Ohio Revised Code Search

...No 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....

...F) of this section, every provider or health care facility that 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)...

...(A) Each individual or group evidence of coverage that is delivered, issued for delivery, 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 c...

...ing equipment that is dedicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, 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 inter...

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

...s for genotypes, mutations, or chromosomal changes, including carrier status, that are linked to physical or mental disorders or impairments, or that indicate a susceptibility to illness, disease, or other disorders, whether physical or mental, which test is a direct test for genotypes, mutations, or chromosomal changes, and not an indirect manifestation of genetic disorders. (B) No health insuring corporation shal...

...(A) No 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 pres...

...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...

...he cost to an enrollee under an individual or group health insuring corporation policy, contract, or agreement according 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 synchroni...

...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 ...

...1 of the Revised Code. (4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code. (5) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code. (6) "Terminal condition" means an irreversible, incurable, and untreatable condition that is caused by disease, illness, or injury and will likely result in death. A terminal condition is one in which there can be no rec...

...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 the ...

...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...

...(A) To implement a quality assurance program required by section 1751.73 of 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 d...

...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...

... Revised Code, unless otherwise specifically provided or as otherwise required pursuant to applicable federal law or regulations: (A) "Adverse determination" means a determination by a health insuring corporation or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, the health ...

...922. of the Revised 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...

...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 ...

...The utilization 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...

...s the results of any face-to-face clinical evaluation or second opinion that may 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...

...he Revised Code, or conducting an internal review under section 1751.83 of 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 w...

... a concurrent review 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....

...A health insuring corporation may present evidence of compliance with the requirements of sections 1751.77 to 1751.82 of the Revised Code by submitting evidence 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 organiz...