Establish network adequacy standards for health insurers

As Introduced

136th
General Assembly

Regular
Session
H. B. No. 219

2025-2026

Representative Deeter

To
enact section 3901.93 of the Revised Code
to
establish network adequacy standards for health insurers.

BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section
1.
That
section 3901.93 of the Revised Code be enacted to read as follows:

Sec.
3901.93.
(A)
As used in this section:

(1)
"Business day" has the same meaning as in section 3901.81
of the Revised Code.

(2)
"Cost sharing" has the same meaning as in section 3902.50
of the Revised Code.

(3)
"Covered benefit," "covered person," "health
benefit plan," and "health plan issuer" have the same
meanings as in section 3922.01 of the Revised Code.

(4)
"Emergency services" has the same meaning as in section
1753.28 of the Revised Code.

(5)
"Material change" means any change to a network plan or the
population of covered persons that impacts the ability of a health
plan issuer to comply with this section.

(6)
"Network plan" means a health benefit plan under which the
financing and delivery of medical care, including items and services
paid for as medical care, are provided, in whole or in part, through
a defined set of providers under contract with the health plan
issuer.

(7)
"Provider" has the same meaning as in section 1751.01 of
the Revised Code.

(8)
"Specialty health care services" means the delivery of
covered benefits in a manner that is physically accessible and
provides communication and accommodations needed by covered persons
with disabilities.

(B)(1)
A health plan issuer that delivers, issues for delivery, or uses a
network plan in this state shall maintain a network that ensures that
all covered persons, including both children and adults, have access
to both of the following:

(a)
A sufficient network of providers in terms of the number and
specialty, including providers that serve predominantly low-income
and medically underserved individuals, to allow access to covered
benefits without unreasonable travel or delay;

(b)
Emergency services that are available at all times.

(2)
For tiered network plans, the adequacy of the network is determined,
for the purposes of this section, based on the lowest cost sharing
tier.

(C)
The superintendent of insurance shall establish reasonable criteria
for the purpose of evaluating the adequacy of a network plan under
this section, taking into account all of the following:

(1)
The ratio, for each specialty associated with a covered benefit, of
full-time equivalent providers, including facility based providers,
to covered persons;

(2)
The ratio of full-time equivalent primary care providers to covered
persons;

(3)
The geographic accessibility of providers, including primary care
providers, specialty providers, hospitals, and facility-based
providers;

(4)
The geographic variation and population dispersion of covered
persons;

(5)
Waiting times for an appointment with in-network providers;

(6)
Hours of operation of in-network providers;

(7)
The ability of the network to meet the needs of covered persons,
including the following:

(a)
Persons who are low-income;

(b)
Children;

(c)
Adults;

(d)
Persons with serious, chronic, or complex health conditions;

(e)
Persons with physical or mental disabilities;

(f)
Persons with limited English proficiency.

(8)
The volume of technological and specialty care services available to
serve the needs of covered persons requiring those services;

(9)
The number of in-network providers accepting new patients.

(D)
The superintendent shall establish requirements for network plans to
have a minimum number of providers within a specified area, limits on
travel distance to providers, and limits on travel time to providers.

(E)
The superintendent shall conduct periodic surveys of covered persons
and providers to assist the superintendent in monitoring the adequacy
of a network plan and shall publish the results of those surveys on
the department of insurance's web site.

(F)(1)
A health plan issuer shall establish and maintain a process to assure
that covered persons obtain covered benefits at an in-network level,
including in-network cost sharing, from an out-of-network provider,
or shall make other arrangements acceptable to the superintendent,
when either of the following applies:

(a)
The health plan issuer has a sufficient network but does not have an
appropriate in-network provider available to provide the covered
benefit to the covered person without unreasonable travel or delay.

(b)
The health plan issuer has an insufficient number or type of
appropriate in-network providers available to provide the covered
benefit to the covered person without unreasonable travel or delay.

(2)
The health plan issuer shall inform a covered person who is diagnosed
with a condition or disease that requires specialty health care
services of the process required by division (E)(1) of this section
when either of the following apply:

(a)
The health plan issuer does not have an in-network provider of the
required specialty with the professional training and expertise to
treat or provide health care services for the condition or disease.

(b)
The health plan issuer cannot provide reasonable access to an
in-network provider with the required specialty with the professional
training and expertise to treat or provide health care services for
the condition or disease without unreasonable travel or delay.

(3)
The health plan issuer shall treat the health care services the
covered person receives from an out-of-network provider under
division (F) of this section as if the services were provided by an
in-network provider, including by counting the covered person's cost
sharing for such services toward the maximum out-of-pocket limit
applicable to services obtained from in-network providers under the
network plan.

(4)
The health plan issuer shall address requests to obtain a covered
benefit from an out-of-network provider in a timely fashion
appropriate to the covered person's condition.

(5)
The health plan issuer shall document all requests to obtain a
covered benefit from an out-of-network provider in accordance with
this section and shall provide such documentation to the
superintendent upon request.

(6)
Nothing in division (F) of this section shall be construed to absolve
a health plan issuer from establishing and maintaining an adequate
network of providers in accordance with this section or to allow
covered persons to circumvent the use of covered benefits available
through a health plan issuer's in-network providers.

(G)
A health plan issuer shall establish and maintain adequate
arrangements to ensure all covered persons have reasonable access to
in-network providers located near the covered person's home or place
of employment. In determining whether the health plan issuer has
complied with this division, the superintendent shall give due
consideration to the relative availability of providers with the
requisite expertise and training in the service area under
consideration.

(H)
A health plan issuer shall monitor, on an ongoing basis, the ability,
clinical capacity, and legal authority of in-network providers to
furnish covered benefits under the network plan.

(I)
No health plan issuer shall deliver, issue for delivery, or use a
network plan in this state before a copy of the plan, the premium
rates, and an access arrangement are filed with the department of
insurance in a form and manner determined by the superintendent. If
the superintendent finds that the network plan or the access
arrangement does not meet the requirements of this section, the
superintendent shall provide written notice of such finding to the
health plan issuer, and the health plan issuer shall not deliver,
issue for delivery, or use the network plan in this state. A health
plan issuer shall notify the superintendent of any material change to
a network plan or access arrangement approved under this division not
later than fifteen business days after the change occurs or is
implemented. An access arrangement submitted under this division
shall include all the following:

(1)
The factors used by the health plan issuer to build the provider
network, including a description of the network and the criteria used
to select and tier providers;

(2)
The health plan issuer's procedures for making and authorizing
referrals within and outside the network;

(3)
The health plan issuer's process for monitoring and assuring, on an
ongoing basis, the adequacy of the network to meet the health care
needs of covered persons;

(4)
The health plan issuer's efforts to address the needs of covered
persons, including children, adults, persons with limited English
proficiency or illiteracy, diverse cultural or ethnic backgrounds,
physical or mental disabilities, and serious, chronic, or complex
medical conditions;

(5)
The health plan issuer's methods for assessing the health care needs
of covered persons and the satisfaction of covered persons with
services;

(6)
The health plan issuer's method of informing covered persons of the
covered benefits included in the network plan and procedures for
navigating the plan, such as:

(a)
Grievance and appeals procedures;

(b)
Processes for choosing and changing providers;

(c)
Processes for updating provider directories;

(d)
A statement of health care services offered, including those services
offered through preventive care benefit;

(e)
Procedures for covering and approving emergency, urgent, and
specialty care.

(7)
The health plan issuer's system for ensuring the coordination and
continuity of care for both of the following:

(a)
Covered persons referred to specialty physicians;

(b)
Covered persons using ancillary services, including social services
and other community resources, and for ensuring appropriate discharge
planning.

(8)
The health plan issuer's process for enabling covered persons to
change primary care professionals;

(9)
The health plan issuer's proposed plan for providing continuity of
care in the event of contract termination between the health plan
issuer and any in-network providers or in the event of the health
plan issuer's insolvency or other inability to continue operations,
including an explanation of how covered persons will be notified of
the contract termination or the health plan issuer's insolvency or
other cessation of operations and transitioned to other providers in
a timely manner;

(10)
The health plan issuer's process for monitoring access to physician
specialist services in emergency room care, anesthesiology,
radiology, hospitalist care, and pathology or laboratory services at
in-network hospitals;

(11)
Any other information required by the superintendent to determine
compliance with this section.

(J)
The health plan issuer shall make available to covered persons a
provider directory that clearly identifies which providers and
facilities belong to each network and which networks are applicable
to each specific plan offered in this state. If a covered person
receives care from an out-of-network provider that is listed,
incorrectly, as an in-network provider in a directory provided under
this division, the health plan issuer shall compensate the provider
at the provider's billed rate at no expense to the covered person
beyond the regular cost sharing obligation for in-network services.

(K)
The superintendent may adopt rules in accordance with Chapter 119. of
the Revised Code to administer and enforce this section.