5120.57 Reimbursement for health care services rendered to insured offender.

(A) For each offender who is in the custody or under the supervision of the department of rehabilitation and correction, the department may make a determination as to whether the offender is covered under an individual or group sickness and accident insurance policy or an individual or group health insuring corporation policy, contract, or agreement. If the offender has coverage of that type, the department shall familiarize itself with the terms and conditions to receive benefits under the policy, contract, or agreement.

(B) If, pursuant to division (A) of this section, it is determined that the offender is covered under an individual or group sickness and accident insurance policy or an individual or group health insuring corporation policy, contract, or agreement and if, while that coverage is in force, the department renders or arranges for the rendering of health care services to the person in accordance with the terms and conditions of the policy, contract, or agreement, the department or provider of the health care services, as appropriate under the terms and conditions of the policy, contract, or agreement, may submit a claim for payment for the health care services to the appropriate third-party payer. If the policy holder is the offender, the offender shall be required to assign payment of benefits directly to the provider or department, as appropriate. If the policy holder is not the offender, the policy holder shall be asked to voluntarily provide policy information and assign payments directly to the provider or department, as appropriate. The department shall provide the third-party payer with a copy of the assignment of benefits by the policy holder. The policy holder and the third-party payer shall make all arrangements necessary to ensure that payment of any amount due on the claim is made to the provider or department as specified in the assignment. The department shall remain ultimately responsible for payment of all health care services provided to an offender in the custody or under the supervision of the department but shall be the payer of last resort. If the department pays a provider for health care services rendered to an offender and payment subsequently is made for the same services by a third-party payer, the provider shall refund the duplicate payment to the department and, the department shall deposit the refunded payment into the offender financial responsibility fund as described in division (E) of this section.

(C) If, pursuant to division (A) of this section, it is determined that the offender is covered under an individual or group sickness and accident insurance policy or an individual or group health insuring corporation policy, contract, or agreement, the department shall make a determination, after considering security, public safety, and transportation issues, whether or not to render or arrange for the rendering of health care services in accordance with the terms and conditions of the policy, contract, or agreement. The department, based on security, public safety, or transportation concerns or any combination of those concerns, may arrange for the rendering of health care services for the offender at a health care facility, by a provider, or at a health care facility and by a provider not covered by the policy, contract, or agreement and pay the costs of the health care services for the offender.

(D) If the department renders or arranges for the rendering of health care services to an offender and pays for the services, the department reserves the right to seek reimbursement from a third-party payer for the services if it subsequently is determined that the offender was covered under an individual or group sickness and accident insurance policy or an individual or group health insuring corporation policy, contract, or agreement. The department shall submit a claim for reimbursement of the type described in this division within the time frames applicable to claims submitted by a policy holder in accordance with the terms and conditions of the policy, contract, or agreement.

(E) Any payment made to the department pursuant to division (B) of this section shall be deposited into the offender financial responsibility fund created in section 5120.56 of the Revised Code.

(F) If, at the time the department arranges for health care services for an offender and a provider renders those services, the department determines pursuant to division (A) of this section that the offender is covered, or potentially is covered, under an individual or group sickness and accident insurance policy or an individual or group health insuring corporation policy, contract, or agreement, then all of the following apply:

(1) The department is responsible for any cost-sharing, co-payments, or deductibles required under the policy, contract, or agreement.

(2) If the insurer or potential insurer denies the claim for payment, the department remains liable for payment to the provider of services.

(3) If an insurer covers a service, but the amount the insurer pays to the provider is less than the amount negotiated and established by contract then in effect between the department and the provider, the department is liable for reimbursing the difference to the provider.

(G) Nothing in this section requires a third-party payer to reimburse any provider or the department for health care services not covered under the terms or conditions of an individual or group sickness and accident insurance policy, an individual or group health insuring corporation policy, contract, or agreement, or any other policy, contract, or agreement.

Cite as R.C. § 5120.57

History. Effective Date: 09-06-2002