Ohio § 3959.01

§ 3959.01.

As used in this chapter: (A) “ Administration fees ” means any amount charged a covered person for services rendered.  “ Administration fees ” includes commissions earned or paid by any person relative to services performed

by an administrator. (B) “ Administrator ” means any person who adjusts or settles claims on, residents of this state in connection

with life, dental, health, prescription drugs, or disability insurance or self-insurance

programs.  “ Administrator ” includes a pharmacy benefit manager, except as described in division (B)(6) of this

section.  “Administrator” does not include any of the following: (1) An insurance agent or solicitor licensed in this state whose activities are limited

exclusively to the sale of insurance and who does not provide any administrative services; (2) Any person who administers or operates the workers' compensation program of a self-insuring

employer under Chapter 4123. of the Revised Code; (3) Any person who administers pension plans for the benefit of the person's own members

or employees or administers pension plans for the benefit of the members or employees

of any other person; (4) Any person that administers an insured plan or a self-insured plan that provides

life, dental, health, or disability benefits exclusively for the person's own members

or employees; (5) Any health insuring corporation holding a certificate of authority under Chapter

1751. of the Revised Code or an insurance company that is authorized to write life

or sickness and accident insurance in this state; (6) On and after July 1, 2027, a pharmacy benefit manager licensed under Chapter 3957.

of the Revised Code but only with respect to agreements that are entered into, amended,

or renewed on or after that date. (C) “ Aggregate excess insurance ” means that type of coverage whereby the insurer agrees to reimburse the insured

employer or trust for all benefits or claims paid during an agreement period on behalf

of all covered persons under the plan or trust which exceed a stated deductible amount

and subject to a stated maximum. (D) “ Contracted pharmacy ” or “ pharmacy ” means a pharmacy located in this state participating in either the network of a

pharmacy benefit manager or in a health care or pharmacy benefit plan through a direct

contract or through a contract with a pharmacy services administration organization,

group purchasing organization, or another contracting agent. (E) “ Contributions ” means any amount collected from a covered person to fund the self-insured portion

of any plan in accordance with the plan's provisions, summary plan descriptions, and

contracts of insurance. (F) “Fiduciary” has the meaning set forth in section 1002(21)(A) of the “Employee Retirement

Income Security Act of 1974,” 88 Stat. 829, 29 U.S.C. 1001 , as amended. (G) “ Fiscal year ” means the twelve-month accounting period commencing on the date the plan is established

and ending twelve months following that date, and each corresponding twelve-month

accounting period thereafter as provided for in the summary plan description. (H) “ Insurer ” means an entity authorized to do the business of insurance in this state or, for

the purposes of this section, a health insuring corporation authorized to issue health

care plans in this state. (I) “ Managed care organization ” means an entity that provides medical management and cost containment services and

includes a medicaid managed care organization, as defined in section 5167.01 of the Revised Code . (J) “Multiple employer welfare arrangement” has the same meaning as in section 1739.01 of the Revised Code . (K) “Pharmacy benefit manager” has the same meaning as in section 3957.01 of the Revised Code . (L) “ Plan ” means any arrangement in written form for the payment of life, dental, health, or

disability benefits to covered persons defined by the summary plan description and

includes a drug benefit plan administered by a pharmacy benefit manager. (M) “ Plan sponsor ” means the person who establishes the plan. (N) “ Self-insurance program ” means a program whereby an employer provides a plan of benefits for its employees

without involving an intermediate insurance carrier to assume risk or pay claims.  “ Self-insurance program ” includes but is not limited to employer programs that pay claims up to a prearranged

limit beyond which they purchase insurance coverage to protect against unpredictable

or catastrophic losses. (O) “ Specific excess insurance ” means that type of coverage whereby the insurer agrees to reimburse the insured

employer or trust for all benefits or claims paid during an agreement period on behalf

of a covered person in excess of a stated deductible amount and subject to a stated

maximum. (P) “ Summary plan description ” means the written document adopted by the plan sponsor which outlines the plan of

benefits, conditions, limitations, exclusions, and other pertinent details relative

to the benefits provided to covered persons thereunder. (Q) “Third-party payer” has the same meaning as in section 3901.38 of the Revised Code .