasing to offer coverage in the individual market in accordance with division (D) of this section and the applicable laws of this state.

(d) If the insurer offers coverage in the market through a network plan, the individual no longer resides, lives, or works in the service area, or in an area for which the insurer is authorized to do business; provided, however, that such coverage is terminated uniformly without regard to any health status-related factor of covered individuals.

(e) If the coverage is made available in the individual market only through one or more bona fide associations, the membership of the individual in the association, on the basis of which the coverage is provided, ceases; provided, however, that such coverage is terminated under division (C)(2)(e) of this section uniformly without regard to any health status-related factor of covered individuals.

An insurer offering coverage to individuals solely through membership in a bona fide association shall not be deemed, by virtue of that offering, to be in the individual market for purposes of sections 3923.58 and 3923.581 of the Revised Code. Such an insurer shall not be required to accept applicants for coverage in the individual market pursuant to sections 3923.58 and 3923.581 of the Revised Code unless the insurer also offers coverage to individuals other than through bona fide associations.

(3) An insurer may cancel or decide not to renew the coverage of a dependent of an individual if the dependent has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage and if the cancellation or nonrenewal is not based, either directly or indirectly, on any health status-related factor in relation to the dependent.

(D)(1) If an insurer decides to discontinue offering a particular type of health insurance coverage offered in the individual market, coverage of such type may be discontinued by the insurer if the insurer does all of the following:

(a) Provides notice to each individual provided coverage of this type in such market of the discontinuation at least ninety days prior to the date of the discontinuation of the coverage;

(b) Offers to each individual provided coverage of this type in such market, the option to purchase any other individual health insurance coverage currently being offered by the insurer for individuals in that market;

(c) In exercising the option to discontinue coverage of this type and in offering the option of coverage under division (D)(1)(b) of this section, acts uniformly without regard to any health status-related factor of covered individuals or of individuals who may become eligible for such coverage.

(2) If an insurer elects to discontinue offering all health insurance coverage in the individual market in this state, health insurance coverage may be discontinued by the insurer only if both of the following apply:

(a) The insurer provides notice to the department of insurance and to each individual of the discontinuation at least one hundred eighty days prior to the date of the expiration of the coverage.

(b) All health insurance delivered or issued for delivery in this state in such market is discontinued and coverage under that health insurance in that market is not renewed.

(3) In the event of a discontinuation under division (D)(2) of this section in the individual market, the insurer shall not provide for the issuance of any health insurance coverage in the market and this state during the five-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.

(E) Notwithstanding divisions (C) and (D) of this section, an insurer may, at the time of coverage renewal, modify the health insurance coverage for a policy form offered to individuals in the individual market if the modification is consistent with the law of this state and effective on a uniform basis among all individuals with that policy form.

(F) Such policies are subject to sections 2743 and 2747 of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and 300gg-47, as amended.

(G) Sections 3924.031 and 3924.032 of the Revised Code shall apply to sickness and accident insurance policies offered in the individual market in the same manner as they apply to health benefit plans offered in the small employer market.

In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of this section also apply to all group sickness and accident insurance policies that are not sold in connection with an employment-related group health plan and that provide more than short-term, limited duration coverage.

In applying divisions (C) to (G) of this section with respect to health insurance coverage that is made available by an insurer in the individual market to individuals only through one or more associations, the term "individual" includes the association of which the individual is a member.

For purposes of this section, any policy issued pursuant to division (C) of section 3923.13 of the Revised Code in connection with a public or private college or university student health insurance program is considered to be issued to a bona fide association.

As used in this section, "bona fide association" has the same meaning as in section 3924.03 of the Revised Code, and "health status-related factor" and "network plan" have the same meanings as in section 3924.031 of the Revised Code.

This section does not apply to any policy that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy that is less than twelve months, or other policy that offers only supplemental benefits.

Last updated November 23, 2021 at 3:54 PM

Section 3923.571 | Conditions applying to group policies of sickness and accident insurance sold in connection with employment-related group health plan.

• Effective: March 22, 1999
• Latest Legislation: House Bill 698 - 122nd General Assembly

Except as otherwise provided in section 2721 of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, the following conditions apply to all group policies of sickness and accident insurance that are sold in connection with an employment-related group health plan and that are not subject to section 3924.03 of the Revised Code:

(A) Any such policy shall comply with the requirements of division (A) of section 3924.03 and section 3924.033 of the Revised Code.

(B)(1) Except as provided in section 2712(b) to (e) of the "Health Insurance Portability and Accountability Act of 1996," if an insurer offers coverage in the small or large group market in connection with a group policy, the insurer shall renew or continue in force such coverage at the option of the policyholder.

(2) An insurer may cancel or decide not to renew the coverage of an employee or of a dependent of an employee if the employee or dependent, as applicable, has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage and if the cancellation or nonrenewal is not based, either directly or indirectly, on any health status-related factor in relation to the employee or dependent.

As used in division (B)(2) of this section, "health status-related factor" has the same meaning as in section 3924.031 of the Revised Code.

(C)(1) No such policy, or insurer offering health insurance coverage in connection with such a policy, shall require any individual, as a condition of coverage or continued coverage under the policy, to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual covered under the policy on the basis of any health status-related factor in relation to the individual or to an individual covered under the policy as a dependent of the individual.

(2) Nothing in division (C)(1) of this section shall be construed to restrict the amount that an employer may be charged for coverage under a group policy, or to prevent a group policy, and an insurer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

(D) Such policies shall provide for the special enrollment periods described in section 2701(f) of the "Health Insurance Portability and Accountability Act of 1996."

(E) At least once in every twelve-month period, an insurer shall provide to all late enrollees, as defined in section 3924.01 of the Revised Code, who are identified by the policyholder, the option to enroll in the group policy. The enrollment option shall be provided for a minimum period of thirty consecutive days. All delays of coverage imposed under the group policy, including any pre-existing condition exclusion period or service waiting period, shall begin on the date the insurer receives notice of the late enrollee's application or request for coverage, and shall run concurrently with each other.

Section 3923.58 | [Suspended eff. 1/1/2014 to 1/1/2026, per Section 3 of S.B. 9 of the 130th General Assembly, as amended] Open enrollment coverage - insurers in the business of issuing individual policies of sickness and accident insurance.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A) As used in sections 3923.58 and 3923.59 of the Revised Code:

(1) "Base rate" means, as to any health benefit plan that is issued by a carrier in the individual market, the lowest premium rate for new or existing business prescribed by the carrier for the same or similar coverage under a plan or arrangement covering any individual with similar case characteristics.

(2) "Carrier," "health benefit plan," and "MEWA" have the same meanings as in section 3924.01 of the Revised Code.

(3) "Network plan" means a health benefit plan of a carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier.

(4) "Ohio health care basic and standard plans" means those plans established under section 3924.10 of the Revised Code.

(5) "Pre-existing conditions provision" means a policy provision that excludes or limits coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage as to a condition which, during a specified period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received, or a pregnancy existing on the effective date of coverage.

(B) Beginning in January of each year, carriers in the business of issuing health benefit plans to individuals and nonemployer groups, except individual health benefit plans issued pursuant to sections 1751.16 and 3923.122 of the Revised Code, shall accept applicants for open enrollment coverage, as set forth in this division, in the order in which they apply for coverage and subject to the limitation set forth in division (G) of this section. Carriers shall accept for coverage pursuant to this section individuals to whom both of the following conditions apply:

(1) The individual is not applying for coverage as an employee of an employer, as a member of an association, or as a member of any other group.

(2) The individual is not covered, and is not eligible for coverage, under any other private or public health benefits arrangement, including the medicare program established under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, or any other act of congress or law of this or any other state of the United States that provides benefits comparable to the benefits provided under this section, any medicare supplement policy, or any continuation of coverage policy under state or federal law.

(C) A carrier shall offer to any individual accepted under this section the Ohio health care basic and standard plans or health benefit plans that are substantially similar to the Ohio health care basic and standard plans in benefit plan design and scope of covered services.

A carrier may offer other health benefit plans in addition to, but not in lieu of, the plans required to be offered under this division. A basic health benefit plan shall provide, at a minimum, the coverage provided by the Ohio health care basic plan or any health benefit plan that is substantially similar to the Ohio health care basic plan in benefit plan design and scope of covered services. A standard health benefit plan shall provide, at a minimum, the coverage provided by the Ohio health care standard plan or any health benefit plan that is substantially similar to the Ohio health care standard plan in benefit plan design and scope of covered services.

For purposes of this division, the superintendent of insurance shall determine whether a health benefit plan is substantially similar to the Ohio health care basic and standard plans in benefit plan design and scope of covered services.

(D)(1) Health benefit plans issued under this section may establish pre-existing conditions provisions that exclude or limit coverage for a period of up to twelve months following the individual's effective date of coverage and that may relate only to conditions during the six months immediately preceding the effective date of coverage. A health insuring corporation may apply a pre-existing condition provision for any basic health care service related to a transplant of a body organ if the transplant occurs within one year after the effective date of an enrollee's coverage under this section except with respect to a newly born child who meets the requirements for coverage under section 1751.61 of the Revised Code.

(2) In determining whether a pre-existing conditions provision applies to an insured or dependent, each policy shall credit the time the insured or dependent was covered under a previous policy, contract, or plan if the previous coverage was continuous to a date not more than sixty-three days prior to the effective date of the new coverage, exclusive of any applicable service waiting period under the policy.

(E) Premiums charged to individuals under this section may not exceed the amounts specified below:

(1) For calendar years 2010 and 2011, an amount that is two times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business, and for which similar copayments and deductibles are applied;

(2) For calendar year 2012 and every year thereafter, an amount that is one and one-half times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business and for which similar copayments and deductibles are applied, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.581 of the Revised Code, have resulted in the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the premium limit established by division (E)(1) of this section shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.

(F) In offering health benefit plans under this section, a carrier may require the purchase of health benefit plans that condition the reimbursement of health services upon the use of a specific network of providers.

(G)(1) A carrier shall not be required to accept new applicants under this section if the total number of the carrier's current insureds with open enrollment coverage issued under this section calculated as of the immediately preceding thirty-first day of December and excluding the carrier's medicare supplement policies and conversion or continuation of coverage policies under state or federal law and any policies described in division (L) of this section meets the following limits:

(a) For calendar years 2010 and 2011, four per cent of the carrier's total number of individual or nonemployer group insureds in this state;

(b) For calendar year 2012 and every year thereafter, eight per cent of the carrier's total number of insured individuals and nonemployer group insureds in this state, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.581 of the Revised Code, have resulted in the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the enrollment limit established by division (G)(1)(a) of this section shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.

(2) An officer of the carrier shall certify to the department of insurance when it has met the enrollment limit set forth in division (G)(1) of this section. Upon providing such certification, the carrier shall be relieved of its open enrollment requirement under this section as long as the carrier continues to meet the open enrollment limit. If the total number of the carrier's current insureds with open enrollment coverage issued under this section falls below the enrollment limit, the carrier shall accept new applicants. A carrier may establish a waiting list if the carrier has met the open enrollment limit and shall notify the superintendent if the carrier has a waiting list in effect.

(H) A carrier shall not be required to accept under this section applicants who, at the time of enrollment, are confined to a health care facility because of chronic illness, permanent injury, or other infirmity that would cause economic impairment to the carrier if the applicants were accepted. A carrier shall not be required to make the effective date of benefits for individuals accepted under this section earlier than ninety days after the date of acceptance, except that when the individual had prior coverage with a health benefit plan that was terminated by a carrier because the carrier exited the market and the individual was accepted for open enrollment under this section within sixty-three days of that termination, the effective date of benefits shall be the date of enrollment.

(I) The requirements of this section do not apply to any carrier that is currently in a state of supervision, insolvency, or liquidation. If a carrier demonstrates to the satisfaction of the superintendent that the requirements of this section would place the carrier in a state of supervision, insolvency, or liquidation, or would otherwise jeopardize the carrier's economic viability overall or in the individual market, the superintendent may waive or modify the requirements of division (B) or (G) of this section. The actions of the superintendent under this division shall be effective for a period of not more than one year. At the expiration of such time, a new showing of need for a waiver or modification by the carrier shall be made before a new waiver or modification is issued or imposed.

(J) No hospital, health care facility, or health care practitioner, and no person who employs any health care practitioner, shall balance bill any individual or dependent of an individual for any health care supplies or services provided to the individual or dependent who is insured under a policy issued under this section. The hospital, health care facility, or health care practitioner, or any person that employs the health care practitioner, shall accept payments made to it by the carrier under the terms of the policy or contract insuring or covering such individual as payment in full for such health care supplies or services.

As used in this division, "hospital" has the same meaning as in section 3727.01 of the Revised Code; "health care practitioner" has the same meaning as in section 4769.01 of the Revised Code; and "balance bill" means charging or collecting an amount in excess of the amount reimbursable or payable under the policy or health care service contract issued to an individual under this section for such health care supply or service. "Balance bill" does not include charging for or collecting copayments or deductibles required by the policy or contract.

(K) A carrier may pay an agent a commission in the amount of not more than five per cent of the premium charged for initial placement or for otherwise securing the issuance of a policy or contract issued to an individual under this section, and not more than four per cent of the premium charged for the renewal of such a policy or contract. The superintendent may adopt, in accordance with Chapter 119. of the Revised Code, such rules as are necessary to enforce this division.

(L) This section does not apply to any policy that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy that is less than twelve months, or other policy that offers only supplemental benefits.

(M) If a carrier offers a health benefit plan in the individual market through a network plan, the carrier may do both of the following:

(1) Limit the individuals that may apply for such coverage to those who live, work, or reside in the service area of the network plan;

(2) Within the service area of the network plan, deny the coverage to individuals if the carrier has demonstrated both of the following to the superintendent:

(a) The carrier will not have the capacity to deliver services adequately to any additional individuals because of the carrier's obligations to existing group contract holders and individuals.

(b) The carrier is applying division (M)(2) of this section uniformly to all individuals without regard to any health status-related factors of those individuals.

(N) A carrier that, pursuant to division (M)(2) of this section, denies coverage to an individual in the service area of a network plan, shall not offer coverage in the individual market within that service area for at least one hundred eighty days after the date the carrier denies the coverage.

Last updated March 23, 2022 at 10:28 AM

Section 3923.581 | [Suspended eff. 1/1/2014 to 1/1/2026, per Section 3 of S.B. 9 of the 130th General Assembly, as amended] Open enrollment coverage - carriers in the business of issuing health benefit plans to individuals or nonemployer groups.

• Effective: October 16, 2009
• Latest Legislation: House Bill 1 - 128th General Assembly

(A) As used in this section:

(1) "Base rate" means, as to any health benefit plan that is issued by a carrier in the individual market, the lowest premium rate for new or existing business prescribed by the carrier for the same or similar coverage under a plan or arrangement covering any individual with similar case characteristics.

(2) "Carrier," "health benefit plan," "MEWA," and "pre-existing conditions provision" have the same meanings as in section 3924.01 of the Revised Code.

(3) "Federally eligible individual" means an eligible individual as defined in 45 C.F.R. 148.103.

(4) "Health status-related factor" means any of the following:

(a) Health status;

(b) Medical condition, including both physical and mental illnesses;

(c) Claims experience;

(d) Receipt of health care;

(e) Medical history;

(f) Genetic information;

(g) Evidence of insurability, including conditions arising out of acts of domestic violence;

(h) Disability.

(5) "Network plan" means a health benefit plan of a carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier.

(6) "Ohio health care basic and standard plans" means those plans established under section 3924.10 of the Revised Code.

(B) Beginning in January of each year, carriers in the business of issuing health benefit plans to individuals or nonemployer groups shall accept federally eligible individuals for open enrollment coverage, as provided in this section, in the order in which they apply for coverage and subject to the limitation set forth in division (J) of this section.

(C) No carrier shall do either of the following:

(1) Decline to offer such coverage to, or deny enrollment of, such individuals;

(2) Apply any pre-existing conditions provision to such coverage.

(D) A carrier shall offer to federally eligible individuals the Ohio health care basic and standard plans or plans substantially similar to the basic and standard plans in benefit design and scope of covered services. For purposes of this division, the superintendent of insurance shall determine whether a plan is substantially similar to the basic or standard plan in benefit design and scope of covered services.

(E) Premiums charged to individuals under this section may not exceed the amounts specified below:

(1) For calendar years 2010 and 2011, an amount that is two times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business, and for which similar copayments and deductibles are applied;

(2) For calendar year 2012 and every calendar year thereafter, an amount that is one and one-half times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business and for which similar copayments and deductibles are applied, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.58 of the Revised Code, have resulted in a market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the premium limit established by division (E)(1) of this section shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.

(F) If a carrier offers a health benefit plan in the individual market through a network plan, the carrier may do both of the following:

(1) Limit the federally eligible individuals that may apply for such coverage to those who live, work, or reside in the service area of the network plan;

(2) Within the service area of the network plan, deny the coverage to federally eligible individuals if the carrier has demonstrated both of the following to the superintendent:

(a) The carrier will not have the capacity to deliver services adequately to any additional individuals because of the carrier's obligations to existing group contract holders and individuals.

(b) The carrier is applying division (F)(2) of this section uniformly to all federally eligible individuals without regard to any health status-related factor of those individuals.

(G) A carrier that, pursuant to division (F)(2) of this section, denies coverage to an individual in the service area of a network plan, shall not offer coverage in the individual market within that service area for at least one hundred eighty days after the date the coverage is denied.

(H) A carrier may refuse to issue health benefit plans to federally eligible individuals if the carrier has demonstrated both of the following to the superintendent:

(1) The carrier does not have the financial reserves necessary to underwrite additional coverage.

(2) The carrier is applying division (H) of this section uniformly to all federally eligible individuals in this state consistent with the applicable laws and rules of this state and without regard to any health status-related factor relating to those individuals.

(I) A carrier that, pursuant to division (H) of this section, refuses to issue health benefit plans to federally eligible individuals, shall not offer health benefit plans in the individual market in this state for at least one hundred eighty days after the date the coverage is denied or until the carrier has demonstrated to the superintendent that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later.

(J)(1) Except as provided in division (J)(2) of this section, a carrier shall not be required to accept new applicants under this section if the total number of the carrier's current insureds with open enrollment coverage issued under this section calculated as of the immediately preceding thirty-first day of December and excluding the carrier's medicare supplement policies and conversion or continuation of coverage policies under state or federal law and any policies described in division (L) of section 3923.58 of the Revised Code meets the following limits:

(a) For calendar years 2010 and 2011, four per cent of the carrier's total number of individual or nonemployer group insureds in this state;

(b) For calendar year 2012 and every year thereafter, eight per cent of the carrier's total number of insured individuals and nonemployer group insureds in this state, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.58 of the Revised Code, have resulted in the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the enrollment limit established by division (J)(1)(a) shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.

(2) An officer of the carrier shall certify to the department of insurance when it has met the enrollment limit set forth in division (J)(1) of this section. Upon providing such certification, the carrier shall be relieved of its open enrollment requirement under this section for as long as the carrier continues to meet the open enrollment limit. If the total number of the carrier's current insureds with open enrollment coverage issued under this section falls below the enrollment limit, the carrier shall accept new applicants. A carrier may establish a waiting list if the carrier has met the open enrollment limit and shall notify the superintendent if the carrier has a waiting list in effect. In the event that all the carriers subject to this section have individually met the enrollment limit set forth in division (J)(1) of this section in a calendar year, carriers shall again accept applicants for open enrollment coverage pursuant to this section, subject to an additional enrollment limit equal to one-half of the limitation set forth in division (J)(1) of this section.

(K) The superintendent may provide for the application of this section on a service-area-specific basis.

(L) The requirements of this section do not apply to any health benefit plan described in division (L) of section 3923.58 of the Revised Code.

(M) A carrier may pay an agent a commission in the amount of not more than five per cent of the premium charged for initial placement or for otherwise securing the issuance of a policy or contract issued to an individual under this section, and not more than four per cent of the premium charged for the renewal of such a policy or contract. The superintendent may adopt, in accordance with Chapter 119. of the Revised Code, such rules as are necessary to enforce this division.

Last updated March 23, 2022 at 10:29 AM

Section 3923.582 | [Suspended eff. 1/1/2014 to 1/1/2026, per Section 3 of S.B. 9 of the 130th General Assembly, as amended] Open enrollment coverage - responsibilities of superintendent of insurance.

• Effective: October 16, 2009
• Latest Legislation: House Bill 1 - 128th General Assembly

(A) The superintendent of insurance may adopt rules in accordance with Chapter 119. of the Revised Code to implement sections 3923.58 and 3923.581 of the Revised Code, including, but not limited to, rules relating to both of the following:

(1) Requirements for adequate notice by carriers to consumers of the availability and premium rates of open enrollment coverage;

(2) Reporting and data collection requirements for implementation of the open enrollment program and to evaluate the performance of the open enrollment program and the individual health insurance market of this state.

(B) On or before June 30, beginning calendar year 2011 and continuing every year thereafter, the superintendent shall issue a report to the governor and the general assembly on the open enrollment program and the performance of the individual health insurance market in this state. The report shall include a determination by the superintendent, supported by a signed letter from a member of the American academy of actuaries, as to whether the amendments by this act to sections 3923.58 and 3923.581 of the Revised Code, have caused the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase and, if so, by how many percentage points.

Last updated March 23, 2022 at 10:30 AM

Section 3923.59 | [Suspended eff. 1/1/2014 to 1/1/2026, per Section 3 of S.B. 9 of the 130th General Assembly, as amended] Open enrollment reinsurance program.

• Effective: June 30, 1997
• Latest Legislation: House Bill 374 - 122nd General Assembly

Any insurer may reinsure coverage of any individual or nonemployer group acquired under section 3923.58 or 3923.581 of the Revised Code with the open enrollment reinsurance program in accordance with division (G) of section 3924.11 of the Revised Code. Premium rates charged for coverage reinsured by the program shall be established in accordance with section 3924.12 of the Revised Code.

Last updated March 23, 2022 at 10:46 AM

Section 3923.60 | Standard medical reference compendia for coverage of prescription drugs.

• Effective: December 26, 2011
• Latest Legislation: House Bill 218 - 129th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, no group or individual policy of sickness and accident insurance that provides coverage for prescription drugs shall limit or exclude coverage for any drug approved by the United States food and drug administration on the basis that the drug has not been approved by the United States food and drug administration for the treatment of the particular indication for which the drug has been prescribed, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia adopted by the United States department of health and human services under 42 U.S.C. 1395x(t)(2), as amended, or in medical literature that meets the criteria specified in division (B) of this section.

(B) Medical literature may be accepted for purposes of division (A) of this section only if all of the following apply:

(1) Two articles from major peer-reviewed professional medical journals have recognized, based on scientific or medical criteria, the drug's safety and effectiveness for treatment of the indication for which it has been prescribed;

(2) No article from a major peer-reviewed professional medical journal has concluded, based on scientific or medical criteria, that the drug is unsafe or ineffective or that the drug's safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed;

(3) Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the international committee of medical journal editors or is published in a journal specified by the United States department of health and human services pursuant to section 1861(t)(2)(B) of the "Social Security Act," 107 Stat. 591 (1993), 42 U.S.C. 1395x(t)(2)(B), as amended, as acceptable peer-reviewed medical literature.

(C) Coverage of a drug required by division (A) of this section includes medically necessary services associated with the administration of the drug.

(D) Division (A) of this section shall not be construed to do any of the following:

(1) Require coverage for any drug if the United States food and drug administration has determined its use to be contraindicated for the treatment of the particular indication for which the drug has been prescribed;

(2) Require coverage for experimental drugs not approved for any indication by the United States food and drug administration;

(3) Alter any law with regard to provisions limiting the coverage of drugs that have not been approved by the United States food and drug administration;

(4) Require reimbursement or coverage for any drug not included in the drug formulary or list of covered drugs specified in a policy of sickness and accident insurance;

(5) Prohibit a policy of sickness and accident insurance from limiting or excluding coverage of a drug, provided that the decision to limit or exclude coverage of the drug is not based primarily on the coverage of drugs required by this section.

(E) This section, as amended, applies only to policies of sickness and accident insurance that are described in division (A) of this section and that are delivered, issued for delivery, or renewed in this state on or after the effective date of this amendment.

Section 3923.601 | Standardized prescription identification information - pharmacy benefits to be included.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A)(1) This section applies to both of the following:

(a) A sickness and accident insurer that issues or requires the use of a standardized identification card or an electronic technology for submission and routing of prescription drug claims pursuant to a policy, contract, or agreement for health care services;

(b) A person that a sickness and accident insurer contracts with to issue a standardized identification card or an electronic technology described in division (A)(1)(a) of this section.

(2) Notwithstanding division (A)(1) of this section, this section does not apply to the issuance or required use of a standardized identification card or an electronic technology for the submission and routing of prescription drug claims in connection with any of the following:

(a) Any individual or group policy of sickness and accident insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage under a one-time-limited-duration policy that is less than twelve months; coverage issued as a supplement to liability insurance; insurance arising out of workers' compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(b) Coverage provided under the medicaid program.

(c) Coverage provided under an employer's self-insurance plan or by any of its administrators, as defined in section 3959.01 of the Revised Code, to the extent that federal law supersedes, preempts, prohibits, or otherwise precludes the application of this section to the plan and its administrators.

(B) A standardized identification card or an electronic technology issued or required to be used as provided in division (A)(1) of this section shall contain uniform prescription drug information in accordance with either division (B)(1) or (2) of this section.

(1) The standardized identification card or the electronic technology shall be in a format and contain information fields approved by the national council for prescription drug programs or a successor organization, as specified in the council's or successor organization's pharmacy identification card implementation guide in effect on the first day of October most immediately preceding the issuance or required use of the standardized identification card or the electronic technology.

(2) If the insurer or person under contract with the insurer to issue a standardized identification card or an electronic technology requires the information for the submission and routing of a claim, the standardized identification card or the electronic technology shall contain any of the following information:

(a) The insurer's name;

(b) The insured's name, group number, and identification number;

(c) A telephone number to inquire about pharmacy-related issues;

(d) The issuer's international identification number, labeled as "ANSI BIN" or "RxBIN";

(e) The processor's control number, labeled as "RxPCN";

(f) The insured's pharmacy benefits group number if different from the insured's medical group number, labeled as "RxGrp."

(C) If the standardized identification card or the electronic technology issued or required to be used as provided in division (A)(1) of this section is also used for submission and routing of nonpharmacy claims, the designation "Rx" is required to be included as part of the labels identified in divisions (B)(2)(d) and (e) of this section if the issuer's international identification number or the processor's control number is different for medical and pharmacy claims.

(D) Each sickness and accident insurer described in division (A) of this section shall annually file a certificate with the superintendent of insurance certifying that it or any person it contracts with to issue a standardized identification card or electronic technology for submission and routing of prescription drug claims complies with this section.

(E)(1) Except as provided in division (E)(2) of this section, if there is a change in the information contained in the standardized identification card or the electronic technology issued to an insured, the insurer or person under contract with the insurer to issue a standardized identification card or an electronic technology shall issue a new card or electronic technology to the insured.

(2) An insurer or person under contract with the insurer is not required under division (E)(1) of this section to issue a new card or electronic technology to an insured more than once during a twelve-month period.

(F) Nothing in this section shall be construed as requiring an insurer to produce more than one standardized identification card or one electronic technology for use by insureds accessing health care benefits provided under a policy of sickness and accident insurance.

Last updated November 23, 2021 at 3:55 PM

Section 3923.602 | Medication synchronization for insured.

• Effective: March 22, 2020
• Latest Legislation: Senate Bill 229 - 132nd General Assembly

(A) As used in this section:

(1) "Cost-sharing" means the cost to an insured under a policy of sickness and accident insurance or a public employee benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the policy or plan.

(2) "Drug" has the same meaning as in section 4729.01 of the Revised Code.

(3) "Medication synchronization" means a pharmacy service that synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained on the same date each month.

(4) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.

(5) "Prescription" means a written, electronic, or oral order issued by a prescriber for drugs or combinations or mixtures of drugs to be used by a particular individual.

(B) Notwithstanding section 3901.71 of the Revised Code, each policy of sickness and accident insurance that provides prescription drug coverage and each public employee benefit plan that provides prescription drug coverage shall provide for medication synchronization for an insured if all of the following conditions are met:

(1) The insured elects to participate in medication synchronization;

(2) The insured, the prescriber, and a pharmacist at a network pharmacy agree that medication synchronization is in the best interest of the insured;

(3) The prescription drug to be included in the medication synchronization meets the requirements of division (C) of this section.

(C) To be eligible for inclusion in medication synchronization for an insured, a prescription drug must meet all of the following requirements:

(1) Be covered by the policy or plan;

(2) Be prescribed for the treatment and management of a chronic disease or condition and be subject to refills;

(3) Satisfy all relevant prior authorization criteria;

(4) Not have quantity limits, dose optimization criteria, or other requirements that would be violated if synchronized;

(5) Not have special handling or sourcing needs, as determined by the policy or plan, that require a single, designated pharmacy to fill or refill the prescription;

(6) Be formulated so that the quantity or amount dispensed can be effectively divided in order to achieve synchronization;

(7) Not be a schedule II controlled substance, opioid analgesic, or benzodiazepine, as those terms are defined in section 3719.01 of the Revised Code.

(D)(1) To provide for medication synchronization under division (B) of this section, a policy or plan shall authorize coverage of a prescription drug subject to medication synchronization when the drug is dispensed in a quantity or amount that is less than a thirty-day supply.

(2) The requirement of division (D)(1) of this section applies only once for each prescription drug subject to medication synchronization for the same insured, except when either of the following occurs:

(a) The prescriber changes the dosage or frequency of administration of the prescription drug subject to medication synchronization.

(b) The prescriber prescribes a different drug.

(E)(1) A policy or plan that provides for medication synchronization under division (B) of this section shall permit and apply a prorated daily cost-sharing rate for a supply of a prescription drug subject to medication synchronization that is dispensed at a network pharmacy.

(2) Division (E)(1) of this section does not require a policy or plan to waive any cost-sharing requirements in its entirety.

(F) A policy or plan that provides for medication synchronization under division (B) of this section shall not use payment structures that incorporate dispensing fees that are determined by calculating the days' supply of drugs dispensed. Dispensing fees shall be based exclusively on the total number of prescriptions that are filled or refilled.

(G) This section does not require a sickness and accident insurer or public employee benefit plan to provide to a network pharmacy or a pharmacist at a network pharmacy any monetary or other financial incentive for the purpose of encouraging the pharmacy or pharmacist to recommend medication synchronization to an insured.

Section 3923.61 | Public employee benefit plans - prescription drugs.

• Effective: May 8, 1996
• Latest Legislation: Senate Bill 107 - 121st General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, no public employee benefit plan that provides coverage for prescription drugs shall limit or exclude coverage for any drug approved by the United States food and drug administration on the basis that the drug has not been approved by the United States food and drug administration for the treatment of the particular indication for which the drug has been prescribed, provided the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia specified in division (B)(1) of this section or in medical literature that meets the criteria specified in division (B)(2) of this section.

(B)(1) The compendia accepted for purposes of division (A) of this section are the following:

(a) The "AMA drug evaluations," a publication of the American medical association;

(b) The "AHFS (American hospital formulary service) drug information," a publication of the American society of health system pharmacists;

(c) "Drug information for the health care provider," a publication of the United States pharmacopeia convention.

(2) Medical literature may be accepted for purposes of division (A) of this section only if all of the following apply:

(a) Two articles from major peer-reviewed professional medical journals have recognized, based on scientific or medical criteria, the drug's safety and effectiveness for treatment of the indication for which it has been prescribed;

(b) No article from a major peer-reviewed professional medical journal has concluded, based on scientific or medical criteria, that the drug is unsafe or ineffective or that the drug's safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed;

(c) Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the international committee of medical journal editors or is published in a journal specified by the United States department of health and human services pursuant to section 1861(t)(2)(B) of the "Social Security Act," 107 Stat. 591 (1993), 42 U.S.C. 1395x(t)(2)(B), as amended, as acceptable peer-reviewed medical literature.

(C) Coverage of a drug required by division (A) of this section includes medically necessary services associated with the administration of the drug.

(D) Division (A) of this section shall not be construed to do any of the following:

(1) Require coverage for any drug if the United States food and drug administration has determined its use to be contraindicated for the treatment of the particular indication for which the drug has been prescribed;

(2) Require coverage for experimental drugs not approved for any indication by the United States food and drug administration;

(3) Alter any law with regard to provisions limiting the coverage of drugs that have not been approved by the United States food and drug administration;

(4) Require reimbursement or coverage for any drug not included in the drug formulary or list of covered drugs specified in a public employee benefit plan;

(5) Prohibit a public employee benefit plan from limiting or excluding coverage of a drug, provided that the decision to limit or exclude coverage of the drug is not based primarily on the coverage of drugs required by this section.

(E) This section, as amended, applies only to public employee benefit plans that are described in division (A) of this section and that are established or modified in this state on or after the effective date of this amendment.

Section 3923.62 | Disclosing determination of usual and customary fee for dental benefits.

• Effective: October 12, 1994
• Latest Legislation: House Bill 433 - 120th General Assembly

(A) Each insurer that delivers, issues for delivery, or renews individual or group sickness and accident insurance policies providing dental benefits, and that bases payment for those benefits on a usual and customary fee charged by dentists, and each administrator of a self-insured dental plan that bases payment for dental benefits on a usual and customary fee charged by dentists, shall disclose all of the following in accordance with division (B) of this section:

(1) The frequency of the determination of the usual and customary fee;

(2) A general description of the methodology used to determine usual and customary fees;

(3) The geographic area used to determine usual and customary fees;

(4) If the usual and customary fee for a service is determined by taking a sample of fees submitted on actual claims from dentists and then selecting a percentile of those fees, the percentile that is used by the insurer.

(B) The insurer or administrator shall disclose the information described in division (A) of this section to a policyholder, certificate holder, or participant of a self-insured plan, if requested by the policyholder, certificate holder, or participant. The disclosure shall be made within thirty days after the insurer or administrator receives the request from the policyholder, certificate holder, or participant.

(C) A violation of this section is an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

(D) As used in this section, "administrator" means a person who is licensed under Chapter 3959. of the Revised Code.

Section 3923.63 | Coverage of inpatient care and follow-up care for mother and her newborn.

• Effective: April 6, 2017
• Latest Legislation: House Bill 216 - 131st General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, each individual or group policy of sickness and accident insurance delivered, issued for delivery, or renewed in this state that provides maternity benefits shall provide coverage of inpatient care and follow-up care for a mother and her newborn as follows:

(1) The policy shall cover a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and a minimum of ninety-six hours of inpatient care following a cesarean delivery. Services covered as inpatient care shall include medical, educational, and any other services that are consistent with the inpatient care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals.

(2) The policy shall cover a physician-directed source of follow-up care or a source of follow-up care directed by an advanced practice registered nurse. Services covered as follow-up care shall include physical assessment of the mother and newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system, performance of any medically necessary and appropriate clinical tests, and any other services that are consistent with the follow-up care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals. The coverage shall apply to services provided in a medical setting or through home health care visits. The coverage shall apply to a home health care visit only if the health care professional who conducts the visit is knowledgeable and experienced in maternity and newborn care.

When a decision is made in accordance with division (B) of this section to discharge a mother or newborn prior to the expiration of the applicable number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to all follow-up care that is provided within seventy-two hours after discharge. When a mother or newborn receives at least the number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to follow-up care that is determined to be medically necessary by the health care professionals responsible for discharging the mother or newborn.

(B) Any decision to shorten the length of inpatient stay to less than that specified under division (A)(1) of this section shall be made by the physician attending the mother or newborn, except that if a certified nurse-midwife is attending the mother in collaboration with a physician, the decision may be made by the c ertified nurse-midwife. Decisions regarding early discharge shall be made only after conferring with the mother or a person responsible for the mother or newborn. For purposes of this division, a person responsible for the mother or newborn may include a parent, guardian, or any other person with authority to make medical decisions for the mother or newborn.

(C)(1) No sickness and accident insurer may do either of the following:

(a) Terminate the participation of a health care professional or health care facility as a provider under a sickness and accident insurance policy solely for making recommendations for inpatient or follow-up care for a particular mother or newborn that are consistent with the care required to be covered by this section;

(b) Establish or offer monetary or other financial incentives for the purpose of encouraging a person to decline the inpatient or follow-up care required to be covered by this section.

(2) Whoever violates division (C)(1)(a) or (b) of this section has engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

(D) This section does not do any of the following:

(1) Require a policy to cover inpatient or follow-up care that is not received in accordance with the policy's terms pertaining to the health care professionals and facilities from which an individual is authorized to receive health care services;

(2) Require a mother or newborn to stay in a hospital or other inpatient setting for a fixed period of time following delivery;

(3) Require a child to be delivered in a hospital or other inpatient setting;

(4) Authorize a certified nurse-midwife to practice beyond the authority to practice nurse-midwifery in accordance with Chapter 4723. of the Revised Code;

(5) Establish minimum standards of medical diagnosis, care or treatment for inpatient or follow-up care for a mother or newborn. A deviation from the care required to be covered under this section shall not, solely on the basis of this section, give rise to a medical claim or derivative medical claim, as those terms are defined in section 2305.113 of the Revised Code.

Section 3923.64 | Public employee benefit plans - maternity benefits.

• Effective: April 6, 2017
• Latest Legislation: House Bill 216 - 131st General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, each public employee benefit plan established or modified in this state that provides maternity benefits shall provide coverage of inpatient care and follow-up care for a mother and her newborn as follows:

(1) The plan shall cover a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and a minimum of ninety-six hours of inpatient care following a cesarean delivery. Services covered as inpatient care shall include medical, educational, and any other services that are consistent with the inpatient care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals.

(2) The plan shall cover a physician-directed source of follow-up care or a source of follow-up care directed by an advanced practice registered nurse. Services covered as follow-up care shall include physical assessment of the mother and newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system, performance of any medically necessary and appropriate clinical tests, and any other services that are consistent with the follow-up care recommended in the protocols and guidelines developed by national organizations that represent pediatric, obstetric, and nursing professionals. The coverage shall apply to services provided in a medical setting or through home health care visits. The coverage shall apply to a home health care visit only if the health care professional who conducts the visit is knowledgeable and experienced in maternity and newborn care.

When a decision is made in accordance with division (B) of this section to discharge a mother or newborn prior to the expiration of the applicable number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to all follow-up care that is provided within seventy-two hours after discharge. When a mother or newborn receives at least the number of hours of inpatient care required to be covered, the coverage of follow-up care shall apply to follow-up care that is determined to be medically necessary by the health care professionals responsible for discharging the mother or newborn.

(B) Any decision to shorten the length of inpatient stay to less than that specified under division (A)(1) of this section shall be made by the physician attending the mother or newborn, except that if a c ertified nurse-midwife is attending the mother in collaboration with a physician, the decision may be made by the c ertified nurse-midwife. Decisions regarding early discharge shall be made only after conferring with the mother or a person responsible for the mother or newborn. For purposes of this division, a person responsible for the mother or newborn may include a parent, guardian, or any other person with authority to make medical decisions for the mother or newborn.

(C)(1) No public employer who offers an employee benefit plan may do either of the following:

(a) Terminate the participation of a health care professional or health care facility as a provider under the plan solely for making recommendations for inpatient or follow-up care for a particular mother or newborn that are consistent with the care required to be covered by this section;

(b) Establish or offer monetary or other financial incentives for the purpose of encouraging a person to decline the inpatient or follow-up care required to be covered by this section.

(2) Whoever violates division (C)(1)(a) or (b) of this section has engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

(D) This section does not do any of the following:

(1) Require a plan to cover inpatient or follow-up care that is not received in accordance with the plan's terms pertaining to the health care professionals and facilities from which an individual is authorized to receive health care services;

(2) Require a mother or newborn to stay in a hospital or other inpatient setting for a fixed period of time following delivery;

(3) Require a child to be delivered in a hospital or other inpatient setting;

(4) Authorize a certified nurse-midwife to practice beyond the authority to practice nurse-midwifery in accordance with Chapter 4723. of the Revised Code;

(5) Establish minimum standards of medical diagnosis, care, or treatment for inpatient or follow-up care for a mother or newborn. A deviation from the care required to be covered under this section shall not, solely on the basis of this section, give rise to a medical claim or derivative medical claim, as those terms are defined in section 2305.113 of the Revised Code.

Section 3923.65 | Coverage for emergency services.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A) As used in this section:

(1) "Emergency medical condition" means a medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:

(a) Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

(b) Serious impairment to bodily functions;

(c) Serious dysfunction of any bodily organ or part.

(2) "Emergency services" means the following:

(a) A medical screening examination, as required by federal law, that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to evaluate an emergency medical condition;

(b) Such further medical examination and treatment that are required by federal law to stabilize an emergency medical condition and are within the capabilities of the staff and facilities available at the hospital, including any trauma and burn center of the hospital.

(B) Every individual or group policy of sickness and accident insurance that provides hospital, surgical, or medical expense coverage shall cover emergency services without regard to the day or time the emergency services are rendered or to whether the policyholder, the hospital's emergency department where the services are rendered, or an emergency physician treating the policyholder, obtained prior authorization for the emergency services.

(C) Every individual policy or certificate furnished by an insurer in connection with any sickness and accident insurance policy shall provide information regarding the following:

(1) The scope of coverage for emergency services;

(2) The appropriate use of emergency services, including the use of the 9-1-1 system and any other telephone access systems utilized to access prehospital emergency services;

(3) Any copayments for emergency services.

(D) This section does not apply to any individual or group policy of sickness and accident insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage under a one-timelimitedduration policy that is less than twelve months; coverage issued as a supplement to liability insurance; insurance arising out of workers' compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

Last updated November 22, 2021 at 5:00 PM

Section 3923.80 | Denial of coverage to cancer clinical trial participant.

• Effective: April 7, 2009
• Latest Legislation: Senate Bill 196 - 127th General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, no health benefit plan or public employee benefit plan shall deny coverage for the costs of any routine patient care administered to an insured participating in any stage of an eligible cancer clinical trial, if that care would be covered under the plan if the insured was not participating in a clinical trial.

(B) The coverage that may not be excluded under division (A) of this section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to any other coverage under the plan, policy, or arrangement for services performed by participating and nonparticipating providers. Nothing in this section shall be construed as requiring reimbursement to a provider or facility providing the routine care that does not have a health care contract with the entity issuing the health benefit plan or public employee benefit plan, or as prohibiting the entity issuing a health benefit plan or public employee benefit plan that does not have a health care contract with the provider or facility providing the routine care from negotiating a single case or other agreement for coverage.

(C) As used in this section:

(1) "Eligible cancer clinical trial" means a cancer clinical trial that meets all of the following criteria:

(a) A purpose of the trial is to test whether the intervention potentially improves the trial participant's health outcomes.

(b) The treatment provided as part of the trial is given with the intention of improving the trial participant's health outcomes.

(c) The trial has a therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology.

(d) The trial does one of the following:

(i) Tests how to administer a health care service, item, or drug for the treatment of cancer;

(ii) Tests responses to a health care service, item, or drug for the treatment of cancer;

(iii) Compares the effectiveness of a health care service, item, or drug for the treatment of cancer with that of other health care services, items, or drugs for the treatment of cancer;

(iv) Studies new uses of a health care service, item, or drug for the treatment of cancer.

(e) The trial is approved by one of the following entities:

(i) The national institutes of health or one of its cooperative groups or centers under the United States department of health and human services;

(ii) The United States food and drug administration;

(iii) The United States department of defense;

(iv) The United States department of veterans' affairs.

(2) "Subject of a cancer clinical trial" means the health care service, item, or drug that is being evaluated in the clinical trial and that is not routine patient care.

(3) "Health benefit plan" has the same meaning as in section 3924.01 of the Revised Code.

(4) "Routine patient care" means all health care services consistent with the coverage provided in the health benefit plan or public employee benefit plan for the treatment of cancer, including the type and frequency of any diagnostic modality, that is typically covered for a cancer patient who is not enrolled in a cancer clinical trial, and that was not necessitated solely because of the trial.

(5) For purposes of this section, a health benefit plan or public employee benefit plan may exclude coverage for any of the following:

(a) A health care service, item, or drug that is the subject of the cancer clinical trial;

(b) A health care service, item, or drug provided solely to satisfy data collection and analysis needs for the cancer clinical trial that is not used in the direct clinical management of the patient;

(c) An investigational or experimental drug or device that has not been approved for market by the United States food and drug administration;

(d) Transportation, lodging, food, or other expenses for the patient, or a family member or companion of the patient, that are associated with the travel to or from a facility providing the cancer clinical trial;

(e) An item or drug provided by the cancer clinical trial sponsors free of charge for any patient;

(f) A service, item, or drug that is eligible for reimbursement by a person other than the insurer, including the sponsor of the cancer clinical trial.

Section 3923.81 | Covered person's payments not to exceed insurer payments.

• Effective: March 23, 2007
• Latest Legislation: Senate Bill 5 - 126th General Assembly

(A) If a person is covered by a health benefit plan issued by a sickness and accident insurer, health insuring corporation, or multiple employer welfare arrangement and the person is required to pay for health care costs out-of-pocket or with funds from a savings account, the amount the person is required to pay to a health care provider or pharmacy shall not exceed the amount the sickness and accident insurer, health insuring corporation, or multiple employer welfare arrangement would pay under applicable reimbursement rates negotiated with the provider or pharmacy. This division does not preclude a person from reaching an agreement with a health care provider or pharmacy on terms that are more favorable to the person than negotiated reimbursement rates that otherwise would apply as long as the claim submitted reflects the alternative amount negotiated, except that a health care provider or pharmacy shall not waive all or part of a copay or deductible if prohibited by any other provision of the Revised Code. The requirements of this division do not apply to amounts owed to a provider or pharmacy with whom the sickness and accident insurer, health insuring corporation, or multiple employer welfare arrangement has no applicable negotiated reimbursement rate.

(B) Each sickness and accident insurer, health insuring corporation, or multiple employer welfare arrangement shall establish and maintain a system whereby a person covered by a health benefit plan may obtain information regarding potential out of pocket costs for services provided by in-network providers.

(C) As used in this section:

(1) "Health benefit plan" means any policy of sickness and accident insurance or any policy, contract, or agreement covering one or more "basic health care services," "supplemental health care services," or "specialty health care services," as defined in section 1751.01 of the Revised Code, offered or provided by a health insuring corporation or by a sickness and accident insurer or multiple employer welfare arrangement.

(2) "Reimbursement rates" means any rates that apply to a payment made by a sickness and accident insurer, health insuring corporation, or multiple employer welfare arrangement for charges covered by a health benefit plan.

(3) "Savings account" includes health savings accounts, health reimbursement arrangements, flexible savings accounts, medical savings accounts, and similar accounts and arrangements.

Section 3923.82 | Coverage for alcohol or drug related losses or expenses.

• Effective: April 7, 2009
• Latest Legislation: House Bill 493 - 127th General Assembly

(A) As used in this section, "health benefit plan" has the same meaning as in section 3924.01 of the Revised Code.

(B) Notwithstanding section 3901.71 of the Revised Code, no health benefit plan or public employee benefit plan shall contain a provision that limits or excludes an insured's coverage under the plan for a loss or expense the insured sustains that is the result of the insured's use of alcohol or other drugs or both and the loss or expense is otherwise covered under the plan.

(C) Nothing in this section shall be construed as doing either of the following:

(1) Requiring coverage for the treatment of alcohol or substance abuse except as otherwise required by law;

(2) Prohibiting the enforcement of an exclusion based on injuries sustained by an insured during the commission of an offense by the insured in which the insured is convicted of or pleads guilty or no contest to a felony.

(D) Not later than four years after the effective date of this section, the department of insurance shall conduct an analysis of the impact of the requirements of this section on the cost of and coverage provided by health benefit plans in this state and prepare a written report of its findings from the analysis. The department shall submit the report to the governor and, in accordance with section 101.68 of the Revised Code, to the general assembly.

Section 3923.83 | Standardized prescription identification information - pharmacy benefits to be included - public employee benefit plan.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A)(1) This section applies to both of the following:

(a) A public employee benefit plan that issues or requires the use of a standardized identification card or an electronic technology for submission and routing of prescription drug claims pursuant to a policy, contract, or agreement for health care services;

(b) A person or entity that a public employee benefit plan contracts with to issue a standardized identification card or an electronic technology described in division (A)(1)(a) of this section.

(2) Notwithstanding division (A)(1) of this section, this section does not apply to the issuance or required use of a standardized identification card or an electronic technology for the submission and routing of prescription drug claims in connection with either of the following:

(a) Any individual or group policy of insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage under a one-time-limited-duration policy that is less than twelve months; coverage issued as a supplement to liability insurance; insurance arising out of workers' compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(b) Coverage provided under the medicaid program.

(B) A standardized identification card or an electronic technology issued or required to be used as provided in division (A)(1) of this section shall contain uniform prescription drug information in accordance with either division (B)(1) or (2) of this section.

(1) The standardized identification card or the electronic technology shall be in a format and contain information fields approved by the national council for prescription drug programs or a successor organization, as specified in the council's or successor organization's pharmacy identification card implementation guide in effect on the first day of October most immediately preceding the issuance or required use of the standardized identification card or the electronic technology.

(2) If the public employee benefit plan or person under contract with the plan to issue a standardized identification card or an electronic technology requires the information for the submission and routing of a claim, the standardized identification card or the electronic technology shall contain any of the following information:

(a) The plan's name;

(b) The insured's name, group number, and identification number;

(c) A telephone number to inquire about pharmacy-related issues;

(d) The issuer's international identification number, labeled as "ANSI BIN" or "RxBIN";

(e) The processor's control number, labeled as "RxPCN";

(f) The insured's pharmacy benefits group number if different from the insured's medical group number, labeled as "RxGrp."

(C) If the standardized identification card or the electronic technology issued or required to be used as provided in division (A)(1) of this section is also used for submission and routing of nonpharmacy claims, the designation "Rx" is required to be included as part of the labels identified in divisions (B)(2)(d) and (e) of this section if the issuer's international identification number or the processor's control number is different for medical and pharmacy claims.

(D)(1) Except as provided in division (D)(2) of this section, if there is a change in the information contained in the standardized identification card or the electronic technology issued to an insured, the public employee benefit plan or person under contract with the plan to issue a standardized identification card or electronic technology shall issue a new card or electronic technology to the insured.

(2) A public employee benefit plan or person under contract with the plan is not required under division (D)(1) of this section to issue a new card or electronic technology to an insured more than once during a twelve-month period.

(E) Nothing in this section shall be construed as requiring a public employee benefit plan to produce more than one standardized identification card or one electronic technology for use by insureds accessing health care benefits provided under a health benefit plan.

Last updated November 23, 2021 at 3:56 PM

Section 3923.84 | Coverage for autism spectrum disorder.

• Effective: April 6, 2017
• Latest Legislation: House Bill 463 - 131st General Assembly

(A) Notwithstanding section 3901.71 of the Revised Code, each individual and group sickness and accident insurance policy that is delivered, issued for delivery, or renewed in this state shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. A sickness and accident insurer shall not terminate an individual's coverage, or refuse to deliver, execute, issue, amend, adjust, o r renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder. Nothing in this section shall be applied to nongrandfathered plans in the individual and small group markets or to medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies. Except as otherwise provided in division (B) of this section, coverage under this section shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to substantially all medical and surgical benefits under the policy.

(B) Benefits provided under this section shall cover, at minimum, all of the following:

(1) For speech and language therapy or occupational therapy for an insured under the age of fourteen that is performed by a licensed therapist, twenty visits per year for each service;

(2) For clinical therapeutic intervention for an insured under the age of fourteen that is provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform such services in accordance with a health treatment plan, twenty hours per week;

(3) For mental or behavioral health outpatient services for an insured under the age of fourteen that are performed by a licensed psychologist, psychiatrist, or physician providing consultation, assessment, development, or oversight of treatment plans, thirty visits per year.

(C)(1) Except as provided in division (C)(2) of this section, this section shall not be construed as limiting benefits that are otherwise available to an insured under a policy.

(2) A policy of sickness and accident insurance shall stipulate that coverage provided under this section be contingent upon both of the following:

(a) The covered individual receiving prior authorization for the services in question;

(b) The services in question being prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism.

(D)(1) Except for inpatient services, if an insured is receiving treatment for an autism spectrum disorder, a sickness and accident insurer may review the treatment plan annually, unless the insurer and the insured's treating physician or psychologist agree that a more frequent review is necessary.

(2) Any such agreement as described in division (D)(1) of this section shall apply only to a particular insured being treated for an autism spectrum disorder and shall not apply to all individuals being treated for autism spectrum disorder by a physician or psychologist.

(3) The insurer shall cover the cost of obtaining any review or treatment plan.

(E) This section shall not be construed as affecting any obligation to provide services to an insured under an individualized family service plan, an individualized education program, or an individualized service plan.

(F) As used in this section:

(1) "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

(2) "Autism spectrum disorder" means any of the pervasive developmental disorders or autism spectrum disorder as defined by the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association available at the time an individual is first evaluated for suspected developmental delay.

(3) "Clinical therapeutic intervention" means therapies supported by empirical evidence, which include, but are not limited to, applied behavioral analysis, that satisfy both of the following:

(a) Are necessary to develop, maintain, or restore, to the maximum extent practicable, the function of an individual;

(b) Are provided by or under the supervision of any of the following:

(i) A certified Ohio behavior analyst as defined in section 4783.01 of the Revised Code;

(ii) An individual licensed under Chapter 4732. of the Revised Code to practice psychology;

(iii) An individual licensed under Chapter 4757. of the Revised Code to practice professional counseling, social work, or marriage and family therapy.

(4) "Diagnosis of autism spectrum disorder" means medically necessary assessment, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

(5) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.

(6) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

(7) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

(8) "Therapeutic care" means services provided by a speech therapist, occupational therapist, or physical therapist licensed or certified in the state in which the person practices.

(9) "Treatment for autism spectrum disorder" means evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician who is a developmental pediatrician or a licensed psychologist trained in autism who determines the care to be medically necessary, including any of the following:

(a) Clinical therapeutic intervention;

(b) Pharmacy care;

(c) Psychiatric care;

(d) Psychological care;

(e) Therapeutic care.

(G) If any provision of this section or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the section and the application of such remainder to other persons or circumstances shall not be affected thereby.

Section 3923.85 | Cancer medication; coverage for orally and intravenously administered treatments.

• Effective: March 23, 2015
• Latest Legislation: House Bill 201 - 130th General Assembly

(A) As used in this section, "cost sharing" means the cost to an individual insured under an individual or group policy of sickness and accident insurance or a public employee benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the policy or plan.

(B) Notwithstanding section 3901.71 of the Revised Code and subject to division (D) of this section, no individual or group policy of sickness and accident insurance that is delivered, issued for delivery, or renewed in this state and no public employee benefit plan that is established or modified in this state shall fail to comply with either of the following:

(1) The policy or plan shall not provide coverage or impose cost sharing for a prescribed, orally administered cancer medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intraveneously administered or injected cancer medications.

(2) The policy or plan shall not comply with division (B)(1) of this section by imposing an increase in cost sharing solely for orally administered, intravenously administered, or injected cancer medications.

(C) Notwithstanding any provision of this section to the contrary, a policy or plan shall be deemed to be in compliance with this section if the cost sharing imposed under such a policy or plan for orally administered cancer treatments does not exceed one hundred dollars per prescription fill. The costsharing limit of one hundred dollars per prescription fill shall apply to a high deductible plan, as defined in 26 U.S.C. 223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only after the deductible has been met.

(D)(1) The prohibitions in division (B) of this section do not preclude an individual or group policy of sickness and accident insurance or public employee benefit plan from requiring an insured or plan member to obtain prior authorization before orally administered cancer medication is dispensed to the insured or plan member.

(2) Division (B) of this section does not apply to the offer or renewal of any individual or group policy of sickness and accident insurance that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, disability income, or other policy that offers only supplemental benefits.

(E) An insurer that offers any sickness and accident insurance or any public employee benefit plan that offers coverage for basic health care services is not required to comply with division (B) of this section if all of the following apply:

(1) The insurer or plan submits documentation certified by an independent member of the American academy of actuaries to the superintendent of insurance showing that compliance with division (B)(1) of this section for a period of at least six months independently caused the insurer or plan's costs for claims and administrative expenses for the coverage of basic health care services to increase by more than one per cent per year.

(2) The insurer or plan submits a signed letter from an independent member of the American academy of actuaries to the superintendent of insurance opining that the increase in costs described in division (E)(1) of this section could reasonably justify an increase of more than one per cent in the annual premiums or rates charged by the insurer or plan for the coverage of basic health care services.

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

(i) Compliance with division (B)(1) of this section for a period of at least six months independently caused the insurer or plan's costs for claims and administrative expenses for the coverage of basic health care services to increase more than one per cent per year.

(ii) The increase in costs reasonably justifies an increase of more than one per cent in the annual premiums or rates charged by the insurer or plan for the coverage of basic health care services.

(b) Any determination made by the superintendent under division (E)(3) of this section is subject to Chapter 119. of the Revised Code.

Section 3923.851 | Prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for treatment of chronic pain; exceptions.

• Effective: April 6, 2017
• Latest Legislation: Senate Bill 319 - 131st General Assembly

(A) As used in this section:

(1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code.

(2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code.

(3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code.

(4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code.

(5) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.

(6) "Terminal condition" means an irreversible, incurable, and untreatable condition that is caused by disease, illness, or injury and will likely result in death. A terminal condition is one in which there can be no recovery, although there may be periods of remission.

(B)(1) An individual or group policy of sickness and accident insurance or a public employee benefit plan that is delivered, issued for delivery, or renewed in this state and covers prescription drugs shall contain prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for the treatment of chronic pain, except when the drug is prescribed under one of the following circumstances:

(a) To an individual who is a hospice patient in a hospice care program;

(b) To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program;

(c) To an individual who has cancer or another condition associated with the individual's cancer or history of cancer.

(2) When implementing division (B)(1) of this section, the sickness and accident insurer or public employee benefit plan shall consider either or both of the following, as applicable to the case in which the opioid analgesic is prescribed:

(a) If the course of treatment with the drug continues for more than ninety days, the requirements of section 4731.052 of the Revised Code;

(b) If the morphine equivalent daily dose for the drug exceeds eighty milligrams or the individual is being treated with a benzodiazepine at the time the opioid analgesic is prescribed, the guidelines established by the governor's cabinet opiate action team and presented in the document titled "Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) 'Trigger Point'" or a successor document, unless the guidelines are no longer in effect at the time the opioid analgesic is prescribed.

(C) If a sickness and accident insurer or public employee benefit plan measures the efficiency, quality of care, or clinical performance of a prescriber, including through the use of patient satisfaction surveys, it shall not penalize the prescriber, financially or otherwise, for deciding not to prescribe an opioid analgesic.

Section 3923.86 | Statement provided to insureds under vision policy.

• Effective: October 24, 2024
• Latest Legislation: Senate Bill 40 - 135th General Assembly

(A) As used in this section, "covered dental services," "covered vision services," "dental care provider," "vision care materials," and "vision care provider" have the same meanings as in section 3963.01 of the Revised Code.

(B) A sickness and accident insurer or public employee benefit plan shall provide the information required in this division to all insured individuals receiving coverage under an individual or group policy of sickness and accident insurance or public employee benefit plan for vision care services, vision care materials, or dental care services. The information shall be in a conspicuous format, shall be easily accessible to insured individuals, and shall do all of the following:

(1) For vision care coverage, include the following statement:

"IMPORTANT: If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you his or her normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request."

(2) For dental care coverage, include the following statement:

"IMPORTANT: If you opt to receive dental care services that are not covered benefits under this plan, a participating dental care provider may charge you his or her normal fee for such services. Prior to providing you with dental care services that are not covered benefits, the dental care provider will provide you with an estimated cost for each service."

(3) Disclose any business interest the insurer or plan has in a source or supplier of vision care materials;

(4) Include an explanation that the insured individual may incur out-of-pocket expenses as a result of the purchase of vision care services, vision care materials, or dental care services that are not covered. The explanation shall be communicated in a manner and format similar to how the insurer or plan provides an insured individual with information on coverage levels and out-of-pocket expenses that may be incurred by the insured individual under the policy or plan when purchasing out-of-network vision care services, vision care materials, or dental care services.

(C) A pattern of continuous or repeated violations of this section is an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

Last updated August 22, 2024 at 4:19 PM

Section 3923.87 | Compliance with section 3959.20.

• Effective: October 17, 2019
• Latest Legislation: House Bill 166 - 133rd General Assembly

Each sickness and accident insurer or public employee benefit plan shall comply with the requirements of section 3959.20 of the Revised Code as they pertain to health plan issuers.

As used in this section, "health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.

Section 3923.89 | Payment or reimbursement to pharmacist.

• Effective: December 16, 2020
• Latest Legislation: House Bill 203 - 133rd General Assembly

A sickness and accident insurer or public employee benefit plan may provide payment or reimbursement to a pharmacist for providing a health care service to a patient if both of the following are the case:

(A) The pharmacist provided the health care service to the patient in accordance with Chapter 4729. of the Revised Code, including any of the following services:

(1) Managing drug therapy under a consult agreement pursuant to section 4729.39 of the Revised Code;

(2) Administering immunizations in accordance with section 4729.41 of the Revised Code;

(3) Administering drugs in accordance with section 4729.45 of the Revised Code.

(B) The patient's individual or group policy of sickness and accident insurance or public employee benefit plan provides for payment or reimbursement of the service.

Section 3923.90 | Teledentistry to be included in coverage.

• Effective: March 20, 2019
• Latest Legislation: Senate Bill 259 - 132nd General Assembly

(A) As used in this section, "teledentistry" has the same meaning as in section 4715.43 of the Revised Code.

(B) No individual or group policy of sickness and accident insurance or public employee benefit plan shall deny coverage for the costs of any services provided to an insured through teledentistry if those services would be covered if the services were delivered other than through teledentistry.

(C) The coverage that may not be excluded under division (B) of this section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to any other coverage for services performed by participating and nonparticipating providers.

Section 3923.99 | Penalty.

• Effective: January 1, 1980
• Latest Legislation: House Bill 43 - 113th General Assembly

Whoever violates section 3923.14, 3923.16, 3923.161, or 3923.21 of the Revised Code shall be fined not more than one thousand dollars.