Chapter 3961. DISCOUNT MEDICAL PLANS
As used in sections 3961.01 to
3961.09 of the Revised Code:
| (A) |
| (1) |
"Discount medical plan" means a business
arrangement or contract in which a person, in exchange for fees, dues, charges,
or other consideration, offers access to members to providers of medical
services and the right to receive discounted medical services from those
providers. |
| (2) |
"Discount medical
plan" does not include any of the following:
| (a) |
A plan that does not require a membership
or charge a fee to use the plan's medical card; |
| (b) |
A plan that offers discounts for only
pharmaceutical supplies or prescription drugs, or both, and no other medical
services; |
| (c) |
A plan offered by a
sickness and accident insurer that is regulated under Title XXXIX of the
Revised Code, a health insuring corporation that is regulated under Title XVII
of the Revised Code, or an affiliate of such insurer or corporation if the
insurer, corporation, or affiliate discloses in writing in not less than
twelve-point type on any applications, advertisements, marketing materials, and
brochures describing the plan that the plan is not insurance.
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|
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| (B) |
| (1) |
"Discount medical plan organization" or
"organization" means a person who does business in this state; offers to
members access to providers of medical services and the right to receive
discounted medical services from those providers; contracts with providers,
provider networks, or other discount medical plan organizations to offer
discounted medical services to members; and determines the fee members pay to
participate in the plan. |
| (2) |
"Discount medical plan organization" does not include a sickness and accident
insurer that is regulated under Title XXXIX of the Revised Code or a health
insuring corporation that is regulated under Title XVII of the Revised Code.
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|
| (C) |
"Facility" means
an institution where medical services are performed, including, but not limited
to, a hospital or other licensed inpatient center; ambulatory surgical or
treatment center; skilled nursing center; residential treatment center;
rehabilitation center; diagnostic, laboratory, and imaging center; and any
other health care setting. |
| (D) |
"Health care professional" means a physician or other health care provider who
is licensed, accredited, certified, or otherwise authorized to perform
specified medical services within the scope of the person's license,
accreditation, certification, or other authorization and performs medical
services consistent with the laws of this state. |
| (E) |
| (1) |
"Marketer"
means a person or entity who markets, promotes, sells, or distributes a
discount medical plan, including, but not limited to, a private label entity
that places its name on and markets or distributes a discount medical plan
pursuant to a written agreement with a discount medical plan organization
described under section
3961.03 of the Revised Code.
|
| (2) |
"Marketer" does not mean a
sickness and accident insurer that is regulated under Title XXXIX of the
Revised Code, a health insuring corporation that is regulated under Title XVII
of the Revised Code, or an affiliate of such insurer or corporation if the
insurer, corporation, or affiliate discloses in writing in not less than
twelve-point type on any applications, advertisements, marketing materials, and
brochures describing the plan that the plan is not insurance. |
|
| (F) |
"Medical services" means any
maintenance care of the human body; preventative care for the human body; or
care, service, or treatment of an illness or dysfunction of, or injury to, the
human body. "Medical services" includes, but is not limited to, physician care,
inpatient care, hospital surgical services, emergency services, ambulance
services, dental care services, vision care services, pharmaceutical supplies,
prescription drugs, mental health services, substance abuse services,
chiropractic services, podiatric services, laboratory services, and medical
equipment and supplies. |
| (G) |
"Member" means any individual who pays fees, dues, charges, or other
consideration to a discount medical plan organization for access to providers
of medical services and the right to receive the benefits of a discount medical
plan. |
| (H) |
"Person" means an
individual, corporation, partnership, association, joint venture, joint stock
company, trust, unincorporated organization, any similar entity, or any
combination of these entities. |
| (I) |
"Provider" means any health care professional or
facility that has contracted, directly or indirectly, with a discount medical
plan organization to offer discounted medical services to members. |
| (J) |
"Provider agreement" means any agreement
entered into between a discount medical plan organization and a provider or
provider network to offer discounted medical services to members as described
in section
3961.02 of the Revised Code.
|
| (K) |
"Provider network" means a
person that negotiates, directly or indirectly, with a discount medical plan
organization on behalf of more than one provider to offer discounted medical
services to members. |
Effective Date:
03-23-2007 .
| (A) |
A discount
medical plan organization shall not offer to members, or advertise to
prospective members, discounted medical services unless the services are
offered pursuant to a provider agreement. A discount medical plan organization
may enter into a provider agreement directly with a provider, indirectly
through a provider network to which a provider belongs, or through another
discount medical plan organization that contracts with providers directly or
through a provider network. |
| (B) |
A
provider agreement between a discount medical plan organization and a provider
shall contain all of the following:
| (1) |
A
list of medical services and products offered at a discount; |
| (2) |
The discounted rates for medical services
or a fee schedule that reflects the provider's discounted rates; |
| (3) |
A statement that the provider will not
charge members more than the discounted rates described in division (B)(2) of
this section. |
|
| (C) |
A
provider agreement between a discount medical plan organization and a provider
network shall require the provider network to do all of the following:
| (1) |
Maintain an up-to-date list of the
provider network's contracted providers and supply that list to the discount
medical plan organization on a monthly basis; |
| (2) |
Have a written agreement with each
provider who offers discounted medical services that contains both of the
following:
| (a) |
The items listed in division
(B) of this section; |
| (b) |
A grant of
authority that allows the provider network to contract with discount medical
plan organizations on behalf of the provider. |
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| (D) |
A provider agreement between a discount
medical plan organization and another discount medical plan organization shall
require that the other discount medical plan organization have provider
agreements in place that comply with division (A) of this section and division
(B) or (C) of this section, as applicable. |
| (E) |
A discount medical plan organization shall keep
for the duration of the agreement a copy of each provider agreement into which
the organization has entered. |
Effective Date:
03-23-2007 .
| (A) |
Prior to a
discount medical plan organization allowing a marketer to market, promote,
sell, or distribute a discount medical plan, the organization shall enter into
a written agreement with the marketer. This agreement shall prohibit the
marketer from using or issuing any advertising, marketing materials, brochures,
or discount medical cards without the organization's written approval.
|
| (B) |
A discount medical plan
organization is bound by and responsible for a marketer's activities that are
within the scope of the marketer's agency relationship with the organization.
|
| (C) |
A discount medical plan
organization shall approve in writing all advertisements, marketing materials,
brochures, and discount cards prior to a marketer using these materials to
market, promote, sell, or distribute the discount medical plan. |
Effective Date:
03-23-2007 .
| (A) |
A discount
medical plan organization or marketer shall disclose all of the following
information in writing in not less than twelve-point type on the first content
page of any advertisements, marketing materials, or brochures made available to
the public relating to a discount medical plan and with any enrollment forms:
| (1) |
A statement that the discount medical
plan is not insurance; |
| (2) |
A
statement that the range of discounts for medical services offered under the
discount medical plan will vary depending on the type of provider and medical
services; |
| (3) |
A statement that the
discount medical plan is prohibited from making members' payments to providers
for medical services received under the discount medical plan; |
| (4) |
A statement that the member is obligated
to pay for all discounted medical services received under the discount medical
plan; |
| (5) |
The discount medical plan
organization's toll-free telephone number and internet web site address that a
member or prospective member may use to obtain additional information about and
assistance with the discount medical plan and up-to-date lists of providers
participating in the discount medical plan. |
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| (B) |
If a discount medical plan organization's or
marketer's initial contact with a prospective member is by telephone, the
organization or marketer shall disclose all of the information listed in
division (A) of this section orally in addition to including such disclosures
in the initial written materials provided to the prospective or new member.
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| (C) |
In addition to the
disclosures required under division (A) of this section, a discount medical
plan organization shall provide to each prospective member, at the time of
enrollment, a copy of the terms and conditions of the discount medical plan,
including any limitations or restrictions on the refund of any processing fees
or periodic charges associated with the discount medical plan. A discount
medical plan organization also shall provide each new member a written document
containing the terms and conditions of the discount medical plan and including
all of the following:
| (2) |
Benefits provided under the
discount medical plan; |
| (3) |
Any
processing fees and periodic charges associated with the discount medical plan,
including, but not limited to, if applicable, the procedures for changing the
mode of payment and any accompanying additional charges; |
| (4) |
Any limitations, exclusions, or
exceptions regarding the receipt of discount medical plan benefits; |
| (5) |
Any waiting periods for certain medical
services under the discount medical plan; |
| (6) |
Procedures for obtaining discounts under
the discount medical plan, such as requiring members to contact the discount
medical plan organization to request that the organization make an appointment
with a provider on the member's behalf; |
| (7) |
Cancellation and refund rights described
in section
3961.06 of the Revised Code;
|
| (8) |
Membership renewal,
termination, and cancellation terms and conditions; |
| (9) |
Procedures for adding new family members
to the discount medical plan; |
| (10) |
Procedures for filing complaints under the discount medical plan organization's
complaint system and a statement explaining that, if the member remains
dissatisfied after completing the organization's complaint system, the member
may contact the department of insurance; |
| (11) |
Name, mailing address, and toll-free
telephone number of the discount medical plan organization that a member may
use to make inquiries about the discount medical plan, send cancellation
notices, and file complaints. |
|
| (D) |
A discount medical plan organization shall
maintain on an internet web site page an up-to-date list of the names and
addresses of the providers with which the organization has contracted directly
or indirectly through a provider network. The organization's internet web site
address shall be prominently displayed on all of the organization's
advertisements, marketing materials, brochures, and discount medical plan
cards. |
| (E) |
When a discount
medical plan organization or marketer sells a discount medical plan together
with any other product, the organization or marketer shall do either of the
following:
| (1) |
Provide the charges for each
discount medical plan in writing to the member; |
| (2) |
Reimburse the member for all periodic
charges for the discount medical plan and all periodic charges for any other
product if the member cancels membership in accordance with division (B) of
section 3961.06 of the Revised Code.
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Effective Date:
03-23-2007; 2008
HB562 09-22-2008
.
A discount medical plan organization shall not do any of the
following:
| (A) |
Except when otherwise
permitted in sections
3961.01 to
3961.09 of the Revised Code, as a
disclaimer of any relationship between discount medical plan benefits and
insurance, or in a description of an insurance product connected with a
discount medical plan, use the term "insurance" in the organization's
advertisements, marketing material, brochures, or discount medical plan cards.
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| (B) |
Use in the organization's
advertisements, marketing material, brochures, or discount medical plan cards
the terms "health plan," "coverage," "benefits," "copay," "copayments,"
"deductible," "pre-existing conditions," "guaranteed issue," "premium," "PPO,"
"preferred provider organization," or any other terms in a manner that could
mislead a person into believing that the discount medical plan is health
insurance. |
| (C) |
Make misleading,
deceptive, or fraudulent statements or representations regarding the terms or
benefits of the discount medical plan, including, but not limited to,
statements or representations regarding discounts, range of discounts, or
access to those discounts offered under the discount medical plan. |
| (D) |
Except for hospital services, have
restrictions on access to discount medical plan providers, including, but not
limited to, waiting and notification periods. |
| (E) |
Pay providers fees for medical services or collect
or accept money from a member to pay a provider for medical services received
under the discount medical plan. |
Effective Date:
03-23-2007 .
| (A) |
A discount
medical plan organization shall permit members to cancel membership in a
discount medical plan at any time. |
| (B) |
If a member gives notice of cancellation within
thirty days after the date the member receives the written document described
in division (C) of section
3961.04 of the Revised Code for
the discount medical plan, the discount medical plan organization, within
thirty days of the member giving notice of cancellation, shall fully refund any
fees except for a nominal fee associated with enrollment costs that shall not
exceed thirty dollars. |
| (C) |
A
discount medical plan organization shall not charge or collect a periodic fee
after the member has returned to the organization the member's discount medical
plan card or given the organization notice of cancellation. |
| (D) |
Cancellation of membership in a discount
medical plan occurs when the member gives notice of cancellation to the
discount medical plan organization or marketer by delivering the notice by
hand, depositing the notice in a mailbox if the notice is properly addressed to
the discount medical plan organization or marketer and postage is prepaid, or
sending an electronic message to the discount medical plan organization's or
marketer's electronic message address. |
| (E) |
A discount medical plan organization shall make a
pro rata reimbursement of all periodic fees charged to a member, less nominal
fees associated with enrollment, if a discount medical plan organization
cancels a member's membership for any reason other than the member's failure to
pay fees. |
Effective Date:
03-23-2007 .
| (A) |
The
superintendent of insurance may examine or investigate the business and affairs
of a discount medical plan organization as the superintendent deems appropriate
to protect the interests of the residents of this state. |
| (B) |
When examining or investigating a discount medical
plan organization pursuant to division (A) of this section, the superintendent
may do both of the following:
| (1) |
Order a
discount medical plan organization to produce any records, files, advertising
and solicitation materials, lists of providers with which the organization
contracted, lists of members, provider agreements described in section
3961.02 of the Revised Code,
agreements between a marketer and discount medical plan organization described
in section
3961.03 of the Revised Code, or
other information; |
| (2) |
Take
statements under oath to determine whether a discount medical plan organization
has violated or is violating sections
3961.01 to
3961.08 of the Revised Code or is
acting contrary to the public interest. |
|
| (C) |
| (1) |
All records
and other information concerning a discount medical plan organization obtained
by the superintendent or the superintendent's deputies, examiners, assistants,
agents, or other employees pursuant to division (B) of this section are
confidential and not public records as defined in section
149.43 of the Revised Code unless
the organization is given notice and opportunity for hearing pursuant to
Chapter 119. of the Revised Code concerning the records and other information
obtained under division (B) of this section. If no administrative action is
initiated with respect to a particular matter about which the superintendent
obtained records or other information under division (B) of this section, the
records and other information shall remain confidential for three years after
the file on the matter is closed. Release of the records and other information
after the three-year period shall be governed by section
149.43 of the Revised Code.
|
| (2) |
The records and other
information described in division (C)(1) of this section shall remain
confidential for all purposes except where the superintendent or the
superintendent's deputies, examiners, assistants, agents, or other employees
appropriately take official action regarding the affairs of the discount
medical plan organization or marketer or in connection with actual or potential
criminal proceeding. |
|
| (D) |
Notwithstanding division (C) of this section, the
superintendent may do any of the following:
| (1) |
Share records and other information
obtained pursuant to division (B) of this section with other persons employed
by or acting on behalf of the superintendent; local, state, federal, and
international regulatory and law enforcement agencies; local, state, and
federal prosecutors; and the national association of insurance commissioners
and its affiliates and subsidiaries if the recipient agrees and has authority
to agree to maintain the confidential status of the records or other
information; |
| (2) |
Disclose records
and other information obtained pursuant to division (B) of this section in
furtherance of any regulatory or legal action brought by or on behalf of the
superintendent or this state resulting from the exercise of the
superintendent's official duties. |
|
| (E) |
Notwithstanding divisions (C) and (D) of this
section, the superintendent may authorize the national association of insurance
commissioners and its affiliates and subsidiaries by agreement to share
confidential records and other information obtained pursuant to division (B) of
this section with local, state, federal, and international regulatory and law
enforcement agencies and local, state, and federal prosecutors if the recipient
agrees and has authority to agree to maintain the confidential status of the
records and other information. |
| (F) |
Any applicable privilege or claim of
confidentiality is not waived as a result of sharing or disclosing information
pursuant to division (D)(1) or (E) of this section. |
| (G) |
Employees or agents of the department of insurance
shall not be required by any court in this state to testify in a civil action
if the testimony concerns any matter related to records or other information
considered confidential under this section. |
| (H) |
Nothing in this section shall be construed to
limit the superintendent's powers under section
3901.04 of the Revised Code.
|
Effective Date:
03-23-2007 .
| (A) |
No person
shall fail to comply with sections
3961.01 to
3961.09 of the Revised Code. If
the superintendent of insurance determines that any person has violated
sections 3961.01 to
3961.07 of the Revised Code, the
superintendent may take one or more of the following actions:
| (1) |
Assess a civil penalty in an amount not
to exceed twenty-five thousand dollars per violation if the person knew or
should have known of the violation; |
| (2) |
Assess administrative costs to cover the
expenses incurred in the administrative action, including, but not limited to,
expenses incurred in the investigation and hearing process. Costs collected
under this division shall be paid into the state treasury to the credit of the
department of insurance operating fund created in section
3901.021 of the Revised Code.
|
| (3) |
Order corrective actions in
lieu of or in addition to the other penalties described in this section,
including, but not limited to, suspending civil penalties if a discount medical
plan organization complies with the terms of the corrective action order;
|
| (4) |
Order restitution to members.
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|
| (B) |
Before imposing a
penalty under division (A) of this section, the superintendent shall give a
discount medical plan organization notice and opportunity for hearing as
described in Chapter 119. of the Revised Code to the extent that Chapter 119.
of the Revised Code does not conflict with any of the following service
requirements:
| (1) |
| (a) |
A notice of opportunity for hearing, a
hearing officer's findings and recommendations, or any order issued by the
superintendent under division (A) of this section shall be served by certified
mail, return receipt requested, to the last known address of a discount medical
plan organization. For purposes of division (B) of this section, an
organization's last known address is the address listed on the organization's
disclosures required under section
3961.04 of the Revised Code.
|
| (b) |
If the certified mail envelope
described in division (B)(1)(a) of this section is returned to the
superintendent with an endorsement showing that service was refused or that the
envelope was unclaimed, the notices, findings and recommendations, and orders
described in division (B)(1)(a) of this section and all subsequent notices
required under Chapter 119. of the Revised Code may be served by ordinary mail
to the discount medical plan organization's last known address. The time period
to request an administrative hearing described in Chapter 119. of the Revised
Code shall begin to run from the date the ordinary mailing was sent. A
certificate of mailing shall evidence any mailings sent by ordinary mail
pursuant to this division and shall complete service to the organization unless
the ordinary mail envelope is returned to the superintendent with an
endorsement showing failure of delivery. |
| (c) |
If service by ordinary mail as described
in division (B)(1)(b) of this section fails, the superintendent may publish a
summary of the substantive provisions of the notice, findings and
recommendations, or orders described in division (B)(1)(a) of this section once
a week for three consecutive weeks in a newspaper of general circulation in the
county of the discount medical plan organization's last known address. The
notice shall be considered served on the date of the third publication.
|
| (d) |
Any notice required to be
served under Chapter 119. of the Revised Code also shall be served upon the
party's attorney by ordinary mail if the party's attorney has entered an
appearance in the matter. |
| (e) |
In
lieu of certified or ordinary mail or publication notice as described in
divisions (B)(1)(a), (b), and (c) of this section, the superintendent may
perfect service on a party by personal delivery of the notice by the
superintendent's designee. |
| (f) |
Notices regarding the scheduling of hearings and all other notices not
described in division (B)(1)(a) of this section shall be sent by ordinary mail
to the party and the party's attorney. |
|
| (2) |
A subpoena or subpoena duces tecum from
the superintendent or the superintendent's designee or attorney to a witness
for appearance at a hearing, for the production of documents or other evidence,
or for taking testimony for use at a hearing shall be served by certified mail,
return receipt requested. The subpoenas described in this division shall be
enforced in the manner described in section
119.09 of the Revised Code. Nothing
in this division shall be construed to limit the superintendent's other
statutory powers to issue subpoenas. |
|
| (C) |
| (1) |
If a
violation of sections
3961.01 to
3961.07 of the Revised Code has
caused, is causing, or is about to cause substantial and material harm, the
superintendent may issue a cease-and-desist order requiring a person to cease
and desist from engaging in a violation. |
| (2) |
The superintendent shall, immediately after
issuing an order pursuant to division (C)(1) of this section, serve notice of
the order by certified mail, return receipt requested, or by any other manner
described in division (B) of this section to the person subject to the order
and all other persons involved in the violation. The notice shall specify the
particular act, omission, practice, or transaction that is the subject of the
order and set a date, not more than fifteen days after the date the order was
issued, for a hearing on the continuation or revocation of the order. The
person subject to the order shall comply with the order immediately upon
receiving the order. After an order is issued pursuant to division (C)(1) of
this section, the superintendent may publicize and notify all interested
parties that a cease-and-desist order was issued. |
| (3) |
Upon application by the person subject to the
order and for good cause, the superintendent may continue the hearing date
described in division (C)(2) of this section. Chapter 119. of the Revised Code
applies to the hearing on the order to the extent that the chapter does not
conflict with the procedures described in this section. The superintendent
shall, within fifteen days after objections are submitted concerning the
hearing officer's report and recommendations, issue a final order either
confirming or revoking the cease-and-desist order described in division (C)(1)
of this section. The final order may be appealed as described in section
119.12 of the Revised Code.
|
| (4) |
The remedy described in
division (C) of this section is cumulative and concurrent with other remedies
available under this section. |
|
| (D) |
If the superintendent has reasonable cause to
believe that an order issued pursuant to this section has been violated in
whole or in part, the superintendent may request the attorney general to
commence any appropriate action against the violator. In an action described in
this division, a court may impose any of the following penalties:
| (1) |
A civil penalty of not more than
twenty-five thousand dollars per violation; |
| (4) |
Any other appropriate relief.
|
|
| (E) |
The superintendent
shall deposit any penalties assessed under division (A)(1) or (D) of this
section into the state treasury to the credit of the department of insurance
operating fund created in section
3901.021 of the Revised Code.
|
Effective Date:
03-23-2007 .
The superintendent of insurance may adopt rules in accordance
with Chapter 119. of the Revised Code for purposes of implementing sections
3961.01 to
3961.08 of the Revised Code.
Effective Date:
03-23-2007 .