Ohio Revised Code Search

...A health insuring corporation policy, contract, or agreement shall not be construed to exclude illness or injury upon the ground that the subscriber might have elected to have such illness or injury covered by workers' compensation under Chapter 4123. of the Revised Code unless the policy, contract, or agreement clearly excludes work or occupational related illness or injury, or the policy, contract, or agreement, or...

...eement excludes or reduces the benefits payable to or on behalf of an insured because benefits are also payable or have been paid under a supplemental sickness and accident insurance policy 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...

...(A) The following conditions apply to all individual health insuring corporation contracts: (1) Except as provided in section 2742(b) to (e) of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-42, as amended, a health insuring corporation that provides individual coverage to an individual shall renew or continue in force such coverage at the op...

...Except as otherwise provided in 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) E...

...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....

...criber prior to the effective date of a termination of a contract between the health insuring corporation and the provider or health care facility.

...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 continue coverage for a newly born child beyond the thirty-one day period described in division (B) of this section, the subscriber shall notify the health ...

...te claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component. (2) Regardless of whether separate payments are made for the benefit provided under division (B)(1) or (2) of this section, the total benefit for a screening mammography or supplemental breast cancer scree...

...Sections 3923.41 to 3923.48 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.

...(A) As used in this section, "genetic screening or testing" means a laboratory test of a person's genes or chromosomes 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 c...

...and drug administration; (3) Alter any law with regard to provisions limiting the coverage of drugs that have not been approved by the United States food and drug administration; (4) Require reimbursement or coverage for any drug not included in the drug formulary or list of covered drugs specified in a health insuring corporation contract; (5) Prohibit a health insuring corporation from limiting or excluding...

...(A) Each individual or group health insuring corporation policy, contract, or agreement delivered, issued for delivery, or renewed in this state that provides maternity benefits shall provide coverage of inpatient care and follow-up care for a mother and her newborn as follows: (1) The policy, contract, or agreement shall cover a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and ...

...ment 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 synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained o...

...dent of insurance makes the following determinations from the documentation and opinion submitted pursuant to divisions (E)(1) and (2) of this section: (i) Compliance with division (B)(1) of this section for a period of at least six months independently caused the health insuring corporation's costs for claims and administrative expenses for the coverage of basic health care services to increase more than one per ce...

...(A) As used in this section: (1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code. (2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code. (3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code. (4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code. (5) "Pre...

...tor or fiscal officer shall provide for payment to the health insuring corporation referred to in the employee's authorization, for the amount covering the sum of the deductions thereby authorized.

...ntal 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.

...f there are changes to federal or state laws or federal regulatory guidance or compliance information prescribing that the drug in question is no longer approved or safe for the intended purpose. (e) A twelve-month approval provided under division (B)(6)(a) of this section does not apply to and is not required for any of the following: (i) Medications that are prescribed for a non-maintenance condition; (ii) Medic...

...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...

...s not meet the requirements for benefit payment under the health insuring corporation's policy, contract, or agreement, and coverage is therefore denied, reduced, or terminated. (B) "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting. (C) "Authorized person" means a parent, guardian, or other person authorized to act on behalf of an enrollee with res...

...(A)(1) Sections 1751.77 to 1751.87 and Chapter 3922. 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 ...

...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 ...

...nister the program and oversee review determinations. A clinical peer in the same, or in a similar, specialty as typically manages the medical condition, procedure, or treatment under review shall evaluate the clinical appropriateness of adverse determinations that are the subject of an appeal. (C) The health insuring corporation shall issue utilization review determinations in a timely manner pursuant to the requir...