Chapter 3924. SMALL EMPLOYER HEALTH BENEFIT PLANS; PROVISION OF HEALTH CARE COVERAGE
As used in sections
3924.01 to
3924.14 of the Revised
Code:
(A) |
"Actuarial certification" means a written
statement prepared by a member of the American academy of actuaries, or by any
other person acceptable to the superintendent of insurance, that states that,
based upon the person's examination, a carrier offering health benefit plans to
small employers is in compliance with sections
3924.01 to
3924.14 of the Revised Code.
"Actuarial certification" shall include a review of the appropriate records of,
and the actuarial assumptions and methods used by, the carrier relative to
establishing premium rates for the health benefit plans. |
(B) |
"Adjusted average market premium price" means the average market premium price
as determined by the board of directors of the Ohio health reinsurance program
either on the basis of the arithmetic mean of all carriers' premium rates for
an OHC plan sold to groups with similar case characteristics by all carriers
selling OHC plans in the state, or on any other equitable basis determined by
the board. |
(C) |
"Base premium rate" means, as to any health
benefit plan that is issued by a carrier and that covers at least two but no
more than fifty employees of a small employer, the lowest premium rate for a
new or existing business prescribed by the carrier for the same or similar
coverage under a plan or arrangement covering any small employer with similar
case characteristics. |
(D) |
"Carrier" means any sickness and accident
insurance company or health insuring corporation authorized to issue health
benefit plans in this state or a MEWA. A sickness and accident insurance
company that owns or operates a health insuring corporation, either as a
separate corporation or as a line of business, shall be considered as a
separate carrier from that health insuring corporation for purposes of sections
3924.01 to
3924.14 of the Revised
Code. |
(E) |
"Case characteristics" means, with respect to a
small employer, the geographic area in which the employees work; the age and
sex of the individual employees and their dependents; the appropriate industry
classification as determined by the carrier; the number of employees and
dependents; and such other objective criteria as may be established by the
carrier. "Case characteristics" does not include claims experience, health
status, or duration of coverage from the date of issue. |
(F) |
"Dependent" means the spouse or child of an eligible employee, subject to
applicable terms of the health benefits plan covering the employee. |
(G) |
"Eligible employee" means an employee who works a normal work week of
thirty or more hours. "Eligible employee" does not
include a temporary or substitute employee, or a seasonal employee who works
only part of the calendar year on the basis of natural or suitable times or
circumstances. |
(H) |
"Health benefit plan" means any hospital or
medical expense policy or certificate or any health plan provided by a carrier,
that is delivered, issued for delivery, renewed, or used in this state on or
after the date occurring six months after November 24, 1995. "Health benefit
plan" does not include policies covering only accident, credit, dental,
disability income, long-term care, hospital indemnity, medicare supplement,
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 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. |
(I) |
"Late enrollee" means an eligible employee or dependent who enrolls in a small
employer's health benefit plan other than during the first period in which the
employee or dependent is eligible to enroll under the plan or during a special
enrollment period described in section 2701(f) of the "Health Insurance
Portability and Accountability Act of 1996,"
Pub. L. No. 104-191, 110 Stat. 1955,
42 U.S.C.A. 300gg, as amended. |
(J) |
"MEWA" means any "multiple employer welfare arrangement" as defined in section
3 of the "Federal Employee Retirement Income Security Act of 1974," 88 Stat.
832, 29 U.S.C.A. 1001, as amended, except for any arrangement
which is fully insured as defined in division (b)(6)(D) of section 514 of that
act. |
(K) |
"Midpoint rate" means, for small employers with
similar case characteristics and plan designs and as determined by the
applicable carrier for a rating period, the arithmetic average of the
applicable base premium rate and the corresponding highest premium
rate. |
(L) |
"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 enrollment date as to a
condition for which medical advice, diagnosis, care, or treatment was
recommended or received during a specified period immediately preceding the
enrollment date. Genetic information shall not be treated as such a condition
in the absence of a diagnosis of the condition related to such information. For purposes of this
division, "enrollment date" means, with respect to an individual covered under
a group health benefit plan, the date of enrollment of the individual in the
plan or, if earlier, the first day of the waiting period for such
enrollment.
|
(M) |
"Service waiting period" means the period of time
after employment begins before an employee is eligible to be covered for
benefits under the terms of any applicable health benefit plan offered by the
small employer. |
(N) |
(1) |
"Small employer" means, in connection with a group
health benefit plan and with respect to a calendar year and a plan year, an
employer who employed an average of at least two but no more than fifty
eligible employees on business days during the preceding calendar year and who
employs at least two employees on the first day of the plan year. |
(2) |
For purposes of division (N)(1) of this section, all persons treated as a
single employer under subsection (b), (c), (m), or (o) of section 414 of the
"Internal Revenue Code of 1986," 100 Stat. 2085,
26 U.S.C.A. 1, as amended, shall be considered one
employer. In the case of an employer that was not in existence throughout the
preceding calendar year, the determination of whether the employer is a small
or large employer shall be based on the average number of eligible employees
that it is reasonably expected the employer will employ on business days in the
current calendar year. Any reference in division (N) of this section to an
"employer" includes any predecessor of the employer. Except as otherwise
specifically provided, provisions of sections
3924.01 to
3924.14 of the Revised Code that
apply to a small employer that has a health benefit plan shall continue to
apply until the plan anniversary following the date the employer no longer
meets the requirements of this division. |
|
(O) |
"OHC plan" means an Ohio health care plan, which is the basic, standard, or
carrier reimbursement plan for small employers and individuals established in
accordance with section
3924.10 of the Revised
Code. |
Amended by
130th General Assembly File No. TBD, HB 201, §1,
eff. 3/23/2015.
Amended by
128th General AssemblyFile No.18, HB 300,
§1, eff.
5/26/2010.
Effective Date: 03-22-1999
.
(A) |
An
individual or group health benefit plan is subject to sections
3924.01 to
3924.14 of the Revised Code if it
provides health care benefits covering at least two but no more than fifty
employees of a small employer, and if it meets either of the following
conditions:
(1) |
Any portion of the premium or
benefits is paid by a small employer, or any covered individual is reimbursed,
whether through wage adjustments or otherwise, by a small employer for any
portion of the premium. |
(2) |
The
health benefit plan is treated by the employer or any of the covered
individuals as part of a plan or program for purposes of section 106 or 162 of
the "Internal Revenue Code of 1986," 100 Stat. 2085,
26 U.S.C.A. 1, as amended. |
|
(B) |
Notwithstanding division (A) of this section,
divisions (D), (E)(2), (F), and (G) of section
3924.03 of the Revised Code and
section 3924.04 of the Revised Code do not
apply to health benefit policies that are not sold to owners of small
businesses as an employment benefit plan. Such policies shall clearly state
that they are not being sold as an employment benefit plan and that the owner
of the business is not responsible, either directly or indirectly, for paying
the premium or benefits. |
(C) |
Every health benefit plan offered or delivered by a carrier, other than a
health insuring corporation, to a small employer is subject to sections
3923.23,
3923.231,
3923.232,
3923.233, and
3923.234 of the Revised Code and
any other provision of the Revised Code that requires the reimbursement,
utilization, or consideration of a specific category of a licensed or certified
health care practitioner. |
(D) |
Except as expressly provided in sections
3924.01 to
3924.14 of the Revised Code, no
health benefit plan offered to a small employer is subject to any of the
following:
(1) |
Any law that would inhibit any
carrier from contracting with providers or groups of providers with respect to
health care services or benefits; |
(2) |
Any law that would impose any restriction
on the ability to negotiate with providers regarding the level or method of
reimbursing care or services provided under the health benefit plan; |
(3) |
Any law that would require any carrier to
either include a specific provider or class of provider when contracting for
health care services or benefits, or to exclude any class of provider that is
generally authorized by statute to provide such care. |
|
Effective Date:
06-30-1997 .
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, health benefit plans
covering small employers are subject to the following conditions, as
applicable:
(A) |
(1) |
Pre-existing conditions provisions shall not
exclude or limit coverage for a period beyond twelve months, or eighteen months
in the case of a late enrollee, following the individual's enrollment date and
may only relate to a physical or mental condition, regardless of the cause of
the condition, for which medical advice, diagnosis, care, or treatment was
recommended or received within the six months immediately preceding the
enrollment date. Division (A)(1) of this section is subject to the exceptions
set forth in section 2701(d) of the "Health Insurance Portability and
Accountability Act of 1996."
|
(2) |
The period of any such pre-existing condition
exclusion shall be reduced by the aggregate of the periods of creditable
coverage, if any, applicable to the employee or dependent as of the enrollment
date. |
(3) |
A period of creditable
coverage shall not be counted, with respect to enrollment of an individual
under a group health benefit plan, if, after that period and before the
enrollment date, there was a sixty-three-day period during all of which the
individual was not covered under any creditable coverage. Subsections (c)(2) to
(4) and (e) of section 2701 of the "Health Insurance Portability and
Accountability Act of 1996" apply with respect to crediting previous coverage.
|
(4) |
As used in division (A) of
this section:
(a) |
"Creditable coverage" has
the same meaning as in section 2701(c)(1) of the "Health Insurance Portability
and Accountability Act of 1996." |
(b) |
"Enrollment date" means, with respect to
an individual covered under a group health benefit plan, the date of enrollment
of the individual in the plan or, if earlier, the first day of the waiting
period for such enrollment. |
|
|
(B) |
(1) |
Except as
provided in section 2712(b) to (e) of the "Health Insurance Portability and
Accountability Act of 1996," if a carrier offers coverage in the small employer
market in connection with a group health benefit plan, the carrier shall renew
or continue in force such coverage at the option of the plan sponsor of the
plan. |
(2) |
A carrier may cancel or
decide not to renew the coverage of any eligible employee or of a dependent of
an eligible 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) |
A carrier
shall not exclude any eligible employee or dependent, who would otherwise be
covered under a health benefit plan, on the basis of any actual or expected
health condition of the employee or dependent. If, prior to November 24, 1995, a carrier excluded an eligible
employee or dependent, other than a late enrollee, on the basis of an actual or
expected health condition, the carrier shall, upon the initial renewal of the
coverage on or after that date, extend coverage to the employee or dependent if
all other eligibility requirements are met.
|
(D) |
No health benefit plan issued by a carrier shall
limit or exclude, by use of a rider or amendment applicable to a specific
individual, coverage by type of illness, treatment, medical condition, or
accident, except for pre-existing conditions as permitted under division (A) of
this section. If a health benefit plan that is delivered or issued for delivery
prior to April 14, 1993, contains such limitations or exclusions, by use of a
rider or amendment applicable to a specific individual, the plan shall
eliminate the use of such riders or amendments within eighteen months after
April 14, 1993. |
(E) |
(1) |
Except as provided in sections
3924.031 and
3924.032 of the Revised Code, and
subject to such rules as may be adopted by the superintendent of insurance in
accordance with Chapter 119. of the Revised Code, a carrier shall offer and
make available every health benefit plan that it is actively marketing to every
small employer that applies to the carrier for such coverage. Division (E)(1) of this section does not apply to a health
benefit plan that a carrier makes available in the small employer market only
through one or more bona fide associations. Division (E)(1) of this section shall not be construed to
preclude a carrier from establishing employer contribution rules or group
participation rules for the offering of coverage in connection with a group
health benefit plan in the small employer market, as allowed under the law of
this state. As used in division (E)(1) of this section, "employer contribution
rule" means a requirement relating to the minimum level or amount of employer
contribution toward the premium for enrollment of employees and dependents and
"group participation rule" means a requirement relating to the minimum number
of employees or dependents that must be enrolled in relation to a specified
percentage or number of eligible individuals or employees of an employer.
|
(2) |
Each health benefit
plan, at the time of initial group enrollment, shall make coverage available to
all the eligible employees of a small employer without a service waiting
period. The decision of whether to impose a service waiting period shall be
made by the small employer. Such waiting periods shall not be greater than
ninety days. |
(3) |
Each health
benefit plan shall provide for the special enrollment periods described in
section 2701(f) of the "Health Insurance Portability and Accountability Act of
1996." |
(4) |
At least once in every
twelve-month period, a carrier shall provide to all late enrollees who are
identified by the small employer, the option to enroll in the health benefit
plan. The enrollment option shall be provided for a minimum period of thirty
consecutive days. All delays of coverage imposed under the health benefit plan,
including any pre-existing condition exclusion period, affiliation period, or
service waiting period, shall begin on the date the carrier receives notice of
the late enrollee's application or request for coverage, and shall run
concurrently with each other. |
|
(F) |
The benefit structure of any health benefit plan
may, at the time of coverage renewal, be changed by the carrier to make it
consistent with the benefit structure contained in health benefit plans being
marketed to new small employer groups. If the health benefit plan is available
in the small employer market other than only through one or more bona fide
associations, the modification must be consistent with the law of this state
and effective on a uniform basis among small employer group plans. |
(G) |
A carrier may obtain any facts and
information necessary to apply this section, or supply those facts and
information to any other third-party payer, without the consent of the
beneficiary. Each person claiming benefits under a health benefit plan shall
provide any facts and information necessary to apply this section. For purposes of this section, "bona fide association" means an
association that has been actively in existence for at least five years; has
been formed and maintained in good faith for purposes other than obtaining
insurance; does not condition membership in the association on any health
status-related factor, as defined in section
3924.031 of the Revised Code,
relating to an individual, including an employee or dependent; makes health
insurance coverage offered through the association available to all members
regardless of any health status-related factor, as defined in section
3924.031 of the Revised Code,
relating to such members or to individuals eligible for coverage through a
member; does not make health insurance coverage offered through the association
available other than in connection with a member of the association; and meets
any other requirement imposed by the superintendent. To maintain its status as
a "bona fide association," each association shall annually certify to the
superintendent that it meets the requirements of this paragraph.
|
Effective Date:
03-22-1999 .
(A) |
As used in
this section and section
3924.032 of the Revised Code:
(1) |
"Health status-related factor" means any
of the following:
(b) |
Medical condition, including
both physical and mental illnesses; |
(d) |
Receipt of health care; |
(g) |
Evidence of insurability, including
conditions arising out of acts of domestic violence; |
|
(2) |
"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.
|
|
(B) |
If a carrier offers
a health benefit plan in the small employer market through a network plan, the
carrier may do both of the following:
(1) |
Limit the small employers that may apply for such coverage to those with
eligible employees 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 small employers if the carrier has
demonstrated both of the following to the superintendent of insurance:
(a) |
The carrier will not have the capacity to
deliver services adequately to the members of any additional groups because of
the carrier's obligations to existing group contract holders and members.
|
(b) |
The carrier is applying
division (B)(2) of this section uniformly to all small employers without regard
to the claims experience of those employers and their eligible employees and
dependents or to any health status-related factor relating to such employees
and dependents. |
|
|
(C) |
A carrier that, pursuant to division (B)(2) of
this section, denies coverage to a small employer in the service area of a
network plan, shall not offer coverage in the small employer market within that
service area for at least one hundred eighty days after the date the coverage
is denied. |
Effective Date:
06-30-1997 .
(A) |
A carrier
may refuse to issue health benefit plans in the small employer market if the
carrier has demonstrated both of the following to the superintendent of
insurance:
(1) |
The carrier does not have the
financial reserves necessary to underwrite additional coverage. |
(2) |
The carrier is applying division (A) of
this section uniformly to all employers in the small employer market in this
state consistent with the applicable laws and rules of this state and without
regard to the claims experience of those employers and their employees and
dependents or to any health status-related factor relating to such employees
and dependents. |
|
(B) |
A
carrier that, pursuant to division (A) of this section, refuses to issue health
benefit plans in the small employer market, shall not offer health benefit
plans in the small employer 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. |
(C) |
The superintendent may provide for the
application of this section on a service-area-specific basis. |
Effective Date:
06-30-1997 .
(A) |
Each
carrier, in connection with the offering of a health benefit plan to a small
employer, shall disclose to the employer, as part of its solicitation and sales
materials, the following information:
(1) |
The
provisions of the plan concerning the carrier's right to change premium rates
and the factors that may affect changes in premium rates; |
(2) |
The provisions of the plan relating to
renewability of coverage; |
(3) |
The
provisions of the plan relating to any pre-existing condition exclusion;
|
(4) |
The benefits and premiums
available under all health benefit plans for which the employer is qualified.
|
|
(B) |
The information
described in division (A) of this section shall be provided in a manner
determined to be understandable by the average small employer, and in a manner
sufficient to reasonably inform a small employer regarding the employer's
rights and obligations under the health benefit plan. |
(C) |
Nothing in this section requires a carrier to
disclose any information that is by law proprietary and trade secret
information. |
Effective Date:
03-22-1999 .
(A) |
(1) |
With respect to any health benefit plan of a
carrier and except as otherwise provided in divisions (A)(2) and (3) of this
section, the premium rates charged or offered for a rating period for the same
or similar coverage under a health benefit plan covering any small employer
with similar case characteristics shall not vary from the applicable midpoint
rate by more than forty per cent of the midpoint rate, as to all health benefit
plans issued on or after the effective date of this section. |
(2) |
A carrier may apply a low claims
discount not to exceed five per cent of the midpoint rate to small employers
with favorable claims experience. A premium rate for a rating period may fall
outside the range set forth in division (A) of this section as the result of a
low claims discount. |
(3) |
If the
premium rates charged or offered for the same or similar coverage under a
health benefit plan covering any small employer with similar case
characteristics, as determined by the carrier, exceeds the premium rate
limitations described in divisions (A)(1) and (2) of this section, any increase
in premium rates for a new rating period shall not exceed the sum of both of
the following:
(a) |
Any percentage change in
the base premium rate measured from the first day of the prior rating period to
the first day of the new rating period; |
(b) |
Any adjustment due to change in case
characteristics or plan design of the small employer, as determined by the
carrier. |
|
(4) |
For
purposes of this section, a small employer carrier shall treat all health
benefit plans issued or renewed in the same calendar month as having the same
rating period. |
|
(B) |
If
a carrier utilizes industry as a case characteristic in establishing premium
rates, the rate factor associated with any industry classification shall not
vary by more than fifteen per cent from the arithmetic average of the rate
factors associated with all industry classifications. |
(C) |
Subject to divisions (A) and (B) of this section,
any increase in premium rates for a new rating period shall not exceed any
percentage change in the base premium rate measured from the first day of the
prior rating period to the first day of the new rating period plus fifteen per
cent, adjusted on a pro rata basis for rating periods greater or less than one
year, of the base premium rate for the new rating period and any adjustments
due to a change in case characteristics or plan design of the small employer,
as determined by the carrier. |
(D) |
The superintendent of insurance may adopt rules in accordance with Chapter 119.
of the Revised Code that set forth alternative methods of calculating the
premium rates required under this section, which methods result in premium
rates that are consistent with, and meet the applicable requirements of, this
section. A carrier that utilizes any such method of calculation is deemed to be
in compliance with this section. |
(E) |
If a carrier has established a separate class of
business for one or more small employer health care alliances in accordance
with section
1731.09 of the Revised Code, this
section shall apply in accordance with section
1731.09 of the Revised Code.
|
Effective Date:
04-14-1993;
03-23-2007 .
Effective Date:
03-22-1999 .
(A) |
Compliance with the underwriting and rating
requirements contained in sections
3924.01 to
3924.14 of the Revised Code shall
be demonstrated through actuarial certification. Carriers offering health
benefit plans to small employers shall file annually with the superintendent of
insurance an actuarial certification stating that the underwriting and rating
methods of the carrier do all of the following:
(1) |
Comply with accepted actuarial practices; |
(2) |
Are uniformly applied to health benefit plans covering small employers;
|
(3) |
Comply
with the applicable provisions of sections
3924.01 to
3924.14 of the Revised Code.
|
|
(B) |
If a carrier has established a separate class of
business for one or more small employer health care alliances in accordance
with section
1731.09 of the Revised Code, this
section shall apply in accordance with section
1731.09 of the Revised Code.
|
(C) |
Carriers offering health benefit plans to small employers
shall file premium rates with the superintendent in accordance with section
3923.02 of the Revised Code with
respect to the carrier's sickness and accident insurance policies sold to small
employers and in accordance with section
1751.12 of the Revised Code with
respect to the carrier's health insuring corporation policies sold to small
employers. |
Amended by
128th General AssemblyFile No.9, HB 1,
§101.01, eff.
10/16/2009.
Effective Date:
04-14-1993; 03-23-2007
(A) |
There is
hereby established a nonprofit entity to be known as the "Ohio health
reinsurance program." Any carrier issuing health benefit plans in this state on
or after April 14, 1993, may be a member of the program. |
(B) |
A carrier may elect to be a member of the program
by filing a written intention to participate with the superintendent of
insurance at least thirty days prior to the implementation of the program. Any
carrier that does not file a written intention to participate within that time
period may not participate for three years after April 14, 1993, and may file
an intention to participate only at that time or on any subsequent three-year
anniversary date. However, the superintendent may permit a carrier to
participate in the program at other intervals for reasons based on financial
solvency. |
(C) |
The board of
directors of the program may permit a carrier to participate in the program at
any time for good cause shown. The board shall establish an application process
for carriers seeking to change their status under this division. |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 06-30-1997
.
(A) |
The board
of directors of the Ohio health reinsurance program shall consist of nine
appointed members who shall serve staggered terms as determined by the initial
board for its members and by the plan of operation of the program for members
of subsequent boards. Within thirty days after April 14, 1993, the members of
the board shall be appointed, as follows:
(1) |
The chairperson of the senate committee having jurisdiction over insurance
shall appoint the following members:
(a) |
Two
member carriers that are small employer carriers; |
(b) |
One member carrier that is a health
insuring corporation predominantly in the small employer market; |
(c) |
One representative of providers of health
care. |
|
(2) |
The
chairperson of the committee in the house of representatives having
jurisdiction over insurance shall appoint the following members:
(a) |
One member carrier that is a small
employer carrier; |
(b) |
One member
carrier whose principal health insurance business is in the large employer
market; |
(c) |
One representative of
an employer with fifty or fewer employees; |
(d) |
One representative of consumers in this
state. |
|
(3) |
The
superintendent of insurance shall appoint a representative of a member carrier
operating in the small employer market who is a fellow of the society of
actuaries. The superintendent, a member of the house of representatives
appointed by the speaker of the house of representatives, and a member of the
senate appointed by the president of the senate, shall be ex-officio members of
the board. The membership of all boards subsequent to the initial board shall
reflect the distribution described in division (A) of this section. The chairperson of the initial board and each subsequent board
shall represent a small employer member carrier and shall be elected by a
majority of the voting members of the board. Each chairperson shall serve for
the maximum duration established in the plan of operation.
|
|
(B) |
Within one
hundred eighty days after the appointment of the initial board, the board shall
establish a plan of operation and, thereafter, any amendments to the plan that
are necessary or suitable, to assure the fair, reasonable, and equitable
administration of the program. The board shall, immediately upon adoption,
provide to the superintendent copies of the plan of operation and all
subsequent amendments to it. |
(C) |
The plan of operation shall establish rules, conditions, and procedures for all
of the following:
(1) |
The handling and
accounting of assets and moneys of the program and for an annual fiscal
reporting to the superintendent; |
(2) |
Filling vacancies on the board;
|
(3) |
Selecting an administrator of
the program, and setting forth the powers and duties of the administrator. The
administrator may be a carrier as defined in section
3924.01 of the Revised Code or a
person licensed as an administrator under Chapter 3959. of the Revised Code, or
the board may, in its sole discretion, choose to serve as administrator of the
program. |
(4) |
Reinsuring risks in
accordance with sections
3924.07 to
3924.14 of the Revised Code;
|
(5) |
Collecting assessments subject
to section
3924.13 of the Revised Code from
all members to provide for claims reinsured by the program and for
administrative expenses incurred or estimated to be incurred during the period
for which the assessment is made; |
(6) |
Providing protection for carriers from
the financial risk associated with small employers that present poor credit
risks; |
(7) |
Establishing standards
for the coverage of small employers that have a high turnover of employees;
|
(8) |
Establishing an appeals process
for carriers to seek relief when a carrier has experienced an unfair share of
administrative and credit risks; |
(9) |
Establishing the adjusted average market
premium prices for use by the OHC plans for individuals, for groups of two to
twenty-five employees, and for groups of twenty-six to fifty employees that are
offered in the state; |
(10) |
Establishing participation standards at issue and renewal for reinsured cases;
|
(11) |
Reinsuring risks and
collecting assessments in accordance with division (G) of section
3924.11 of the Revised Code;
|
(12) |
Any additional matters as
determined by the board. |
|
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 03-22-1999
.
The Ohio health
reinsurance program shall have the general powers and authority granted under
the laws of the state to insurance companies licensed to transact sickness and
accident insurance, except the power to issue insurance. The board of directors
of the program also shall have the specific authority to do all of the
following:
(A) |
Enter into contracts as are necessary or proper to
carry out the provisions and purposes of sections
3924.07 to
3924.14 of the Revised Code,
including the authority to enter into contracts with similar programs of other
states for the joint performance of common functions, or with persons or other
organizations for the performance of administrative functions; |
(B) |
Sue or be sued, including taking any legal actions necessary or proper for
recovery of any assessments for, on behalf of, or against any program or board
member; |
(C) |
Take such legal action as is necessary to avoid
the payment of improper claims against the program; |
(D) |
Make
recommendations to the superintendent of insurance regarding the design
of the OHC plans which, when offered by a carrier, are eligible for
reinsurance and issue reinsurance policies in accordance with the requirements
of sections
3924.07 to
3924.14 of the Revised Code;
|
(E) |
Establish rules, conditions, and procedures
pertaining to the reinsurance of members' risks by the program; |
(F) |
Establish appropriate rates, rate schedules, rate adjustments, rate
classifications, and any other actuarial functions appropriate to the operation
of the program; |
(G) |
Assess members in accordance with division (G) of
section 3924.11 and the provisions of
section 3924.13 of the Revised Code, and
make such advance interim assessments as may be reasonable and necessary for
organizational and interim operating expenses. Any interim assessments shall be
credited as offsets against any regular assessments due following the close of
the calendar year. |
(H) |
Appoint members to appropriate legal, actuarial,
and other committees if necessary to provide technical assistance with respect
to the operation of the program, policy and other contract design, and any
other function within the authority of the program; |
(I) |
Borrow money to effect the purposes of the program. Any notes or other evidence
of indebtedness of the program not in default shall be legal investments for
carriers and may be carried as admitted assets. |
(J) |
Reinsure risks, collect assessments, and otherwise carry out its duties under
division (G) of section
3924.11 of the Revised Code;
|
(K) |
Study the operation of the Ohio health reinsurance
program and the open enrollment reinsurance program and, based on its findings,
make legislative recommendations to the general assembly for improvements in
the effectiveness, operation, and integrity of the programs; |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Amended by
128th General AssemblyFile No.18, HB 300,
§1, eff.
5/26/2010.
Effective Date: 03-22-1999
.
(A) |
The board of directors of the Ohio health
reinsurance program may make recommendations to the superintendent of
insurance, and the superintendent may adopt or amend by rule adopted in
accordance with Chapter 119. of the Revised Code, the OHC basic, standard, and
carrier reimbursement plans which, when offered by a carrier, are eligible for
reinsurance under the program. The superintendent shall establish the form and
level of coverage to be made available by carriers in their OHC plans. The
plans shall include benefit levels, deductibles, coinsurance factors,
exclusions, and limitations for the plans. The forms and levels of coverage
shall specify which components of health benefit plans offered by a carrier may
be reinsured. The OHC plans are subject to division (C) of section
3924.02 of the Revised Code and to
the provisions in Chapters 1751., 1753., 3923., and any other chapter of the
Revised Code that require coverage or the offer of coverage of a health care
service or benefit. |
(B) |
Prior to adopting any rule that makes changes to
the OHC basic or standard plan, the superintendent shall conduct an actuarial
analysis of the cost impact of the proposed rule. The plans may include cost containment features
including any of the following:
(1) |
Utilization review of health care services, including review of the medical
necessity of hospital and physician services; |
(2) |
Case management benefit alternatives; |
(3) |
Selective contracting with hospitals, physicians, and other health care
providers; |
(4) |
Reasonable benefit differentials applicable to participating and
nonparticipating providers; |
(5) |
Employee assistance program options that provide preventive and early
intervention mental health and substance abuse services; |
(6) |
Other provisions for the cost-effective management of the
plans. |
|
(C) |
OHC plans established for use by health insuring
corporations shall be consistent with the basic method of operation of such
corporations. |
(D) |
Each carrier shall certify to the superintendent
of insurance, in the form and manner prescribed by the superintendent, that the
OHC plans filed by the carrier are in substantial compliance with the
provisions of the OHC plans designed or adopted under this section. Upon
receipt by the superintendent of the certification, the carrier may use the
certified plans. |
(E) |
Each carrier shall, on and after sixty days after
the date that the program becomes operational and as a condition of transacting
business in this state, renew coverage provided to any individual or group
under its OHC plans. |
(F) |
The OHC plans in effect as of June 1, 2009, shall
remain in effect until those plans are amended or new plans are adopted in
accordance with this section. |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Amended by
129th General AssemblyFile No.28, HB 153,
§101.01, eff.
9/29/2011.
Amended by
128th General AssemblyFile No.18, HB 300,
§1, eff.
5/26/2010.
Effective Date: 03-22-1999
.
Any member of the Ohio health reinsurance program may reinsure
small employer groups or individuals in accordance with the following
conditions and limitations:
(A) |
A
small employer group or individual may be reinsured within sixty days after the
commencement of the group's or individual's coverage under the plan. |
(B) |
(1) |
The carrier may reinsure either the entire eligible group or any eligible
individual, in accordance with the premium rates established in section
3924.12 of the Revised Code, upon
commencement of the coverage. |
(2) |
The carrier may reinsure an eligible employee, or the dependents of an eligible
employee, who were previously excluded from group coverage for medical reasons,
and shall reinsure such employees or dependents within sixty days after the
carrier is required to include them in the group coverage. |
|
(C) |
With respect to an OHC plan,
the program shall reinsure the level of coverage provided. |
(D) |
With respect to other plans issued to small
employers, the program shall reinsure the level of coverage provided up to, but
not exceeding, the level of coverage provided in an OHC carrier reimbursement
plan. In the coverage provided to small employers, carriers shall be required
to use high-cost care management, hospital precertification techniques, and
other cost containment mechanisms established by the program. |
(E) |
A carrier may not reinsure existing
business, except pursuant to division (A) of this section. |
(F) |
If an employer group is covered under a plan other
than an OHC carrier reimbursement plan and the carrier chooses to reinsure the
group subsequent to the initial coverage period, or if a new individual joins
the group and the carrier wants to reinsure that individual, the carrier shall
not force the employer to change to an OHC carrier reimbursement plan. The
carrier shall allow the employer to maintain the same benefit plan and reinsure
only that portion of the plan that is consistent with an OHC carrier
reimbursement plan. |
(G) |
With
respect to coverage provided to an individual acquired under section
3923.58 or a federally eligible
individual acquired under section
3923.581 of the Revised Code, the
following conditions and limitations apply:
(1) |
Within sixty days after the commencement
of the initial coverage, any carrier may reinsure coverage of such an
individual with the open enrollment reinsurance program in accordance with
division (G) of this section. Premium rates charged for coverage reinsured by
the program shall be established in accordance with section
3924.12 of the Revised Code.
|
(2) |
The board of directors of the
Ohio health reinsurance program shall establish the open enrollment reinsurance
fund for coverage provided under section
3923.58 of the Revised Code and,
with respect to federally eligible individuals, coverage provided under section
3923.581 of the Revised Code. The
fund shall be maintained separately from any reinsurance fund established for
Ohio health care plans issued pursuant to sections
3924.07 to
3924.14 of the Revised Code. The
board shall calculate, on a retrospective basis, the amount needed for
maintenance of the open enrollment reinsurance fund and, on the basis of that
calculation, shall determine the amount to be assessed each carrier that is
required to provide open enrollment coverage. Assessments shall be apportioned by the board among all
carriers participating in the open enrollment reinsurance program in proportion
to their respective shares of the total premiums, net of reinsurance premiums
paid by a carrier for open enrollment coverage and net of reinsurance premiums
paid by the carrier for all other individual health benefit plans, earned in
this state from all health benefit plans covering individuals that are issued
by all such carriers during the calendar year coinciding with or ending during
the fiscal year of the open enrollment program, or on any other equitable basis
reflecting coverage of individuals in this state as may be provided in the plan
of operation adopted by the board. In no event shall the assessment of any
carrier under this section exceed, on an annual basis, three per cent of its
Ohio premiums for health benefit plans covering individuals as reported on its
most recent annual statement filed with the superintendent of insurance.
The board shall submit its determination of the amount of the
assessment to the superintendent for review of the accuracy of the calculation
of the assessment. Upon approval by the superintendent, each carrier shall,
within thirty days after receipt of the notice of assessment, submit the
assessment to the board for purposes of the open enrollment reinsurance fund.
|
(3) |
If the assessments made
and collected pursuant to division (G)(2) of this section are not sufficient to
pay the claims reinsured under division (G) of this section and the allocated
administrative expenses, incurred or estimated to be incurred during the period
for which the assessment was made, the secretary of the board shall immediately
notify the superintendent, and the superintendent shall suspend the operation
of open enrollment under section
3923.58 of the Revised Code and,
with respect to federally eligible individuals, under section
3923.581 of the Revised Code until
the board has collected in subsequent years through assessments made pursuant
to division (G)(2) of this section an amount sufficient to pay such claims and
administrative expenses. |
(4) |
(a) |
Any carrier that is subject to open
enrollment under section
3923.58 of the Revised Code may
elect not to participate in the open enrollment reinsurance program under
division (G) of this section by filing an application with the superintendent
and obtaining the superintendent's approval. In determining whether to approve
an application, the superintendent shall consider whether the carrier meets all
of the following standards:
(i) |
Demonstration
by the carrier of a substantial and established market presence; |
(ii) |
Demonstrated experience in the
individual market and history of rating and underwriting individual plans;
|
(iii) |
Commitment to comply with the
requirements of section
3923.58 of the Revised Code;
|
(iv) |
Financial ability to assume
and manage the risk of enrolling open enrollment individuals without the need
for, or protection of, reinsurance. |
|
(b) |
A carrier whose application for
nonparticipation has been rejected by the superintendent may appeal the
decision in accordance with Chapter 119. of the Revised Code. A carrier that
has received approval of the superintendent not to participate in the open
enrollment reinsurance program shall, on or before the first day of December,
annually certify to the superintendent that it continues to meet the standards
described in division (G)(4)(a) of this section. |
(c) |
In any year subsequent to the year in
which its application not to participate has been approved, a carrier may elect
to participate in the open enrollment reinsurance program by giving notice to
the superintendent and board on or before the thirty-first day of December. If,
after a period of nonparticipation, a carrier elects to participate in the open
enrollment reinsurance program, the carrier retains the risks it assumed during
the period when it was not participating. |
(d) |
The superintendent may, at any time,
authorize a carrier to modify an election not to participate if the risk from
the carrier's open enrollment business jeopardizes the financial condition of
the carrier. If the superintendent authorizes the carrier to again participate
in the open enrollment reinsurance program, the carrier shall retain the risks
it assumed during the period of nonparticipation. |
|
(5) |
(a) |
The
open enrollment reinsurance program shall be operated separately from the Ohio
health reinsurance program. |
(b) |
A
carrier's election to participate in the open enrollment reinsurance program
under division (G) of this section shall not be construed as an election to
participate in the Ohio health reinsurance program under section
3924.07 of the Revised Code.
|
|
|
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 03-22-1999
.
(A) |
The Ohio
health reinsurance program shall not provide reinsurance for any individual
reinsured under the program until five thousand dollars in benefit payments
have been made by a member of the program for services provided to that
individual during a calendar year, which payments would have been reimbursed
through the program but for the five-thousand-dollar deductible. The member
shall retain ten per cent of the next fifty thousand dollars of benefit
payments made during that calendar year, and the program shall reinsure the
remainder. However, a member's maximum liability under this section with
respect to any one individual reinsured under the program shall not exceed ten
thousand dollars in any one calendar year. |
(B) |
The board of directors of the Ohio health
reinsurance program shall periodically review the deductible amount and the
maximum liability amount set forth in division (A) of this section and,
considering the rate of inflation, adjust each amount as the board considers
necessary. |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 06-30-1997
.
(A) |
Except as
provided in division (B) of this section, premium rates charged for coverage
reinsured by the Ohio health reinsurance program shall be established as
follows:
(1) |
For whole group reinsurance
coverage, one and one-half times the adjusted average market premium price
established by the program for that classification or group with similar
characteristics and coverage, with respect to the eligible employees of a small
employer and their dependents, all of whose coverage is reinsured with the
program, minus a ceding expense factor determined by the board of directors of
the program; |
(2) |
For individual
reinsurance coverage, five times the adjusted average market premium price
established by the program for an individual in that classification or group
with similar characteristics and coverage, with respect to an eligible employee
or the employee's dependents, minus a ceding expense factor determined by the
board. |
|
(B) |
Premium
rates charged for reinsurance by the program to a health insuring corporation
that is approved by the secretary of health and human services as a federally
qualified health maintenance organization pursuant to the "Social Security
Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, and
as such is subject to requirements that limit the amount of risk that may be
ceded to the program, may be modified to reflect the portion of risk that may
be ceded to the program. |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 06-30-1997
.
(A) |
Following
the close of each calendar year, the administrator of the Ohio health
reinsurance program shall determine the net premiums, the program expenses for
administration, and the incurred losses, if any, for the year, taking into
account investment income and other appropriate gains and losses. For purposes
of this section, health benefit plan premiums earned by MEWAs shall be
established by adding paid claim losses and administrative expenses of the
MEWA. Health benefit plan premiums and benefits paid by a carrier that are less
than an amount determined by the board of directors of the program to justify
the cost of collection shall not be considered for purposes of determining
assessments. For purposes of this division, "net premiums" means health benefit
plan premiums, less administrative expense allowances. |
(B) |
Any net loss for the year shall be recouped first
by assessments of carriers in accordance with this division. Assessments shall
be apportioned by the board among all carriers participating in the program in
proportion to their respective shares of the total premiums, net of reinsurance
premiums paid for coverage under this program earned in the state from health
benefit plans covering small employers that are issued by participating members
during the calendar year coinciding with or ending during the fiscal year of
the program, or on any other equitable basis reflecting coverage of small
employers as may be provided in the plan of operation. An assessment shall be
made pursuant to this division against a health insuring corporation that is
approved by the secretary of health and human services as a federally qualified
health maintenance organization pursuant to the "Social Security Act," 49 Stat.
620 (1935), 42 U.S.C.A. 301, as amended, subject to an assessment
adjustment formula adopted by the board for such health insuring corporations
that recognizes the restrictions imposed on the entities by federal law. The
adjustment formula shall be adopted by the board prior to the first anniversary
of the program's operation. In no event shall the assessment made pursuant to
this division exceed, on an annual basis, one per cent of the carrier's Ohio
small employer group premium as reported on its most recent annual statement
filed with the superintendent of insurance. If an excess is actuarially
projected, the superintendent may take any action necessary to lower the
assessment to the maximum level of one per cent. |
(C) |
If assessments exceed actual losses and
administrative expenses of the program, the excess shall be held at interest
and used by the board to offset future losses or to reduce program premiums. As
used in this division, "future losses" includes reserves for incurred but not
reported claims. |
(D) |
Each
carrier's proportion of participation in the program shall be determined
annually by the board based on annual statements and other reports deemed
necessary by the board and filed by the carrier with the board. MEWAs shall
report to the board claims payments made and administrative expenses incurred
in this state on an annual basis on a form prescribed by the superintendent.
|
(E) |
Provision shall be made in
the plan of operation for the imposition of an interest penalty for late
payment of assessments. |
(F) |
A
carrier may seek from the superintendent a deferment, in whole or in part, from
any assessment issued by the board. The superintendent may defer, in whole or
in part, the assessment of a carrier if, in the opinion of the superintendent,
payment of the assessment would endanger the carrier's ability to fulfill its
contractual obligations. |
(G) |
In
the event an assessment against a carrier is deferred in whole or in part, the
amount by which the assessment is deferred may be assessed against the other
carriers in a manner consistent with the basis for assessments set forth in
this section. In such event, the other carriers assessed shall have a claim in
the amount of the assessment against the carrier receiving the deferment. The
carrier receiving the deferment shall remain liable to the program for the
amount deferred. The superintendent may attach appropriate conditions to any
deferment. |
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 03-22-1999
.
Neither the participation as members of the Ohio health
reinsurance program or as members of the board of directors of the program, the
establishment of rates, forms, or procedures for coverage issued by the
program, nor any other joint or collective action required by sections
3924.01 to 3924.14 of the Revised
Code, shall be the basis of any legal action or any criminal or civil liability
or penalty against the program, the board, or any of its members either jointly
or separately.
Amended by
132nd General Assembly File No. TBD, HB 49, §610.53, eff.
9/29/2017.
Suspended by
130th General Assembly File No. 15, SB 9, §3,
which provides that during the period beginning on January 1,
2014, and expiring January 1, 2022, the operation of this section is suspended.
If the amendments made by 42 U.S.C. 300gg-1 and 300gg-6, regarding the
requirements related to health insurance coverage become ineffective prior to
the expiration of the suspension on January 1, 2022, then this section, in
either its present form or as later amended, again becomes
operational..
Effective Date: 06-30-1997
.
(A) |
As used in
this section:
(1) |
"Beneficiary,"
"hospital,"and "third-party payer" have the same meanings as in section
3901.38 of the Revised Code.
|
(2) |
"Overcharged" means charged
more than the usual and customary charge, rate, or fee that is charged by the
provider or hospital for a particular item or service. |
(3) |
"Provider" has the same meaning as in
section 3902.11 of the Revised Code.
|
|
(B) |
If a beneficiary
identifies on the billing statement of a provider or hospital any item or
service for which the beneficiary was overcharged by more than five hundred
dollars and the beneficiary notifies the third-party payer of the error at any
time after the thirty-day period immediately following the date on which the
third-party payer makes payment to the provider or hospital for the item or
service, the provider or hospital shall refund to the beneficiary an amount
equal to fifteen per cent of the amount overcharged. |
(C) |
A provider or hospital shall not be required to
comply with division (B) of this section if, at the time the third-party payer
receives notice of the overcharge from the beneficiary, the provider, hospital,
or third-party payer is in the process of correcting the error and such process
can be documented. |
Effective Date:
07-24-2002 .
(A) |
As used in
this section, "employer" means any person who employs an individual. |
(B) |
No employer shall engage in any act or
practice that, due solely to the actual or expected health condition of one or
more individuals, excludes or causes the exclusion of any individual from
coverage under an existing employer-provided policy, contract, or plan of
health benefits for which the individual would otherwise be eligible.
|
(C) |
If an employer violates
division (B) of this section, the prosecuting attorney of the county in which
an individual who was excluded from benefits resides may commence a civil
action in the court of common pleas to obtain a judgment for a civil penalty as
described in this division. If the court of common pleas determines in an action under this
division that an employer violated division (B) of this section, it shall
impose a civil penalty of not more than ten thousand dollars or, if the
violator previously has been determined by any court of common pleas to have
violated division (B) of this section, not more than twenty-five thousand
dollars. Any civil penalty imposed pursuant to this division shall be deposited
by the clerk of the court into the county treasury.
|
Effective Date:
11-24-1995 .
(A) |
As used in
this section:
(1) |
"Carrier," "dependent," and
"health benefit plan" have the same meanings as in section
3924.01 of the Revised Code.
|
(2) |
"Health status-related factor"
means any of the following:
(b) |
Medical condition,
including both physical and mental illnesses; |
(d) |
Receipt of health care; |
(g) |
Evidence of insurability, including
conditions arising out of acts of domestic violence; |
|
|
(B) |
No group
health benefit plan, or carrier offering health insurance coverage in
connection with a group health benefit plan, shall require any individual, as a
condition of enrollment or continued enrollment under the plan, to pay a
premium or contribution that is greater than the premium or contribution for a
similarly situated individual enrolled in the plan on the basis of any health
status-related factor in relation to the individual or to an individual
enrolled under the plan as a dependent of the individual. |
(C) |
Nothing in division (B) of this section shall be
construed to restrict the amount that an employer may be charged for coverage
under a group health benefit plan, or to prevent a group health benefit plan,
and a carrier 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. |
Effective Date:
06-30-1997 .
(A) |
As used
in sections 3924.41 and 3924.42 of the Revised Code, "health insurer" means any
sickness and accident insurer or health insuring corporation. "Health insurer"
also includes any group health plan as defined in section 607 of the federal
"Employee Retirement Income Security Act of 1974," 88 Stat. 832, 29 U.S.C.A.
1167. |
(B) |
Notwithstanding any other provision of the Revised
Code, no health insurer shall take into consideration the availability of, or
eligibility for, the medicaid program in this state
or in any other state when determining an individual's eligibility for coverage or
when making payments to or on behalf of an enrollee, subscriber, policyholder,
or certificate holder. |
Amended by
130th General Assembly File No. 25, HB 59, §101.01, eff.
9/29/2013.
Effective Date: 06-04-1997
.
No health insurer
shall impose requirements on the department of medicaid, when it
has been assigned the rights of an individual who is eligible for
medicaid and who is covered
under a health care policy, contract, or plan issued by the health insurer,
that are different from the requirements applicable to an agent or assignee of
any other individual so covered.
Amended by
130th General Assembly File No. 25, HB 59, §101.01, eff.
9/29/2013.
Effective Date: 07-01-2000
.
(A) |
As used in
sections 3924.46 to
3924.49 of the Revised Code,
"health insurer" has the same meaning as in section
3924.41 of the Revised Code.
|
(B) |
No health insurer shall deny
enrollment of a child under the health plan of the child's parent on the basis
that any of the following applies:
(1) |
The
child was born out of wedlock. |
(2) |
The child is not claimed as a dependent on the federal tax return of the
parent. |
(3) |
The child does not
reside in the household of the parent, or in the service area of the health
insurer. |
|
Effective Date:
06-30-1994 .
If a child has health care coverage through a health insurer of
a noncustodial parent, the health insurer shall do all of the following:
(A) |
Provide such information to the
custodial parent of the child as may be necessary for the child to obtain
benefits through the coverage; |
(B) |
Permit the custodial parent, or a provider with
the approval of the custodial parent, to submit claims for covered services
without the approval of the noncustodial parent; |
(C) |
Make payment on claims submitted in accordance
with division (B) of this section directly to the custodial parent, the
provider, or the department of job and family services. |
Effective Date:
07-01-2000 .
(A) |
If a
parent of a child is required by a court or administrative order to provide
health care coverage for the child, and if the parent is eligible for family
health care coverage provided by a health insurer, the health insurer shall do
both of the following:
(1) |
If the child is
otherwise eligible for the coverage, permit the parent to enroll the child
under the family coverage without regard to any enrollment period restrictions;
|
(2) |
If the parent is enrolled
under the coverage but fails to make application to obtain coverage for the
child, enroll the child under the family coverage upon application of the
child's other parent or pursuant to a child support order containing provisions
in compliance with sections
3119.29 to
3119.56 of the Revised Code.
|
|
(B) |
The health insurer
shall not terminate the child's coverage unless the health insurer is provided
satisfactory written evidence of either of the following:
(1) |
The court or administrative order is no
longer in effect. |
(2) |
The child is
or will be enrolled under comparable health care coverage provided by another
health insurer, which coverage will take effect not later than the effective
date of the termination of the current coverage. |
|
(C) |
As used in this section, "child support order" has
the same meaning as in section
3119.01 of the Revised Code.
|
Effective Date:
12-13-2002 .
(A) |
If a
parent of a child is required by a court or administrative order to provide
health insurance coverage for the child, which coverage is available through an
employer doing business in this state, the employer shall do all of the
following:
(1) |
If the child is otherwise
eligible for the family coverage, permit the parent to enroll the child under
the coverage without regard to any enrollment period restrictions; |
(2) |
If the parent is enrolled under the
coverage but fails to make application to obtain coverage for the child, enroll
the child under the family coverage upon application of the child's other
parent or pursuant to a child support order containing provisions in compliance
with sections
3119.29 to
3119.56 of the Revised Code;
|
(3) |
Withhold from the employee's
compensation the employee's share of premiums for the health care coverage, if
any, and pay that amount to the health insurer providing the coverage;
|
(4) |
Comply with the requirements of
sections 3119.36 to
3119.364 and
3119.42 of the Revised Code and
any rules adopted by the department of job and family services under section
3119.51 of the Revised Code.
|
|
(B) |
The employer shall
not terminate the child's coverage unless the employer has eliminated family
coverage for all of its employees or unless the employer is provided
satisfactory written evidence of either of the following:
(1) |
The court or administrative order is no
longer in effect. |
(2) |
The child is
or will be enrolled under comparable health care coverage that will take effect
not later than the effective date of the termination of the current coverage.
|
|
(C) |
As used in this
section, "child support order" has the same meaning as in section
3119.01 of the Revised Code.
|
Effective Date:
12-13-2002 .
(A) |
As used in
this section:
(1) |
"Child" means, in
connection with any adoption or placement for adoption of the child, an
individual who has not attained age eighteen as of the date of the adoption or
placement for adoption. |
(2) |
"Health
insurer" has the same meaning as in section
3924.41 of the Revised Code.
|
(3) |
"Placement for adoption" means
the assumption and retention by a person of a legal obligation for total or
partial support of a child in anticipation of the adoption of the child. The
child's placement with a person terminates upon the termination of that legal
obligation. |
|
(B) |
If an
individual or group health plan of a health insurer makes coverage available
for dependent children of participants or beneficiaries, the plan shall provide
benefits to dependent children placed with participants or beneficiaries for
adoption under the same terms and conditions as apply to the natural, dependent
children of the participants and beneficiaries, irrespective of whether the
adoption has become final. |
(C) |
A
health plan described in division (B) of this section shall not restrict
coverage under the plan of any dependent child adopted by a participant or
beneficiary, or placed with a participant or beneficiary for adoption, solely
on the basis of a pre-existing condition of the child at the time that the
child would otherwise become eligible for coverage under the plan, if the
adoption or placement for adoption occurs while the participant or beneficiary
is eligible for coverage under the plan. |
Effective Date:
06-30-1997 .
(A) |
As used in
this section:
(1) |
"Beneficiary" and "benefits
contract" have the same meanings as in section
3901.38 of the Revised Code.
|
(2) |
"Confinement" means any period
of time during which a person is in the custody or under the supervision of the
department of rehabilitation and correction or is confined in a local jail,
workhouse, or other correctional facility of the type described in section
307.93,
341.14,
341.19,
341.23,
753.02,
753.04,
753.16,
2301.56, or
2947.19 of the Revised Code.
|
(3) |
"Law enforcement officer" has
the same meaning as in section
2901.01 of the Revised Code.
|
|
(B) |
Except as provided
in division (C) of this section, no benefits contract shall limit or exclude
coverage for the reason that the beneficiary is under confinement or is
otherwise under the custody of a law enforcement officer, and a governmental
entity is wholly or primarily responsible for rendering or arranging for the
rendering of health care services for the beneficiary. |
(C) |
A benefits contract may limit or exclude coverage
for health care services rendered to such a beneficiary if the injury or
sickness for which the services were rendered resulted from an action or
omission for which the governmental entity operating the correctional facility,
or the governmental entity with which the law enforcement officer is
affiliated, is liable. |
Effective Date:
09-06-2002 .
As used in sections 3924.61 to
3924.74 of the Revised Code:
(A) |
"Account holder" means the
natural person who opens a medical savings account or on whose behalf a medical
savings account is opened. |
(B) |
"Eligible medical expense" means any expense for a service rendered by a
licensed health care provider or a Christian Science practitioner, or for an
article, device, or drug prescribed by a licensed health care provider or
provided by a Christian Science practitioner, when intended for use in the
mitigation, treatment, or prevention of disease; any amount paid for
transportation to the location at which such a service is rendered; any amount
paid for lodging necessitated by the receipt of care at a nonlocal hospital; or
premiums paid for comprehensive sickness and accident insurance, coverage under
a health care plan of a health insuring corporation organized under Chapter
1751. of the Revised Code, long-term care insurance as defined in section
3923.41 of the Revised Code,
medicare supplemental coverage as defined in section
3923.33 of the Revised Code, or
payments made pursuant to cost sharing agreements under comprehensive sickness
and accident plans. An "eligible medical expense" does not include expenses
otherwise paid or reimbursed, including medical expenses paid or reimbursed
under an automobile or motor vehicle insurance policy, a workers' compensation
insurance policy or plan, or an employer-sponsored health coverage policy,
plan, or contract. |
(C) |
"Dependent" has the same meaning as in section 152 of the "Internal Revenue
Code of 1986," 100 Stat. 2085,
26 U.S.C.A. 1, as amended. |
Effective Date:
06-30-1997 .
(A) |
A medical
savings account may be opened by or on behalf of any natural person, to pay the
person's eligible medical expenses and the eligible medical expenses of that
person's spouse or dependent. A medical savings account may be opened by or on
behalf of a person only if that person participates in a sickness or accident
insurance plan, a plan offered by a health insuring corporation organized under
Chapter 1751. of the Revised Code, or a self-funded, employer-sponsored health
benefit plan established pursuant to the "Employee Retirement Income Security
Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended.
While the medical savings account is open, the account holder shall continue to
participate in such a plan. |
(B) |
A
person who refuses to participate in a policy, plan, or contract of health
coverage that is funded by the person's employer, and who receives additional
monetary compensation by virtue of refusing that coverage, may not open a
medical savings account unless the medical savings account also is sponsored by
the person's employer. |
Effective Date:
06-30-1997 .
The owners of interest in a medical savings account are the
account holder and the account holder's spouse and dependents. No medical
savings account shall be subject to garnishment or attachment.
Effective Date:
06-30-1997 .
(A) |
At the
time a medical savings account is opened, an administrator for the account
shall be designated. If an employer opens an account for an employee, the
employer may designate the administrator. If an account is opened by any person
other than an employer, or if an employer chooses not to designate an
administrator for an account opened for an employee, the account holder shall
designate the administrator. The administrator shall manage the account in a
fiduciary capacity for the benefit of the account holder. |
(B) |
Medical savings accounts shall be administered by
one of the following:
(1) |
A federally or
state-chartered bank, savings and loan association, savings bank, or credit
union; |
(2) |
A trust company
authorized to act as a fiduciary; |
(3) |
An insurer authorized under Title XXXIX
[39] of the Revised Code to engage in the business of sickness and accident
insurance; |
(4) |
A dealer or
salesperson licensed under Chapter 1707. of the Revised Code; |
(5) |
An administrator licensed under Chapter
3959. of the Revised Code; |
(6) |
A
certified public accountant; |
(7) |
An
employer that administers an employee benefit plan subject to regulation under
the "Employee Retirement Income Security Act of 1974," 88 Stat. 829,
29 U.S.C.A. 1001, as amended, or that maintains medical
savings accounts for its employees; |
(8) |
Health insuring corporations organized
under Chapter 1751. of the Revised Code. |
|
(C) |
Each administrator shall send to the account
holder, at least annually, a statement setting forth the balance remaining in
the account holder's account and detailing the activity in the account since
the last statement was issued. Upon an administrator's receipt of a written
request from an account holder for a current statement, the administrator shall
promptly send the statement to the account holder. |
(D) |
When an account holder documents to the
administrator of the account the account holder's payment of, or the account
holder's obligation for, an eligible medical expense for the account holder or
the account holder's spouse or dependents, the administrator shall reimburse
the account holder for, or shall pay for, the eligible medical expense with
funds from the account holder's account, if sufficient funds are available in
the account holder's account. If there are not sufficient funds in the account
to fully reimburse the account holder or pay the expenses, the administrator
shall reimburse the account holder or pay the expenses using whatever funds are
in the account. The reimbursement or payment shall be made within thirty days
of the administrator's receipt of the documentation. At the time of making the
reimbursement or payment, the administrator shall notify the account holder if
the medical expense does not count toward meeting the deductible or other
obligation for the receipt of benefits that is required by the insurer or other
third-party payer providing health coverage to the account holder. The
administrator shall keep a record of the amounts disbursed from the account for
documented eligible medical expenses and of the dates on which the expenses
were incurred. This record shall be made available to any sickness and accident
insurer or other third-party payer providing health coverage to the account
holder, for use by the insurer or third-party payer in determining whether the
account holder has met the deductible or other obligation required for the
receipt of benefits from the insurer or third-party payer. |
(E) |
When an account is opened, the administrator shall
give written notice to the account holder of the date of the last business day
of the administrator's business year. |
Effective Date:
06-30-1997 .
Each employer that opens a medical savings account for an
employee shall inform the employee, in writing at the time the account is
opened, of the federal and state tax status of deposits made to the account.
Effective Date:
10-01-1996 .
(A) |
In
determining Ohio adjusted gross income under Chapter 5747. of the Revised Code,
an account holder may deduct an amount equaling the total of the deposits that
the account holder, the account holder's spouse, or the account holder's
employer made to the account during the taxable year, to the extent that the
funds for the deposits have not otherwise been deducted or excluded in
determining the account holder's federal adjusted gross income. The amount
deducted by an account holder for a taxable year shall not exceed three
thousand dollars. If two married persons each have an account, each spouse may
claim the deduction described in this section, and the amount deducted by each
spouse shall not exceed three thousand dollars, whether the spouses file
returns jointly or separately. |
(B) |
The maximum deduction allowed under division (A)
of this section shall be adjusted annually by the department of taxation to
reflect increases in the consumer price index for all items for all urban
consumers for the midwest region, as determined by the United States bureau of
labor statistics for the period of the first day of January of the preceding
calendar year to the last day of December of the preceding calendar year. The
department of taxation shall determine in September of each tax year the
adjustment that will be effective for the succeeding tax year. The department
shall not make the adjustment in any tax year in which the maximum deduction
resulting from the adjustment is less than the maximum deduction allowed for
the previous tax year. |
(C) |
In
determining Ohio adjusted gross income under Chapter 5747. of the Revised Code,
an account holder may deduct the investment earnings of a medical savings
account from the account holder's federal adjusted gross income, to the extent
that these earnings have been included in the account holder's federal adjusted
gross income. |
(D) |
In determining
Ohio adjusted gross income under Chapter 5747. of the Revised Code, an account
holder shall add to the account holder's federal adjusted gross income an
amount equal to the sum of the amounts described in divisions (D)(1) and (2) of
this section to the extent that those amounts were included in the account
holder's federal adjusted gross income and previously deducted in determining
the account holder's Ohio adjusted gross income. In determining the extent to
which amounts withdrawn from the account shall be included in the account
holder's Ohio adjusted gross income, the tax commissioner shall be guided by
sections 72 and 408 of the Internal Revenue Code governing the determination of
the amount of withdrawals from an individual retirement account to be included
in federal gross income.
(1) |
Amounts
withdrawn from the account during the taxable year used for any purpose other
than to reimburse the account holder for, or to pay, the eligible medical
expenses of the account holder or the account holder's spouse or dependents;
|
(2) |
Investment earnings during the
taxable year on amounts withdrawn from the account that are described in
division (D)(1) of this section. |
|
(E) |
Amounts withdrawn from a medical savings account
to reimburse the account holder for, or to pay, the account holder's eligible
medical expenses, or the eligible medical expenses of the account holder's
spouse or dependents, shall not be included in the account holder's Ohio
adjusted gross income in determining taxes due under Chapter 5747. of the
Revised Code. |
(F) |
If a dependent
of an account holder becomes ineligible to continue to participate in the
account holder's policy, plan, or contract of health coverage, the account
holder may withdraw funds from the account holder's account and use those funds
to pay the premium for the first year of a policy, plan, or contract of health
coverage for the dependent and to pay any deductible for the first year of that
policy, plan, or contract. Funds withdrawn and used for that purpose shall not
be included in the account holder's Ohio adjusted gross income in determining
taxes due under Chapter 5747. of the Revised Code. |
Effective Date:
09-06-2002 .
An account holder may withdraw funds from the account holder's
account at any time, for any purpose. However, the administrator of a medical
savings account shall not disburse funds to an account holder during the year
in which the funds were deposited, except to reimburse the account holder for,
or pay for, a documented eligible medical expense of the account holder or the
account holder's spouse or dependent.
Effective Date:
06-30-1997 .
(A) |
If an
account holder, whose medical savings account has been opened by the account
holder's employer, later ceases to be employed by that employer, the account
holder may, within sixty days of the account holder's final date of employment,
request in writing to the administrator of the account that the administrator
continue to administer the account.
(1) |
If
the administrator agrees to continue to administer the account, funds in the
account may continue to be used to pay the eligible medical expenses of the
account holder and the account holder's spouse and dependents, pursuant to
sections 3924.61 to
3924.74 of the Revised Code. If the account holder later becomes employed by a new employer
that opens a new medical savings account on the account holder's behalf, the
account holder may transfer any funds remaining in the account opened by the
account holder's former employer to the account opened by the account holder's
new employer. For purposes of determining taxes due under Chapter 5747. of the
Revised Code, this transfer of funds shall not be considered a withdrawal of
funds from a medical savings account, nor shall it be considered a deposit to a
medical savings account.
|
(2) |
If the administrator does not agree to continue to administer the account, or
if the account holder requests that the account be closed, the administrator
shall close the account and mail a check or other negotiable instrument in the
amount of the account balance as of that date to the account holder. The amount
distributed shall be included in the account holder's Ohio adjusted gross
income in determining taxes due under Chapter 5747. of the Revised Code.
|
|
(B) |
Within sixty days
of the account holder's final date of employment, the account holder may
transfer any funds remaining in the account opened by the account holder's
former employer to another medical savings account owned by the account holder.
For purposes of determining taxes due under Chapter 5747. of the Revised Code,
this transfer of funds shall not be considered a withdrawal of funds from a
medical savings account, nor shall it be considered a deposit to a medical
savings account. |
(C) |
An
administrator of an account opened by an employer shall not close an account
without the permission of the account holder until at least sixty-one days
after the account holder's final date of employment. The employer shall notify
the administrator of the employee's final date of employment. |
Effective Date:
06-30-1997 .
(A) |
An account
holder may designate a beneficiary or beneficiaries of the account holder's
medical savings account. |
(B) |
Any
funds remaining in a medical savings account upon the death of an account
holder shall be distributed to the decedent's estate and shall be subject to
taxation as part of the decedent's estate under Chapter 5731. of the Revised
Code. |
Effective Date:
10-01-1996 .
An employer making deposits to an employee's medical savings
account on a periodic installment basis may advance to the employee, interest
free, an amount needed to cover the employee's eligible medical expenses when
such expenses exceed the amount then available in the employee's account, if
the employee agrees to repay the advance from future installments or upon the
termination of employment. If such an advance causes the employee's federal
adjusted gross income to be greater than it would have been had the advance not
been made, the amount by which the employee's federal adjusted gross income was
increased may be deducted by the employee in determining the employee's Ohio
adjusted gross income under Chapter 5747. of the Revised Code.
Effective Date:
10-01-1996 .
Funds disbursed from a medical savings account pursuant to a
filing for protection by an account holder under Title 11 of the United States
Code shall not be included in the account holder's Ohio adjusted gross income
for the year of disbursement in determining taxes due under Chapter 5747. of
the Revised Code.
Effective Date:
10-01-1996 .
The superintendent of insurance shall prepare and periodically
revise a brochure that clearly and concisely explains the operation of medical
savings accounts authorized under sections
3924.61 to
3924.74 of the Revised Code, and
that describes how an employer's or individual's use of a medical savings
account may affect the employer's or individual's purchase of policies, plans,
and contracts of health coverage. The superintendent shall make the brochure
available, upon request, to consumers, insurers, and other third-party payers.
The superintendent may adopt rules in accordance with Chapter 119. of the
Revised Code to implement this section.
Effective Date:
10-01-1996 .
(A) |
As used in
this section:
(1) |
"Health care insurer" means
any person legally engaged in the business of providing sickness and accident
insurance contracts in this state, a health insuring corporation organized
under Chapter 1751. of the Revised Code, or any legal entity that is
self-insured and provides health care benefits to its employees or members.
|
(2) |
"Small employer" has the same
meaning as in section
3924.01 of the Revised Code.
|
|
(B) |
(1) |
Subject to division (B)(2) of this section,
nothing in sections
3924.61 to
3924.74 of the Revised Code shall
be construed to limit the rights, privileges, or protections of employees or
small employers under sections
3924.01 to
3924.14 of the Revised Code.
|
(2) |
If any account holder enrolls
or applies to enroll in a policy or contract offered by a health care insurer
providing sickness and accident coverage that is more comprehensive than, and
has a deductible amount that is less than, the coverage and deductible amount
of the policy under which the account holder currently is enrolled, the health
care insurer to which the account holder applies may subject the account holder
to the same medical review, waiting periods, and underwriting requirements to
which the health care insurer generally subjects other enrollees or applicants,
unless the account holder enrolls or applies to enroll during a designated
period of open enrollment. |
|
Effective Date:
06-30-1997 .
The superintendent of insurance may include coordination of
benefits regarding medical savings accounts in the rules on coordination of
benefits adopted under section
3902.14 of the Revised Code.
Effective Date:
10-01-1996 .