Ohio § 1751.01

§ 1751.01.

As used in this chapter: (A)(1) “ Basic health care services ” means the following services when medically necessary: (a) Physician's services, except when such services are supplemental under division (B)

of this section; (b) Inpatient hospital services; (c) Outpatient medical services; (d) Emergency health services; (e) Urgent care services; (f) Diagnostic laboratory services and diagnostic and therapeutic radiologic services; (g) Diagnostic and treatment services, other than prescription drug services, for biologically

based mental illnesses; (h) Preventive health care services, including, but not limited to, voluntary family

planning services, infertility services, periodic physical examinations, prenatal

obstetrical care, and well-child care; (i) Routine patient care for patients enrolled in an eligible cancer clinical trial pursuant

to section 3923.80 of the Revised Code . “Basic health care services” does not include experimental procedures. Except as provided by divisions (A)(2) and (3) of this section in connection with

the offering of coverage for diagnostic and treatment services for biologically based

mental illnesses, a health insuring corporation shall not offer coverage for a health

care service, defined as a basic health care service by this division, unless it offers

coverage for all listed basic health care services.  However, this requirement does not apply to the coverage of beneficiaries enrolled

in medicare pursuant to a medicare contract, or to the coverage of beneficiaries enrolled

in the federal employee health benefits program pursuant to 5 U.S.C.A. 8905 , or to the coverage of medicaid recipients, or to the coverage of beneficiaries under

any federal health care program regulated by a federal regulatory body, or to the

coverage of beneficiaries under any contract covering officers or employees of the

state that has been entered into by the department of administrative services. (2) A health insuring corporation may offer coverage for diagnostic and treatment services

for biologically based mental illnesses without offering coverage for all other basic

health care services.  A health insuring corporation may offer coverage for diagnostic and treatment services

for biologically based mental illnesses alone or in combination with one or more supplemental

health care services.  However, a health insuring corporation that offers coverage for any other basic

health care service shall offer coverage for diagnostic and treatment services for

biologically based mental illnesses in combination with the offer of coverage for

all other listed basic health care services. (3) A health insuring corporation that offers coverage for basic health care services

is not required to offer coverage for diagnostic and treatment services for biologically

based mental illnesses in combination with the offer of coverage for all other listed

basic health care services if all of the following apply: (a) The health insuring corporation submits documentation certified by an independent

member of the American academy of actuaries to the superintendent of insurance showing

that incurred claims for diagnostic and treatment services for biologically based

mental illnesses for a period of at least six months independently caused the health

insuring corporation's costs for claims and administrative expenses for the coverage

of basic health care services to increase by more than one per cent per year. (b) The health insuring corporation submits a signed letter from an independent member

of the American academy of actuaries to the superintendent of insurance opining that

the increase in costs described in division (A)(3)(a) of this section could reasonably

justify an increase of more than one per cent in the annual premiums or rates charged

by the health insuring corporation for the coverage of basic health care services. (c) The superintendent of insurance makes the following determinations from the documentation

and opinion submitted pursuant to divisions (A)(3)(a) and (b) of this section: (i) Incurred claims for diagnostic and treatment services for biologically based mental

illnesses for a period of at least six months independently caused the health insuring

corporation's costs for claims and administrative expenses for the coverage of basic

health care services to increase by more than one per cent per year. (ii) The increase in costs reasonably justifies an increase of more than one per cent

in the annual premiums or rates charged by the health insuring corporation for the

coverage of basic health care services. Any determination made by the superintendent under this division is subject to Chapter

119. of the Revised Code. (B)(1) “ Supplemental health care services ” means any health care services other than basic health care services that a health

insuring corporation may offer, alone or in combination with either basic health care

services or other supplemental health care services, and includes: (a) Services of facilities for intermediate or long-term care, or both; (b) Dental care services; (c) Vision care and optometric services including lenses and frames; (d) Podiatric care or foot care services; (e) Mental health services, excluding diagnostic and treatment services for biologically

based mental illnesses; (f) Short-term outpatient evaluative and crisis-intervention mental health services; (g) Medical or psychological treatment and referral services for alcohol and drug abuse

or addiction; (h) Home health services; (i) Prescription drug services; (j) Nursing services; (k) Services of a dietitian licensed under Chapter 4759. of the Revised Code; (l) Physical therapy services; (m) Chiropractic services; (n) Any other category of services approved by the superintendent of insurance. (2) If a health insuring corporation offers prescription drug services under this division,

the coverage shall include prescription drug services for the treatment of biologically

based mental illnesses on the same terms and conditions as other physical diseases

and disorders. (C) “ Specialty health care services ” means one of the supplemental health care services listed in division (B) of this

section, when provided by a health insuring corporation on an outpatient-only basis

and not in combination with other supplemental health care services. (D) “ Biologically based mental illnesses ” means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar

disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and

panic disorder, as these terms are defined in the most recent edition of the diagnostic

and statistical manual of mental disorders published by the American psychiatric association. (E) “ Closed panel plan ” means a health care plan that requires enrollees to use participating providers. (F) “ Compensation ” means remuneration for the provision of health care services, determined on other

than a fee-for-service or discounted-fee-for-service basis. (G) “ Contractual periodic prepayment ” means the formula for determining the premium rate for all subscribers of a health

insuring corporation. (H) “ Corporation ” means a corporation formed under Chapter 1701. or 1702. of the Revised Code or the

similar laws of another state. (I) “ Emergency health services ” means those health care services that must be available on a seven-days-per-week,

twenty-four-hours-per-day basis in order to prevent jeopardy to an enrollee's health

status that would occur if such services were not received as soon as possible, and

includes, where appropriate, provisions for transportation and indemnity payments

or service agreements for out-of-area coverage. (J) “ Enrollee ” means any natural person who is entitled to receive health care benefits provided

by a health insuring corporation. (K) “ Evidence of coverage ” means any certificate, agreement, policy, or contract issued to a subscriber that

sets out the coverage and other rights to which such person is entitled under a health

care plan. (L) “ Health care facility ” means any facility, except a health care practitioner's office, that provides preventive,

diagnostic, therapeutic, acute convalescent, rehabilitation, mental health, intellectual

disability, intermediate care, or skilled nursing services. (M) “ Health care services ” means basic, supplemental, and specialty health care services. (N) “ Health delivery network ” means any group of providers or health care facilities, or both, or any representative

thereof, that have entered into an agreement to offer health care services in a panel

rather than on an individual basis. (O) “ Health insuring corporation ” means a corporation, as defined in division (H) of this section, that, pursuant

to a policy, contract, certificate, or agreement, pays for, reimburses, or provides,

delivers, arranges for, or otherwise makes available, basic health care services,

supplemental health care services, or specialty health care services, or a combination

of basic health care services and either supplemental health care services or specialty

health care services, through either an open panel plan or a closed panel plan. “Health insuring corporation” does not include a limited liability company formed

pursuant to Chapter 1705. or 1706. of the Revised Code, an insurer licensed under

Title XXXIX of the Revised Code if that insurer offers only open panel plans under

which all providers and health care facilities participating receive their compensation

directly from the insurer, a corporation formed by or on behalf of a political subdivision

or a department, office, or institution of the state, or a public entity formed by

or on behalf of a board of county commissioners, a county board of developmental disabilities,

an alcohol and drug addiction services board, a board of alcohol, drug addiction,

and mental health services, or a community mental health board, as those terms are

used in Chapters 340. and 5126. of the Revised Code.  Except as provided by division (D) of section 1751.02 of the Revised Code , or as otherwise provided by law, no board, commission, agency, or other entity under

the control of a political subdivision may accept insurance risk in providing for

health care services.  However, nothing in this division shall be construed as prohibiting such entities

from purchasing the services of a health insuring corporation or a third-party administrator

licensed under Chapter 3959. of the Revised Code. (P) “ Intermediary organization ” means a health delivery network or other entity that contracts with licensed health

insuring corporations or self-insured employers, or both, to provide health care services,

and that enters into contractual arrangements with other entities for the provision

of health care services for the purpose of fulfilling the terms of its contracts with

the health insuring corporations and self-insured employers. (Q) “ Intermediate care ” means residential care above the level of room and board for patients who require

personal assistance and health-related services, but who do not require skilled nursing

care. (R) “ Medical record ” means the personal information that relates to an individual's physical or mental

condition, medical history, or medical treatment. (S)(1) “ Open panel plan ” means a health care plan that provides incentives for enrollees to use participating

providers and that also allows enrollees to use providers that are not participating

providers. (2) No health insuring corporation may offer an open panel plan, unless the health insuring

corporation is also licensed as an insurer under Title XXXIX of the Revised Code,

the health insuring corporation, on June 4, 1997, holds a certificate of authority

or license to operate under Chapter 1736. or 1740. of the Revised Code, or an insurer

licensed under Title XXXIX of the Revised Code is responsible for the out-of-network

risk as evidenced by both an evidence of coverage filing under section 1751.11 of the Revised Code and a policy and certificate filing under section 3923.02 of the Revised Code . (T) “ Osteopathic hospital ” means a hospital registered under section 3701.07 of the Revised Code that advocates osteopathic principles and the practice and perpetuation of osteopathic

medicine by doing any of the following: (1) Maintaining a department or service of osteopathic medicine or a committee on the

utilization of osteopathic principles and methods, under the supervision of an osteopathic

physician; (2) Maintaining an active medical staff, the majority of which is comprised of osteopathic

physicians; (3) Maintaining a medical staff executive committee that has osteopathic physicians as

a majority of its members. (U) “ Panel ” means a group of providers or health care facilities that have joined together to

deliver health care services through a contractual arrangement with a health insuring

corporation, employer group, or other payor. (V) “Person” has the same meaning as in section 1.59 of the Revised Code , and, unless the context otherwise requires, includes any insurance company holding

a certificate of authority under Title XXXIX of the Revised Code, any subsidiary and

affiliate of an insurance company, and any government agency. (W) “ Premium rate ” means any set fee regularly paid by a subscriber to a health insuring corporation.  A “premium rate” does not include a one-time membership fee, an annual administrative

fee, or a nominal access fee, paid to a managed health care system under which the

recipient of health care services remains solely responsible for any charges accessed

for those services by the provider or health care facility. (X) “ Primary care provider ” means a provider that is designated by a health insuring corporation to supervise,

coordinate, or provide initial care or continuing care to an enrollee, and that may

be required by the health insuring corporation to initiate a referral for specialty

care and to maintain supervision of the health care services rendered to the enrollee. (Y) “ Provider ” means any natural person or partnership of natural persons who are licensed, certified,

accredited, or otherwise authorized in this state to furnish health care services,

or any professional association organized under Chapter 1785. of the Revised Code,

provided that nothing in this chapter or other provisions of law shall be construed

to preclude a health insuring corporation, health care practitioner, or organized

health care group associated with a health insuring corporation from employing certified

nurse practitioners, certified nurse anesthetists, clinical nurse specialists, certified

nurse-midwives, pharmacists, dietitians, physician assistants, dental assistants,

dental hygienists, optometric technicians, or other allied health personnel who are

licensed, certified, accredited, or otherwise authorized in this state to furnish

health care services. (Z) “ Provider sponsored organization ” means a corporation, as defined in division (H) of this section, that is at least

eighty per cent owned or controlled by one or more hospitals, as defined in section 3727.01 of the Revised Code , or one or more physicians licensed to practice medicine or surgery or osteopathic

medicine and surgery under Chapter 4731. of the Revised Code, or any combination of

such physicians and hospitals.  Such control is presumed to exist if at least eighty per cent of the voting rights

or governance rights of a provider sponsored organization are directly or indirectly

owned, controlled, or otherwise held by any combination of the physicians and hospitals

described in this division. (AA) “ Solicitation document ” means the written materials provided to prospective subscribers or enrollees, or

both, and used for advertising and marketing to induce enrollment in the health care

plans of a health insuring corporation. (BB) “ Subscriber ” means a person who is responsible for making payments to a health insuring corporation

for participation in a health care plan, or an enrollee whose employment or other

status is the basis of eligibility for enrollment in a health insuring corporation. (CC) “ Urgent care services ” means those health care services that are appropriately provided for an unforeseen

condition of a kind that usually requires medical attention without delay but that

does not pose a threat to the life, limb, or permanent health of the injured or ill

person, and may include such health care services provided out of the health insuring

corporation's approved service area pursuant to indemnity payments or service agreements.