Ohio Revised Code Search

...(A) If, after completion of an examination involving information collected from a six-month period, the superintendent finds that a third-party payer has committed a series of violations that, taken together, constitutes a consistent pattern or practice of violating division (A) of section 3901.3811 of the Revised Code, the superintendent may impose on the third-party payer any of the administrative remedies specifie...

...Sections 3901.38 and 3901.381 to 3901.3813 of the Revised Code do not apply to the following: (A) Policies offering coverage that is regulated under Chapters 3935. and 3937. of the Revised Code; (B) An employer's self-insurance plan and any of its administrators, as defined in section 3959.01 of the Revised Code, to the extent that federal law supersedes, preempts, prohibits, or otherwise precludes the applicatio...

...(A) As used in this section: (1) "Automated transaction" has the same meaning as in section 1306.01 of the Revised Code, and includes electronic transactions between two or more persons conducting business pursuant to the laws of this state relating to insurance. (2) "Contact point" means any electronic identification to which messages can be sent, including, but not limited to, any of the following: (a) An el...

...(A) As used in this section: (1) "Health benefit plan" means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a vision or dental benefit plan. "Health benefit plan" does not include any of the following: (a) A plan of self-insurance; (b) Insurance arising out of...

...(A) As used in sections 3901.45 and 3901.46 of the Revised Code: (1) "AIDS," "HIV," "AIDS-related condition," and "HIV test" have the same meanings as in section 3701.24 of the Revised Code. (2) "Insurer" means any person authorized to engage in the business of life or sickness and accident insurance under Title XXXIX of the Revised Code or any person or governmental entity providing health services coverage for ...

...As used in this section, "membership organization" means a fraternal or other association or group of individuals involved in the same occupation, activity, or interest that is organized and maintained in good faith for purposes other than to obtain insurance and is not organized or maintained for the purpose of engaging in activities for gain or profit. (A) In underwriting an individual policy of life or sickness a...

...As used in sections 3901.51 to 3901.55 of the Revised Code: (A) "Clearing corporation" has the same meaning as in section 1308.01 of the Revised Code, except that with respect to securities issued by institutions organized or existing under the laws of any foreign country or securities used to meet the deposit requirements pursuant to the laws of a foreign country as a condition of doing business in that country, "c...

...An insurer may offer a wellness or health improvement program that provides rewards or incentives, including merchandise; gift cards; debit cards; premium discounts or rebates; contributions to a health savings account; modifications to copayment, deductible, or coinsurance amounts; or any combination of these incentives, to encourage participation or to reward participation in the program. A wellness or health im...

...(A) Each insurer domiciled in this state shall file a report with the superintendent of insurance disclosing material acquisitions and material dispositions of assets, and material nonrenewals, cancellations, or revisions of ceded reinsurance agreements, unless such transactions previously have been reported to the superintendent for review, approval, or information purposes, pursuant to another provision of Title XX...

...As used in this section and sections 3901.811 to 3901.815 of the Revised Code: (A) "Auditing entity" means any person or government entity that performs a pharmacy audit, including a payer, a pharmacy benefit manager, or a third-party administrator licensed under Chapter 3959. of the Revised Code. (B) "Business day" means any day of the week excluding Saturday, Sunday, and a legal holiday, as defined in section 1.1...

...As used in sections 3901.83 to 3901.833 of the Revised Code: (A) "Clinical practice guidelines" means a systematically developed statement to assist health care provider and patient decisions with regard to appropriate health care for specific clinical circumstances and conditions. (B) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice ...

...(A) As used in this section: (1) "Full-time employee" means an employee working an average of at least thirty hours of service per week during a calendar month, or at least one hundred thirty hours of service during the calendar month. (2) "Group policyholder" means a policyholder for a health insurance policy covering fifty or more full-time employees. "Group policyholder" includes an authorized representative o...

...A direct primary care agreement that meets all of the following shall not be considered insurance and nothing in Title XXXIX or Chapter 1739., 1751., or 1753. of the Revised Code shall apply to such an agreement: (A) It is in writing. (B) It is between a patient, or that patient's legal representative, and a health care provider and is related to services to be provided in exchange for the payment of a fee to be ...

...(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 sect...

...(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...

...(A) As used in this section: (1) "Cost sharing" means the cost to a covered individual under a health benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan. (2) "Health benefit plan," "health care services," and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code. (3) "Health care prof...

...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 requireme...

...(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...

...(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...

...(A) As used in this section: (1) "Hearing aid" means any wearable instrument or device designed or offered for the purpose of aiding or compensating for impaired human hearing, including all attachments, accessories, and parts thereof, except batteries and cords, that is dispensed by a licensed audiologist, a licensed hearing aid dealer or fitter, or an otolaryngologist. (2) "Otolaryngologist" means a licensed ph...

...(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'...

...The proceedings authorized by sections 3903.01 to 3903.59 of the Revised Code may be applied to any one or more of the following: (A) All insurers who are doing, or have done, an insurance business in this state, and against whom claims arising from that business may exist now or in the future; (B) All insurers who purport to do an insurance business in this state; (C) All insurers who have insureds resident in th...

...(A) No delinquency proceeding shall be commenced under this chapter by anyone other than the superintendent of insurance of this state. No court has jurisdiction to entertain, hear, or determine any delinquency proceeding commenced by any other person. (B) No court of this state has jurisdiction to entertain, hear, or determine any complaint praying for the dissolution, liquidation, rehabilitation, sequestration, co...

...(A) Upon complaint or motion of any receiver, conservator, rehabilitator, or liquidator appointed in a proceeding under sections 3903.01 to 3903.59 of the Revised Code, any court of general jurisdiction may issue a temporary restraining order, a preliminary injunction, a permanent injunction, or such other orders that the court considers necessary and proper to prevent any one or more of the following: (1) The trans...

...(A) Any officer, manager, director, trustee, owner, employee, or agent of any insurer, or any other persons with authority over or in charge of any segment of the insurer's affairs, shall cooperate with the superintendent of insurance in any proceeding under sections 3903.01 to 3903.59 of the Revised Code or any investigation preliminary to the proceeding. The term "person" as used in this section includes, but is no...