Ohio Revised Code Search

...n section 2721 of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, the following conditions apply to all group health insuring corporation contracts that are sold in connection with an employment-related group health care plan and that are not subject to section 3924.03 of the Revised Code: (A)(1) Except as provided in section 2...

... individual or group health insuring corporation policy, contract, or agreement that makes family coverage available may be delivered, issued for delivery, or renewed in this state, unless the policy, contract, or agreement covers adopted children of the subscriber 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...

...hat contracts with a health insuring corporation to provide health care services to the health insuring corporation's enrollees or subscribers shall seek compensation for covered services solely from the health insuring corporation and not, under any circumstances, from the enrollees or subscribers, except for approved copayments and deductibles. (B) No subscriber or enrollee of a health insuring corporation ...

...ery, or renewed by a health insuring corporation in this state, and that makes coverage available for family members of a subscriber, also shall provide that coverage applicable to children is payable from the moment of birth with respect to a newly born child of the subscriber or subscriber's spouse. (B) Coverage for a newly born child is effective for a period of thirty-one days from the date of birth. (C) To con...

...es, and that has an average radiation exposure delivery of less than one rad mid-breast. "Screening mammography" includes digital breast tomosynthesis. "Screening mammography" includes two views for each breast. The term also includes the professional interpretation of the film. "Screening mammography" does not include diagnostic mammography. (2) "Medicare reimbursement rate" means the reimbursement rate paid in ...

... Code apply to every health insuring corporation that offers long-term care and that holds a certificate of authority under this chapter.

... disorders. (B) No health insuring corporation shall do either of the following: (1) Consider any information obtained from genetic screening or testing in processing an application for coverage for health care services under an individual or group policy, contract, or agreement or in determining insurability under such a policy, contract, or agreement; (2) Inquire, directly or indirectly, into the results of g...

...individual or group health insuring corporation policy, contract, or agreement that provides coverage for prescription drugs shall limit or exclude coverage for any drug approved by the United States food and drug administration on the basis that the drug has not been approved by the United States food and drug administration for the treatment of the particular indication for which the drug has been prescribed,...

...nsurance under sections 3901.19 to 3901.26 of the Revised Code. (D) This section does not do any of the following: (1) Require a policy, contract, or agreement to cover inpatient or follow-up care that is not received in accordance with the policy's, contract's, or agreement's terms pertaining to the providers and facilities from which an individual is authorized to receive health care services; (2) Require a moth...

...rding to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the policy, contract, or agreement. (2) "Drug" has the same meaning as in section 4729.01 of the Revised Code. (3) "Medication synchronization" means a pharmacy service that synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained on the sam...

...o a high deductible plan, as defined in 26 U.S.C. 223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only after the deductible has been met. (D) The prohibitions in division (B) of this section do not preclude an individual or group health insuring corporation policy, contract, or agreement from requiring an enrollee to obtain prior authorization before orally administered cancer medication is dispensed to ...

... individual or group health insuring corporation policy, contract, or agreement that is delivered, issued for delivery, or renewed in this state and covers prescription drugs shall contain prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for the treatment of chronic pain, except when the drug is prescribed under one of the foll...

...(A) An employee of the state, of any political subdivision of the state, or of any institution supported in whole or in part by the state, may authorize the deduction from the employee's salary or wages of the amount of the employee's premium rate to any health insuring corporation holding a certificate of authority pursuant to this chapter. The employee's authorization shall be evidenced by approval of the head of ...

...Each health insuring corporation subject to this chapter may accept from governmental agencies, or from private persons, payments covering all or part of the cost of policies, contracts, and agreements entered into between the health insuring corporation and its subscribers or groups of subscribers.

...practice under sections 3901.19 to 3901.26 of the Revised Code. (F) The superintendent of insurance may adopt rules in accordance with Chapter 119. of the Revised Code as necessary to implement the provisions of this section. (G) This section does not apply to any of the following types of coverage: a policy, contract, certificate, or agreement that covers only a specified accident, accident only, credit, dental, d...

...Each health insuring corporation providing basic health care services shall implement a quality assurance program for use in connection with those policies, contracts, and agreements providing basic health care services. Each health insuring corporation required to implement a quality assurance program shall annually file a certificate with the superintendent of insurance certifying that its quality assurance progra...

... the Revised Code, a health insuring corporation shall do both of the following: (1) Develop and maintain the appropriate infrastructure and disclosure systems necessary to measure and report, on a regular basis, the quality of health care services provided to enrollees, based on a systematic collection, analysis, and reporting of relevant data. The health insuring corporation shall assure that a committee that inc...

...A health insuring corporation may present evidence of compliance with the requirements of sections 1751.73 and 1751.74 of the Revised Code by submitting certification to the superintendent of insurance of its accreditation by an independent, private accrediting organization, such as the national committee on quality assurance, the national quality health council, the joint commission on accreditation of health care o...

...tation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health insuring corporation. (K) "Physician" means a provider who holds a license issued under Chapter 4731. of the Revised Code authorizing the practice of medicine and surgery or osteopathic medicine and surgery or a comparable license from another state. (L) "Prospective review" means utilization re...

...ed Code apply to any health insuring corporation that provides or performs utilization review services in connection with its policies, contracts, and agreements covering basic health care services and to any designee of the health insuring corporation, or to any utilization review organization that performs utilization review functions on behalf of the health insuring corporation in connection with policies, c...

...A health insuring corporation that conducts utilization review shall prepare a written utilization review program that describes all review activities, both delegated and nondelegated, for covered health care services provided, including the following: (A) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services; (B) The use of data sources and clinical review ...

... review program of a health insuring corporation shall be implemented in accordance with all of the following: (A) The program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health insuring corporation may develop its own clinical review criteria or may purchase or license such criteria from qualified vendors. A hea...

...y be required (B) A health insuring corporation shall maintain written procedures for determining whether a requested service is a service covered under the terms of an enrollee's policy, contract, or agreement, making utilization review determinations, and notifying enrollees, participating providers, and health care facilities acting on behalf of enrollees, of its determinations. (C) For prospective review determ...

... the Revised Code, a health insuring corporation may afford an enrollee an opportunity for an external review under section 3922.08 or 3922.10 of the Revised Code. If an external review is conducted pursuant to this section, the health insuring corporation is not required to afford the enrollee an opportunity for any of the reviews that were disregarded pursuant to this section, including the external review th...

...iew determination, a health insuring corporation shall give the provider or health care facility rendering the health care service an opportunity to request in writing on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making the adverse determination. The provider or health care facility may not request a reconsideration without the prior consent of the enrollee. The reconsiderat...