Ohio Revised Code Search

...nformation provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such documents are available and appropriate, shall consider all of the following when conducting its review: (A) The covered person's medical records; (B) The...

...ed in division (I) of this section: (1) After an adverse benefit determination, if both of the following apply: (a) The covered person's treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person, or would jeopardize the covered person's ability to regain maximum function, if treated after the time ...

...ications established under section 3922.14 of the Revised Code. (C)(1) Except as provided in division (C)(2) of this section, an independent review organization is eligible for accreditation by the superintendent under this section only if it is accredited by a nationally recognized private accrediting entity that the superintendent has determined has accreditation standards that are equivalent to or exceed th...

...ction against any of the following: (1) An employer that provides health care benefits to employees through a health plan issuer; (2) A clinical reviewer or independent review organization that participates in an external review under this chapter; (3) A health plan issuer that provides coverage for benefits pursuant to this chapter. (B) An independent review organization and any clinical reviewer an indepe...

...ptive act or practice under sections 3901.19 to 3901.26 of the Revised Code. Additionally, health plan issuers holding a certificate of authority from the superintendent are also subject to the following: (A) If, after notice and hearing, the superintendent of insurance finds that a health plan issuer has failed to comply with the requirements of this chapter, the superintendent may suspend or revoke the hea...

... issued to either of the following: (1) Five or more or, with respect to long-term care or disability income insurance, two or more employees of any corporation, copartnership, or individual employer, or of any governmental corporation or agency or a department thereof; (2) Ten or more or, with respect to long-term care or disability income insurance, two or more members of any trade or professional associat...

...(A) As used in this section: (1) "Association" means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide sickness and accident insurance in accordance with this section. (2) "Insurer" means any insurance company authorized to do the business of sickness and accident insurance in this state. (3) "Insured" means a person covered under a group polic...

...(A) As used in this section: (1) "Association" means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide health coverage in accordance with this section. (2) "Insurer" includes any insurance company authorized to do the business of sickness and accident insurance in this state and any health insuring corporation holding a certificate of authority ...

...(A)(1) A policyholder has the right to rescind an individual policy of sickness and accident insurance delivered or issued for delivery in this state at least until midnight of the tenth day after the date on which the policyholder receives the policy, by returning the policy to the insurer or an agent of the insurer. No reason need be stated for the return or the rescission. (2) The policy may provide that the cove...

...de, section 3923.33 and sections 3923.331 to 3923.339 of the Revised Code shall apply to: (1) All medicare supplement policies delivered or issued for delivery in this state on or after the effective date of this amendment; and (2) All certificates issued under group medicare supplement policies, which certificates are delivered or issued for delivery in this state on or after the effective date of this amendment. ...

... to which all of the following apply: (1) The policy covers a specified disease or a limited plan of coverage. (2) The policy is specifically designed, advertised, represented, and sold as a supplement to other basic sickness and accident insurance coverage. (3) The entire premium for the policy is paid by the insured, the insured's family, or the insured's guardian. (B) This section applies to supplemental sickn...

...(A) As used in this section: (1) "Consolidated corporation" means any mutual insurance company that merged or consolidated with a hospital service association. (2) "Individual policy" means a policy other than a policy issued pursuant to section 3923.11, 3923.12, or 3923.13 of the Revised Code. (3) "Individual policyholder" means a person who is an insured under an individual policy. (4) "Cancel" means any cancel...

...newed in this state on or after January 1, 1989, unless the policy covers adopted children of the insured on the same basis as other dependents. The coverage required by this section is subject to the requirements and restrictions set forth in section 3924.51 of the Revised Code.

...ed in division (D)(3) of section 3923.41 of the Revised Code, shall file evidence with the superintendent of insurance that the association has at the outset a minimum of one hundred persons and has been organized and maintained in good faith for purposes other than that of obtaining insurance, has been in active existence for at least one year, and has a constitution and bylaws that provide all of the followin...

...t adhering to one of the following: (1) For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the insurer can demonstrate that the insured misrepresented facts that were material to the insurer's offer of coverage to the insured. (2) For a policy or certi...

...ection 3923.56 of the Revised Code: (1) "Child health supervision services" means periodic review of a child's physical and emotional status performed by a physician, by a health care professional under the supervision of a physician, or, in the case of hearing screening, by an individual acting in accordance with section 3701.505 of the Revised Code. (2) "Periodic review" means a review performed in accorda...

...ce with division (B) of this section: (1) The frequency of the determination of the usual and customary fee; (2) A general description of the methodology used to determine usual and customary fees; (3) The geographic area used to determine usual and customary fees; (4) If the usual and customary fee for a service is determined by taking a sample of fees submitted on actual claims from dentists and then selecting ...

...(A) Notwithstanding section 3901.71 of the Revised Code, no health benefit plan or public employee benefit plan shall deny coverage for the costs of any routine patient care administered to an insured participating in any stage of an eligible cancer clinical trial, if that care would be covered under the plan if the insured was not participating in a clinical trial. (B) T...

...viders. (C) As used in this section: (1) "Health benefit plan" means any policy of sickness and accident insurance or any policy, contract, or agreement covering one or more "basic health care services," "supplemental health care services," or "specialty health care services," as defined in section 1751.01 of the Revised Code, offered or provided by a health insuring corporation or by a sickness and accident insure...

...as the same meaning as in section 3924.01 of the Revised Code. (B) Notwithstanding section 3901.71 of the Revised Code, no health benefit plan or public employee benefit plan shall contain a provision that limits or excludes an insured's coverage under the plan for a loss or expense the insured sustains that is the result of the insured's use of alcohol or other drugs or both and the loss or expense is ot...

...e the same meanings as in section 3963.01 of the Revised Code. (B) A sickness and accident insurer or public employee benefit plan shall provide the information required in this division to all insured individuals receiving coverage under an individual or group policy of sickness and accident insurance or public employee benefit plan for vision care services, vision care materials, or dental care services. The info...

...uding any of the following services: (1) Managing drug therapy under a consult agreement pursuant to section 4729.39 of the Revised Code; (2) Administering immunizations in accordance with section 4729.41 of the Revised Code; (3) Administering drugs in accordance with section 4729.45 of the Revised Code. (B) The patient's individual or group policy of sickness and accident insurance or public employee benefit...

...g to the superintendent of insurance: (1) The carrier does not have the financial reserves necessary to underwrite additional coverage. (2) The carrier is applying division (A) of this section uniformly to all employers in the small employer market in this state consistent with the applicable laws and rules of this state and without regard to the claims experience of those employers and their employees and dependen...

...materials, the following information: (1) The provisions of the plan concerning the carrier's right to change premium rates and the factors that may affect changes in premium rates; (2) The provisions of the plan relating to renewability of coverage; (3) The provisions of the plan relating to any pre-existing condition exclusion; (4) The benefits and premiums available under all health benefit plans for which the...

...equirements contained in sections 3924.01 to 3924.06 of the Revised Code shall be demonstrated through actuarial certification. Carriers offering health benefit plans to small employers shall file annually with the superintendent of insurance an actuarial certification stating that the underwriting and rating methods of the carrier do all of the following: (1) Comply with accepted actuarial practices; (2) Are un...