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The Legislative Service Commission staff updates the Revised Code on an ongoing basis, as it completes its act review of enacted legislation. Updates may be slower during some times of the year, depending on the volume of enacted legislation.

Chapter 3902 | Insurance Policies And Contracts

 
 
 
Section
Section 3902.01 | Purpose of sections.
 

(A) The purpose of sections 3902.01 to 3902.08 of the Revised Code is to establish minimum standards for language used in policies and certificates of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies or certificates of health insuring corporations, delivered or issued for delivery in this state, to facilitate ease of reading by insureds and subscribers.

(B) Sections 3902.01 to 3902.08 of the Revised Code are not intended to increase the risk assumed by insurance companies or other entities subject to sections 3902.01 to 3902.08 of the Revised Code or to supersede their obligation to comply with the substance of other applicable insurance laws. Sections 3902.01 to 3902.08 of the Revised Code are not intended to impede flexibility and innovation in the development of policy forms or content, or to lead to the standardization of policy forms or content.

Section 3902.02 | Insurance policy and contract definitions.
 

As used in sections 3902.01 to 3902.08 of the Revised Code:

(A) "Policy" or "policy form" means any policy, contract, plan or agreement of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies, contracts, certificates, and agreements of health insuring corporations, delivered or issued for delivery in this state by any company subject to sections 3902.01 to 3902.08 of the Revised Code; any certificate, contract or policy issued by a fraternal benefit society; any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this state; and any evidence of coverage issued by a health insuring corporation.

(B) "Company" or "insurer" means any entity authorized to do the business of life insurance and annuities, sickness and accident insurance, credit life insurance, or credit disability insurance; a fraternal benefit society; and a health insuring corporation.

Section 3902.03 | Policies to which sections apply - exceptions - non-English language policies.
 

(A) Sections 3902.01 to 3902.08 of the Revised Code apply to all policies delivered or issued for delivery in this state by any company on or after the date such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code. Sections 3902.01 to 3902.08 of the Revised Code do not apply to:

(1) Any policy that is a security subject to federal jurisdiction;

(2) Any group policy, other than a group credit life insurance policy, or a group credit disability insurance policy. This division does not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this state.

(3) Any group annuity contract that serves as a funding vehicle for pension, profit-sharing, or deferred compensation plans;

(4) Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form approved, or permitted to be issued prior to the dates such forms must be approved pursuant to sections 3902.01 to 3902.08 of the Revised Code;

(5) The renewal of a policy delivered or issued for delivery prior to the dates such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code.

(B) Any non-English language policy delivered or issued for delivery in this state is deemed to be in compliance with division (A)(1) of section 3902.04 of the Revised Code if the insurer certifies that such policy is translated from an English language policy that complies with division (A)(1) of section 3902.04 of the Revised Code.

Section 3902.04 | Requirements for policy forms.
 

(A) No policy forms, except as stated in section 3902.03 of the Revised Code, shall be delivered or issued for delivery in this state on or after the dates such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code, unless:

(1) The text achieves a minimum score of forty on the Flesch reading ease test, or an equivalent score on any other comparable test as provided in division (C) of this section;

(2) It is printed, except for specification pages, schedules, and tables, in not less than ten-point type, one point leaded;

(3) The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text of the policy, or to any endorsements or riders;

(4) It contains a table of contents or an index of the principal sections of the policy, if the policy has more than three thousand words printed on three or fewer pages of text, or if the policy has more than three pages regardless of the number of words.

(B) For the purposes of this section, a Flesch reading ease test score shall be measured by the following method:

(1) For policy forms containing ten thousand words or less of text, the entire form shall be analyzed. For policy forms containing more than ten thousand words, the readability of two two-hundred word samples per page may be analyzed instead of the entire form. The samples shall be separated by at least twenty printed lines.

(2) The number of words and sentences in the text shall be counted and the total number of words divided by the total number of sentences. The figure obtained shall be multiplied by a factor of one and fifteen thousandths.

(3) The total number of syllables shall be counted and divided by the total number of words. The figure obtained shall be multiplied by a factor of eighty-four and six-tenths.

(4) The sum of the figures computed under divisions (B)(2) and (3) of this section subtracted from two hundred six and eight hundred thirty-five thousandths equals the Flesch reading ease score for the policy form.

(5) For purposes of divisions (B)(2), (3), and (4) of this section, the following procedures shall be used:

(a) A contraction, hyphenated word, or numbers and letters, when separated by spaces, shall be counted as one word.

(b) A unit of words ending with a period, semicolon, or colon, but excluding headings and captions, shall be counted as a sentence.

(c) A syllable means a unit of spoken language consisting of one or more letters of a word as divided by an accepted dictionary. Where the dictionary shows two or more equally acceptable pronunciations of a word, the pronunciation containing fewer syllables may be used.

(6) As used in this section, "text" includes all printed matter, except the following:

(a) The name and address of the insurer, the name, number, or title of the policy, the table of contents or index, captions and subcaptions, specification pages, schedules, or tables;

(b) Any policy language that is drafted to conform to the requirements of any federal law, regulation, or agency interpretation; any policy language required by any collectively bargained agreement; any medical terminology; any words that are defined in the policy; and any policy language required by law or regulation; provided however, the insurer identifies the language or terminology excepted by this paragraph and certifies, in writing, that the language or terminology is entitled to be excepted by this paragraph.

(C) Any other reading test may be approved by the superintendent of insurance for use as an alternative to the Flesch reading ease test if it is comparable in result to the Flesch reading ease test.

(D) Every filing subject to this section shall be accompanied by a certificate signed by an officer of the insurer stating that the filing meets the minimum reading ease score on the test used, or stating that the score is lower than the minimum required but should be approved in accordance with section 3902.06 of the Revised Code. To confirm the accuracy of any certification, the superintendent may require the submission of further information to verify the certification in question.

(E) At the option of the insurer, riders, endorsements, applications, and other forms made a part of the policy may be scored as separate forms or as part of the policy with which they may be used.

Section 3902.05 | Construction.
 

Nothing in sections 3902.01 to 3902.08 of the Revised Code shall be construed to negate any law of this state permitting the issuance of any policy form after it has been on file for the time period specified.

Section 3902.06 | Superintendent may authorize lower test score.
 

The superintendent of insurance may authorize a lower score than the Flesch reading ease score required in division (A)(1) of section 3902.04 of the Revised Code whenever, in his discretion, he finds that a lower score meets any of the following conditions:

(A) The lower score will provide a more accurate reflection of the readability of a policy form;

(B) The lower score is warranted by the nature of a particular policy form or type or class of policy forms;

(C) The lower score is caused by certain policy language that is drafted to conform to the requirements of any law, rule, or agency interpretation.

Section 3902.07 | Approval of policy form notwithstanding provisions of other laws.
 

A policy form meeting the requirements of section 3902.04 of the Revised Code shall be approved notwithstanding the provisions of any other laws that specify the content of policies, if the policy form provides the policyholders and claimants protection not less favorable than they would be entitled to under such laws.

Section 3902.08 | Policy forms compliance date.
 

(A) Except as provided in section 3902.03 of the Revised Code, sections 3902.01 to 3902.08 of the Revised Code apply to all policy forms filed on or after January 9, 1983. No policy form shall be delivered or issued for delivery in this state on or after January 9, 1985 unless approved by the superintendent of insurance, or permitted to be issued, pursuant to sections 3902.01 to 3902.08 of the Revised Code. Any policy form that has been approved or permitted to be issued prior to January 9, 1985, and that meets the standards set by sections 3902.01 to 3902.08 of the Revised Code need not be refiled for approval, but may continue to be lawfully delivered or issued for delivery in this state upon the filing with the superintendent of a list of such forms identified by form number and accompanied by a certificate as to each such form in the manner provided in division (D) of section 3902.04 of the Revised Code.

(B) The superintendent may, in the superintendent's discretion, extend the dates in division (A) of this section.

Section 3902.11 | Coordination of benefits definitions.
 

As used in sections 3902.11 to 3902.14 of the Revised Code:

(A) "Beneficiary" and "third-party payer" have the same meanings as in section 3901.38 of the Revised Code.

(B) "Plan of health coverage" means any of the following if the policy, contract, or agreement contains a coordination of benefits provision:

(1) An individual or group sickness and accident insurance policy, which policy provides for hospital, dental, surgical, or medical services;

(2) Any individual or group contract of a health insuring corporation, which contract provides for hospital, dental, surgical, or medical services;

(3) Any other individual or group policy or agreement under which a third-party payer provides for hospital, dental, surgical, or medical services.

(C) "Provider" means a hospital, nursing home, physician, podiatrist, dentist, pharmacist, chiropractor, or other licensed health care provider entitled to reimbursement by a third-party payer for services rendered to a beneficiary under a benefits contract.

Section 3902.12 | Primary or secondary health coverage.
 

When a plan of health coverage is primary, its benefits are paid without regard to the benefits of another plan. When a plan of health coverage is secondary, its benefits are determined by taking into consideration the payments made or to be made by another plan. When there are more than two plans, a plan may be primary as to one and may be secondary as to another.

Section 3902.13 | Order of benefits for health coverage plan.
 

(A) A plan of health coverage determines its order of benefits using the first of the following that applies:

(1) A plan that does not coordinate with other plans is always the primary plan.

(2) The benefits of the plan that covers a person as an employee, member, insured, or subscriber, other than a dependent, is the primary plan. The plan that covers the person as a dependent is the secondary plan.

(3) When more than one plan covers the same child as a dependent of different parents who are not divorced or separated, the primary plan is the plan of the parent whose birthday falls earlier in the year. The secondary plan is the plan of the parent whose birthday falls later in the year. If both parents have the same birthday, the benefits of the plan that covered the parent the longer is the primary plan. The plan that covered the parent the shorter time is the secondary plan. If the other plan's provision for coordination of benefits does not include the rule contained in this division because it is not subject to regulation under this division, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule of the other plan will determine the order of benefits.

(4)(a) Except as provided in division (A)(4)(b) of this section, if more than one plan covers a person as a dependent child of divorced or separated parents, benefits for the child are determined in the following order:

(i) The plan of the parent who is the residential parent and legal custodian of the child;

(ii) The plan of the spouse of the parent who is the residential parent and legal custodian of the child;

(iii) The plan of the parent who is not the residential parent and legal custodian of the child.

(b) If the specific terms of a court decree state that one parent is responsible for the health care expenses of the child, the plan of that parent is the primary plan. A parent responsible for the health care pursuant to a court decree must notify the insurer or health insuring corporation of the terms of the decree.

(5) The primary plan is the plan that covers a person as an employee who is neither laid off or retired, or that employee's dependent. The secondary plan is the plan that covers that person as a laid-off or retired employee, or that employee's dependent.

(6) If none of the rules in divisions (A)(1), (2), (3), (4), and (5) of this section determines the order of benefits, the primary plan is the plan that covered an employee, member, insured, or subscriber longer. The secondary plan is the plan that covered that person the shorter time.

(B) When a plan of health coverage is determined to be a secondary plan it acts to provide benefits in excess of those provided by the primary plan.

(C) The secondary plan shall not be required to make payment in an amount which exceeds the amount it would have paid if it were the primary plan, but in no event, when combined with the amount paid by the primary plan, shall payments by the secondary plan exceed one hundred per cent of expenses allowable under the provisions of the applicable policies and contracts.

(D) A third-party payer may require a beneficiary to file a claim with the primary plan before it determines the amount of its payment obligation, if any, with regard to that claim.

(E) Nothing in this section shall be construed to require a plan to make a payment until it determines whether it is the primary plan or the secondary plan and what benefits are payable under the primary plan.

(F) A plan may obtain any facts and information necessary to apply the provisions of this section, or supply this information to any other third-party payer or provider, or any agent of such third-party payer or provider, without the consent of the beneficiary. Each person claiming benefits under the plan shall provide any information necessary to apply the provisions of this section.

(G) If the amount of payments made by any plan is more than should have been paid, the plan may recover the excess from whichever party received the excess payment.

(H) No third-party payer shall administer a plan of health coverage delivered, issued for delivery, or renewed on or after June 29, 1988, unless such plan complies with this section.

(I)(1) A third-party payer that is subject to this section and has reason to believe payment has been made by another third-party payer for the same service may request from that third-party payer, and shall be provided by the third-party payer, such data as necessary to determine whether duplicate payment has been made.

(2) A third-party payer that meets the criteria of a secondary payer in accordance with this section may seek repayment of any duplicate payment that may have been made from the person to whom it made payment. If the person who received the duplicate payment is a provider, absent a finding of a court of competent jurisdiction that the provider has engaged in civil or criminal fraudulent activities, the request for the return of any duplicate payment shall be made within three years after the close of the provider's fiscal year in which the duplicate payment has been made.

(J) Nothing in this section shall be construed to affect the prohibition of section 3923.37 of the Revised Code.

(K)(1) No third-party payer shall knowingly fail to comply with the order of benefits as set forth in division (A) of this section.

(2) No primary plan shall direct or encourage an insured to use the benefits of a secondary plan that results in a reduction of payment by such primary plan.

(L) Whoever violates division (K) of this section is deemed to have engaged in an unfair and deceptive insurance act or practice under sections 3901.19 to 3901.26 of the Revised Code, and is subject to proceedings pursuant to those sections.

Section 3902.14 | Rules.
 

The superintendent of insurance may, pursuant to Chapter 119. of the Revised Code, adopt rules to carry out the purposes of sections 3902.11 to 3902.14 of the Revised Code.

Section 3902.21 | Standard claim form definitions.
 

As used in sections 3902.22 and 3902.23 of the Revised Code, "third-party payer" has the same meaning as in section 3901.38 of the Revised Code.

Section 3902.22 | Superintendent to develop standard claim form.
 

The superintendent of insurance shall develop a standard claim form to be used by all third-party payers and providers for reimbursement of health care services and supplies, taking into consideration the special needs of, and differences between, third-party payers. The standard claim form shall be prescribed in rules the superintendent shall adopt in accordance with Chapter 119. of the Revised Code. The superintendent may prescribe a separate claim form for each third-party payer. If a national standard claim form is established by the sickness and accident insurance industry, the superintendent shall amend the rules to comply with the national standards. The standard claim form shall include a method to specify the national provider identifiers assigned to the physical therapists and other health care professionals rendering services designated as physical therapy, as required under section 4755.56 of the Revised Code.

Section 3902.23 | Use of form mandatory.
 

Beginning one hundred eighty days after rules adopted under section 3902.22 of the Revised Code take effect, no third-party payer shall fail to use the standard claim form prescribed in those rules.

Section 3902.30 | Coverage for telemedicine services.
 

(A) As used in this section:

(1) "Health benefit plan," "health care services," and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.

(2) "Health care professional" means any of the following:

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

(b) A physician assistant licensed under Chapter 4731. of the Revised Code;

(c) An advanced practice registered nurse as defined in section 4723.01 of the Revised Code.

(3) "In-person health care services" means health care services delivered by a health care professional through the use of any communication method where the professional and patient are simultaneously present in the same geographic location.

(4) "Recipient" means a patient receiving health care services or a health care professional with whom the provider of health care services is consulting regarding the patient.

(5) "Telemedicine services" means a mode of providing health care services through synchronous or asynchronous information and communication technology by a health care professional, within the professional's scope of practice, who is located at a site other than the site where the recipient is located.

(B)(1) A health benefit plan shall provide coverage for telemedicine services on the same basis and to the same extent that the plan provides coverage for the provision of in-person health care services.

(2) A health benefit plan shall not exclude coverage for a service solely because it is provided as a telemedicine service.

(C) A health benefit plan shall not impose any annual or lifetime benefit maximum in relation to telemedicine services other than such a benefit maximum imposed on all benefits offered under the plan.

(D) This section shall not be construed as doing any of the following:

(1) Prohibiting a health benefit plan from assessing cost-sharing requirements to a covered individual for telemedicine services, provided that such cost-sharing requirements for telemedicine services are not greater than those for comparable in-person health care services;

(2) Requiring a health plan issuer to reimburse a health care professional for any costs or fees associated with the provision of telemedicine services that would be in addition to or greater than the standard reimbursement for comparable in-person health care services;

(3) Requiring a health plan issuer to reimburse a telemedicine provider for telemedicine services at the same rate as in-person services.

(E) This section applies to all health benefit plans issued, offered, or renewed on or after January 1, 2021.

Section 3902.31 | Void contracts.
 

(A) As used in this section:

(1) "Pay in full" means paying for a health service in its entirety without cost-sharing on the part of a third-party payer. "Pay in full" includes payment made under a deductible requirement.

(2) "Third-party payer" and "provider" have the same meanings as in section 3901.38 of the Revised Code.

(B)(1) Subject to division (C) of this section, a provision in a contract entered into between a third-party payer and a provider is void and against public policy if it does either of the following:

(a) Establishes a minimum amount that the provider is required to charge an individual for a health service when that individual pays in full for the service;

(b) Prohibits a provider from advertising the provider's rates for a service.

(2) Division (B)(1)(b) of this section shall not be construed as prohibiting a provision in a contract between a provider and a third-party payer that prohibits a provider from disclosing or advertising contractually agreed upon reimbursement rates for providers.

(C)(1) This section shall apply to all new contracts between a third-party payer and a provider entered into on or after the effective date of this section.

(2) For existing contracts, this section shall apply on the earlier of either of the following:

(a) Three years after the effective date of this section;

(b) The expiration date of the contract or renewal of the contract.

Section 3902.36 | Compliance with federal mental health and addiction parity laws.
 

(A) As used in this section:

(1) "Health benefit plan" and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.

(2) "Mental Health Parity and Addiction Equity Act" means the federal "Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008," Pub. L. No. 110-343, as amended, and any federal regulations implementing that act.

(B) Each health plan issuer and health benefit plan subject to the Mental Health Parity and Addiction Equity Act shall comply with all applicable requirements of that act. The requirements of this section do not apply to a health plan issuer or a health benefit plan that is exempt from the requirements of that act by operation of law or other federal guidance.

(C) The superintendent of insurance shall implement and enforce all applicable provisions of the Mental Health Parity and Addiction Equity Act and shall do all of the following:

(1) Proactively ensure compliance by health plan issuers;

(2) Evaluate all consumer and provider complaints regarding mental health and substance use disorder benefits for possible parity violations;

(3) Adopt rules in accordance with Chapter 119. of the Revised Code as necessary to do both of the following:

(a) Effectuate any provisions of the Mental Health Parity and Addiction Equity Act that relate to the business of insurance;

(b) Enforce, monitor compliance with, and ensure continued compliance with this section.

(D) Nothing in this section is subject to the requirements of section 3901.71 of the Revised Code.

Section 3902.50 | Definitions for R.C. 3902.50 to 3902.72.
 

As used in sections 3902.50 to 3902.72 of the Revised Code:

(A) "Ambulance" has the same meaning as in section 4765.01 of the Revised Code.

(B) "Clinical laboratory services" has the same meaning as in section 4731.65 of the Revised Code.

(C) "Cost sharing" means the cost to a covered person under a health benefit plan according to any copayment, coinsurance, deductible, or other out-of-pocket expense requirement.

(D) "Covered" or "coverage" means the provision of benefits related to health care services to a covered person in accordance with a health benefit plan.

(E) "Covered person," "health benefit plan," "health care services," and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.

(F) "Drug" has the same meaning as in section 4729.01 of the Revised Code.

(G) "Emergency facility" has the same meaning as in section 3701.74 of the Revised Code.

(H) "Emergency services" means all of the following as described in 42 U.S.C. 1395dd:

(1) Medical screening examinations undertaken to determine whether an emergency medical condition exists;

(2) Treatment necessary to stabilize an emergency medical condition;

(3) Appropriate transfers undertaken prior to an emergency medical condition being stabilized.

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

(J) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code.

(K) "Prior authorization requirement" means any practice implemented by a health plan issuer in which coverage of a health care service, device, or drug is dependent upon a covered person or a provider obtaining approval from the health plan issuer prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization requirement" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.

(L) "Unanticipated out-of-network care" means health care services, including clinical laboratory services, that are covered under a health benefit plan and that are provided by an out-of-network provider when either of the following conditions applies:

(1) The covered person did not have the ability to request such services from an in-network provider.

(2) The services provided were emergency services.

Last updated September 9, 2021 at 5:16 PM

Section 3902.51 | Out-of-network care reimbursement requirement, negotiations.
 

(A)(1)(a) A health plan issuer shall reimburse an out-of-network provider for unanticipated out-of-network care when both of the following apply:

(i) The services are provided to a covered person at an in-network facility.

(ii) The services would be covered if provided by an in-network provider.

(b) A health plan issuer shall reimburse both of the following for emergency services provided to a covered person at an out-of-network emergency facility:

(i) An out-of-network provider;

(ii) The out-of-network emergency facility.

(c) A health plan issuer shall reimburse both of the following for emergency services provided to a covered person by an out-of-network ambulance:

(i) An out-of-network provider;

(ii) The out-of-network ambulance.

(2) In the case of clinical laboratory services provided in connection with care described in division (A)(1) of this section, a health plan issuer shall reimburse any out-of-network provider and any out-of-network facility that provided the clinical laboratory services.

(3) For purposes of sections 3902.50 to 3902.54 of the Revised Code:

(a) In the request for reimbursement, the provider, facility, emergency facility, or ambulance shall include the proper billing code for the service for which reimbursement is requested.

(b) The health plan issuer shall send the provider, facility, emergency facility, or ambulance its intended reimbursement as described in division (B)(1) of this section.

(c) Within the period of time specified by the superintendent of insurance in rule, the provider, facility, emergency facility, or ambulance shall either notify the health plan issuer of its acceptance of the reimbursement or seek to negotiate reimbursement under division (B)(2) of this section. Failure to timely notify the issuer of an intent to negotiate shall be considered acceptance of the issuer's reimbursement.

(B)(1) Unless the provider, facility, emergency facility, or ambulance wishes to negotiate reimbursement under division (B)(2) of this section, the reimbursement required to be paid to the provider, facility, emergency facility, or ambulance under division (A) of this section shall be the greatest of the following amounts:

(a) The amount negotiated with in-network providers, facilities, emergency facilities, or ambulances for the service in question in that geographic region under that health benefit plan, excluding any in-network cost sharing imposed under the health benefit plan. If there is more than one such amount, the relevant amount shall be the median of those amounts, excluding any in-network cost sharing imposed under the health benefit plan. In determining the median amount, the amount negotiated with each in-network provider, facility, emergency facility, or ambulance shall be treated as a separate amount even if the same amount is paid to more than one provider. If there is no per-service amount, such as under a capitation or similar payment arrangement, the amount described in division (B)(1)(a) of this section shall be disregarded.

(b) The amount for the service calculated using the same method the health benefit plan generally uses to determine payments for out-of-network health care services, such as the usual, customary, and reasonable amount, excluding any in-network cost sharing imposed under the health benefit plan. This amount shall be determined with reduction for cost sharing that generally applies under the health benefit plan with respect to out-of-network health care services.

(c) The amount that would be paid under the medicare program, part A or part B of Title XVIII of the Social Security Act, 42 U.S.C. 1395, as amended, for the service in question, excluding any in-network cost sharing imposed under the health benefit plan.

(2) In lieu of accepting reimbursement under division (B)(1) of this section, a provider, facility, emergency facility, or ambulance may notify the health plan issuer that the provider, facility, emergency facility, or ambulance wishes to negotiate reimbursement. Upon receipt of such notice, the health plan issuer shall attempt a good faith negotiation with the provider, facility, emergency facility, or ambulance.

(C)(1) For unanticipated out-of-network care provided at an in-network facility in this state, a provider shall not bill a covered person for the difference between the health plan issuer's reimbursement and the provider's charge for the services.

(2) For emergency services provided at an out-of-network emergency facility in this state, neither the emergency facility nor an out-of-network provider shall bill a covered person for the difference between the health plan issuer's reimbursement and the emergency facility's or the provider's charge for the services.

(3) For emergency services provided by an out-of-network ambulance in this state, neither the ambulance nor an out-of-network provider shall bill a covered person for the difference between the health plan issuer's reimbursement and the ambulance's or provider's charge for the services.

(4) In the case of clinical laboratory services provided in this state in connection with care described in division (A)(1) of this section, no out-of-network provider or out-of-network facility shall bill a covered person for the difference between the health plan issuer's reimbursement and the provider's or facility's charge for the clinical laboratory services.

(D) A health plan issuer shall not require cost sharing for any service described in division (A) of this section from the covered person at a rate higher than if the services were provided in network.

(E) For health care services, other than those described in division (A) of this section, that are covered under a health benefit plan but are provided to a covered person by an out-of-network provider at an in-network facility, both of the following apply:

(1) For services provided in this state, the provider shall not bill the covered person for the difference between the health plan issuer's out-of-network reimbursement and the provider's charge for the services unless all of the following conditions are met:

(a) The provider informs the covered person that the provider is not in the covered person's health benefit plan network.

(b) The provider provides to the covered person a good faith estimate of the cost of the services, including the provider's charge, the estimated reimbursement by the health plan issuer, and the covered person's responsibility. The estimate shall contain a disclaimer that the covered person is not required to obtain the health care service at that location or from that provider.

(c) The covered person affirmatively consents to receive the services.

(2) The health plan issuer may reimburse the provider at either the in-network or out-of-network rate as described in the covered person's health benefit plan.

(F) Nothing in this section is subject to section 3901.71 of the Revised Code.

Section 3902.52 | Out-of-network care arbitration.
 

(A)(1) If a negotiation undertaken pursuant to division (B)(2) of section 3902.51 of the Revised Code has not successfully concluded within thirty days, or if both parties agree that they are at an impasse, the provider, facility, emergency facility, or ambulance may send a request for arbitration to the superintendent of insurance and shall notify the health plan issuer of its request. To be eligible for arbitration, both of the following must apply:

(a) The service in question was provided not more than one year prior to the request.

(b) The billed amount exceeds seven hundred fifty dollars, except as provided in division (A)(2)(b) of this section.

(2)(a) In seeking arbitration, a provider, facility, emergency facility, or ambulance may bundle up to fifteen claims with respect to the same health benefit plan that involve the same or similar services provided under similar circumstances. Any bundled claims shall be for services using the same coding set and providers of the same license type.

(b) A claim that is bundled with other claims may be seven hundred fifty dollars or less so long as the sum of the bundled claims is greater than seven hundred fifty dollars.

(B) If arbitration is requested under division (A) of this section, each party shall submit its final offer to the arbitrator. The parties also may submit, and the arbitrator may consider, evidence that relates to the factors described in division (C) of this section if the evidence is in a form that can be verified and authenticated.

(C) An arbitrator shall consider all of the following factors in rendering a decision:

(1) The in-network rates that other health benefit plans reimburse, and have reimbursed, that particular provider, facility, emergency facility, or ambulance for the service in question, including the factors that went into those rates such as guaranteed patient volume or availability of providers in the provider's, facility's, emergency facility's, or ambulance's geographic area;

(2) The in-network rates that the health benefit plan reimburses, or has reimbursed, other providers, facilities, emergency facilities, or ambulances for the service in question in that particular geographic area, including the factors that went into those rates such as guaranteed patient volume or availability of providers in that particular geographic area;

(3) If the health plan issuer and the provider, facility, emergency facility, or ambulance have had a contractual relationship in the previous six years, any in-network reimbursement rates previously agreed upon between the issuer and the provider, facility, emergency facility, or ambulance;

(4) The results of, or any documents submitted in the course of, a previous arbitration between the parties conducted under this section that the arbitrator considers relevant in rendering a decision.

(D) After considering the evidence submitted by the parties pursuant to division (B) of this section and the criteria described in division (C) of this section, the arbitrator shall issue a decision that awards the final offer of either party that best reflects a fair reimbursement rate based upon the factors considered under division (C) of this section.

(E) The nonprevailing party shall pay seventy per cent of the arbitrator's fees, and the prevailing party shall pay thirty per cent.

(F) A final arbitration decision shall be binding except as to other remedies available at law.

(G) Documents and other evidence submitted to an arbitrator under this section are confidential, not public records for the purposes of section 149.43 of the Revised Code, and shall not be released except as authorized pursuant to this division. If release of the evidence is required pursuant to a court order, the arbitrator shall release the evidence pursuant to the court order but shall redact from the evidence released information that constitutes intellectual property, trade secrets, or information requiring redaction pursuant to a rule adopted by the superintendent of insurance.

(H) As used in this section, "provider" includes a practice of providers to the extent permitted by rules adopted by the superintendent of insurance under division (D) of section 3902.54 of the Revised Code including but not limited to rules adopted regarding the maximum number of providers in a practice.

Section 3902.53 | Out-of-network care rules, prompt pay requirements, violations.
 

(A)(1) Except as provided in division (A)(2) of this section, sections 3901.38 to 3901.3814 of the Revised Code shall not apply with respect to a claim during a period of negotiation under section 3902.51 of the Revised Code or a period of arbitration under section 3902.52 of the Revised Code. Sections 3901.38 to 3901.3814 of the Revised Code shall apply upon the completion of a successful negotiation or upon the rendering of an arbitration decision.

(2) The superintendent of insurance may adopt rules pursuant to division (D) of section 3902.54 of the Revised Code specifying situations in which sections 3901.38 to 3901.3814 of the Revised Code apply during periods of negotiation under section 3902.51 of the Revised Code.

(B) A pattern of continuous or repeated violations of section 3902.51 or 3902.52 of the Revised Code by a health plan issuer is an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

(C) A provider who violates section 3902.51 or 3902.52 of the Revised Code shall be subject to professional discipline under Title XLVII of the Revised Code as applicable.

Section 3902.54 | Out-of-network care arbitrator requirements.
 

(A)(1) The superintendent of insurance shall contract with a single arbitration entity to perform all arbitrations described in section 3902.52 of the Revised Code. The superintendent shall ensure that the arbitration entity, any arbitrators the arbitration entity designates to conduct an arbitration, and any officer, director, or employee of the arbitration entity do not have any material, professional, familial, or financial connection with any of the following:

(a) The health plan issuer involved in a dispute;

(b) An officer, director, or employee of the health plan issuer;

(c) A provider, facility, emergency facility, ambulance, medical group, or independent practice organization involved with the service in question;

(d) The development or manufacture of any principal drug, device, procedure, or other therapy in dispute;

(e) The covered person who received the service that is the subject of a dispute or the covered person's immediate family.

(2) The superintendent shall require the arbitration entity to do all of the following:

(a) Utilize arbitrators who are knowledgeable and experienced in applicable principles of contract and insurance law;

(b) Ensure that the arbitrators have access to appropriate specialists including certified coding specialists, physicians, nurses, other clinicians, and health insurance experts as necessary to render a determination;

(c) Utilize a secure electronic portal for the submission, processing, and management of arbitration applications;

(d) Perform all arbitrations under section 3902.52 of the Revised Code on a flat fee basis.

(B) In selecting the arbitration entity with which to contract, the superintendent shall at minimum require a prospective arbitration entity to submit to the superintendent a disclosure containing all of the following accompanied by an application fee prescribed by the superintendent:

(1) The name, telephone number, and address of the applicant;

(2) If the applicant has issued any outstanding shares that are listed on a national securities exchange or are regularly quoted in an over-the-counter market by one or more members of a national or affiliated securities association, the name of each person holding more than five per cent stock or call or put options in the applicant;

(3) The name of each person holding bonds or notes issued by the applicant totaling over one hundred thousand dollars;

(4) The name of each entity the applicant controls and the nature and extent of such control, including the nature of the controlled entity's business;

(5) The name of each entity in which the applicant has more than five per cent ownership interest, including the nature of the entity's business;

(6) The name, contact information, and work history of each director, officer, and executive and any current or previous relationship each of those persons has or had with a health plan issuer, provider, facility, emergency facility, medical group, or independent practice organization;

(7) The percentage of revenue the arbitration entity receives from its arbitration services;

(8) A description of the applicant's arbitration process, including information about how the applicant will meet the superintendent's standards and how the applicant will avoid conflicts of interest;

(9) The fee the applicant would charge for an arbitration.

(C)(1) The superintendent shall require the contracted arbitration entity to submit to the superintendent on an annual basis the disclosure described in division (B) of this section.

(2) The superintendent shall require the contracted arbitration entity to submit to the superintendent on an annual basis, and the superintendent shall issue, a report containing all of the following:

(a) The number of arbitrations conducted under section 3902.52 of the Revised Code;

(b) The provider type, whether individual, practice, facility, emergency facility, or ambulance, that engaged in the arbitrations;

(c) The specialty of the provider engaging in the arbitrations;

(d) The out-of-network situation;

(e) The percentage of times the arbitrator decides in favor of the health plan issuer versus the provider, facility, emergency facility, or ambulance.

(D) The superintendent of insurance shall adopt rules pursuant to Chapter 119. of the Revised Code as necessary to implement sections 3902.50 to 3902.54 of the Revised Code.

Rules adopted by the superintendent may relate to the definitions of "provider," "facility," "emergency facility," and "ambulance." The requirements of section 121.95 of the Revised Code do not apply to rules adopted in accordance with this division.

Section 3902.60 | Advanced cancer fail first drug coverage definitions.
 

As used in sections 3902.60 and 3902.61 of the Revised Code:

(A) "Associated conditions" means the symptoms or side effects of stage four advanced metastatic cancer, or the treatment thereof, which would, in the judgment of the health care practitioner in question, jeopardize the health of a covered individual if left untreated.

(B) "Stage four advanced metastatic cancer" means a cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.

Last updated August 31, 2021 at 4:37 PM

Section 3902.61 | Advanced cancer fail first drug coverage prohibitions.
 

(A) Notwithstanding section 3901.71 and sections 3901.831 to 3901.833 of the Revised Code, a health benefit plan issued, delivered, or renewed in this state on or after the effective date of this section that directly or indirectly covers the treatment of stage four advanced metastatic cancer shall not make coverage of a drug that is prescribed to treat such cancer or associated conditions dependent upon a covered person demonstrating either of the following:

(1) Failure to successfully respond to a different drug;

(2) A history of failing to respond to a different drug or drugs.

(B) Division (A) of this section applies only to uses of such drug or drugs that are consistent with either of the following:

(1) An indication approved by, or described in, as applicable, either of the following for the treatment of stage four advanced metastatic cancer:

(a) The United States food and drug administration;

(b) The national comprehensive cancer network drugs and biologics compendium.

(2) The best practices for the treatment of stage four advanced metastatic cancer, as supported by peer-reviewed medical literature.

(C) A violation of this section is an unfair and deceptive practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

Section 3902.70 | Health plan issuer contracts with 340B program participants definitions.
 

As used in this section and section 3902.71 of the Revised Code:

(A) "340B covered entity" and "third-party administrator" have the same meanings as in section 5167.01 of the Revised Code.

(B) "Terminal distributor of dangerous drugs" has the same meaning as in section 4729.01 of the Revised Code.

Last updated August 31, 2021 at 4:37 PM

Section 3902.71 | Health plan issuer contracts with 340B program participants.
 

(A) On and after the effective date of this section , a contract entered into between a health plan issuer, including a third-party administrator, and a 340B covered entity shall not contain any of the following provisions:

(1) A reimbursement rate for a prescription drug that is less than the national average drug acquisition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. 1395w-3a(c)(6)(B);

(2) A dispensing fee reimbursement amount that is less than the reimbursement amount provided to a terminal distributor of dangerous drugs under section 5164.753 of the Revised Code;

(3) A fee that is not imposed on a health care provider that is not a 340B covered entity;

(4) A fee amount that exceeds the fee amount for a health care provider that is not a 340B covered entity.

(B) No health plan issuer or third-party administrator making payments pursuant to a health benefit plan shall discriminate against a 340B covered entity in a manner that prevents or interferes with an enrollee's choice to receive a prescription drug from a 340B covered entity or its contracted pharmacies.

(C) Any provision of a contract entered into between a health plan issuer and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensing fee or reimbursement rate that applies for health care providers that are not 340B covered entities.

Section 3902.72 | Health plan issuer disclosure of drug data.
 

(A) As used in this section, "health care provider" has the same meaning as in section 3701.74 of the Revised Code.

(B) A health plan issuer, including a pharmacy benefit manager, shall, upon request of a covered person, the covered person's health care provider, or the third-party representative, furnish the following data for any and all drugs covered under a related health benefit plan:

(1) The covered person's eligibility information for any and all covered drugs;

(2) Cost-sharing information for any and all covered drugs, including a description of any variance in cost-sharing based on pharmacy, whether retail or mail order, or health care provider dispensing or administering the drugs;

(3) Any applicable utilization management requirements for any and all covered drugs, including prior authorization requirements, step therapy, quantity limits, and site-of-service restrictions.

(C) A health plan issuer, including a pharmacy benefit manager, providing the data required under division (B) of this section shall ensure that the data meets all of the following:

(1) It is current not later than one business day after any change is made.

(2) It is provided in real time.

(3) It is provided in the same format that the request is made by the covered person, the covered person's health care provider, or the third-party representative.

(D) The format in which a health plan issuer, including a pharmacy benefit manager, replies to a request made under division (B) of this section shall use established industry content and transport standards published by either of the following:

(1) A standards developing organization accredited by the American national standards institute, including the national council for prescription drug programs, ASC X12, health level 7;

(2) A relevant federal or state governing body, including the centers for medicare and medicaid services or the office of the national coordinator for health information technology.

(E) A health plan issuer, including a pharmacy benefit manager, shall furnish the data required under division (B) of this section regardless of whether the request is made using the drug's unique billing code, such as a national drug code or health care common procedure coding system code, or a descriptive term, such as the brand or generic name of the drug.

(F) A health plan issuer, including a pharmacy benefit manager, shall not deny or delay a request as a method of blocking the data required under division (B) of this section from being shared based on how the drug was requested.

(G) A health plan issuer, including a pharmacy benefit manager, furnishing the data required under division (B) of this section shall not do any of the following:

(1) Restrict, prohibit, or otherwise hinder, in any way, a health care provider from communicating or sharing any of the following:

(a) Any of the data required under division (B) of this section;

(b) Additional information on any lower-cost or clinically appropriate alternatives, whether or not they are covered under the covered person's health benefit plan;

(c) Additional payment or cost-sharing information that may reduce the covered person's out-of-pocket costs, such as cash price or patient assistance and support programs whether sponsored by a manufacturer, foundation, or other entity.

(2) Except as may be required by law, interfere with, prevent, or materially discourage access, exchange, or use of the data required under division (B) of this section, including any of the following:

(a) Charging fees;

(b) Not responding to a request at the time the request is made, if such a response is reasonably possible;

(c) Implementing technology in nonstandard ways;

(d) Instituting covered person consent requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using such data.

(3) Penalize a health care provider for disclosing such data to a covered person or for prescribing, administering, or ordering a clinically appropriate or lower-cost alternative.

(H)(1) A health plan issuer, including a pharmacy benefit manager, shall treat a personal representative of a covered person as the covered person for purposes of this section.

(2) If under applicable law a person has authority to act on behalf of a covered person in making decisions related to health care, a health plan issuer, including a pharmacy benefit manager, or its affiliates or entities acting on its behalf, shall treat such person as a personal representative under this section.

(I) Divisions (A) to (H) of this section take effect January 1, 2022.

Last updated September 9, 2021 at 1:16 PM