Ohio § 3923.281

§ 3923.281.

(A) As used in this section: (1) “ Biologically based mental illness ” 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. (2) “Policy of sickness and accident insurance” has the same meaning as in section 3923.01 of the Revised Code , but excludes any hospital indemnity, medicare supplement, long-term care, disability

income, one-time-limited-duration policy that is less than twelve months, supplemental

benefit, or other policy that provides coverage for specific diseases or accidents

only;  any policy that provides coverage for workers' compensation claims compensable

pursuant to Chapters 4121. and 4123. of the Revised Code;  and any policy that provides

coverage to medicaid recipients. (B) Notwithstanding section 3901.71 of the Revised Code , and subject to division (E) of this section, every policy of sickness and accident

insurance shall provide benefits for the diagnosis and treatment of biologically based

mental illnesses on the same terms and conditions as, and shall provide benefits no

less extensive than, those provided under the policy of sickness and accident insurance

for the treatment and diagnosis of all other physical diseases and disorders, if both

of the following apply: (1) The biologically based mental illness is clinically diagnosed by a physician authorized

under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic

medicine and surgery;  a psychologist licensed under Chapter 4732. of the Revised

Code;  a licensed professional clinical counselor, licensed professional counselor,

independent social worker, or independent marriage and family therapist licensed under

Chapter 4757. of the Revised Code;  or a clinical nurse specialist or certified nurse

practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty

is mental health. (2) The prescribed treatment is not experimental or investigational, having proven its

clinical effectiveness in accordance with generally accepted medical standards. (C) Division (B) of this section applies to all coverages and terms and conditions of

the policy of sickness and accident insurance, including, but not limited to, coverage

of inpatient hospital services, outpatient services, and medication;  maximum lifetime

benefits;  copayments;  and individual and family deductibles. (D) Nothing in this section shall be construed as prohibiting a sickness and accident

insurance company from taking any of the following actions: (1) Negotiating separately with mental health care providers with regard to reimbursement

rates and the delivery of health care services; (2) Offering policies that provide benefits solely for the diagnosis and treatment of

biologically based mental illnesses; (3) Managing the provision of benefits for the diagnosis or treatment of biologically

based mental illnesses through the use of pre-admission screening, by requiring beneficiaries

to obtain authorization prior to treatment, or through the use of any other mechanism

designed to limit coverage to that treatment determined to be necessary; (4) Enforcing the terms and conditions of a policy of sickness and accident insurance. (E) An insurer that offers any policy of sickness and accident insurance is not required

to provide benefits for the diagnosis and treatment of biologically based mental illnesses

pursuant to division (B) of this section if all of the following apply: (1) The insurer 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 insurer's costs for claims

and administrative expenses for the coverage of all other physical diseases and disorders

to increase by more than one per cent per year. (2) The insurer submits a signed letter from an independent member of the American academy

of actuaries to the superintendent of insurance opining that the increase described

in division (E)(1) of this section could reasonably justify an increase of more than

one per cent in the annual premiums or rates charged by the insurer for the coverage

of all other physical diseases and disorders. (3) The superintendent of insurance makes the following determinations from the documentation

and opinion submitted pursuant to divisions (E)(1) and (2) of this section: (a) Incurred claims for diagnostic and treatment services for biologically based mental

illnesses for a period of at least six months independently caused the insurer's costs

for claims and administrative expenses for the coverage of all other physical diseases

and disorders to increase by more than one per cent per year. (b) The increase in costs reasonably justifies an increase of more than one per cent

in the annual premiums or rates charged by the insurer for the coverage of all other

physical diseases and disorders. Any determination made by the superintendent under this division is subject to Chapter

119. of the Revised Code.