reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.58 | Conditions Applying to All Group Health Insuring Corporation Contracts Sold in Connection With Employment-Related Group Health Care Plan.

Effective:
March 22, 1999
Latest Legislation:
House Bill 698 - 122nd General Assembly
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) Except as provided in section 2712(b) to (e) of the "Health Insurance Portability and Accountability Act of 1996," if a health insuring corporation offers coverage in the small or large group market in connection with a group contract, the corporation shall renew or continue in force such coverage at the option of the contract holder.
(2) A health insuring corporation may cancel or decide not to renew the coverage of any eligible employee or of a dependent of an eligible employee under the group contract in accordance with division (B) of section 1751.18 of the Revised Code.
(B) Such group contracts are subject to division (A)(3) of section 3924.03 and sections 3924.033 and 3924.27 of the Revised Code.
(C) Such group contracts shall provide for the special enrollment periods described in section 2701(f) of the "Health Insurance Portability and Accountability Act of 1996."
(D) At least once in every twelve-month period, a health insuring corporation shall provide to all late enrollees, as defined in section 3924.01 of the Revised Code, who are identified by the contract holder, the option to enroll in the group contract. The enrollment option shall be provided for a minimum period of thirty consecutive days. All delays of coverage imposed under the group contract, including any affiliation period, shall begin on the date the health insuring corporation receives notice of the late enrollee's application or request for coverage, and shall run concurrently with each other.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.59 | Coverage of Adopted Children.

Effective:
March 22, 1999
Latest Legislation:
House Bill 698 - 122nd General Assembly
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 3924.51 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.60 | Provider or Facility Limited to Seek Compensation for Covered Services Solely From Hic.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided for in divisions (E) and (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) No subscriber or enrollee of a health insuring corporation is liable to any contracting provider or health care facility for the cost of any covered health care services, if the subscriber or enrollee has acted in accordance with the evidence of coverage.
(C) Except as provided for in divisions (E) and (F) of this section, every contract between a health insuring corporation and provider or health care facility shall contain a provision approved by the superintendent of insurance requiring the provider or health care facility to seek compensation solely from the health insuring corporation and not, under any circumstances, from the subscriber or enrollee, except for approved copayments and deductibles.
(D) Nothing in this section shall be construed as preventing a provider or health care facility from billing the enrollee or subscriber of a health insuring corporation for noncovered services.
(E) Upon application by a health insuring corporation and a provider or health care facility, the superintendent may waive the requirements of divisions (A) and (C) of this section when, in addition to the reserve requirements contained in section 1751.28 of the Revised Code, the health insuring corporation provides sufficient assurances to the superintendent that the provider or health care facility has been provided with financial guarantees. No waiver of the requirements of divisions (A) and (C) of this section is effective as to enrollees or subscribers for whom the health insuring corporation is compensated under a provider agreement or risk contract entered into under the medicaid program.
(F) The requirements of divisions (A) to (C) of this section apply only to health care services provided to an enrollee or subscriber prior to the effective date of a termination of a contract between the health insuring corporation and the provider or health care facility.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.61 | Coverage for Newly Born Child.

Effective:
June 30, 1997
Latest Legislation:
House Bill 374 - 122nd General Assembly
(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 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 insuring corporation within that period.
(D) If payment of a specific premium rate is required to provide coverage under this section for an additional child, the evidence of coverage may require the subscriber to make this payment to the health insuring corporation within the thirty-one day period described in division (B) of this section in order to continue the coverage beyond that period.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.63 | Long-Term Care Insurance.

Effective:
June 4, 1997
Latest Legislation:
Senate Bill 67 - 122nd General Assembly
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.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.65 | Health Insuring Corporation - Prohibited Activities.

Effective:
April 6, 2023
Latest Legislation:
House Bill 281 - 134th General Assembly
(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 chromosomal changes, and not an indirect manifestation of genetic 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 genetic screening or testing or use such information, in whole or in part, to cancel, refuse to issue or renew, limit benefits under, or set premiums for, an individual or group policy, contract, or agreement.
(C) Any health insuring corporation that has engaged in, is engaged in, or is about to engage in a violation of division (B) of this section is subject to the jurisdiction of the superintendent of insurance under section 3901.04 of the Revised Code.
Last updated March 10, 2023 at 11:09 AM
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.691 | Prior Authorization Requirements or Other Utilization Review Measures as Conditions of Providing Coverage of an Opioid Analgesic.

Effective:
April 6, 2017
Latest Legislation:
Senate Bill 319 - 131st General Assembly
(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) "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 recovery, although there may be periods of remission.
(B)(1) An 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 following circumstances:
(a) To an individual who is a hospice patient in a hospice c are program;
(b) To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program;
(c) To an individual who has cancer or another condition associated with the individual's cancer or history of cancer.
(2) When implementing division (B)(1) of this section, the health insuring corporation shall consider either or both of the following, as applicable to the case in which the opioid analgesic is prescribed:
(a) If the course of treatment with the drug continues for more than ninety days, the requirements of section 4731.052 of the Revised Code;
(b) If the morphine equivalent daily dose for the drug exceeds eighty milligrams or the individual is being treated with a benzodiazepine at the time the opioid analgesic is prescribed, the guidelines established by the governor's cabinet opiate action team and presented in the document titled "Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) 'Trigger Point'" or a successor document, unless the guidelines are no longer in effect at the time the opioid analgesic is prescribed.
(C) If a health insuring corporation measures the efficiency, quality of care, or clinical performance of a prescriber, including through the use of patient satisfaction surveys, it shall not penalize the prescriber, financially or otherwise, for deciding not to prescribe an opioid analgesic.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.70 | Authorization of Payroll Deductions for Public Employees.

Effective:
June 4, 1997
Latest Legislation:
Senate Bill 67 - 122nd General Assembly
(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 the department, division, office, or institution in which the employee is employed.
(B) In the case of employees of the state, the employee's authorization shall be directed to and filed with the director of administrative services. In the case of employees of a political subdivision, the employee's authorization shall be directed to and filed with the fiscal officer of such political subdivision. In the case of employees of any institution supported in whole or in part by the state, the employee's authorization shall be directed to and filed with the fiscal officer of such institution.
(C) Upon the filing of the employee's authorization in accordance with division (B) of this section, the director 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.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.71 | Accepting Payments for Cost of Policies, Contracts, and Agreements.

Effective:
June 4, 1997
Latest Legislation:
Senate Bill 67 - 122nd General Assembly
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.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.73 | Implementing Quality Assurance Programs.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
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 program does all of the following:
(A) Identifies a corporate board or committee or designates an executive staff person responsible for program implementation and compliance;
(B) Includes a process enabling the selection and retention of quality providers and health care facilities through credentialing, recredentialing, and monitoring procedures;
(C) Provides for ongoing monitoring of the quality assurance program;
(D) Assures a process for compliance by any entity or entities with which the health insuring corporation contracts for services;
(E) Includes a process to take remedial action to correct quality problems.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.75 | Determination That Accreditation Constitutes Compliance.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
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 organizations, the accreditation association for ambulatory health care, or the American accreditation healthcare commission/utilization review accreditation commission. The superintendent, upon review of the organization's accreditation process, may determine that such accreditation constitutes compliance by the health insuring corporation with the requirements of these sections.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.78 | Application of Provisions.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
(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 of the health insuring corporation in connection with policies, contracts, or agreements of the health insuring corporation covering basic health care services.
(2) Nothing in sections 1751.77 to 1751.82 or section 1751.823 of the Revised Code shall be construed to require a health insuring corporation to provide or perform utilization review services in connection with health care services provided under a policy, plan, or agreement of supplemental health care services or specialty health care services.
(B)(1) Each health insuring corporation shall be responsible for monitoring all utilization review and internal review activities carried out by, or on behalf of, the health insuring corporation and for ensuring that all requirements of sections 1751.77 to 1751.87 and Chapter 3922. of the Revised Code, and any rules adopted thereunder, are met. The health insuring corporation shall also ensure that appropriate personnel have operational responsibility for the conduct of the health insuring corporation's utilization review program.
(2) If a health insuring corporation contracts to have a utilization review organization or other entity perform the utilization review functions required by sections 1751.77 to 1751.87 and Chapter 3922. of the Revised Code, and any rules adopted thereunder, the superintendent of insurance shall hold the health insuring corporation responsible for monitoring the activities of the utilization review organization or other entity and for ensuring that the requirements of those sections and rules are met.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.79 | Utilization Review Program Requirements.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
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 criteria in making decisions;
(C) Mechanisms to ensure consistent application of criteria and compatible decisions;
(D) Data collection processes and analytical methods used in assessing utilization of health care services;
(E) Mechanisms for assuring confidentiality of clinical and proprietary information;
(F) The periodic assessment of utilization review activities, and the reporting of these assessments to the health insuring corporation's board, by a utilization review committee, a quality assurance committee, or any similar committee;
(G) The functional responsibility for day-to-day program management by staff;
(H) Defined methods by which guidelines are approved and communicated to providers and health care facilities.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.80 | Implementing Utilization Review Programs.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
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 vendors. A health insuring corporation shall make its clinical review rationale available upon request to authorized government agencies. The rationale made available to authorized government agencies is confidential and is not a public record as defined in section 149.43 of the Revised Code.
(B) Qualified providers shall administer 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 requirements of sections 1751.81 and 1751.82 of the Revised Code and the enrollee grievance requirements. The health insuring corporation shall obtain information required to make a utilization review determination, including pertinent clinical information, and shall establish a process to ensure that utilization reviewers apply clinical review criteria consistently.
(D) If the health insuring corporation delegates any utilization review activities to a utilization review organization, the health insuring corporation shall maintain adequate oversight, including a process by which the health insuring corporation evaluates the performance of the organization, and shall maintain copies of both of the following:
(1) A written description of the organization's activities and responsibilities, including reporting requirements;
(2) Evidence of formal approval of the organization's program by the health insuring corporation.
(E) The health insuring corporation or its designee utilization review organization shall provide enrollees and participating providers with access to its review staff by means of a toll-free telephone number or collect-call telephone line.
(F) When conducting prospective or concurrent review, the health insuring corporation or its designee utilization review organization shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency, and duration of health care services.
(G) Compensation to persons providing utilization review services for the health insuring corporation shall not contain incentives, direct or indirect, for them to make inappropriate review decisions.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.811 | Internal and External Reviews.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
In lieu of conducting a prospective, concurrent, or retrospective review under section 1751.81 of the Revised Code, providing a reconsideration under section 1751.82 of the 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 were disregarded pursuant to this section, including the external review that may have resulted from a review that was disregarded pursuant to this section, unless new clinical information is submitted to the health insuring corporation.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.82 | Reconsideration of Adverse Determination.

Effective:
May 1, 2000
Latest Legislation:
House Bill 4 - 123rd General Assembly
(A) In a case involving a prospective determination or 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. The reconsideration shall occur within three business days after the health insuring corporation's receipt of the written request for reconsideration, and shall be conducted between the provider or health care facility rendering the health care service and the reviewer who made the adverse determination. If that reviewer cannot be available within three business days, the reviewer may designate another reviewer.
(B) If the reconsideration process described in division (A) of this section does not resolve the difference of opinion, the enrollee, an authorized person, or the provider or health care facility acting on behalf of the enrollee may request an internal review under section 1751.83 of the Revised Code. The provider or health care facility may not request an internal review without the prior consent of the enrollee.
(C) Reconsideration is not a prerequisite to an internal or external review of an adverse determination.
(D) The time period allowed by division (A) of this section for a reconsideration of an adverse determination shall not apply if the seriousness of the medical condition of the enrollee requires a more expedited reconsideration. The health insuring corporation shall maintain written procedures for making such an expedited reconsideration.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.821 | Determination That Accreditation Constitutes Compliance.

Effective:
May 1, 2000
Latest Legislation:
House Bill 4 - 123rd General Assembly
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 organizations, or the American accreditation healthcare commission/utilization review accreditation commission. The superintendent, upon review of the organization's accreditation process, may determine that such accreditation constitutes compliance by the health insuring corporation with the requirements of these sections.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.822 | Cooperation With Utilization Review Program.

Effective:
May 1, 2000
Latest Legislation:
House Bill 4 - 123rd General Assembly
Each participating provider or health care facility submitting a claim shall cooperate with the utilization review program of a health insuring corporation or utilization review organization and shall provide the health insuring corporation or its designee access to an enrollee's medical records during regular business hours, or copies of those records at a reasonable cost.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.823 | Filing Certificate of Compliance.

Effective:
May 1, 2000
Latest Legislation:
House Bill 4 - 123rd General Assembly
A health insuring corporation shall annually file a certificate with the superintendent of insurance certifying its compliance with sections 1751.77 to 1751.82 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.83 | Maintaining Internal Review System.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
A health insuring corporation shall establish and maintain an internal review system that has been approved by the superintendent of insurance. The system shall provide for review by a clinical peer and include adequate and reasonable procedures for review and resolution of appeals from enrollees concerning adverse determinations made under section 1751.81 of the Revised Code, including procedures for verifying and reviewing appeals from enrollees whose medical conditions require expedited review.
A health insuring corporation shall consider and provide a written response to each request for an internal review not later than thirty days after receipt of the request, except that if the seriousness of the enrollee's medical condition requires an expedited review, the health insuring corporation shall provide the written response not later than seven days after receipt of the request or in accordance with applicable preemptive federal laws or regulations. The response shall state the reason for the health insuring corporation's decision, inform the enrollee of the right to pursue a further review, and explain the procedures for initiating the review, including the time frames within which the enrollee must request the review, as specified in section 3922.02 of the Revised Code. Failure by a health insuring corporation to provide a written response within the time frames specified under this section shall be deemed a denial by the health insuring corporation for purposes of requesting an external review under Chapter 3922. of the Revised Code.
If the health insuring corporation has denied, reduced, or terminated coverage for a health care service on the grounds that the service is not a service covered under the terms of the enrollee's policy, contract, or agreement, the response shall inform the enrollee of the right to request a review by the superintendent of insurance under Chapter 3922. of the Revised Code. If the health insuring corporation has denied, reduced, or terminated coverage for a health care service on the grounds that the service is not medically necessary, the response shall inform the enrollee of the right to request an external review under Chapter 3922. of the Revised Code.
The health insuring corporation shall make available to the superintendent for inspection copies of all documents in the health insuring corporation's possession related to reviews conducted pursuant to this section, including medical records related to those reviews, and of responses, for three years following completion of the review.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.85 | Information for Vision Care Services or Materials.

Effective:
March 20, 2019
Latest Legislation:
House Bill 156 - 132nd General Assembly
(A) As used in this section, "covered vision services," "vision care materials," and "vision care provider" have the same meanings as in section 3963.01 of the Revised Code.
( B) A health insuring corporation shall provide the information required in this division to all enrollees receiving coverage under an individual or group health insuring corporation policy, contract, or agreement providing coverage for vision care services or vision care materials. The information shall be in a conspicuous format, shall be easily accessible to enrollees, and shall do all of the following:
(1) Include the following statement:
"IMPORTANT: If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you his or her normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request."
(2) Disclose any business interest the health insuring corporation has in a source or supplier of vision care materials ;
(3) Include an explanation that the enrollee may incur out-of-pocket expenses as a result of the purchase of vision care services or vision care materials that are not covered vision services. The explanation shall be communicated in a manner and format similar to how the health insuring corporation provides an enrollee with information on coverage levels and out-of-pocket expenses that may be incurred by the enrollee under the policy, contract, or agreement when purchasing out-of-network vision care services or vision care materials.
(C) A pattern of continuous or repeated violations of this section is an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.86 | Violation Deemed Unfair and Deceptive Act or Practice.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
(A) No health insuring corporation shall fail to comply with sections 1751.77 to 1751.82 of the Revised Code.
(B) Whoever violates division (A) of this section is deemed to have engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.87 | Cause of Action Not Created.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
Nothing in sections 1751.77 to 1751.83 of the Revised Code shall be construed to create a cause of action against an employer that provides health care benefits to employees through a health insuring corporation.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.89 | Medicare and Medicaid Exceptions.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
Sections 1751.77 to 1751.83 of the Revised Code do not apply to either of the following:
(A) Coverage provided to beneficiaries enrolled in the medicare+choice program operated under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended;
(B) Coverage provided to medicaid recipients;
(C) Coverage provided to participants of the children's buy-in program.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.90 | Coverage for Teledentistry.

Effective:
March 20, 2019
Latest Legislation:
Senate Bill 259 - 132nd General Assembly
(A) As used in this section, "teledentistry" has the same meaning as in section 4715.43 of the Revised Code.
(B) No individual or group health insuring corporation policy, contract, or agreement shall deny coverage for the costs of any services provided to an insured through teledentistry if those services would be covered if the services were delivered other than through teledentistry.
(C) The coverage that may not be excluded under division (B) of this section is subject to all terms, conditions, restrictions, exclusions, and limitations that apply to other coverage for services performed by participating and nonparticipating providers.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.91 | Reimbursement for Pharmacists Providing Health Care.

Effective:
December 16, 2020
Latest Legislation:
House Bill 203 - 133rd General Assembly
A health insuring corporation may provide payment or reimbursement to a pharmacist for providing a health care service to a patient if both of the following are the case:
(A) The pharmacist provided the health care service to the patient in accordance with Chapter 4729. of the Revised Code, including 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 health insuring corporation policy, contract, or agreement provides for payment or reimbursement of the service.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1751 | Health Insuring Corporation Law › Section 1751.92 | Compliance Cost-Sharing Provisions.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
Each health insuring corporation shall comply with the requirements of section 3959.20 of the Revised Code as they pertain to health plan issuers.
As used in this section, "health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.01 | Physician-Health Plan Partnership Act Definitions.

Effective:
June 25, 2008
Latest Legislation:
House Bill 125 - 127th General Assembly
As used in this chapter, "basic health care services," "enrollee," "health care facility," "health care services," "health insuring corporation," "medical record," "person," "primary care provider," "provider," "specialty health care services," "subscriber," and "supplemental health care services" have the same meanings as in section 1751.01 of the Revised Code.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.06 | Notice of Status of the Provider's Application.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
A health insuring corporation shall notify a provider seeking to enter into a participation contract with the health insuring corporation of the status of the provider's application within one hundred twenty days after the health insuring corporation's receipt of the provider's completed application. That time period may be extended by a health insuring corporation if, due to extenuating circumstances, the health insuring corporation needs additional time to consider the application and notifies the provider of the reason for the delay.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.07 | Information Given to Provider.

Effective:
June 25, 2008
Latest Legislation:
House Bill 125 - 127th General Assembly
(A)(1) Prior to entering into a participation contract with a provider under section 1751.13 of the Revised Code, a health insuring corporation shall disclose basic information regarding its programs and procedures to the provider. The information shall include all of the following:
(a) How a participating provider is reimbursed for the participating provider's services, including the range and structure of any financial risk sharing arrangements, a description of any incentive plans, and, if reimbursed according to a type of fee-for-service arrangement, the level of reimbursement for the participating provider's services;
(b) Insofar as division (A)(1) of section 3963.03 of the Revised Code is applicable, all of the information that is described in that division and is not included in division (A)(1)(a) of this section.
(2) Prior to entering into a participation contract with a provider under section 1751.13 of the Revised Code, a health insuring corporation shall disclose the following information upon the provider's request:
(a) How referrals to other participating providers or to nonparticipating providers are made;
(b) The availability of dispute resolution procedures and the potential for cost to be incurred;
(c) How a participating provider's name and address will be used in marketing materials.
(B) A health insuring corporation shall provide all of the following to a participating provider:
(1) Any material incorporated by reference into the participation contract, that is not otherwise available as a public record, if such material affects the participating provider;
(2) Administrative manuals related to provider participation, if any;
(3) Insofar as division (B) of section 3963.03 of the Revised Code is applicable, the summary disclosure form with the disclosures required under that division;
(4) A signed and dated copy of the final participation contract.
(C) Nothing in this section requires a health insuring corporation providing specialty health care services or supplemental health care services to disclose the health insuring corporation's aggregate maximum allowable fee table used to determine providers' fees or fee schedules.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.10 | Categories of Providers.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
Nothing in this chapter or Chapter 1751. of the Revised Code requires a health insuring corporation to employ or contract with, or prohibits a health insuring corporation from employing or contracting with, any category of provider for the provision of basic or supplemental health care services, which health care services are within the recognized scope of practice of that category of provider.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.13 | Obtaining Covered Obstetric and Gynecological Services Without Referral.

Effective:
October 14, 1999
Latest Legislation:
House Bill 4 - 123rd General Assembly
Every individual or group health insuring corporation policy, contract, or agreement that provides basic health care services but does not allow direct access to obstetricians or gynecologists shall permit a female enrollee to obtain covered obstetric and gynecological services from a participating obstetrician or gynecologist without obtaining a referral from the enrollee's primary care provider.
No individual or group health insuring corporation policy, contract, or agreement may limit the number of allowable visits to a participating obstetrician or gynecologist. A health insuring corporation may require a participating obstetrician or gynecologist to comply with the health insuring corporation's coverage protocols and procedures, including utilization review, for obstetric and gynecological services.
A health insuring corporation policy, contract, or agreement may not impose additional copayments for directly accessed obstetric and gynecological services, unless the policy, contract, or agreement imposes additional copayments for direct access to any participating provider other than a primary care provider.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.14 | Procedures for Standing Referrals to Specialists.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
(A) A health insuring corporation that does not allow direct access to all specialists shall establish and implement a procedure by which an enrollee may receive a standing referral to a specialist. The procedure shall provide for a standing referral to a specialist if a primary care provider determines in consultation with a specialist that an enrollee needs continuing care from a specialist. The referral shall be made pursuant to a treatment plan approved by the health insuring corporation in consultation with the primary care provider, a specialist, and the enrollee. The treatment plan may limit the number of visits to the specialist, limit the period of time that the visits are authorized, or require that the specialist provide the primary care provider with regular reports on the health care provided to the enrollee.
(B) A health insuring corporation shall establish and implement a procedure by which an enrollee with a condition or disease that requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling may receive a referral to a specialist who has expertise in treating the condition or disease for the purpose of having the specialist coordinate the enrollee's health care. The procedure shall provide for such a referral if a primary care provider determines in consultation with the specialist that the enrollee needs the specialist's expertise. The referral shall be made pursuant to a treatment plan approved by the health insuring corporation in consultation with the primary care provider, the specialist, and the enrollee. After the referral is made, the specialist is authorized to provide health care services to the enrollee in the same manner as the enrollee's primary care provider, subject to the terms of the treatment plan.
(C) The determinations described in divisions (A) and (B) of this section shall be made within three business days after a request for the determination is made by the enrollee or the enrollee's primary care provider and all appropriate medical records and other items of information necessary to make the determination have been provided.
(D) Once a determination in favor of a referral is made, the referral shall be made within four business days after the determination. This time period does not apply to standing referrals involving a rare or unusual condition for which appropriate specialists are limited in number or otherwise difficult to identify.
Divisions (A) and (B) of this section do not require a health insuring corporation to permit an enrollee to elect referral to a specialist who is not employed by or under contract with the health insuring corporation for the provision of health care services to the health insuring corporation's enrollees.
2023 Ohio Revised Code › Title 17 | Corporations-Partnerships › Chapter 1753 | Physician-Health Plan Partnership Act; Risk-Based Capital for Insurers Model Act › Section 1753.16 | Retroactively Denying Authorization.

Effective:
October 1, 1998
Latest Legislation:
House Bill 361 - 122nd General Assembly
A health insuring corporation or utilization review organization that authorizes a proposed admission, treatment, or health care service by a participating provider based upon the complete and accurate submission of all necessary information relative to an eligible enrollee shall not retroactively deny this authorization if the provider renders the health care service in good faith and pursuant to the authorization and all of the terms and conditions of the provider's contract with the health insuring corporation.