reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.811 | Pharmacy Audits.

Effective:
January 1, 2021
Latest Legislation:
House Bill 339 - 133rd General Assembly
(A) Except as provided in division (B) of this section, an auditing entity is subject to all of the following conditions when performing a pharmacy audit in this state:
(1) If it is necessary that the pharmacy audit be performed on the premises of a pharmacy, the auditing entity shall give the pharmacy that is the subject of the audit written notice of the date or dates on which the audit will be performed and the range of prescription numbers from which the auditing entity will select pharmacy records to audit. Notice of the date or dates on which the audit will be performed shall be given not less than ten business days before the date the audit is to commence. Notice of the range of prescription numbers from which the auditing entity will select pharmacy records to audit shall be received by the pharmacy not less than seven business days before the date the audit is to commence.
(2) The auditing entity shall not include in the pharmacy audit a review of a claim for payment for the provision of dangerous drugs or pharmacy services if the date of the pharmacy's initial submission of the claim for payment occurred more than twenty-four months before the date the audit commences.
(3) Absent an indication that there was an error in the dispensing of a drug, the auditing entity or payer shall not seek to recoup from the pharmacy that is the subject of the audit any amount that the pharmacy audit identifies as being the result of clerical or recordkeeping errors in the absence of financial harm. For purposes of this provision, an error in the dispensing of a drug is any of the following: selecting an incorrect drug, issuing incorrect directions, or dispensing a drug to the incorrect patient.
(4) The auditing entity shall not use the accounting practice of extrapolation when calculating a monetary penalty to be imposed or amount to be recouped as the result of the pharmacy audit.
(B)(1) The condition in division (A)(1) of this section does not apply if, prior to the audit, the auditing entity has evidence, from its review of claims data, statements, or physical evidence or its use of other investigative methods, indicating that fraud or other intentional or willful misrepresentation exists.
(2) The condition in division (A)(3) of this section does not apply if the auditing entity has evidence, from its review of claims data, statements, or physical evidence or its use of other investigative methods, indicating that fraud or other intentional or willful misrepresentation exists.
(3) Division (A)(4) of this section does not apply when the accounting practice of extrapolation is required by state or federal law.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.812 | Rights of Pharmacy.

Effective:
March 23, 2015
Latest Legislation:
Senate Bill 258 - 130th General Assembly
A pharmacy may do any of the following when a pharmacy audit is performed:
(A) Validate a pharmacy record by using original or photocopied records from hospitals, physicians, or other health care providers;
(B) Validate one or more claims for payment for the provision of dangerous drugs or pharmacy services by using either of the following:
(1) An original pharmacy record or photocopy of the record;
(2) An original prescription or photocopy of the prescription in any form that constitutes a valid prescription in this state, including a written prescription, a prescription made through an electronic prescribing system, a prescription delivered by facsimile, a prescription made by issuing an order for medication administration, and the record a pharmacist maintains under section 4729.37 of the Revised Code documenting a prescription received by telephone.
(C) Resubmit a disputed or denied claim for payment using any commercially reasonable method of resubmission, including resubmission by facsimile, mail, or electronic means, as long as the time period for resubmissions established by the relevant payer has not expired.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.813 | Proceedings After Audit.

Effective:
March 23, 2015
Latest Legislation:
Senate Bill 258 - 130th General Assembly
(A) Except as provided in division (B) of this section, all of the following apply after a pharmacy audit is completed:
(1) A pharmacy shall be given not less than thirty days from the date of the on-site audit to provide the auditing entity any additional information necessary to complete the preliminary audit report.
(2) Not later than sixty business days after the audit is completed, the auditing entity shall deliver a preliminary audit report to the pharmacy that was the subject of the audit.
(3) A pharmacy that disputes any finding in the preliminary audit report may submit documentation to the auditing entity to appeal the finding. A pharmacy shall be given not less than thirty business days to make the submission and may request an extension of the time period given. The auditing entity shall grant a request for an extension if it is reasonable.
A pharmacy's submission of documentation to appeal the finding shall be made in accordance with the procedure the auditing entity has established under section 3901.814 of the Revised Code.
(4)(a) An auditing entity shall deliver a final audit report to the pharmacy that was the subject of the audit. Except as provided in division (A)(4)(b) of this section, the report shall be delivered not later than one hundred twenty business days after the pharmacy's receipt of a preliminary audit report.
(b) If an auditing entity has granted a pharmacy's request for an extension of the time to submit documentation to appeal a finding in the preliminary audit report under division (A)(3) of this section, the time limit described in division (A)(4)(a) of this section for the delivery of the final audit report is waived. Instead, the auditing entity shall deliver the final audit report not later than one hundred twenty days after the pharmacy's submission of the documentation.
(B) The provisions of division (A) of this section do not apply if the auditing entity has evidence, from its review of claims data, statements, or physical evidence or its use of other investigative methods, indicating that fraud or other intentional or willful misrepresentation exists.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.814 | Appeal Process.

Effective:
March 23, 2015
Latest Legislation:
Senate Bill 258 - 130th General Assembly
Each auditing entity in this state shall establish in writing separate procedures for a pharmacy to appeal one or more findings in a preliminary audit report issued under section 3901.813 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.815 | Applicability of Provisions.

Effective:
March 23, 2015
Latest Legislation:
Senate Bill 258 - 130th General Assembly
Sections 3901.811 to 3901.814 of the Revised Code shall not apply to an auditing entity that is a medicaid managed care organization if application of those sections to the entity would be in violation of federal law.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.82 | Restatement of the Law, Liability Insurance.

Effective:
October 29, 2018
Latest Legislation:
Senate Bill 239 - 132nd General Assembly
The "Restatement of the Law, Liability Insurance" that was approved at the 2018 annual meeting of the American law institute does not constitute the public policy of this state and is not an appropriate subject of notice.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.83 | Definitions for Sections 3901.83 to 3901.833.

Effective:
April 5, 2019
Latest Legislation:
Senate Bill 265 - 132nd General Assembly
As used in sections 3901.83 to 3901.833 of the Revised Code:
(A) "Clinical practice guidelines" means a systematically developed statement to assist health care provider and patient decisions with regard to appropriate health care for specific clinical circumstances and conditions.
(B) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health plan issuer or utilization review organization to determine whether or not health care services or drugs are appropriate and consistent with medical or scientific evidence.
(C) "Health benefit plan" and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.
(D) "Medical or scientific evidence" has the same meaning as in section 3922.01 of the Revised Code.
(E) "Step therapy exemption" means an overriding of a step therapy protocol in favor of immediate coverage of the health care provider's selected prescription drug.
(F) "Step therapy protocol" means a protocol or program that establishes a specific sequence in which prescription drugs that are for a specified medical condition and that are consistent with medical or scientific evidence for a particular patient are covered, under either a medical or prescription drug benefit, by a health benefit plan, including both self- administered and physician-administered drugs.
(G) "Urgent care services" has the same meaning as in section 3923.041 of the Revised Code.
(H) "Utilization review organization" has the same meaning as in section 1751.77 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.831 | Implementation of Step Therapy Protocol.

Effective:
April 5, 2019
Latest Legislation:
Senate Bill 265 - 132nd General Assembly
(A) If a health plan issuer or a utilization review organization implements a step therapy protocol, that protocol shall be implemented via clinical review criteria that are based on clinical practice guidelines or medical or scientific evidence.
(B) When establishing a step therapy protocol, a health plan issuer and a utilization review organization shall also take into account the needs of atypical patient populations and diagnoses when establishing clinical review criteria.
(C) This section shall not be construed as requiring either a health plan issuer or the state to set up a new entity to develop clinical review criteria for step therapy protocols.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.86 | Retaliatory Provisions - Moneys Collected Paid to State Fire Marshal's Fund.

Effective:
September 1, 2002
Latest Legislation:
Senate Bill 129 - 124th General Assembly
(A) When the laws of any other state, district, territory, or nation impose any taxes, fines, penalties, license fees, deposits of money, securities, or other obligations or prohibitions on insurance companies of this state doing business in that state, district, territory, or nation, or upon their agents therein, the same obligations and prohibitions shall be imposed upon insurance companies of the other state, district, or nation doing business in this state and upon their agents.
When the laws of any other state, district, territory, or nation impose a requirement for countersignature and payment of a fee or commission upon agents of this state for placing any coverage in that state, district, territory, or nation, then the same requirements of countersignature and fee or commission shall be imposed upon agents of that state, district, territory, or nation for placing any coverage in this state.
(B) Beginning on July 1, 1993, twenty per cent of the amount that is collected under division (A) of this section from foreign insurance companies that sell fire insurance to residents of this state shall be paid into the state fire marshal's fund created under section 3737.71 of the Revised Code. The director of commerce, with the approval of the director of budget and management, may increase the percentage described in this division so that it will yield an amount that the director of commerce determines necessary to assist in the maintenance and administration of the office of the fire marshal and in defraying the costs of operating the Ohio fire academy established by section 3737.33 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.87 | No Coverage for Nontherapeutic Abortion.

Effective:
January 1, 2021
Latest Legislation:
House Bill 339 - 133rd General Assembly
(A) No qualified health plan shall provide coverage for a nontherapeutic abortion.
(B) As used in this section:
(1) "Nontherapeutic abortion" has the same meaning as in section 9.04 of the Revised Code.
(2) "Qualified health plan" means any qualified health plan as defined in section 1301 of the "Patient Protection and Affordable Care Act," 42 U.S.C. 18021, offered in this state through an exchange created under that act.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.88 | Actuarial Study Regarding Costs of Health Care Mandates.

Effective:
April 6, 2017
Latest Legislation:
House Bill 463 - 131st General Assembly
The superintendent of insurance shall conduct an actuarial study on the costs of all health care mandates under state law that apply to individual and group health insurance plans that are not subject to the "Employee Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq. This study shall be delivered electronically to the governor, the senate president, and the speaker of the house not later than two years after the effective date of this section .
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.90 | Education on Mental Health and Addiction Services Insurance Parity.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
The superintendent of insurance, in consultation with the director of mental health and addiction services, shall develop consumer and payer education on mental health and addiction services insurance parity and establish and promote a consumer hotline to collect information and help consumers understand and access their insurance benefits.
The department of insurance and the department of mental health and addiction services shall jointly report annually on the department's efforts, which shall include information on consumer and payer outreach activities and identification of trends and barriers to access and coverage in this state. The departments shall submit the report to the general assembly, the joint medicaid oversight committee, and the governor, not later than the thirtieth day of January of each year.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.91 | Adoption or Amendment of Rules Related to Insurance Rating Agencies.

Effective:
March 20, 2019
Latest Legislation:
Senate Bill 273 - 132nd General Assembly
When the superintendent of insurance adopts or amends a rule, including a rule related to the superintendent's duties and powers under Chapters 1751. and 1753. and Title XXXIX of the Revised Code or a rule related to an "insurance rating agency" as defined by section 1.65 of the Revised Code, the superintendent shall give consideration to the inclusion in the rule of the definition of "insurance rating agency" found in section 1.65 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.95 | Direct Primary Care Agreement Not to Be Considered Insurance.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
A direct primary care agreement that meets all of the following shall not be considered insurance and nothing in Title XXXIX or Chapter 1739., 1751., or 1753. of the Revised Code shall apply to such an agreement:
(A) It is in writing.
(B) It is between a patient, or that patient's legal representative, and a health care provider and is related to services to be provided in exchange for the payment of a fee to be paid on a periodic basis.
(C) It allows either party to terminate the agreement as specified in the agreement.
(D) It requires termination to be accomplished through written notification.
(E) It permits termination to take effect immediately upon the other party's receipt of the notification or not more than sixty days after the other party's receipt of the notification.
(F) It does not impose a termination penalty or require payment of a termination fee.
(G) It describes the health care services to be provided under the agreement and the basis on which a periodic fee is to be paid in exchange for those services.
(H) It specifies the periodic fee required and any additional fees that may be charged.
(I) It authorizes the periodic fee and any additional fees to be paid by a third party.
(J) It prohibits the health services provider from charging or receiving any fee other than the fees prescribed in the agreement for those services prescribed in the agreement.
(K) It conspicuously and prominently states that the agreement is not health insurance, is not subject to the insurance laws of this state, and does not meet any individual health insurance mandate that may be required under federal law.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3901 | Superintendent of Insurance › Section 3901.99 | Penalty.

Effective:
July 1, 1996
Latest Legislation:
Senate Bill 2 - 121st General Assembly
(A) Whoever violates section 3901.09 of the Revised Code shall be fined not less than twenty-five nor more than five hundred dollars.
(B) Whoever violates any law relating to the superintendent of insurance, or any law of this state relating to insurance as defined in division (A)(1) of section 3901.04 of the Revised Code, for the violation of which no penalty is otherwise provided in the Revised Code, shall be fined not more than twenty-five thousand dollars, imprisoned not more than six months, or both.
(C) Whoever violates section 3901.54 of the Revised Code is guilty of a felony of the fifth degree.
(D) Whoever violates division (J)(2) of section 3901.07 of the Revised Code is guilty of a misdemeanor of the first degree.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.01 | Purpose of Sections.

Effective:
June 4, 1997
Latest Legislation:
Senate Bill 67 - 122nd General Assembly
(A) The purpose of sections 3902.01 to 3902.08 of the Revised Code is to establish minimum standards for language used in policies and certificates of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies or certificates of health insuring corporations, delivered or issued for delivery in this state, to facilitate ease of reading by insureds and subscribers.
(B) Sections 3902.01 to 3902.08 of the Revised Code are not intended to increase the risk assumed by insurance companies or other entities subject to sections 3902.01 to 3902.08 of the Revised Code or to supersede their obligation to comply with the substance of other applicable insurance laws. Sections 3902.01 to 3902.08 of the Revised Code are not intended to impede flexibility and innovation in the development of policy forms or content, or to lead to the standardization of policy forms or content.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.02 | Insurance Policy and Contract Definitions.

Effective:
June 4, 1997
Latest Legislation:
Senate Bill 67 - 122nd General Assembly
As used in sections 3902.01 to 3902.08 of the Revised Code:
(A) "Policy" or "policy form" means any policy, contract, plan or agreement of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies, contracts, certificates, and agreements of health insuring corporations, delivered or issued for delivery in this state by any company subject to sections 3902.01 to 3902.08 of the Revised Code; any certificate, contract or policy issued by a fraternal benefit society; any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this state; and any evidence of coverage issued by a health insuring corporation.
(B) "Company" or "insurer" means any entity authorized to do the business of life insurance and annuities, sickness and accident insurance, credit life insurance, or credit disability insurance; a fraternal benefit society; and a health insuring corporation.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.03 | Policies to Which Sections Apply - Exceptions - Non-English Language Policies.

Effective:
January 9, 1980
Latest Legislation:
Senate Bill 92 - 113th General Assembly
(A) Sections 3902.01 to 3902.08 of the Revised Code apply to all policies delivered or issued for delivery in this state by any company on or after the date such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code. Sections 3902.01 to 3902.08 of the Revised Code do not apply to:
(1) Any policy that is a security subject to federal jurisdiction;
(2) Any group policy, other than a group credit life insurance policy, or a group credit disability insurance policy. This division does not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this state.
(3) Any group annuity contract that serves as a funding vehicle for pension, profit-sharing, or deferred compensation plans;
(4) Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form approved, or permitted to be issued prior to the dates such forms must be approved pursuant to sections 3902.01 to 3902.08 of the Revised Code;
(5) The renewal of a policy delivered or issued for delivery prior to the dates such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code.
(B) Any non-English language policy delivered or issued for delivery in this state is deemed to be in compliance with division (A)(1) of section 3902.04 of the Revised Code if the insurer certifies that such policy is translated from an English language policy that complies with division (A)(1) of section 3902.04 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.05 | Construction.

Effective:
January 9, 1980
Latest Legislation:
Senate Bill 92 - 113th General Assembly
Nothing in sections 3902.01 to 3902.08 of the Revised Code shall be construed to negate any law of this state permitting the issuance of any policy form after it has been on file for the time period specified.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.06 | Superintendent May Authorize Lower Test Score.

Effective:
January 9, 1980
Latest Legislation:
Senate Bill 92 - 113th General Assembly
The superintendent of insurance may authorize a lower score than the Flesch reading ease score required in division (A)(1) of section 3902.04 of the Revised Code whenever, in his discretion, he finds that a lower score meets any of the following conditions:
(A) The lower score will provide a more accurate reflection of the readability of a policy form;
(B) The lower score is warranted by the nature of a particular policy form or type or class of policy forms;
(C) The lower score is caused by certain policy language that is drafted to conform to the requirements of any law, rule, or agency interpretation.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.07 | Approval of Policy Form Notwithstanding Provisions of Other Laws.

Effective:
January 9, 1980
Latest Legislation:
Senate Bill 92 - 113th General Assembly
A policy form meeting the requirements of section 3902.04 of the Revised Code shall be approved notwithstanding the provisions of any other laws that specify the content of policies, if the policy form provides the policyholders and claimants protection not less favorable than they would be entitled to under such laws.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.08 | Policy Forms Compliance Date.

Effective:
January 1, 2021
Latest Legislation:
House Bill 339 - 133rd General Assembly
(A) Except as provided in section 3902.03 of the Revised Code, sections 3902.01 to 3902.08 of the Revised Code apply to all policy forms filed on or after January 9, 1983. No policy form shall be delivered or issued for delivery in this state on or after January 9, 1985 unless approved by the superintendent of insurance, or permitted to be issued, pursuant to sections 3902.01 to 3902.08 of the Revised Code. Any policy form that has been approved or permitted to be issued prior to January 9, 1985, and that meets the standards set by sections 3902.01 to 3902.08 of the Revised Code need not be refiled for approval, but may continue to be lawfully delivered or issued for delivery in this state upon the filing with the superintendent of a list of such forms identified by form number and accompanied by a certificate as to each such form in the manner provided in division (D) of section 3902.04 of the Revised Code.
(B) The superintendent may, in the superintendent's discretion, extend the dates in division (A) of this section.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.11 | Coordination of Benefits Definitions.

Effective:
July 24, 2002
Latest Legislation:
Senate Bill 4 - 124th General Assembly
As used in sections 3902.11 to 3902.14 of the Revised Code:
(A) "Beneficiary" and "third-party payer" have the same meanings as in section 3901.38 of the Revised Code.
(B) "Plan of health coverage" means any of the following if the policy, contract, or agreement contains a coordination of benefits provision:
(1) An individual or group sickness and accident insurance policy, which policy provides for hospital, dental, surgical, or medical services;
(2) Any individual or group contract of a health insuring corporation, which contract provides for hospital, dental, surgical, or medical services;
(3) Any other individual or group policy or agreement under which a third-party payer provides for hospital, dental, surgical, or medical services.
(C) "Provider" means a hospital, nursing home, physician, podiatrist, dentist, pharmacist, chiropractor, or other licensed health care provider entitled to reimbursement by a third-party payer for services rendered to a beneficiary under a benefits contract.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.12 | Primary or Secondary Health Coverage.

Effective:
June 29, 1988
Latest Legislation:
Senate Bill 169 - 117th General Assembly
When a plan of health coverage is primary, its benefits are paid without regard to the benefits of another plan. When a plan of health coverage is secondary, its benefits are determined by taking into consideration the payments made or to be made by another plan. When there are more than two plans, a plan may be primary as to one and may be secondary as to another.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.14 | Rules.

Effective:
June 29, 1988
Latest Legislation:
Senate Bill 169 - 117th General Assembly
The superintendent of insurance may, pursuant to Chapter 119. of the Revised Code, adopt rules to carry out the purposes of sections 3902.11 to 3902.14 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.21 | Standard Claim Form Definitions.

Effective:
July 24, 2002
Latest Legislation:
Senate Bill 4 - 124th General Assembly
As used in sections 3902.22 and 3902.23 of the Revised Code, "third-party payer" has the same meaning as in section 3901.38 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.22 | Superintendent to Develop Standard Claim Form.

Effective:
April 6, 2007
Latest Legislation:
House Bill 403 - 126th General Assembly
The superintendent of insurance shall develop a standard claim form to be used by all third-party payers and providers for reimbursement of health care services and supplies, taking into consideration the special needs of, and differences between, third-party payers. The standard claim form shall be prescribed in rules the superintendent shall adopt in accordance with Chapter 119. of the Revised Code. The superintendent may prescribe a separate claim form for each third-party payer. If a national standard claim form is established by the sickness and accident insurance industry, the superintendent shall amend the rules to comply with the national standards. The standard claim form shall include a method to specify the national provider identifiers assigned to the physical therapists and other health care professionals rendering services designated as physical therapy, as required under section 4755.56 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.23 | Use of Form Mandatory.

Effective:
July 24, 2002
Latest Legislation:
Senate Bill 4 - 124th General Assembly
Beginning one hundred eighty days after rules adopted under section 3902.22 of the Revised Code take effect, no third-party payer shall fail to use the standard claim form prescribed in those rules.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.31 | Void Contracts.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
(A) As used in this section:
(1) "Pay in full" means paying for a health service in its entirety without cost-sharing on the part of a third-party payer. "Pay in full" includes payment made under a deductible requirement.
(2) "Third-party payer" and "provider" have the same meanings as in section 3901.38 of the Revised Code.
(B)(1) Subject to division (C) of this section, a provision in a contract entered into between a third-party payer and a provider is void and against public policy if it does either of the following:
(a) Establishes a minimum amount that the provider is required to charge an individual for a health service when that individual pays in full for the service;
(b) Prohibits a provider from advertising the provider's rates for a service.
(2) Division (B)(1)(b) of this section shall not be construed as prohibiting a provision in a contract between a provider and a third-party payer that prohibits a provider from disclosing or advertising contractually agreed upon reimbursement rates for providers.
(C)(1) This section shall apply to all new contracts between a third-party payer and a provider entered into on or after the effective date of this section.
(2) For existing contracts, this section shall apply on the earlier of either of the following:
(a) Three years after the effective date of this section;
(b) The expiration date of the contract or renewal of the contract.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.36 | Compliance With Federal Mental Health and Addiction Parity Laws.

Effective:
March 24, 2021
Latest Legislation:
Senate Bill 284 - 133rd General Assembly
(A) As used in this section:
(1) "Health benefit plan" and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.
(2) "Mental Health Parity and Addiction Equity Act" means the federal "Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008," Pub. L. No. 110-343, as amended, and any federal regulations implementing that act.
(B) Each health plan issuer and health benefit plan subject to the Mental Health Parity and Addiction Equity Act shall comply with all applicable requirements of that act. The requirements of this section do not apply to a health plan issuer or a health benefit plan that is exempt from the requirements of that act by operation of law or other federal guidance.
(C) The superintendent of insurance shall implement and enforce all applicable provisions of the Mental Health Parity and Addiction Equity Act and shall do all of the following:
(1) Proactively ensure compliance by health plan issuers;
(2) Evaluate all consumer and provider complaints regarding mental health and substance use disorder benefits for possible parity violations;
(3) Adopt rules in accordance with Chapter 119. of the Revised Code as necessary to do both of the following:
(a) Effectuate any provisions of the Mental Health Parity and Addiction Equity Act that relate to the business of insurance;
(b) Enforce, monitor compliance with, and ensure continued compliance with this section.
(D) Nothing in this section is subject to the requirements of section 3901.71 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.50 | Definitions for r.c. 3902.50 to 3902.72.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
As used in sections 3902.50 to 3902.72 of the Revised Code:
(A) "Ambulance" has the same meaning as in section 4765.01 of the Revised Code.
(B) "Clinical laboratory services" has the same meaning as in section 4731.65 of the Revised Code.
(C) "Cost sharing" means the cost to a covered person under a health benefit plan according to any copayment, coinsurance, deductible, or other out-of-pocket expense requirement.
(D) "Covered" or "coverage" means the provision of benefits related to health care services to a covered person in accordance with a health benefit plan.
(E) "Covered person," "health benefit plan," "health care services," and "health plan issuer" have the same meanings as in section 3922.01 of the Revised Code.
(F) "Drug" has the same meaning as in section 4729.01 of the Revised Code.
(G) "Emergency facility" has the same meaning as in section 3701.74 of the Revised Code.
(H) "Emergency services" means all of the following as described in 42 U.S.C. 1395dd:
(1) Medical screening examinations undertaken to determine whether an emergency medical condition exists;
(2) Treatment necessary to stabilize an emergency medical condition;
(3) Appropriate transfers undertaken prior to an emergency medical condition being stabilized.
(I) "Health care practitioner" has the same meaning as in section 3701.74 of the Revised Code.
(J) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code.
(K) "Prior authorization requirement" means any practice implemented by a health plan issuer in which coverage of a health care service, device, or drug is dependent upon a covered person or a provider obtaining approval from the health plan issuer prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization requirement" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.
(L) "Unanticipated out-of-network care" means health care services, including clinical laboratory services, that are covered under a health benefit plan and that are provided by an out-of-network provider when either of the following conditions applies:
(1) The covered person did not have the ability to request such services from an in-network provider.
(2) The services provided were emergency services.
Last updated September 9, 2021 at 5:16 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.53 | Out-of-Network Care Rules, Prompt Pay Requirements, Violations.

Effective:
April 12, 2021
Latest Legislation:
House Bill 388 - 133rd General Assembly
(A)(1) Except as provided in division (A)(2) of this section, sections 3901.38 to 3901.3814 of the Revised Code shall not apply with respect to a claim during a period of negotiation under section 3902.51 of the Revised Code or a period of arbitration under section 3902.52 of the Revised Code. Sections 3901.38 to 3901.3814 of the Revised Code shall apply upon the completion of a successful negotiation or upon the rendering of an arbitration decision.
(2) The superintendent of insurance may adopt rules pursuant to division (D) of section 3902.54 of the Revised Code specifying situations in which sections 3901.38 to 3901.3814 of the Revised Code apply during periods of negotiation under section 3902.51 of the Revised Code.
(B) A pattern of continuous or repeated violations of section 3902.51 or 3902.52 of the Revised Code by a health plan issuer is an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.
(C) A provider who violates section 3902.51 or 3902.52 of the Revised Code shall be subject to professional discipline under Title XLVII of the Revised Code as applicable.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.60 | Advanced Cancer Fail First Drug Coverage Definitions.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
As used in sections 3902.60 and 3902.61 of the Revised Code:
(A) "Associated conditions" means the symptoms or side effects of stage four advanced metastatic cancer, or the treatment thereof, which would, in the judgment of the health care practitioner in question, jeopardize the health of a covered individual if left untreated.
(B) "Stage four advanced metastatic cancer" means a cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
Last updated August 31, 2021 at 4:37 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.61 | Advanced Cancer Fail First Drug Coverage Prohibitions.

Effective:
March 24, 2021
Latest Legislation:
Senate Bill 252 - 133rd General Assembly
(A) Notwithstanding section 3901.71 and sections 3901.831 to 3901.833 of the Revised Code, a health benefit plan issued, delivered, or renewed in this state on or after the effective date of this section that directly or indirectly covers the treatment of stage four advanced metastatic cancer shall not make coverage of a drug that is prescribed to treat such cancer or associated conditions dependent upon a covered person demonstrating either of the following:
(1) Failure to successfully respond to a different drug;
(2) A history of failing to respond to a different drug or drugs.
(B) Division (A) of this section applies only to uses of such drug or drugs that are consistent with either of the following:
(1) An indication approved by, or described in, as applicable, either of the following for the treatment of stage four advanced metastatic cancer:
(a) The United States food and drug administration;
(b) The national comprehensive cancer network drugs and biologics compendium.
(2) The best practices for the treatment of stage four advanced metastatic cancer, as supported by peer-reviewed medical literature.
(C) A violation of this section is an unfair and deceptive practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.62 | Coverage for Drugs Refilled Without a Prescription.

Effective:
June 1, 2022
Latest Legislation:
House Bill 37 - 134th General Assembly
(A) As used in this section, "licensed health professional authorized to prescribe drugs" has the same meaning as in section 4729.01 of the Revised Code.
(B) Notwithstanding section 3901.71 of the Revised Code, if a health plan issuer covers a prescription drug under a health benefit plan, the health plan issuer shall also provide coverage for that drug when it is dispensed by a pharmacist to a covered person in accordance with section 4729.281 of the Revised Code.
A health benefit plan shall not impose cost-sharing requirements for a drug dispensed in accordance with section 4729.281 of the Revised Code that are greater than those imposed when that drug is dispensed in accordance with a prescription issued by a licensed health professional authorized to prescribe drugs.
Last updated March 15, 2022 at 5:15 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.70 | Health Plan Issuer Contracts With 340b Program Participants Definitions.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
As used in this section and section 3902.71 of the Revised Code:
(A) "340B covered entity" and "third-party administrator" have the same meanings as in section 5167.01 of the Revised Code.
(B) "Terminal distributor of dangerous drugs" has the same meaning as in section 4729.01 of the Revised Code.
Last updated August 31, 2021 at 4:37 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3902 | Insurance Policies and Contracts › Section 3902.71 | Health Plan Issuer Contracts With 340b Program Participants.

Effective:
April 12, 2021
Latest Legislation:
Senate Bill 263 - 133rd General Assembly
(A) On and after the effective date of this section , a contract entered into between a health plan issuer, including a third-party administrator, and a 340B covered entity shall not contain any of the following provisions:
(1) A reimbursement rate for a prescription drug that is less than the national average drug acquisition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. 1395w-3a(c)(6)(B);
(2) A dispensing fee reimbursement amount that is less than the reimbursement amount provided to a terminal distributor of dangerous drugs under section 5164.753 of the Revised Code;
(3) A fee that is not imposed on a health care provider that is not a 340B covered entity;
(4) A fee amount that exceeds the fee amount for a health care provider that is not a 340B covered entity.
(B) No health plan issuer or third-party administrator making payments pursuant to a health benefit plan shall discriminate against a 340B covered entity in a manner that prevents or interferes with an enrollee's choice to receive a prescription drug from a 340B covered entity or its contracted pharmacies.
(C) Any provision of a contract entered into between a health plan issuer and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensing fee or reimbursement rate that applies for health care providers that are not 340B covered entities.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3903 | Reserve Valuation; Rehabilitation and Liquidation › Section 3903.02 | Citing of Act - Purpose of Act.

Effective:
March 7, 1983
Latest Legislation:
House Bill 830 - 114th General Assembly
(A) Sections 3903.01 to 3903.59 of the Revised Code may be cited as "the insurers supervision, rehabilitation, and liquidation act."
(B) Sections 3903.01 to 3903.59 of the Revised Code do not limit the powers granted the superintendent of insurance under any other section of the Revised Code.
(C) Sections 3903.01 to 3903.59 of the Revised Code shall be liberally construed to effect the purpose stated in division (D) of this section.
(D) The purpose of sections 3903.01 to 3903.59 of the Revised Code is the protection of the interests of insureds, claimants, creditors, and the public generally, with minimum interference with the normal prerogatives of the owners and managers of insurers, through all of the following:
(1) Early detection of any potentially dangerous condition in an insurer, and prompt application of appropriate corrective measures;
(2) Improved methods for rehabilitating insurers, involving the cooperation and management expertise of the insurance industry;
(3) Enhanced efficiency and economy of liquidation, through clarification of the law, to minimize legal uncertainty and litigation;
(4) Equitable apportionment of any unavoidable loss;
(5) Lessening the problems of interstate rehabilitation and liquidation by facilitating cooperation between states in the liquidation process, and by extending the scope of personal jurisdiction over debtors of the insurer outside this state;
(6) Regulation of the insurance business by the impact of the law relating to delinquency procedures and substantive rules on the entire insurance business.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3903 | Reserve Valuation; Rehabilitation and Liquidation › Section 3903.03 | Application of Sections.

Effective:
March 7, 1983
Latest Legislation:
House Bill 830 - 114th General Assembly
The proceedings authorized by sections 3903.01 to 3903.59 of the Revised Code may be applied to any one or more of the following:
(A) All insurers who are doing, or have done, an insurance business in this state, and against whom claims arising from that business may exist now or in the future;
(B) All insurers who purport to do an insurance business in this state;
(C) All insurers who have insureds resident in this state;
(D) All other persons organized or in the process of organizing with the intent to do an insurance business in this state;
(E) All other companies, associations, societies, or entities subject to regulation by the superintendent of insurance under Titles XVII and XXXIX of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3903 | Reserve Valuation; Rehabilitation and Liquidation › Section 3903.04 | Jurisdiction.

Effective:
March 7, 1983
Latest Legislation:
House Bill 830 - 114th General Assembly
(A) No delinquency proceeding shall be commenced under this chapter by anyone other than the superintendent of insurance of this state. No court has jurisdiction to entertain, hear, or determine any delinquency proceeding commenced by any other person.
(B) No court of this state has jurisdiction to entertain, hear, or determine any complaint praying for the dissolution, liquidation, rehabilitation, sequestration, conservation, or receivership of any insurer, or praying for a temporary restraining order, preliminary injunction, or permanent injunction, or other relief preliminary to, incidental to, or relating to delinquency proceedings other than in accordance with sections 3903.01 to 3903.59 of the Revised Code.
(C) In addition to other grounds for jurisdiction provided by the law of this state, a court of common pleas has jurisdiction over a person served pursuant to the Civil Rules in an action brought by the conservator, rehabilitator, or liquidator of a domestic insurer or an alien insurer domiciled in this state if any of the following apply:
(1) The person served is obligated to the insurer in any way as an incident to any agency or brokerage arrangement that may exist or has existed between the insurer and the agent or broker, in any action on or incident to the obligation;
(2) The person served is a reinsurer who has at any time written a policy of reinsurance for an insurer against which a rehabilitation or liquidation order is in effect when the action is commenced, or is an agent or broker of or for the reinsurer, in any action on or incident to the reinsurance contract;
(3) The person served is or has been an officer, manager, trustee, organizer, promoter, or person in a position of comparable authority or influence in an insurer against which a rehabilitation or liquidation order is in effect when the action is commenced, in any action resulting from such a relationship with the insurer.
(D) If the court, on motion of any party, finds that any action should as a matter of substantial justice be tried in a forum outside this state, the court may stay further proceedings on the action in this state.
(E) All actions authorized in sections 3903.01 to 3903.59 of the Revised Code shall be brought in the court of common pleas of Franklin county.