Chapter 3902. INSURANCE POLICIES AND CONTRACTS
| (A) |
The
purpose of sections 3902.01 to
3902.08 of the Revised Code is to
establish minimum standards for language used in policies and certificates of
life insurance and annuities, credit life insurance and credit disability
insurance, and sickness and accident insurance, and subscriber policies or
certificates of health insuring corporations, delivered or issued for delivery
in this state, to facilitate ease of reading by insureds and subscribers.
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| (B) |
Sections 3902.01 to
3902.08 of the Revised Code are
not intended to increase the risk assumed by insurance companies or other
entities subject to sections 3902.01 to
3902.08 of the Revised Code or to
supersede their obligation to comply with the substance of other applicable
insurance laws. Sections 3902.01 to
3902.08 of the Revised Code are
not intended to impede flexibility and innovation in the development of policy
forms or content, or to lead to the standardization of policy forms or content.
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Effective Date:
06-04-1997 .
As used in sections
3902.01 to
3902.08 of the Revised Code:
| (A) |
"Policy" or "policy form" means
any policy, contract, plan or agreement of life insurance and annuities, credit
life insurance and credit disability insurance, and sickness and accident
insurance, and subscriber policies, contracts, certificates, and agreements of
health insuring corporations, delivered or issued for delivery in this state by
any company subject to sections
3902.01 to
3902.08 of the Revised Code; any
certificate, contract or policy issued by a fraternal benefit society; any
certificate issued pursuant to a group insurance policy delivered or issued for
delivery in this state; and any evidence of coverage issued by a health
insuring corporation. |
| (B) |
"Company" or "insurer" means any entity authorized to do the business of life
insurance and annuities, sickness and accident insurance, credit life
insurance, or credit disability insurance; a fraternal benefit society; and a
health insuring corporation. |
Effective Date:
06-04-1997 .
| (A) |
Sections
3902.01 to
3902.08 of the Revised Code apply
to all policies delivered or issued for delivery in this state by any company
on or after the date such forms must be approved under sections
3902.01 to
3902.08 of the Revised Code.
Sections 3902.01 to
3902.08 of the Revised Code do not
apply to:
| (1) |
Any policy that is a security
subject to federal jurisdiction; |
| (2) |
Any group policy, other than a group
credit life insurance policy, or a group credit disability insurance policy.
This division does not exempt any certificate issued pursuant to a group policy
delivered or issued for delivery in this state. |
| (3) |
Any group annuity contract that serves as
a funding vehicle for pension, profit-sharing, or deferred compensation plans;
|
| (4) |
Any form used in connection
with, as a conversion from, as an addition to, or in exchange pursuant to a
contractual provision for, a policy delivered or issued for delivery on a form
approved, or permitted to be issued prior to the dates such forms must be
approved pursuant to sections
3902.01 to
3902.08 of the Revised Code;
|
| (5) |
The renewal of a policy
delivered or issued for delivery prior to the dates such forms must be approved
under sections
3902.01 to
3902.08 of the Revised Code.
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|
| (B) |
Any non-English
language policy delivered or issued for delivery in this state is deemed to be
in compliance with division (A)(1) of section
3902.04 of the Revised Code if the
insurer certifies that such policy is translated from an English language
policy that complies with division (A)(1) of section
3902.04 of the Revised Code.
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Effective Date:
01-09-1980 .
| (A) |
No policy
forms, except as stated in section
3902.03 of the Revised Code, shall
be delivered or issued for delivery in this state on or after the dates such
forms must be approved under sections
3902.01 to
3902.08 of the Revised Code,
unless:
| (1) |
The text achieves a minimum score
of forty on the Flesch reading ease test, or an equivalent score on any other
comparable test as provided in division (C) of this section; |
| (2) |
It is printed, except for specification
pages, schedules, and tables, in not less than ten-point type, one point
leaded; |
| (3) |
The style, arrangement,
and overall appearance of the policy give no undue prominence to any portion of
the text of the policy, or to any endorsements or riders; |
| (4) |
It contains a table of contents or an
index of the principal sections of the policy, if the policy has more than
three thousand words printed on three or fewer pages of text, or if the policy
has more than three pages regardless of the number of words.
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|
| (B) |
For the purposes of
this section, a Flesch reading ease test score shall be measured by the
following method:
| (1) |
For policy forms
containing ten thousand words or less of text, the entire form shall be
analyzed. For policy forms containing more than ten thousand words, the
readability of two two-hundred word samples per page may be analyzed instead of
the entire form. The samples shall be separated by at least twenty printed
lines. |
| (2) |
The number of words and
sentences in the text shall be counted and the total number of words divided by
the total number of sentences. The figure obtained shall be multiplied by a
factor of one and fifteen thousandths. |
| (3) |
The total number of syllables shall be
counted and divided by the total number of words. The figure obtained shall be
multiplied by a factor of eighty-four and six-tenths. |
| (4) |
The sum of the figures computed under
divisions (B)(2) and (3) of this section subtracted from two hundred six and
eight hundred thirty-five thousandths equals the Flesch reading ease score for
the policy form. |
| (5) |
For purposes
of divisions (B)(2), (3), and (4) of this section, the following procedures
shall be used:
| (a) |
A contraction, hyphenated
word, or numbers and letters, when separated by spaces, shall be counted as one
word. |
| (b) |
A unit of words ending
with a period, semicolon, or colon, but excluding headings and captions, shall
be counted as a sentence. |
| (c) |
A
syllable means a unit of spoken language consisting of one or more letters of a
word as divided by an accepted dictionary. Where the dictionary shows two or
more equally acceptable pronunciations of a word, the pronunciation containing
fewer syllables may be used. |
|
| (6) |
As used in this section, "text" includes
all printed matter, except the following:
| (a) |
The name and address of the insurer, the name, number, or title of the policy,
the table of contents or index, captions and subcaptions, specification pages,
schedules, or tables; |
| (b) |
Any
policy language that is drafted to conform to the requirements of any federal
law, regulation, or agency interpretation; any policy language required by any
collectively bargained agreement; any medical terminology; any words that are
defined in the policy; and any policy language required by law or regulation;
provided however, the insurer identifies the language or terminology excepted
by this paragraph and certifies, in writing, that the language or terminology
is entitled to be excepted by this paragraph. |
|
|
| (C) |
Any other reading test may be approved
by the superintendent of insurance for use as an alternative to the Flesch
reading ease test if it is comparable in result to the Flesch reading ease
test. |
| (D) |
Every filing subject to
this section shall be accompanied by a certificate signed by an officer of the
insurer stating that the filing meets the minimum reading ease score on the
test used, or stating that the score is lower than the minimum required but
should be approved in accordance with section
3902.06 of the Revised Code. To
confirm the accuracy of any certification, the superintendent may require the
submission of further information to verify the certification in question.
|
| (E) |
At the option of the insurer,
riders, endorsements, applications, and other forms made a part of the policy
may be scored as separate forms or as part of the policy with which they may be
used. |
Effective Date:
01-09-1980 .
Nothing in sections
3902.01 to
3902.08 of the Revised Code shall
be construed to negate any law of this state permitting the issuance of any
policy form after it has been on file for the time period specified.
Effective Date:
01-09-1980 .
The superintendent of insurance may authorize a lower score
than the Flesch reading ease score required in division (A)(1) of section
3902.04 of the Revised Code
whenever, in his discretion, he finds that a lower score meets any of the
following conditions:
| (A) |
The lower
score will provide a more accurate reflection of the readability of a policy
form; |
| (B) |
The lower score is
warranted by the nature of a particular policy form or type or class of policy
forms; |
| (C) |
The lower score is
caused by certain policy language that is drafted to conform to the
requirements of any law, rule, or agency interpretation. |
Effective Date:
01-09-1980 .
A policy form meeting the requirements of section
3902.04 of the Revised Code shall
be approved notwithstanding the provisions of any other laws that specify the
content of policies, if the policy form provides the policyholders and
claimants protection not less favorable than they would be entitled to under
such laws.
Effective Date:
01-09-1980 .
| (A) |
Except as
provided in section
3902.03
of the Revised Code, sections
3902.01 to
3902.08
of the Revised Code apply to all policy forms filed on or after
January 9, 1983. No
policy form shall be delivered or issued for delivery in this state on or after
January 9, 1985
unless approved by the superintendent of insurance, or permitted to be issued,
pursuant to sections
3902.01 to
3902.08
of the Revised Code. Any policy form that has been approved or permitted to be
issued prior to January 9, 1985,
and that meets the standards set by sections
3902.01 to
3902.08
of the Revised Code need not be refiled for approval, but may continue to be
lawfully delivered or issued for delivery in this state upon the filing with
the superintendent of a list of such forms identified by form number and
accompanied by a certificate as to each such form in the manner provided in
division (D) of section 3902.04 of the Revised Code. |
| (B) |
The
superintendent may, in the superintendent's discretion, extend the dates
in division (A) of this section. |
Amended by
133rd General Assembly File No. TBD, HB 339, §1,
eff. 1/1/2021.
Effective Date:
01-09-1980 .
As used in sections 3902.11 to
3902.14 of the Revised Code:
| (A) |
"Beneficiary" and "third-party
payer" have the same meanings as in section
3901.38 of the Revised Code.
|
| (B) |
"Plan of health coverage"
means any of the following if the policy, contract, or agreement contains a
coordination of benefits provision:
| (1) |
An
individual or group sickness and accident insurance policy, which policy
provides for hospital, dental, surgical, or medical services; |
| (2) |
Any individual or group contract of a
health insuring corporation, which contract provides for hospital, dental,
surgical, or medical services; |
| (3) |
Any other individual or group policy or agreement under which a third-party
payer provides for hospital, dental, surgical, or medical services.
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|
| (C) |
"Provider" means a
hospital, nursing home, physician, podiatrist, dentist, pharmacist,
chiropractor, or other licensed health care provider entitled to reimbursement
by a third-party payer for services rendered to a beneficiary under a benefits
contract. |
Effective Date:
07-24-2002 .
When a plan of health coverage is primary, its benefits are
paid without regard to the benefits of another plan. When a plan of health
coverage is secondary, its benefits are determined by taking into consideration
the payments made or to be made by another plan. When there are more than two
plans, a plan may be primary as to one and may be secondary as to another.
Effective Date:
06-29-1988 .
| (A) |
A plan of
health coverage determines its order of benefits using the first of the
following that applies:
| (1) |
A plan that does
not coordinate with other plans is always the primary plan. |
| (2) |
The benefits of the plan that covers a
person as an employee, member, insured, or subscriber, other than a dependent,
is the primary plan. The plan that covers the person as a dependent is the
secondary plan. |
| (3) |
When more than
one plan covers the same child as a dependent of different parents who are not
divorced or separated, the primary plan is the plan of the parent whose
birthday falls earlier in the year. The secondary plan is the plan of the
parent whose birthday falls later in the year. If both parents have the same
birthday, the benefits of the plan that covered the parent the longer is the
primary plan. The plan that covered the parent the shorter time is the
secondary plan. If the other plan's provision for coordination of benefits does
not include the rule contained in this division because it is not subject to
regulation under this division, but instead has a rule based on the gender of
the parent, and if, as a result, the plans do not agree on the order of
benefits, the rule of the other plan will determine the order of benefits.
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| (4) |
| (a) |
Except as provided in division (A)(4)(b)
of this section, if more than one plan covers a person as a dependent child of
divorced or separated parents, benefits for the child are determined in the
following order:
| (i) |
The plan of the parent
who is the residential parent and legal custodian of the child; |
| (ii) |
The plan of the spouse of the parent who
is the residential parent and legal custodian of the child; |
| (iii) |
The plan of the parent who is not the
residential parent and legal custodian of the child. |
|
| (b) |
If the specific terms of a court decree
state that one parent is responsible for the health care expenses of the child,
the plan of that parent is the primary plan. A parent responsible for the
health care pursuant to a court decree must notify the insurer or health
insuring corporation of the terms of the decree. |
|
| (5) |
The primary plan is the plan that covers
a person as an employee who is neither laid off or retired, or that employee's
dependent. The secondary plan is the plan that covers that person as a laid-off
or retired employee, or that employee's dependent. |
| (6) |
If none of the rules in divisions (A)(1),
(2), (3), (4), and (5) of this section determines the order of benefits, the
primary plan is the plan that covered an employee, member, insured, or
subscriber longer. The secondary plan is the plan that covered that person the
shorter time. |
|
| (B) |
When
a plan of health coverage is determined to be a secondary plan it acts to
provide benefits in excess of those provided by the primary plan. |
| (C) |
The secondary plan shall not be required
to make payment in an amount which exceeds the amount it would have paid if it
were the primary plan, but in no event, when combined with the amount paid by
the primary plan, shall payments by the secondary plan exceed one hundred per
cent of expenses allowable under the provisions of the applicable policies and
contracts. |
| (D) |
A third-party
payer may require a beneficiary to file a claim with the primary plan before it
determines the amount of its payment obligation, if any, with regard to that
claim. |
| (E) |
Nothing in this
section shall be construed to require a plan to make a payment until it
determines whether it is the primary plan or the secondary plan and what
benefits are payable under the primary plan. |
| (F) |
A plan may obtain any facts and information
necessary to apply the provisions of this section, or supply this information
to any other third-party payer or provider, or any agent of such third-party
payer or provider, without the consent of the beneficiary. Each person claiming
benefits under the plan shall provide any information necessary to apply the
provisions of this section. |
| (G) |
If the amount of payments made by any plan is more than should have been paid,
the plan may recover the excess from whichever party received the excess
payment. |
| (H) |
No third-party payer
shall administer a plan of health coverage delivered, issued for delivery, or
renewed on or after June 29, 1988, unless such plan complies with this section.
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| (I) |
| (1) |
A third-party payer that is subject to this
section and has reason to believe payment has been made by another third-party
payer for the same service may request from that third-party payer, and shall
be provided by the third-party payer, such data as necessary to determine
whether duplicate payment has been made. |
| (2) |
A third-party payer that meets the criteria of a
secondary payer in accordance with this section may seek repayment of any
duplicate payment that may have been made from the person to whom it made
payment. If the person who received the duplicate payment is a provider, absent
a finding of a court of competent jurisdiction that the provider has engaged in
civil or criminal fraudulent activities, the request for the return of any
duplicate payment shall be made within three years after the close of the
provider's fiscal year in which the duplicate payment has been made. |
|
| (J) |
Nothing in this section shall
be construed to affect the prohibition of section
3923.37 of the Revised Code.
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| (K) |
| (1) |
No third-party payer shall knowingly fail to
comply with the order of benefits as set forth in division (A) of this section.
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| (2) |
No primary plan shall direct
or encourage an insured to use the benefits of a secondary plan that results in
a reduction of payment by such primary plan. |
|
| (L) |
Whoever violates division (K) of this section is
deemed to have engaged in an unfair and deceptive insurance act or practice
under sections
3901.19 to
3901.26 of the Revised Code, and
is subject to proceedings pursuant to those sections. |
Effective Date:
06-04-1997 .
The superintendent of insurance may, pursuant to Chapter 119.
of the Revised Code, adopt rules to carry out the purposes of sections
3902.11 to 3902.14 of the Revised
Code.
Effective Date:
06-29-1988 .
As used in sections
3902.22 and
3902.23 of the Revised Code,
"third-party payer" has the same meaning as in section
3901.38 of the Revised Code.
Effective Date:
07-24-2002 .
The superintendent of insurance shall develop a standard claim
form to be used by all third-party payers and providers for reimbursement of
health care services and supplies, taking into consideration the special needs
of, and differences between, third-party payers. The standard claim form shall
be prescribed in rules the superintendent shall adopt in accordance with
Chapter 119. of the Revised Code. The superintendent may prescribe a separate
claim form for each third-party payer. If a national standard claim form is
established by the sickness and accident insurance industry, the superintendent
shall amend the rules to comply with the national standards. The standard claim
form shall include a method to specify the national provider identifiers
assigned to the physical therapists and other health care professionals
rendering services designated as physical therapy, as required under section
4755.56 of the Revised Code.
Effective Date:
07-24-2002;
04-06-2007 .
Beginning one hundred eighty days after rules adopted under
section 3902.22 of the Revised Code take
effect, no third-party payer shall fail to use the standard claim form
prescribed in those rules.
Effective Date:
07-24-2002 .
| (A) |
As used in this section:
| (1) |
"Health benefit plan," "health care services," and
"health plan issuer" have the same meanings as in section
3922.01 of the
Revised Code. |
| (2) |
"Health care professional" means any of the
following:
| (a) |
A physician licensed under Chapter 4731. of the
Revised Code to practice medicine and surgery, osteopathic medicine and
surgery, or podiatric medicine and surgery; |
| (b) |
A physician assistant licensed under Chapter 4731. of
the Revised Code; |
| (c) |
An advanced practice registered nurse as defined in
section
4723.01 of the
Revised Code. |
|
| (3) |
"In-person health care services" means health care
services delivered by a health care professional through the use of any
communication method where the professional and patient are simultaneously
present in the same geographic location. |
| (4) |
"Recipient" means a patient receiving health care
services or a health care professional with whom the provider of health care
services is consulting regarding the patient. |
| (5) |
"Telemedicine services" means a mode of providing
health care services through synchronous or asynchronous information and
communication technology by a health care professional, within the
professional's scope of practice, who is located at a site other than the site
where the recipient is located. |
|
| (B) |
| (1) |
A health benefit plan shall provide coverage for
telemedicine services on the same basis and to the same extent that the plan
provides coverage for the provision of in-person health care
services. |
| (2) |
A health benefit plan shall not exclude coverage for a
service solely because it is provided as a telemedicine
service. |
|
| (C) |
A health benefit plan shall not impose any annual or
lifetime benefit maximum in relation to telemedicine services other than such a
benefit maximum imposed on all benefits offered under the plan. |
| (D) |
This section shall not be construed as doing any of
the following:
| (1) |
Prohibiting a health benefit plan from assessing
cost-sharing requirements to a covered individual for telemedicine services,
provided that such cost-sharing requirements for telemedicine services are not
greater than those for comparable in-person health care
services; |
| (2) |
Requiring a health plan issuer to reimburse a health
care professional for any costs or fees associated with the provision of
telemedicine services that would be in addition to or greater than the standard
reimbursement for comparable in-person health care services; |
| (3) |
Requiring a health plan issuer to reimburse a
telemedicine provider for telemedicine services at the same rate as in-person
services. |
|
| (E) |
This section applies to all health benefit plans
issued, offered, or renewed on or after January 1, 2021. |
Added by
133rd General Assembly File No. TBD, HB 166, §101.01, eff.
10/17/2019.
| (A) |
As used in this section:
| (1) |
"Pay in full" means paying for a health service in its
entirety without cost-sharing on the part of a third-party payer. "Pay in full"
includes payment made under a deductible requirement. |
| (2) |
"Third-party payer" and "provider" have the same
meanings as in section
3901.38
of the Revised Code. |
|
| (B) |
| (1) |
Subject to division (C) of this section, a provision
in a contract entered into between a third-party payer and a provider is void
and against public policy if it does either of the following:
| (a) |
Establishes a minimum amount that the provider is
required to charge an individual for a health service when that individual pays
in full for the service; |
| (b) |
Prohibits a provider from advertising the provider's
rates for a service. |
|
| (2) |
Division (B)(1)(b) of this section shall not be
construed as prohibiting a provision in a contract between a provider and a
third-party payer that prohibits a provider from disclosing or advertising
contractually agreed upon reimbursement rates for providers. |
|
| (C) |
| (1) |
This section shall apply to all new contracts between
a third-party payer and a provider entered into on or after the effective date
of this section. |
| (2) |
For existing contracts, this section shall apply on
the earlier of either of the following:
| (a) |
Three years after the effective date of this
section; |
| (b) |
The expiration date of the contract or renewal of the
contract. |
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|
Added by
133rd General Assembly File No. TBD, HB 166, §101.01, eff.
10/17/2019.