Ohio § 3923.022

§ 3923.022.

(A) As used in this section: (1)(a) “ Administrative expense ” means the amount resulting from the following:  the amount of premiums earned by

the insurer for sickness and accident insurance business plus the amount of losses

recovered from reinsurance coverage minus the sum of the amount of claims for losses

paid;  the amount of losses incurred but not reported;  the amount incurred for state

fees, federal and state taxes, and reinsurance;  and the incurred costs and expenses

related, either directly or indirectly, to the payment of commissions, measures to

control fraud, and managed care. (b) “Administrative expense” does not include any amounts collected, or administrative

expenses incurred, by an insurer for the administration of an employee health benefit

plan subject to regulation by the federal “Employee Retirement Income Security Act

of 1974,” 88 Stat. 832, 29 U.S.C.A. 1001 , as amended.  “ Amounts collected or administrative expenses incurred ” means the total amount paid to an administrator for the administration and payment

of claims minus the sum of the amount of claims for losses paid and the amount of

losses incurred but not reported. (2) “ Insurer ” means any insurance company authorized under Title XXXIX of the Revised Code to

do the business of sickness and accident insurance in this state. (3) “ Sickness and accident insurance business ” does not include coverage provided by an insurer for specific diseases or accidents

only;  any hospital indemnity, medicare supplement, long-term care, disability income,

one-time-limited-duration policy that is less than twelve months, or other policy

that offers only supplemental benefits;  or coverage provided to individuals who are

not residents of this state. (4) “ Individual business ” includes both individual sickness and accident insurance and sickness and accident

insurance made available by insurers in the individual market to individuals, with

or without family members or dependents, through group policies issued to one or more

associations or entities. (B) Notwithstanding section 3941.14 of the Revised Code , each insurer shall have aggregate administrative expenses of no more than twenty

per cent of the premium income of the insurer, based on the premiums earned in that

year on the sickness and accident insurance business of the insurer. (C)(1) Each insurer, on the first day of January or within sixty days thereafter, shall

annually prepare, under oath, and deposit in the office of the superintendent of insurance

a statement of the aggregate administrative expenses of the insurer, based on the

premiums earned in the immediately preceding calendar year on the sickness and accident

insurance business of the insurer.  The statement shall itemize and separately detail all of the following information

with respect to the insurer's sickness and accident insurance business: (a) The amount of premiums earned by the insurer both before and after any costs related

to the insurer's purchase of reinsurance coverage; (b) The total amount of claims for losses paid by the insurer both before and after any

reimbursement from reinsurance coverage; (c) The amount of any losses incurred by the insurer but not reported by the insurer

in the current or prior year; (d) The amount of costs incurred by the insurer for state fees and federal and state

taxes; (e) The amount of costs incurred by the insurer for reinsurance coverage; (f) The amount of costs incurred by the insurer that are related to the insurer's payment

of commissions; (g) The amount of costs incurred by the insurer that are related to the insurer's fraud

prevention measures; (h) The amount of costs incurred by the insurer that are related to managed care;  and (i) Any other administrative expenses incurred by the insurer. (2) The statement also shall include all of the information required under division (C)(1)

of this section separately detailed for the insurer's individual business, small group

business, and large group business. (D) No insurer shall fail to comply with this section. (E) If the superintendent determines that an insurer has violated this section, the superintendent,

pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised

Code, may order the suspension of the insurer's license to do the business of sickness

and accident insurance in this state until the superintendent is satisfied that the

insurer is in compliance with this section.  If the insurer continues to do the business of sickness and accident insurance in

this state while under the suspension order, the superintendent shall order the insurer

to pay one thousand dollars for each day of the violation. (F) Any money collected by the superintendent under division (E) of this section shall

be deposited by the superintendent into the state treasury to the credit of the department

of insurance operating fund. (G) The statement of aggregate expenses filed pursuant to this section separately detailing

an insurer's individual, small group, and large group business shall be considered

work papers resulting from the conduct of a market analysis of an entity subject to

examination by the superintendent under division (C) of section 3901.48 of the Revised Code , except that the superintendent may share aggregated market information that identifies

the premiums earned as reported under division (C)(1)(a) of this section, the administrative

expenses reported under division (C)(1)(i) of this section, the amount of commissions

reported under division (C)(1)(f) of this section, the amount of taxes paid as reported

under division (C)(1)(d) of this section, the total of the remaining benefit costs

as reported under divisions (C)(1)(b) and (c) of this section, and the amount of fraud

and managed care expenses reported under divisions (C)(1)(g) and (h) of this section.