Ohio § 1751.12

§ 1751.12.

(A)(1) No contractual periodic prepayment and no premium rate for nongroup and conversion

policies for health care services, or any amendment to them, may be used by any health

insuring corporation at any time until the contractual periodic prepayment and premium

rate, or amendment, have been filed with the superintendent of insurance, and shall

not be effective until the expiration of sixty days after their filing unless the

superintendent sooner gives approval.  The filing shall be accompanied by an actuarial certification in the form prescribed

by the superintendent.  The superintendent shall disapprove the filing, if the superintendent determines

within the sixty-day period that the contractual periodic prepayment or premium rate,

or amendment, is not in accordance with sound actuarial principles or is not reasonably

related to the applicable coverage and characteristics of the applicable class of

enrollees.  The superintendent shall notify the health insuring corporation of the disapproval,

and it shall thereafter be unlawful for the health insuring corporation to use the

contractual periodic prepayment or premium rate, or amendment. (2) No contractual periodic prepayment for group policies for health care services shall

be used until the contractual periodic prepayment has been filed with the superintendent.  The filing shall be accompanied by an actuarial certification in the form prescribed

by the superintendent.  The superintendent may reject a filing made under division (A)(2) of this section

at any time, with at least thirty days' written notice to a health insuring corporation,

if the contractual periodic prepayment is not in accordance with sound actuarial principles

or is not reasonably related to the applicable coverage and characteristics of the

applicable class of enrollees. (3) At any time, the superintendent, upon at least thirty days' written notice to a health

insuring corporation, may withdraw the approval given under division (A)(1) of this

section, deemed or actual, of any contractual periodic prepayment or premium rate,

or amendment, based on information that either of the following applies: (a) The contractual periodic prepayment or premium rate, or amendment, is not in accordance

with sound actuarial principles. (b) The contractual periodic prepayment or premium rate, or amendment, is not reasonably

related to the applicable coverage and characteristics of the applicable class of

enrollees. (4) Any disapproval under division (A)(1) of this section, any rejection of a filing

made under division (A)(2) of this section, or any withdrawal of approval under division

(A)(3) of this section, shall be effected by a written notice, which shall state the

specific basis for the disapproval, rejection, or withdrawal and shall be issued in

accordance with Chapter 119. of the Revised Code. (B) Notwithstanding division (A) of this section, a health insuring corporation may use

a contractual periodic prepayment or premium rate for policies used for the coverage

of beneficiaries enrolled in medicare pursuant to a medicare risk contract or medicare

cost contract, or for policies used for the coverage of beneficiaries enrolled in

the federal employees health benefits program pursuant to 5 U.S.C.A. 8905 , or for policies used for the coverage of medicaid recipients, or for policies used

for the coverage of beneficiaries under any other federal health care program regulated

by a federal regulatory body, or for policies used for 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, if both of the following apply: (1) The contractual periodic prepayment or premium rate has been approved by the United

States department of health and human services, the United States office of personnel

management, the department of medicaid, or the department of administrative services. (2) The contractual periodic prepayment or premium rate is filed with the superintendent

prior to use and is accompanied by documentation of approval from the United States

department of health and human services, the United States office of personnel management,

the department of medicaid, or the department of administrative services. (C) The administrative expense portion of all contractual periodic prepayment or premium

rate filings submitted to the superintendent for review must reflect the actual cost

of administering the product.  The superintendent may require that the administrative expense portion of the filings

be itemized and supported. (D)(1) Copayments, cost sharing, and deductibles must be reasonable and must not be a barrier

to the necessary utilization of services by enrollees. (2) A health insuring corporation, in order to ensure that copayments, cost sharing,

and deductibles are reasonable and not a barrier to the necessary utilization of basic

health care services by enrollees shall impose copayment charges, cost sharing, and

deductible charges that annually do not exceed forty per cent of the total annual

cost to the health insuring corporation of providing all covered health care services

when applied to a standard population expected to be covered under the filed product

in question.  The total annual cost of providing a health care service is the cost to the health

insuring corporation of providing the health care service to its enrollees as reduced

by any applicable provider discount.  This requirement shall be demonstrated by an actuary who is a member of the American

academy of actuaries and qualified to provide such certifications as described in

the United States qualification standards promulgated by the American academy of actuaries

pursuant to the code of professional conduct. (3) For purposes of division (D) of this section, all of the following apply: (a) Copayments imposed by health insuring corporations in connection with a high deductible

health plan that is linked to a health savings account are reasonable and are not

a barrier to the necessary utilization of services by enrollees. (b) Division (D)(2) of this section does not apply to a high deductible health plan that

is linked to a health savings account. (c) Catastrophic-only plans, as defined under the “Patient Protection and Affordable

Care Act,” 124 Stat. 119, 42 U.S.C. 18022 and any related regulations, are not subject to the limits prescribed in division

(D) of this section, provided that such plans meet all applicable minimum federal

requirements. (E) A health insuring corporation shall not impose lifetime maximums on basic health

care services.  However, a health insuring corporation may establish a benefit limit for inpatient

hospital services that are provided pursuant to a policy, contract, certificate, or

agreement for supplemental health care services. (F) The superintendent may adopt rules allowing different copayment, cost sharing, and

deductible amounts for plans with a medical savings account, health reimbursement

arrangement, flexible spending account, or similar account; (G) A health insuring corporation may impose higher copayment, cost sharing, and deductible

charges under health plans if requested by the group contract, policy, certificate,

or agreement holder, or an individual seeking coverage under an individual health

plan.  This shall not be construed as requiring the health insuring corporation to create

customized health plans for group contract holders or individuals. (H) As used in this section, “health savings account” and “high deductible health plan”

have the same meanings as in the “Internal Revenue Code of 1986,” 100 Stat. 2085, 26 U.S.C. 223 , as amended.