Enact the FAMILY Act

As Introduced

136th
General Assembly

Regular
Session
H. B. No. 438

2025-2026

Representatives Rader, Brownlee

Cosponsors: Representatives Grim,
Piccolantonio, Somani, Jarrells, Robinson, McNally, Brennan, Brent,
Upchurch, Abdullahi, White, E., Isaacsohn, Synenberg, Lett, Rogers,
Russo, Miller, J.

To
amend sections 1731.04, 1751.01, 1751.06, 1751.12, 1751.18, 1751.58,
1751.69, 3902.50, 3922.01, 3923.57, 3923.571, 3923.85, 3924.01,
3924.02, 3924.03, 3924.033, 3924.51, and 4125.041 and to enact
sections 3902.55, 3902.56, 3902.57, and 3902.58 of the Revised Code

regarding
health insurance premiums and benefits and to name this act the Fair
Access to Medical Insurance for Local Youth and Families (FAMILY)
Act.

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

Section
1.
That
sections 1731.04, 1751.01, 1751.06, 1751.12, 1751.18, 1751.58,
1751.69, 3902.50, 3922.01, 3923.57, 3923.571, 3923.85, 3924.01,
3924.02, 3924.03, 3924.033, 3924.51, and 4125.041 be amended and
sections 3902.55, 3902.56, 3902.57, and 3902.58 of the Revised Code
be enacted to read as follows:

Sec.
1731.04.
(A)
An agreement between an alliance and an insurer referred to in
division (B) of section 1731.01 of the Revised Code shall contain at
least the following:

(1)
A provision requiring the insurer to offer and sell to small
employers served or to be served by an alliance one or more health
benefit plan options for coverage of their eligible employees and the
eligible dependents and members of the families of the eligible
employees and, if applicable, such members' eligible retirees and the
eligible dependents and members of the families of the retirees,
subject to such conditions and restrictions as may be set forth or
incorporated into the agreement;

(2)
A brief description of each type of health benefit plan option that
is to be so offered and the conditions for the modification,
continuation, and termination of the coverage and benefits
thereunder;

(3)
A statement of the eligibility requirements that an employee or
retiree must meet in order for the employee or retiree to be eligible
to obtain and retain coverage under any health benefit plan option so
offered and, if one of such requirements is that an employee must
regularly work for a minimum number of hours per week, a statement of
such minimum number of hours, which minimum shall not exceed
twenty-five hours per week;

(4)

A
description of any pre-existing condition and waiting period rules;

(5)

A
statement of the premium rates or other charges that apply to each
health benefit plan option or a formula or method of determining the
rates or charges;

(6)

(5)

A
provision prescribing the minimum employer contribution toward
premiums or other charges required in order to permit a small
employer to obtain coverage under a health benefit plan option
offered under an alliance program;

(7)

(6)

A
provision requiring that each health benefit plan under the alliance
program must provide for the continuation of coverage of participants
of an enrolled small employer so long as the small employer
determines that such person is a qualified beneficiary entitled to
such coverage pursuant to Part 6 of Title I of the "Federal
Employee Retirement Income Security Act of 1974," 88 Stat. 832,
29 U.S.C.A. 1001, and the laws of this state, and regulations or
rulings interpreting such provisions. Such coverage provided by the
insurer under the plan to participants shall comply with the "Federal
Employee Retirement Income Security Act of 1974" and the
relevant statutes, regulations, and rulings interpreting that act,
including provisions regarding types of coverage to be provided,
apportionments of limitations on coverage, apportionments of
deductibles, and the rights of qualified beneficiaries to elect
coverage options relating to types of coverage and otherwise.

(B)
An agreement between an alliance and an insurer referred to in
division (B) of section 1731.01 of the Revised Code may contain
provisions relating to, but not limited to, any of the following:

(1)
The application and enrollment process for a small employer and
related provisions pertaining to historical experience, health
statements, and underwriting standards;

(2)
The minimum number of those employees eligible to be participants
that are required to participate in order to permit a small employer
to obtain coverage under a health benefit plan option offered under
the alliance program, which may vary with the number of employees or
those eligible to be participants in respect of the small employer;

(3)
A procedure for allowing an enrolled small employer to change from
one plan option to another under the alliance program, subject to
qualifying by size or otherwise under the alliance program;

(4)
The application of any risk-related pooling or grouping programs and
related premiums, conditions, reviews, and alternatives offered by
the insurer;

(5)
The availability of a medicare supplement coverage option for
eligible participants who are covered by Parts A and B of medicare,
Title XVIII of the "Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301;

(6)
Relevant experience periods, enrollment periods, and contract
periods;

(7)
Effective dates for coverage of eligible participants;

(8)
Conditions under which denial or withdrawal of coverage of
participants or small employers and their employees may occur by
reason of falsification or misrepresentation of material facts or
criminal conduct toward the insurer, small employer, or alliance
under the program;

(9)
Premium rate structures, which may be uniform or make provision for
age-specific rates, differentials based on number of participants of
an enrolled small employer, products and plan options selected, and
other factors, rate adjustments based on consumer price indices,
utilization, or other relevant factors, notification of rate
adjustments, and arbitration;

(10)
Any responsibilities of the alliance for billing, collection, and
transmittal of premiums;

(11)
Inclusion under the alliance program of small employers that are
members of other organizations described in division (A)(1) of
section 1731.01 of the Revised Code that contract with the alliance
for this purpose, and conditions pertaining to those small employer
members and to their employees and retirees, and dependents and
family members of those employees or retirees, as applicable under
the alliance program;

(12)
The agreement of the insurer to offer and sell one or more health
benefit plans to small employer members of another small employer
health care alliance that contracts with the alliance for this
purpose;

(13)
Use of the health benefit plan options of the insurer in the alliance
program and use of the names of the alliance and the insurer;

(14)
Indemnification from claims and liability by reason of acts or
omissions of others;

(15)
Ownership, use, availability, and maintenance of confidentiality of
data and records relating to the alliance program;

(16)
Utilization reports to be provided to the alliance by the insurer;

(17)
Such other provisions as may be agreed upon by the alliance and the
insurer to better provide for the articulation, promotion, financing,
and operation of the alliance program or a health benefit plan under
the program in furtherance of the public purposes stated in section
1731.02 of the Revised Code.

(C)
Neither an alliance program nor an agreement between an alliance and
an insurer is itself a policy or contract of insurance, or a
certificate, indorsement, rider, or application forming any part of a
policy, contract, or certificate of insurance. Chapters 3905., 3933.,
and 3959. of the Revised Code do not apply to an alliance program or
to an agreement between an alliance and an insurer thereunder, as
such, or to the functions of the alliance under an alliance program.

Sec.
1751.01.
As
used in this chapter:

(A)(1)
"Basic health care services" means the following services
when medically necessary

and, except for health care plans offered in the large group market,
the essential health benefits identified in division (B)(1) of
section 3902.57 of the Revised Code
:

(a)
Physician's services, except when such services are supplemental
under division (B) of this section;

(b)
Inpatient hospital services;

(c)
Outpatient medical services;

(d)
Emergency health services;

(e)
Urgent care services;

(f)
Diagnostic laboratory services and diagnostic and therapeutic
radiologic services;

(g)
Diagnostic and treatment services, other than prescription drug
services, for biologically based mental illnesses;

(h)
Preventive health care services, including, but not limited to,
voluntary family planning services, infertility services, periodic
physical examinations, prenatal obstetrical care, and well-child
care;

(i)
Routine patient care for patients enrolled in an eligible cancer
clinical trial pursuant to section 3923.80 of the Revised Code.

"Basic
health care services" does not include experimental procedures.

Except
as provided by divisions (A)(2) and (3) of this section in connection
with the offering of coverage for diagnostic and treatment services
for biologically based mental illnesses, a health insuring
corporation shall not offer coverage for a health care service,
defined as a basic health care service by this division, unless it
offers coverage for all listed basic health care services. However,
this requirement does not apply to the coverage of beneficiaries
enrolled in medicare pursuant to a medicare contract, or to the
coverage of beneficiaries enrolled in the federal employee health
benefits program pursuant to 5 U.S.C.A. 8905, or to the coverage of
medicaid recipients, or to the coverage of beneficiaries under any
federal health care program regulated by a federal regulatory body,
or to 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.

(2)
A health insuring corporation may offer coverage for diagnostic and
treatment services for biologically based mental illnesses without
offering coverage for all other basic health care services. A health
insuring corporation may offer coverage for diagnostic and treatment
services for biologically based mental illnesses alone or in
combination with one or more supplemental health care services.
However, a health insuring corporation that offers coverage for any
other basic health care service shall offer coverage for diagnostic
and treatment services for biologically based mental illnesses in
combination with the offer of coverage for all other listed basic
health care services.

(3)
A health insuring corporation that offers coverage for basic health
care services is not required to offer coverage for diagnostic and
treatment services for biologically based mental illnesses in
combination with the offer of coverage for all other listed basic
health care services if all of the following apply:

(a)
The health insuring corporation 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 health insuring corporation's costs for claims and administrative
expenses for the coverage of basic health care services to increase
by more than one per cent per year.

(b)
The health insuring corporation submits a signed letter from an
independent member of the American academy of actuaries to the
superintendent of insurance opining that the increase in costs
described in division (A)(3)(a) of this section could reasonably
justify an increase of more than one per cent in the annual premiums
or rates charged by the health insuring corporation for the coverage
of basic health care services.

(c)
The superintendent of insurance makes the following determinations
from the documentation and opinion submitted pursuant to divisions
(A)(3)(a) and (b) of this section:

(i)
Incurred claims for diagnostic and treatment services for
biologically based mental illnesses for a period of at least six
months independently caused the health insuring corporation's costs
for claims and administrative expenses for the coverage of basic
health care services to increase by more than one per cent per year.

(ii)
The increase in costs reasonably justifies an increase of more than
one per cent in the annual premiums or rates charged by the health
insuring corporation for the coverage of basic health care services.

Any
determination made by the superintendent under this division is
subject to Chapter 119. of the Revised Code.

(B)(1)
"Supplemental health care services" means any health care
services other than basic health care services that a health insuring
corporation may offer, alone or in combination with either basic
health care services or other supplemental health care services, and
includes:

(a)
Services of facilities for intermediate or long-term care, or both;

(b)
Dental care services;

(c)
Vision care and optometric services including lenses and frames;

(d)
Podiatric care or foot care services;

(e)
Mental health services, excluding diagnostic and treatment services
for biologically based mental illnesses;

(f)
Short-term outpatient evaluative and crisis-intervention mental
health services;

(g)
Medical or psychological treatment and referral services for alcohol
and drug abuse or addiction;

(h)
Home health services;

(i)
Prescription drug services;

(j)
Nursing services;

(k)
Services of a dietitian licensed under Chapter 4759. of the Revised
Code;

(l)
Physical therapy services;

(m)
Chiropractic services;

(n)
Any other category of services approved by the superintendent of
insurance.

(2)
If a health insuring corporation offers prescription drug services
under this division, the coverage shall include prescription drug
services for the treatment of biologically based mental illnesses on
the same terms and conditions as other physical diseases and
disorders.

(C)
"Specialty health care services" means one of the
supplemental health care services listed in division (B) of this
section, when provided by a health insuring corporation on an
outpatient-only basis and not in combination with other supplemental
health care services.

(D)
"Biologically based mental illnesses" 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.

(E)
"Closed panel plan" means a health care plan that requires
enrollees to use participating providers.

(F)
"Compensation" means remuneration for the provision of
health care services, determined on other than a fee-for-service or
discounted-fee-for-service basis.

(G)
"Contractual periodic prepayment" means the formula for
determining the premium rate for all subscribers of a health insuring
corporation.

(H)
"Corporation" means a corporation formed under Chapter
1701. or 1702. of the Revised Code or the similar laws of another
state.

(I)
"Emergency health services" means those health care
services that must be available on a seven-days-per-week,
twenty-four-hours-per-day basis in order to prevent jeopardy to an
enrollee's health status that would occur if such services were not
received as soon as possible, and includes, where appropriate,
provisions for transportation and indemnity payments or service
agreements for out-of-area coverage.

(J)
"Enrollee" means any natural person who is entitled to
receive health care benefits provided by a health insuring
corporation.

(K)
"Evidence of coverage" means any certificate, agreement,
policy, or contract issued to a subscriber that sets out the coverage
and other rights to which such person is entitled under a health care
plan.

(L)
"Health care facility" means any facility, except a health
care practitioner's office, that provides preventive, diagnostic,
therapeutic, acute convalescent, rehabilitation, mental health,
intellectual disability, intermediate care, or skilled nursing
services.

(M)
"Health care services" means basic, supplemental, and
specialty health care services.

(N)
"Health delivery network" means any group of providers or
health care facilities, or both, or any representative thereof, that
have entered into an agreement to offer health care services in a
panel rather than on an individual basis.

(O)
"Health insuring corporation" means a corporation, as
defined in division (H) of this section, that, pursuant to a policy,
contract, certificate, or agreement, pays for, reimburses, or
provides, delivers, arranges for, or otherwise makes available, basic
health care services, supplemental health care services, or specialty
health care services, or a combination of basic health care services
and either supplemental health care services or specialty health care
services, through either an open panel plan or a closed panel plan.

"Health
insuring corporation" does not include a limited liability
company formed pursuant to
former

Chapter
1705.

of the Revised Code as that chapter existed prior to February 11,
2022,

or 1706. of the Revised Code, an insurer licensed under Title XXXIX
of the Revised Code if that insurer offers only open panel plans
under which all providers and health care facilities participating
receive their compensation directly from the insurer, a corporation
formed by or on behalf of a political subdivision or a department,
office, or institution of the state, or a public entity formed by or
on behalf of a board of county commissioners, a county board of
developmental disabilities, an alcohol and drug addiction services
board, a board of alcohol, drug addiction, and mental health
services, or a community mental health board, as those terms are used
in Chapters 340. and 5126. of the Revised Code. Except as provided by
division (D) of section 1751.02 of the Revised Code, or as otherwise
provided by law, no board, commission, agency, or other entity under
the control of a political subdivision may accept insurance risk in
providing for health care services. However, nothing in this division
shall be construed as prohibiting such entities from purchasing the
services of a health insuring corporation or a third-party
administrator licensed under Chapter 3959. of the Revised Code.

(P)
"Intermediary organization" means a health delivery network
or other entity that contracts with licensed health insuring
corporations or self-insured employers, or both, to provide health
care services, and that enters into contractual arrangements with
other entities for the provision of health care services for the
purpose of fulfilling the terms of its contracts with the health
insuring corporations and self-insured employers.

(Q)
"Intermediate care" means residential care above the level
of room and board for patients who require personal assistance and
health-related services, but who do not require skilled nursing care.

(R)
"Medical record" means the personal information that
relates to an individual's physical or mental condition, medical
history, or medical treatment.

(S)(1)
"Open panel plan" means a health care plan that provides
incentives for enrollees to use participating providers and that also
allows enrollees to use providers that are not participating
providers.

(2)
No health insuring corporation may offer an open panel plan, unless
the health insuring corporation is also licensed as an insurer under
Title XXXIX of the Revised Code, the health insuring corporation, on
June 4, 1997, holds a certificate of authority or license to operate
under Chapter 1736. or 1740. of the Revised Code, or an insurer
licensed under Title XXXIX of the Revised Code is responsible for the
out-of-network risk as evidenced by both an evidence of coverage
filing under section 1751.11 of the Revised Code and a policy and
certificate filing under section 3923.02 of the Revised Code.

(T)
"Osteopathic hospital" means a hospital registered under
section 3701.07 of the Revised Code that advocates osteopathic
principles and the practice and perpetuation of osteopathic medicine
by doing any of the following:

(1)
Maintaining a department or service of osteopathic medicine or a
committee on the utilization of osteopathic principles and methods,
under the supervision of an osteopathic physician;

(2)
Maintaining an active medical staff, the majority of which is
comprised of osteopathic physicians;

(3)
Maintaining a medical staff executive committee that has osteopathic
physicians as a majority of its members.

(U)
"Panel" means a group of providers or health care
facilities that have joined together to deliver health care services
through a contractual arrangement with a health insuring corporation,
employer group, or other payor.

(V)
"Person" has the same meaning as in section 1.59 of the
Revised Code, and, unless the context otherwise requires, includes
any insurance company holding a certificate of authority under Title
XXXIX of the Revised Code, any subsidiary and affiliate of an
insurance company, and any government agency.

(W)
"Premium rate" means any set fee regularly paid by a
subscriber to a health insuring corporation. A "premium rate"
does not include a one-time membership fee, an annual administrative
fee, or a nominal access fee, paid to a managed health care system
under which the recipient of health care services remains solely
responsible for any charges accessed for those services by the
provider or health care facility.

(X)
"Primary care provider" means a provider that is designated
by a health insuring corporation to supervise, coordinate, or provide
initial care or continuing care to an enrollee, and that may be
required by the health insuring corporation to initiate a referral
for specialty care and to maintain supervision of the health care
services rendered to the enrollee.

(Y)
"Provider" means any natural person or partnership of
natural persons who are licensed, certified, accredited, or otherwise
authorized in this state to furnish health care services, or any
professional association organized under Chapter 1785. of the Revised
Code, provided that nothing in this chapter or other provisions of
law shall be construed to preclude a health insuring corporation,
health care practitioner, or organized health care group associated
with a health insuring corporation from employing certified nurse
practitioners, certified nurse anesthetists, clinical nurse
specialists, certified nurse-midwives, pharmacists, dietitians,
physician assistants, dental assistants, dental hygienists,
optometric technicians, or other allied health personnel who are
licensed, certified, accredited, or otherwise authorized in this
state to furnish health care services.

(Z)
"Provider sponsored organization" means a corporation, as
defined in division (H) of this section, that is at least eighty per
cent owned or controlled by one or more hospitals, as defined in
section 3727.01 of the Revised Code, or one or more physicians
licensed to practice medicine or surgery or osteopathic medicine and
surgery under Chapter 4731. of the Revised Code, or any combination
of such physicians and hospitals. Such control is presumed to exist
if at least eighty per cent of the voting rights or governance rights
of a provider sponsored organization are directly or indirectly
owned, controlled, or otherwise held by any combination of the
physicians and hospitals described in this division.

(AA)
"Solicitation document" means the written materials
provided to prospective subscribers or enrollees, or both, and used
for advertising and marketing to induce enrollment in the health care
plans of a health insuring corporation.

(BB)
"Subscriber" means a person who is responsible for making
payments to a health insuring corporation for participation in a
health care plan, or an enrollee whose employment or other status is
the basis of eligibility for enrollment in a health insuring
corporation.

(CC)
"Urgent care services" means those health care services
that are appropriately provided for an unforeseen condition of a kind
that usually requires medical attention without delay but that does
not pose a threat to the life, limb, or permanent health of the
injured or ill person, and may include such health care services
provided out of the health insuring corporation's approved service
area pursuant to indemnity payments or service agreements.

Sec.
1751.06.
Upon
obtaining a certificate of authority as required under this chapter,
a health insuring corporation may do all of the following:

(A)
Enroll individuals and their dependents in either of the following
circumstances:

(1)
The individual resides or lives in the approved service area.

(2)
The individual's place of employment is located in the approved
service area.

(B)
Contract with providers and health care facilities for the health
care services to which enrollees are entitled under the terms of the
health insuring corporation's health care contracts;

(C)
Contract with insurance companies authorized to do business in this
state for insurance, indemnity, or reimbursement against the cost of
providing emergency and nonemergency health care services for
enrollees, subject to the provisions set forth in this chapter and
the limitations set forth in the Revised Code;

(D)
Contract with any person pursuant to the requirements of division
(A)(18) of section 1751.03 of the Revised Code for managerial or
administrative services, or for data processing, actuarial analysis,
billing services, or any other services authorized by the
superintendent of insurance. However, a health insuring corporation
shall not enter into a contract for any of the services listed in
this division with an insurance company that is not authorized to
engage in the business of insurance in this state.

(E)
Accept from governmental agencies, private agencies, corporations,
associations, groups, individuals, or other persons, payments
covering all or part of the costs of planning, development,
construction, and the provision of health care services;

(F)
Purchase, lease, construct, renovate, operate, or maintain health
care facilities, and their ancillary equipment, and any property
necessary in the transaction of the business of the health insuring
corporation;

(G)
In the employer group market, impose an affiliation period of not
more than sixty days, or for late enrollees an affiliation period of
not more than ninety days, which period begins on the individual's
date of enrollment and runs concurrently with any waiting period
imposed under the coverage. For purposes of this division,
"affiliation period" means a period of time which, under
the terms of the coverage offered, must expire before the coverage
becomes effective. No health care services or benefits need to be
provided during an affiliation period, and no periodic prepayments
can be charged for any coverage during that period.

(H)
If a health insuring corporation offers coverage in the small
employer group market through a network plan, limit or deny the
coverage in accordance with section 3924.031 of the Revised Code;

(I)
Refuse to issue coverage in the small employer group market pursuant
to section 3924.032 of the Revised Code;

(J)
Establish employer contribution rules or group participation rules
for the offering of coverage in connection with a group contract in
the small employer group market, as provided in division
(E)(1)
(D)(1)

of section 3924.03 of the Revised Code.

Nothing
in this section shall be construed as prohibiting a health insuring
corporation without other commercial enrollment from contracting
solely with federal health care programs regulated by federal
regulatory bodies.

Nothing
in this section shall be construed to limit the authority of a health
insuring corporation to perform those functions not otherwise
prohibited by law.

Sec.
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
described
in division (D)(2) of section 3902.57 of the Revised Code and
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.

Sec.
1751.18.
(A)(1)
No health insuring corporation shall cancel or fail to renew the
coverage of a subscriber or enrollee because of any health
status-related factor in relation to the subscriber or enrollee, the
subscriber's or enrollee's requirements for health care services, or
for any other reason designated under rules adopted by the
superintendent of insurance.

(2)
Unless otherwise required by state or federal law, no health insuring
corporation, or health care facility or provider through which the
health insuring corporation has made arrangements to provide health
care services, shall discriminate against any individual with regard
to enrollment, disenrollment, or the quality of health care services
rendered, on the basis of the individual's race, color, sex, age,
religion, military status as defined in section 4112.01 of the
Revised Code, or status as a recipient of medicare or medicaid, or
any health status-related factor in relation to the individual.
However, a health insuring corporation shall not be required to
accept a recipient of medicare or medical assistance, if an agreement
has not been reached on appropriate payment mechanisms between the
health insuring corporation and the governmental agency administering
these programs.

Further, except as provided in section 1751.65 of the Revised Code, a
health insuring corporation may reject an applicant for nongroup
enrollment on the basis of any health status-related factor in
relation to the applicant.

(B)
A health insuring corporation may cancel or decide not to renew the
coverage of an enrollee if the enrollee has performed an act or
practice that constitutes fraud or intentional misrepresentation of
material fact under the terms of the coverage and if the cancellation
or nonrenewal is not based, either directly or indirectly, on any
health status-related factor in relation to the enrollee.

(C)
An enrollee may appeal any action or decision of a health insuring
corporation taken pursuant to section 2742(b) to (e) of the "Health
Insurance Portability and Accountability Act of 1996," Pub. L.
No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-42, as amended. To
appeal, the enrollee may submit a written complaint to the health
insuring corporation pursuant to section 1751.19 of the Revised Code.
The enrollee may, within thirty days after receiving a written
response from the health insuring corporation, appeal the health
insuring corporation's action or decision to the superintendent.

(D)
As used in this section, "health status-related factor"
means any of the following:

(1)
Health status;

(2)
Medical condition, including both physical and mental illnesses;

(3)
Claims experience;

(4)
Receipt of health care;

(5)
Medical history;

(6)
Genetic information;

(7)
Evidence of insurability, including conditions arising out of acts of
domestic violence;

(8)
Disability.

Sec.
1751.58.
Except
as otherwise provided in section 2721 of the "Health Insurance
Portability and Accountability Act of 1996," Pub. L. No.
104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, the
following conditions apply to all group health insuring corporation
contracts that are sold in connection with an employment-related
group health care plan and that are not subject to section 3924.03 of
the Revised Code:

(A)(1)
Except as provided in section 2712(b) to (e) of the "Health
Insurance Portability and Accountability Act of 1996," if a
health insuring corporation offers coverage in the small or large
group market in connection with a group contract, the corporation
shall renew or continue in force such coverage at the option of the
contract holder.

(2)
A health insuring corporation may cancel or decide not to renew the
coverage of any eligible employee or of a dependent of an eligible
employee under the group contract in accordance with division (B) of
section 1751.18 of the Revised Code.

(B)
Such group contracts are subject to
division
(A)(3) of section 3924.03 and
sections
3924.033 and 3924.27 of the Revised Code.

(C)
Such group contracts shall provide for the special enrollment periods
described in section 2701(f) of the "Health Insurance
Portability and Accountability Act of 1996."

(D)
At least once in every twelve-month period, a health insuring
corporation shall provide to all late enrollees, as defined in
section 3924.01 of the Revised Code, who are identified by the
contract holder, the option to enroll in the group contract. The
enrollment option shall be provided for a minimum period of thirty
consecutive days. All delays of coverage imposed under the group
contract, including any affiliation period, shall begin on the date
the health insuring corporation receives notice of the late
enrollee's application or request for coverage, and shall run
concurrently with each other.

Sec.
1751.69.
(A)
As used in this section, "cost sharing" means the cost to
an individual insured under an individual or group health insuring
corporation policy, contract, or agreement according to any coverage
limit, copayment, coinsurance, deductible, or other out-of-pocket
expense requirements imposed by the policy, contract, or agreement.

(B)
Notwithstanding section 3901.71 of the Revised Code and subject to
division (D) of this section, no individual or group health insuring
corporation policy, contract, or agreement providing basic health
care services or prescription drug services that is delivered, issued
for delivery, or renewed in this state, if the policy, contract, or
agreement provides coverage for cancer chemotherapy treatment, shall
fail to comply with either of the following:

(1)
The policy, contract, or agreement shall not provide coverage or
impose cost sharing for a prescribed, orally administered cancer
medication on a less favorable basis than the coverage it provides or
cost sharing it imposes for intraveneously administered or injected
cancer medications.

(2)
The policy, contract, or agreement shall not comply with division
(B)(1) of this section by imposing an increase in cost sharing solely
for orally administered, intravenously administered, or injected
cancer medications.

(C)
Notwithstanding any provision of this section to the contrary, an
individual or group health insuring corporation policy, contract, or
agreement shall be deemed to be in compliance with this section if
the cost sharing imposed under such a policy, contract, or agreement
for orally administered cancer treatments does not exceed one hundred
dollars per prescription fill. The cost
-
sharing
limit of one hundred dollars per prescription fill shall apply to a
high deductible plan, as defined in 26 U.S.C. 223, or a catastrophic
plan, as
described
in division (D)(2) of section 3902.57 of the Revised Code and
defined
in 42 U.S.C. 18022, only after the deductible has been met.

(D)
The prohibitions in division (B) of this section do not preclude an
individual or group health insuring corporation policy, contract, or
agreement from requiring an enrollee to obtain prior authorization
before orally administered cancer medication is dispensed to the
enrollee.

(E)
A health insuring corporation that offers coverage for basic health
care services is not required to comply with division (B) of this
section if all of the following apply:

(1)
The health insuring corporation submits documentation certified by an
independent member of the American academy of actuaries to the
superintendent of insurance showing that compliance with division
(B)(1) of this section for a period of at least six months
independently caused the health insuring corporation's costs for
claims and administrative expenses for the coverage of basic health
care services to increase by more than one per cent per year.

(2)
The health insuring corporation submits a signed letter from an
independent member of the American academy of actuaries to the
superintendent of insurance opining that the increase in costs
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 health insuring corporation for the coverage of basic
health care services.

(3)(a)
The superintendent of insurance makes the following determinations
from the documentation and opinion submitted pursuant to divisions
(E)(1) and (2) of this section:

(i)
Compliance with division (B)(1) of this section for a period of at
least six months independently caused the health insuring
corporation's costs for claims and administrative expenses for the
coverage of basic health care services to increase more than one per
cent per year.

(ii)
The increase in costs reasonably justifies an increase of more than
one per cent in the annual premiums or rates charged by the health
insuring corporation for the coverage of basic health care services.

(b)
Any determination made by the superintendent under division (E)(3) of
this section is subject to Chapter 119. of the Revised Code.

Sec.
3902.50.
As
used in sections 3902.50 to 3902.72 of the Revised Code:

(A)
"Ambulance" has the same meaning as in section 4765.01 of
the Revised Code.

(B)
"Clinical laboratory services" has the same meaning as in
section 4731.65 of the Revised Code.

(C)
"Cost sharing" means the cost to a covered person under a
health benefit plan according to any copayment, coinsurance,
deductible, or other out-of-pocket expense requirement.

(D)
"Covered" or "coverage" means the provision of
benefits related to health care services to a covered person in
accordance with a health benefit plan.

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

(F)
"Drug" has the same meaning as in section 4729.01 of the
Revised Code.

(G)
"Emergency facility" has the same meaning as in section
3701.74 of the Revised Code.

(H)
"Emergency services" means all of the following as
described in 42 U.S.C. 1395dd:

(1)
Medical screening examinations undertaken to determine whether an
emergency medical condition exists;

(2)
Treatment necessary to stabilize an emergency medical condition;

(3)
Appropriate transfers undertaken prior to an emergency medical
condition being stabilized.

(I)
"Health care practitioner" has the same meaning as in
section 3701.74 of the Revised Code.

(J)
"Pharmacy benefit manager" has the same meaning as in
section 3959.01 of the Revised Code.

(K)

"Preexisting
condition exclusion" means, with respect to a health benefit
plan, a limitation or exclusion of benefits relating to a condition
based on the fact that the condition was present before the date of
enrollment in the plan, whether or not any medical advice, diagnosis,
care, or treatment was recommended or received before such date.
"Condition" does not include genetic information in the
absence of a diagnosis of the condition related to such information.

(L)

"Prior
authorization requirement" means any practice implemented by a
health plan issuer in which coverage of a health care service,
device, or drug is dependent upon a covered person or a provider
obtaining approval from the health plan issuer prior to the service,
device, or drug being performed, received, or prescribed, as
applicable. "Prior authorization requirement" includes
prospective or utilization review procedures conducted prior to
providing a health care service, device, or drug.

(L)
(M)

"Unanticipated out-of-network care" means health care
services, including clinical laboratory services, that are covered
under a health benefit plan and that are provided by an
out-of-network provider when either of the following conditions
applies:

(1)
The covered person did not have the ability to request such services
from an in-network provider.

(2)
The services provided were emergency services.

Sec.
3902.55.
(A)
With respect to the premium rate charged by a health plan issuer for
a health benefit plan offered in the individual or small group
market, all of the following apply:

(1)
The premium rate shall vary with respect to the health benefit plan
involved only by the following:

(a)
Whether the health benefit plan covers an individual or family;

(b)
Rating area, as established in accordance with division (C)(1) of
this section;

(c)
Age, except that such rate shall not vary by more than three to one
for adults;

(d)
Tobacco use, except that such rate shall not vary by more than one
and one-half to one.

(2)
The premium rate shall not vary with respect to the health benefit
plan involved by any other factor not described in division (A) of
this section.

(B)
With respect to family coverage under a health benefit plan, the
rating variations permitted under divisions (A)(1)(c) and (d) of this
section shall be applied based on the portion of the premium that is
attributable to each family member covered under the health benefit
plan.

(C)
The superintendent of insurance shall adopt rules to do the
following:

(1)
Establish one or more rating areas within the state;

(2)
Define the permissible age bands for rating purposes under division
(A)(3) of this section.

(D)
A health plan issuer shall not establish lifetime or annual limits on
the dollar value of benefits described in section 3902.57 of the
Revised Code for any covered person.

Sec.
3902.56.
(A)
Every individual health benefit plan shall accept every individual in
this state who applies for coverage and every group health benefit
plan shall accept every employer in this state that applies for
coverage, regardless of whether any individual or employee has a
preexisting condition. A health benefit plan may restrict enrollment
in coverage to open or special enrollment periods under division (C)
of this section.

(B)
A health plan issuer shall not impose any preexisting condition
exclusion on any person.

(C)(1)
The superintendent of insurance shall adopt rules to ensure that each
individual health benefit plan has open enrollment during a statewide
open enrollment period to allow individuals, including individuals
who are not covered persons, to enroll in the health benefit plan.

(2)
A health plan issuer shall provide special enrollment periods for
individuals who lose coverage as a result of a qualifying event under
42 U.S.C. 9801(f) or 29 U.S.C. 1163.

Sec.
3902.57.
(A)
For purposes of this section, "essential health benefits
package" means, with respect to a health benefit plan, coverage
that does all of the following:

(1)
Provides for the essential health benefits defined by the
superintendent of insurance under division (B) of this section;

(2)
Limits cost sharing for such coverage in accordance with division (C)
of this section;

(3)
Provides the level of coverage described in division (D) of this
section.

(B)(1)
Subject to division (B)(2) of this section, the superintendent shall
define the essential health benefits, except that such benefits shall
include at least the following general categories and the items and
services covered within the categories:

(a)
Ambulatory patient services;

(b)
Emergency services;

(c)
Hospitalization;

(d)
Maternity and newborn care;

(e)
Mental health and substance use disorder services, including
behavioral health treatment;

(f)
Prescription drugs;

(g)
Rehabilitative and habilitative services and devices;

(h)
Laboratory services;

(i)
Preventive and wellness services and chronic disease management;

(j)
Pediatric services, including oral, dental, and vision care.

(2)(a)
The superintendent shall ensure that the scope of the essential
health benefits under division (B)(1) of this section is equal to the
scope of benefits provided under a typical employer plan, as
determined by the superintendent. To inform this determination, the
superintendent shall conduct a survey of employer-sponsored coverage
to determine the benefits typically covered by employers, including
multi-employer plans.

(b)
In defining the essential health benefits described in division
(B)(1) of this section, and in revising the benefits under division
(B)(3)(g) of this section, the superintendent shall submit a report
to the general assembly containing a certification that such
essential health benefits meet the requirements described in division
(B)(2)(a) of this section.

(3)
In defining the essential health benefits under division (B)(1) of
this section, the superintendent shall do all of the following:

(a)
Ensure that such essential health benefits reflect an appropriate
balance among the categories described in division (B)(1) of this
section, so that benefits are not unduly weighted toward any
category;

(b)
Not make coverage decisions, determine reimbursement rates, establish
incentive programs, or design benefits in ways that discriminate
against individuals because of their age, disability, or expected
length of life;

(c)
Take into account the health care needs of diverse segments of the
population, including women, children, persons with disabilities, and
other groups;

(d)
Ensure that health benefits established as essential not be subject
to denial to individuals against their wishes on the basis of the
individuals' age or expected length of life or of the individuals'
present or predicted disability, degree of medical dependency, or
quality of life;

(e)
Provide that a qualified health benefit plan shall not be treated as
providing coverage for the essential health benefits described in
division (B)(1) of this section unless the plan does both of the
following:

(i)
Provides that coverage for emergency services, as defined in section
3923.65 of the Revised Code, will be provided without imposing any
requirement under the plan for prior authorization of services or any
limitation on coverage where the provider of services does not have a
contractual relationship with the plan for the providing of services
that is more restrictive than the requirements or limitations that
apply to emergency services received from providers who do have such
a contractual relationship with the plan;

(ii)
Provides that if emergency services are provided out-of-network, the
cost-sharing requirement is the same requirement that would apply if
such services were provided in-network.

(f)
Periodically review the essential health benefits under division
(B)(1) of this section and provide a report to the general assembly
and the public that contains all of the following:

(i)
An assessment of whether covered persons are facing any difficulty
accessing needed services for reasons of coverage or cost;

(ii)
An assessment of whether the essential health benefits need to be
modified or updated to account for changes in medical evidence or
scientific advancement;

(iii)
Information on how the essential health benefits will be modified to
address any such gaps in access or changes in the evidence base;

(iv)
An assessment of the potential of additional or expanded benefits to
increase costs and the interactions between the addition or expansion
of benefits and reductions in existing benefits to meet the
requirements of division (B)(2)(a) of this section.

(g)
Periodically update the essential health benefits under division
(B)(1) of this section to address any gaps in access to coverage or
changes in the evidence base the superintendent identifies in the
review conducted under division (B)(3)(f) of this section.

(4)
Nothing in this section shall be construed to prohibit a health
benefit plan from providing benefits in excess of the essential
health benefits described in this section.

(C)(1)
A health plan issuer shall not require cost sharing in an amount
greater than seven thousand nine hundred dollars for self-only
coverage and fifteen thousand eight hundred dollars for other than
self-only coverage for plan years beginning after the effective date
of this section.

(2)
For plan years beginning in a calendar year after the effective date
of this section, the cost-sharing limit shall be as follows:

(a)
In the case of self-only coverage, be equal to the dollar amount in
division (C)(1) of this section, increased by the product of that
amount and the premium adjustment percentage under division (C)(3) of
this section for the calendar year;

(b)
In the case of other than self-only coverage, twice the amount in
effect under division (C)(2)(a) of this section. If the amount of any
increase under division (C)(2)(a) of this section is not a multiple
of fifty dollars, such increase shall be rounded to the next lowest
multiple of fifty dollars.

(3)
The premium adjustment percentage for any calendar year shall be the
percentage by which the average per capita premium for health benefit
plans in this state for the preceding calendar year, as estimated by
the superintendent not later than the first day of October of such
preceding calendar year, exceeds such average per capita premium for
2025, as determined by the superintendent.

(D)(1)(a)
Except as provided in division (D)(2) of this section, a health
benefit plan shall provide a level of coverage that is designed to
provide benefits that are actuarially equivalent to sixty per cent of
the full actuarial value of the benefits provided under the plan.

(b)
Under rules issued by the superintendent, the level of coverage of a
plan shall be determined on the basis that the essential health
benefits described in division (B)(1) of this section shall be
provided to a standard population, without regard to the population
the plan may actually provide benefits to.

(2)
A health benefit plan that does not provide the level of coverage
described in division (D)(1) of this section shall be considered as
meeting the requirements of that division with respect to any plan
year if both of the following apply:

(a)
An individual is only eligible to enroll in the health benefit plan
if the individual meets either of the following conditions:

(i)
The individual has not attained the age of thirty before the
beginning of the plan year.

(ii)
The individual meets a hardship exemption as determined by the
superintendent.

(b)
The health benefit plan provides both of the following:

(i)
Except as provided in division (D)(2)(b)(ii) of this section, the
essential health benefits listed in division (B)(1) of this section,
except that the health benefit plan provides no benefits for any plan
year until the individual has incurred cost-sharing expenses in an
amount equal to the annual limitation in effect under division (C) of
this section for the plan year except as provided for in section
3902.58 of the Revised Code;

(ii)
Coverage for at least three primary care visits.

(3)
If a health plan issuer offers a health benefit plan described in
division (D)(2) of this section, the issuer shall only offer the plan
in the individual market.

(E)
The requirements of this section do not apply to health benefit plans
offered in the large group market.

(F)
Nothing in this section is subject to the requirements of section
3901.71 of the Revised Code.

Sec.
3902.58.
(A)
Notwithstanding section 3901.71 of the Revised Code, a health benefit
plan shall provide coverage for and shall not impose any cost-sharing
requirements for the following:

(1)
Evidence-based items or services that have in effect a rating of "A"
or "B" in the current recommendations of the United States
preventive services task force;

(2)
Immunizations that have in effect a recommendation from the advisory
committee on immunization practices of the United States centers for
disease control and prevention with respect to the individual
involved;

(3)
With respect to infants, children, and adolescents, evidence-informed
preventive care and screenings provided for in the comprehensive
guidelines supported by the United States health resources and
services administration;

(4)
With respect to women, such additional preventive care and screenings
not described in division (A)(1) of this section as provided for in
comprehensive guidelines supported by the United States health
resources and services administration.

(B)
The superintendent shall adopt rules to implement sections 3902.50 to
3902.58 of the Revised Code.

(C)
As used in this section, "preventive care" means medical
services based on current, peer-reviewed scientific evidence, and
consistent with guidelines from broadly recognized, nonpartisan,
professional medical organizations. The scope of "preventive
care" shall not be narrowed unless justified by a transparent,
scientific review.

Sec.
3922.01.
As
used in this chapter:

(A)
"Adverse benefit determination" means a decision by a
health plan issuer:

(1)
To deny, reduce, or terminate a requested health care service or
payment in whole or in part, including all of the following:

(a)
A determination that the health care service does not meet the health
plan issuer's requirements for medical necessity, appropriateness,
health care setting, level of care, or effectiveness, including
experimental or investigational treatments;

(b)
A determination of an individual's eligibility for individual health
insurance coverage, including coverage offered to individuals through
a nonemployer group, to participate in a plan or health insurance
coverage;

(c)
A determination that a health care service is not a covered benefit;

(d)
The imposition of an exclusion, including exclusions for
pre-existing
conditions,
source
of injury, network, or any other limitation on benefits that would
otherwise be covered.

(2)
Not to issue individual health insurance coverage to an applicant,
including coverage offered to individuals through a nonemployer
group;

(3)
To rescind coverage on a health benefit plan.

(B)
"Ambulatory review" has the same meaning as in section
1751.77 of the Revised Code.

(C)
"Authorized representative" means an individual who
represents a covered person in an internal appeal or external review
process of an adverse benefit determination who is any of the
following:

(1)
A person to whom a covered individual has given express, written
consent to represent that individual in an internal appeals process
or external review process of an adverse benefit determination;

(2)
A person authorized by law to provide substituted consent for a
covered individual;

(3)
A family member or a treating health care professional, but only when
the covered person is unable to provide consent.

(D)
"Best evidence" means evidence based on all of the
following sources, listed according to priority, as they are
available:

(1)
Randomized clinical trials;

(2)
Cohort studies or case-control studies;

(3)
Case series;

(4)
Expert opinion.

(E)
"Covered person" means a policyholder, subscriber,
enrollee, member, or individual covered by a health benefit plan.
"Covered person" does include the covered person's
authorized representative with regard to an internal appeal or
external review in accordance with division (C) of this section.
"Covered person" does not include the covered person's
representative in any other context.

(F)
"Covered benefits" or "benefits" means those
health care services to which a covered person is entitled under the
terms of a health benefit plan.

(G)
"Emergency medical condition" has the same meaning as in
section 1753.28 of the Revised Code.

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

(I)
"Evidence-based standard" means the conscientious,
explicit, and judicious use of the current best evidence, based on a
systematic review of the relevant research, in making decisions about
the care of individuals.

(J)
"Facility" means an institution providing health care
services, or a health care setting, including hospitals and other
licensed inpatient centers, ambulatory, surgical, treatment, skilled
nursing, residential treatment, diagnostic, laboratory, and imaging
centers, and rehabilitation and other therapeutic health settings.

(K)
"Final adverse benefit determination" means an adverse
benefit determination that is upheld at the completion of a health
plan issuer's internal appeals process.

(L)
"Health benefit plan" means a policy, contract,
certificate, or agreement offered by a health plan issuer to provide,
deliver, arrange for, pay for, or reimburse any of the costs of
health care services, including benefit plans marketed in the
individual or group market by all associations, whether bona fide or
non-bona fide. "Health benefit plan" also means a limited
benefit plan, except as follows. "Health benefit plan" does
not mean any of the following types of coverage: a policy, contract,
certificate, or agreement that covers only a specified accident,
accident only, credit, dental, disability income, long-term care,
hospital indemnity, supplemental coverage, as described in section
3923.37 of the Revised Code, specified disease, or vision care;
coverage issued as a supplement to liability insurance; insurance
arising out of workers' compensation or similar law; automobile
medical payment insurance; or insurance under which benefits are
payable with or without regard to fault and which is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance; a medicare supplement policy of insurance,
as defined by the superintendent of insurance by rule, coverage under
a plan through medicare, medicaid, or the federal employees benefit
program; any coverage issued under Chapter 55 of Title 10 of the
United States Code and any coverage issued as a supplement to that
coverage.

(M)
"Health care professional" means a physician, psychologist,
nurse practitioner, or other health care practitioner licensed,
accredited, or certified to perform health care services consistent
with state law.

(N)
"Health care provider" or "provider" means a
health care professional or facility.

(O)
"Health care services" means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.

(P)
"Health plan issuer" means an entity subject to the
insurance laws and rules of this state, or subject to the
jurisdiction of the superintendent of insurance, that contracts, or
offers to contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services under a health
benefit plan, including a sickness and accident insurance company, a
health insuring corporation, a fraternal benefit society, a
self-funded multiple employer welfare arrangement, or a nonfederal,
government health plan. "Health plan issuer" includes a
third party administrator licensed under Chapter 3959. of the Revised
Code to the extent that the benefits that such an entity is
contracted to administer under a health benefit plan are subject to
the insurance laws and rules of this state or subject to the
jurisdiction of the superintendent.

(Q)
"Health information" means information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that relates to all of the
following:

(1)
The past, present, or future physical, mental, or behavioral health
or condition of a covered person or a member of the covered person's
family;

(2)
The provision of health care services or health-related benefits to a
covered person;

(3)
Payment for the provision of health care services to or for a covered
person.

(R)
"Independent review organization" means an entity that is
accredited to conduct independent external reviews of adverse benefit
determinations pursuant to section 3922.13 of the Revised Code.

(S)
"Medical or scientific evidence" means evidence found in
any of the following sources:

(1)
Peer-reviewed scientific studies published in, or accepted for
publication by, medical journals that meet nationally recognized
requirements for scientific manuscripts and that submit most of their
published articles for review by experts who are not part of the
editorial staff;

(2)
Peer-reviewed medical literature, including literature relating to
therapies reviewed and approved by a qualified institutional review
board, biomedical compendia and other medical literature that meet
the criteria of the national institutes of health's library of
medicine for indexing in index medicus and elsevier science ltd. for
indexing in excerpta medicus;

(3)
Medical journals recognized by the secretary of health and human
services under section 1861(t)(2) of the federal social security act;

(4)
The following standard reference compendia:

(a)
The American hospital formulary service drug information;

(b)
Drug facts and comparisons;

(c)
The American dental association accepted dental therapeutics;

(d)
The United States pharmacopoeia drug information.

(5)
Findings, studies or research conducted by or under the auspices of a
federal government agency or nationally recognized federal research
institute, including any of the following:

(a)
The federal agency for health care research and quality;

(b)
The national institutes of health;

(c)
The national cancer institute;

(d)
The national academy of sciences;

(e)
The centers for medicare and medicaid services;

(f)
The federal food and drug administration;

(g)
Any national board recognized by the national institutes of health
for the purpose of evaluating the medical value of health care
services.

(6)
Any other medical or scientific evidence that is comparable.

(T)
"Person" has the same meaning as in section 3901.19 of the
Revised Code.

(U)
"Protected health information" means health information
related to the identity of an individual, or information that could
reasonably be used to determine the identity of an individual.

(V)
"Rescind" means to retroactively cancel or discontinue
coverage. "Rescind" does not include canceling or
discontinuing coverage that only has a prospective effect or
canceling or discontinuing coverage that is effective retroactively
to the extent it is attributable to a failure to timely pay required
premiums or contributions towards the cost of coverage.

(W)
"Retrospective review" means a review conducted after
services have been provided to a covered person.

(X)
"Superintendent" means the superintendent of insurance.

(Y)
"Utilization review" has the same meaning as in section
1751.77 of the Revised Code.

(Z)
"Utilization review organization" has the same meaning as
in section 1751.77 of the Revised Code.

Sec.
3923.57.
Notwithstanding
any provision of this chapter, every individual policy of sickness
and accident insurance that is delivered, issued for delivery, or
renewed in this state is subject to the following conditions, as
applicable:

(A)
Pre-existing conditions provisions shall not exclude or limit
coverage for a period beyond twelve months following the
policyholder's effective date of coverage and may only relate to
conditions during the six months immediately preceding the effective
date of coverage.

(B)
In determining whether a pre-existing conditions provision applies to
a policyholder or dependent, each policy shall credit the time the
policyholder or dependent was covered under a previous policy,
contract, or plan if the previous coverage was continuous to a date
not more than thirty days prior to the effective date of the new
coverage, exclusive of any applicable service waiting period under
the policy.

(C)(1)
(A)(1)

Except as otherwise provided in division
(C)
(A)

of this section, an insurer that provides an individual sickness and
accident insurance policy to an individual shall renew or continue in
force such coverage at the option of the individual.

(2)
An insurer may nonrenew or discontinue coverage of an individual in
the individual market based only on one or more of the following
reasons:

(a)
The individual failed to pay premiums or contributions in accordance
with the terms of the policy or the insurer has not received timely
premium payments.

(b)
The individual performed an act or practice that constitutes fraud or
made an intentional misrepresentation of material fact under the
terms of the policy.

(c)
The insurer is ceasing to offer coverage in the individual market in
accordance with division
(D)
(B)

of this section and the applicable laws of this state.

(d)
If the insurer offers coverage in the market through a network plan,
the individual no longer resides, lives, or works in the service
area, or in an area for which the insurer is authorized to do
business; provided, however, that such coverage is terminated
uniformly without regard to any health status-related factor of
covered individuals.

(e)
If the coverage is made available in the individual market only
through one or more bona fide associations, the membership of the
individual in the association, on the basis of which the coverage is
provided, ceases; provided, however, that such coverage is terminated
under division
(C)(2)(e)
(A)(2)(e)

of this section uniformly without regard to any health status-related
factor of covered individuals.

(3)
An insurer may cancel or decide not to renew the coverage of a
dependent of an individual if the dependent has performed an act or
practice that constitutes fraud or made an intentional
misrepresentation of material fact under the terms of the coverage
and if the cancellation or nonrenewal is not based, either directly
or indirectly, on any health status-related factor in relation to the
dependent.

(D)(1)
(B)(1)

If an insurer decides to discontinue offering a particular type of
health insurance coverage offered in the individual market, coverage
of such type may be discontinued by the insurer if the insurer does
all of the following:

(a)
Provides notice to each individual provided coverage of this type in
such market of the discontinuation at least ninety days prior to the
date of the discontinuation of the coverage;

(b)
Offers to each individual provided coverage of this type in such
market, the option to purchase any other individual health insurance
coverage currently being offered by the insurer for individuals in
that market;

(c)
In exercising the option to discontinue coverage of this type and in
offering the option of coverage under division
(D)(1)(b)
(B)(1)(b)

of this section, acts uniformly without regard to any health
status-related factor of covered individuals or of individuals who
may become eligible for such coverage.

(2)
If an insurer elects to discontinue offering all health insurance
coverage in the individual market in this state, health insurance
coverage may be discontinued by the insurer only if both of the
following apply:

(a)
The insurer provides notice to the department of insurance and to
each individual of the discontinuation at least one hundred eighty
days prior to the date of the expiration of the coverage.

(b)
All health insurance delivered or issued for delivery in this state
in such market is discontinued and coverage under that health
insurance in that market is not renewed.

(3)
In the event of a discontinuation under division
(D)(2)
(B)(2)

of this section in the individual market, the insurer shall not
provide for the issuance of any health insurance coverage in the
market and this state during the five-year period beginning on the
date of the discontinuation of the last health insurance coverage not
so renewed.

(E)
(C)

Notwithstanding divisions
(C)
(A)

and
(D)
(B)

of this section, an insurer may, at the time of coverage renewal,
modify the health insurance coverage for a policy form offered to
individuals in the individual market if the modification is
consistent with the law of this state and effective on a uniform
basis among all individuals with that policy form.

(F)
(D)

Such policies are subject to sections 2743 and 2747 of the "Health
Insurance Portability and Accountability Act of 1996," Pub. L.
No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and 300gg-47, as
amended.

(G)
(E)

Sections 3924.031 and 3924.032 of the Revised Code shall apply to
sickness and accident insurance policies offered in the individual
market in the same manner as they apply to health benefit plans
offered in the small employer market.

In
accordance with 45 C.F.R. 148.102, divisions
(C)
(A)

to
(G)
(E)

of this section also apply to all group sickness and accident
insurance policies that are not sold in connection with an
employment-related group health plan and that provide more than
short-term, limited duration coverage.

In
applying divisions
(C)
(A)

to
(G)
(E)

of this section with respect to health insurance coverage that is
made available by an insurer in the individual market to individuals
only through one or more associations, the term "individual"
includes the association of which the individual is a member.

For
purposes of this section, any policy issued pursuant to division (C)
of section 3923.13 of the Revised Code in connection with a public or
private college or university student health insurance program is
considered to be issued to a bona fide association.

As
used in this section, "bona fide association" has the same
meaning as in section 3924.03 of the Revised Code, and "health
status-related factor" and "network plan" have the
same meanings as in section 3924.031 of the Revised Code.

This
section does not apply to any policy that provides coverage for
specific diseases or accidents only, or to 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.

Sec.
3923.571.
Except
as otherwise provided in section 2721 of the "Health Insurance
Portability and Accountability Act of 1996," Pub. L. No.
104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, the
following conditions apply to all group policies of sickness and
accident insurance that are sold in connection with an
employment-related group health plan and that are not subject to
section 3924.03 of the Revised Code:

(A)
Any such policy shall comply with the requirements of
division
(A) of section 3924.03 and
section
3924.033 of the Revised Code.

(B)(1)
Except as provided in section 2712(b) to (e) of the "Health
Insurance Portability and Accountability Act of 1996," if an
insurer offers coverage in the small or large group market in
connection with a group policy, the insurer shall renew or continue
in force such coverage at the option of the policyholder.

(2)
An insurer may cancel or decide not to renew the coverage of an
employee or of a dependent of an employee if the employee or
dependent, as applicable, has performed an act or practice that
constitutes fraud or made an intentional misrepresentation of
material fact under the terms of the coverage and if the cancellation
or nonrenewal is not based, either directly or indirectly, on any
health status-related factor in relation to the employee or
dependent.

As
used in division (B)(2) of this section, "health status-related
factor" has the same meaning as in section 3924.031 of the
Revised Code.

(C)(1)
No such policy, or insurer offering health insurance coverage in
connection with such a policy, shall require any individual, as a
condition of coverage or continued coverage under the policy, to pay
a premium or contribution that is greater than the premium or
contribution for a similarly situated individual covered under the
policy on the basis of any health status-related factor in relation
to the individual or to an individual covered under the policy as a
dependent of the individual.

(2)
Nothing in division (C)(1) of this section shall be construed to
restrict the amount that an employer may be charged for coverage
under a group policy, or to prevent a group policy, and an insurer
offering group health insurance coverage, from establishing premium
discounts or rebates or modifying otherwise applicable copayments or
deductibles in return for adherence to programs of health promotion
and disease prevention.

(D)
Such policies shall provide for the special enrollment periods
described in section 2701(f) of the "Health Insurance
Portability and Accountability Act of 1996."

(E)
At least once in every twelve-month period, an insurer shall provide
to all late enrollees, as defined in section 3924.01 of the Revised
Code, who are identified by the policyholder, the option to enroll in
the group policy. The enrollment option shall be provided for a
minimum period of thirty consecutive days. All delays of coverage
imposed under the group policy, including any pre-existing condition
exclusion period or service waiting period, shall begin on the date
the insurer receives notice of the late enrollee's application or
request for coverage, and shall run concurrently with each other.

Sec.
3923.85.
(A)
As used in this section, "cost sharing" means the cost to
an individual insured under an individual or group policy of sickness
and accident insurance or a public employee benefit plan according to
any coverage limit, copayment, coinsurance, deductible, or other
out-of-pocket expense requirements imposed by the policy or plan.

(B)
Notwithstanding section 3901.71 of the Revised Code and subject to
division (D) of this section, no individual or group policy of
sickness and accident insurance that is delivered, issued for
delivery, or renewed in this state and no public employee benefit
plan that is established or modified in this state shall fail to
comply with either of the following:

(1)
The policy or plan shall not provide coverage or impose cost sharing
for a prescribed, orally administered cancer medication on a less
favorable basis than the coverage it provides or cost sharing it
imposes for intraveneously administered or injected cancer
medications.

(2)
The policy or plan shall not comply with division (B)(1) of this
section by imposing an increase in cost sharing solely for orally
administered, intravenously administered, or injected cancer
medications.

(C)
Notwithstanding any provision of this section to the contrary, a
policy or plan shall be deemed to be in compliance with this section
if the cost sharing imposed under such a policy or plan for orally
administered cancer treatments does not exceed one hundred dollars
per prescription fill. The cost
-
sharing
limit of one hundred dollars per prescription fill shall apply to a
high deductible plan, as defined in 26 U.S.C. 223, or a catastrophic
plan,
described
in division (D)(2) of section 3902.57 of the Revised Code and
as
defined in 42 U.S.C. 18022, only after the deductible has been met.

(D)(1)
The prohibitions in division (B) of this section do not preclude an
individual or group policy of sickness and accident insurance or
public employee benefit plan from requiring an insured or plan member
to obtain prior authorization before orally administered cancer
medication is dispensed to the insured or plan member.

(2)
Division (B) of this section does not apply to the offer or renewal
of any individual or group policy of sickness and accident insurance
that provides coverage for specific diseases or accidents only, or to
any hospital indemnity, medicare supplement, disability income, or
other policy that offers only supplemental benefits.

(E)
An insurer that offers any sickness and accident insurance or any
public employee benefit plan that offers coverage for basic health
care services is not required to comply with division (B) of this
section if all of the following apply:

(1)
The insurer or plan submits documentation certified by an independent
member of the American academy of actuaries to the superintendent of
insurance showing that compliance with division (B)(1) of this
section for a period of at least six months independently caused the
insurer or plan's costs for claims and administrative expenses for
the coverage of basic health care services to increase by more than
one per cent per year.

(2)
The insurer or plan submits a signed letter from an independent
member of the American academy of actuaries to the superintendent of
insurance opining that the increase in costs 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 or plan for the coverage of basic health care services.

(3)(a)
The superintendent of insurance makes the following determinations
from the documentation and opinion submitted pursuant to divisions
(E)(1) and (2) of this section:

(i)
Compliance with division (B)(1) of this section for a period of at
least six months independently caused the insurer or plan's costs for
claims and administrative expenses for the coverage of basic health
care services to increase more than one per cent per year.

(ii)
The increase in costs reasonably justifies an increase of more than
one per cent in the annual premiums or rates charged by the insurer
or plan for the coverage of basic health care services.

(b)
Any determination made by the superintendent under division (E)(3) of
this section is subject to Chapter 119. of the Revised Code.

Sec.
3924.01.
As
used in sections 3924.01 to 3924.06 of the Revised Code:

(A)
"Actuarial certification" means a written statement
prepared by a member of the American academy of actuaries, or by any
other person acceptable to the superintendent of insurance, that
states that, based upon the person's examination, a carrier offering
health benefit plans to small employers is in compliance with
sections 3924.01 to 3924.06 of the Revised Code. "Actuarial
certification" shall include a review of the appropriate records
of, and the actuarial assumptions and methods used by, the carrier
relative to establishing premium rates for the health benefit plans.

(B)
"Base premium rate" means, as to any health benefit plan
that is issued by a carrier and that covers at least two but no more
than fifty employees of a small employer, the lowest premium rate for
a new or existing business prescribed by the carrier for the same or
similar coverage under a plan or arrangement covering any small
employer with similar case characteristics.

(C)
"Carrier" means any sickness and accident insurance company
or health insuring corporation authorized to issue health benefit
plans in this state or a MEWA. A sickness and accident insurance
company that owns or operates a health insuring corporation, either
as a separate corporation or as a line of business, shall be
considered as a separate carrier from that health insuring
corporation for purposes of sections 3924.01 to 3924.06 of the
Revised Code.

(D)
"Case characteristics" means, with respect to a small
employer, the geographic area in which the employees work; the age
and sex of the individual employees and their dependents; the
appropriate industry classification as determined by the carrier; the
number of employees and dependents; and such other objective criteria
as may be established by the carrier. "Case characteristics"
does not include claims experience, health status, or duration of
coverage from the date of issue.

(E)
"Dependent" means the spouse or child of an eligible
employee, subject to applicable terms of the health benefits plan
covering the employee.

(F)
"Eligible employee" means an employee who works a normal
work week of thirty or more hours. "Eligible employee" does
not include a temporary or substitute employee, or a seasonal
employee who works only part of the calendar year on the basis of
natural or suitable times or circumstances.

(G)
"Health benefit plan" means any hospital or medical expense
policy or certificate or any health plan provided by a carrier, that
is delivered, issued for delivery, renewed, or used in this state on
or after the date occurring six months after November 24, 1995.
"Health benefit plan" does not include policies covering
only accident, credit, dental, disability income, long-term care,
hospital indemnity, medicare supplement, specified disease, or vision
care; coverage under a one-time-limited-duration policy that is less
than twelve months; coverage issued as a supplement to liability
insurance; insurance arising out of a workers' compensation or
similar law; automobile medical-payment insurance; or insurance under
which benefits are payable with or without regard to fault and which
is statutorily required to be contained in any liability insurance
policy or equivalent self-insurance.

(H)
"Late enrollee" means an eligible employee or dependent who
enrolls in a small employer's health benefit plan other than during
the first period in which the employee or dependent is eligible to
enroll under the plan or during a special enrollment period described
in section 2701(f) of the "Health Insurance Portability and
Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat.
1955, 42 U.S.C.A. 300gg, as amended.

(I)
"MEWA" means any "multiple employer welfare
arrangement" as defined in section 3 of the "Federal
Employee Retirement Income Security Act of 1974," 88 Stat. 832,
29 U.S.C.A. 1001, as amended, except for any arrangement which is
fully insured as defined in division (b)(6)(D) of section 514 of that
act.

(J)
"Midpoint rate" means, for small employers with similar
case characteristics and plan designs and as determined by the
applicable carrier for a rating period, the arithmetic average of the
applicable base premium rate and the corresponding highest premium
rate.

(K)

"Pre-existing conditions provision" means a policy
provision that excludes or limits coverage for charges or expenses
incurred during a specified period following the insured's enrollment
date as to a condition for which medical advice, diagnosis, care, or
treatment was recommended or received during a specified period
immediately preceding the enrollment date. Genetic information shall
not be treated as such a condition in the absence of a diagnosis of
the condition related to such information.

For
purposes of this division, "enrollment date" means, with
respect to an individual covered under a group health benefit plan,
the date of enrollment of the individual in the plan or, if earlier,
the first day of the waiting period for such enrollment.

(L)

"Service waiting period" means the period of time after
employment begins before an employee is eligible to be covered for
benefits under the terms of any applicable health benefit plan
offered by the small employer.

(M)(1)
(L)(1)

"Small employer" means, in connection with a group health
benefit plan and with respect to a calendar year and a plan year, an
employer who employed an average of at least two but no more than
fifty eligible employees on business days during the preceding
calendar year and who employs at least two employees on the first day
of the plan year.

(2)
For purposes of division
(M)(1)
(L)(1)

of this section, all persons treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 of the "Internal
Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as
amended, shall be considered one employer. In the case of an employer
that was not in existence throughout the preceding calendar year, the
determination of whether the employer is a small or large employer
shall be based on the average number of eligible employees that it is
reasonably expected the employer will employ on business days in the
current calendar year. Any reference in division
(M)
(L)

of this section to an "employer" includes any predecessor
of the employer. Except as otherwise specifically provided,
provisions of sections 3924.01 to 3924.06 of the Revised Code that
apply to a small employer that has a health benefit plan shall
continue to apply until the plan anniversary following the date the
employer no longer meets the requirements of this division.

Sec.
3924.02.
(A)
An individual or group health benefit plan is subject to sections
3924.01 to 3924.06 of the Revised Code if it provides health care
benefits covering at least two but no more than fifty employees of a
small employer, and if it meets either of the following conditions:

(1)
Any portion of the premium or benefits is paid by a small employer,
or any covered individual is reimbursed, whether through wage
adjustments or otherwise, by a small employer for any portion of the
premium.

(2)
The health benefit plan is treated by the employer or any of the
covered individuals as part of a plan or program for purposes of
section 106 or 162 of the "Internal Revenue Code of 1986,"
100 Stat. 2085, 26 U.S.C.A. 1, as amended.

(B)
Notwithstanding division (A) of this section, divisions
(D)
(C)
,

(E)(2)
(D)(2)
,

(F)
(E)
,
and
(G)
(F)

of section 3924.03 of the Revised Code and section 3924.04 of the
Revised Code do not apply to health benefit policies that are not
sold to owners of small businesses as an employment benefit plan.
Such policies shall clearly state that they are not being sold as an
employment benefit plan and that the owner of the business is not
responsible, either directly or indirectly, for paying the premium or
benefits.

(C)
Every health benefit plan offered or delivered by a carrier, other
than a health insuring corporation, to a small employer is subject to
sections 3923.23, 3923.231, 3923.232, 3923.233, and 3923.234 of the
Revised Code and any other provision of the Revised Code that
requires the reimbursement, utilization, or consideration of a
specific category of a licensed or certified health care
practitioner.

(D)
Except as expressly provided in sections 3924.01 to 3924.06 of the
Revised Code, no health benefit plan offered to a small employer is
subject to any of the following:

(1)
Any law that would inhibit any carrier from contracting with
providers or groups of providers with respect to health care services
or benefits;

(2)
Any law that would impose any restriction on the ability to negotiate
with providers regarding the level or method of reimbursing care or
services provided under the health benefit plan;

(3)
Any law that would require any carrier to either include a specific
provider or class of provider when contracting for health care
services or benefits, or to exclude any class of provider that is
generally authorized by statute to provide such care.

Sec.
3924.03.
Except
as otherwise provided in section 2721 of the "Health Insurance
Portability and Accountability Act of 1996," Pub. L. No.
104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, health
benefit plans covering small employers are subject to the following
conditions, as applicable:

(A)(1)

Pre-existing
conditions provisions shall not exclude or limit coverage for a
period beyond twelve months, or eighteen months in the case of a late
enrollee, following the individual's enrollment date and may only
relate to a physical or mental condition, regardless of the cause of
the condition, for which medical advice, diagnosis, care, or
treatment was recommended or received within the six months
immediately preceding the enrollment date.

Division
(A)(1) of this section is subject to the exceptions set forth in
section 2701(d) of the "Health Insurance Portability and
Accountability Act of 1996."

(2)
The period of any such pre-existing condition exclusion shall be
reduced by the aggregate of the periods of creditable coverage, if
any, applicable to the employee or dependent as of the enrollment
date.

(3)
A period of creditable coverage shall not be counted, with respect to
enrollment of an individual under a group health benefit plan, if,
after that period and before the enrollment date, there was a
sixty-three-day period during all of which the individual was not
covered under any creditable coverage. Subsections (c)(2) to (4) and
(e) of section 2701 of the "Health Insurance Portability and
Accountability Act of 1996" apply with respect to crediting
previous coverage.

(4)
As used in division (A) of this section:

(a)
"Creditable coverage" has the same meaning as in section
2701(c)(1) of the "Health Insurance Portability and
Accountability Act of 1996."

(b)
"Enrollment date" means, with respect to an individual
covered under a group health benefit plan, the date of enrollment of
the individual in the plan or, if earlier, the first day of the
waiting period for such enrollment.

(B)(1)

Except
as provided in section 2712(b) to (e) of the "Health Insurance
Portability and Accountability Act of 1996," if a carrier offers
coverage in the small employer market in connection with a group
health benefit plan, the carrier shall renew or continue in force
such coverage at the option of the plan sponsor of the plan.

(2)
A carrier may cancel or decide not to renew the coverage of any
eligible employee or of a dependent of an eligible employee if the
employee or dependent, as applicable, has performed an act or
practice that constitutes fraud or made an intentional
misrepresentation of material fact under the terms of the coverage
and if the cancellation or nonrenewal is not based, either directly
or indirectly, on any health status-related factor in relation to the
employee or dependent.

As
used in division
(B)
(A)
(2)
of this section, "health status-related factor" has the
same meaning as in section 3924.031 of the Revised Code.

(C)

(B)

A
carrier shall not exclude any eligible employee or dependent, who
would otherwise be covered under a health benefit plan, on the basis
of any actual or expected health condition of the employee or
dependent.

If,
prior to November 24, 1995, a carrier excluded an eligible employee
or dependent, other than a late enrollee, on the basis of an actual
or expected health condition, the carrier shall, upon the initial
renewal of the coverage on or after that date, extend coverage to the
employee or dependent if all other eligibility requirements are met.

(D)

(C)

No
health benefit plan issued by a carrier shall limit or exclude, by
use of a rider or amendment applicable to a specific individual,
coverage by type of illness, treatment, medical condition, or
accident
,
except for pre-existing conditions as permitted under division (A) of
this section
.
If a health benefit plan that is delivered or issued for delivery
prior to April 14, 1993, contains such limitations or exclusions, by
use of a rider or amendment applicable to a specific individual, the
plan shall eliminate the use of such riders or amendments within
eighteen months after April 14, 1993.

(E)
(D)
(1)
Except as provided in sections 3924.031 and 3924.032 of the Revised
Code, and subject to such rules as may be adopted by the
superintendent of insurance in accordance with Chapter 119. of the
Revised Code, a carrier shall offer and make available every health
benefit plan that it is actively marketing to every small employer
that applies to the carrier for such coverage.

Division

(E)
(D)
(1)
of this section does not apply to a health benefit plan that a
carrier makes available in the small employer market only through one
or more bona fide associations.

Division

(E)
(D)
(1)
of this section shall not be construed to preclude a carrier from
establishing employer contribution rules or group participation rules
for the offering of coverage in connection with a group health
benefit plan in the small employer market, as allowed under the law
of this state. As used in division
(E)
(D)
(1)
of this section, "employer contribution rule" means a
requirement relating to the minimum level or amount of employer
contribution toward the premium for enrollment of employees and
dependents and "group participation rule" means a
requirement relating to the minimum number of employees or dependents
that must be enrolled in relation to a specified percentage or number
of eligible individuals or employees of an employer.

(2)
Each health benefit plan, at the time of initial group enrollment,
shall make coverage available to all the eligible employees of a
small employer without a service waiting period. The decision of
whether to impose a service waiting period shall be made by the small
employer. Such waiting periods shall not be greater than ninety days.

(3)
Each health benefit plan shall provide for the special enrollment
periods described in section 2701(f) of the "Health Insurance
Portability and Accountability Act of 1996."

(4)
At least once in every twelve-month period, a carrier shall provide
to all late enrollees who are identified by the small employer, the
option to enroll in the health benefit plan. The enrollment option
shall be provided for a minimum period of thirty consecutive days.
All delays of coverage imposed under the health benefit plan,
including any
pre-existing
condition exclusion period,
affiliation
period
,

or service waiting period, shall begin on the date the carrier
receives notice of the late enrollee's application or request for
coverage, and shall run concurrently with each other.

(F)

(E)

The
benefit structure of any health benefit plan may, at the time of
coverage renewal, be changed by the carrier to make it consistent
with the benefit structure contained in health benefit plans being
marketed to new small employer groups. If the health benefit plan is
available in the small employer market other than only through one or
more bona fide associations, the modification must be consistent with
the law of this state and effective on a uniform basis among small
employer group plans.

(G)

(F)

A
carrier may obtain any facts and information necessary to apply this
section, or supply those facts and information to any other
third-party payer, without the consent of the beneficiary. Each
person claiming benefits under a health benefit plan shall provide
any facts and information necessary to apply this section.

For
purposes of this section, "bona fide association" means an
association that has been actively in existence for at least five
years; has been formed and maintained in good faith for purposes
other than obtaining insurance; does not condition membership in the
association on any health status-related factor, as defined in
section 3924.031 of the Revised Code, relating to an individual,
including an employee or dependent; makes health insurance coverage
offered through the association available to all members regardless
of any health status-related factor, as defined in section 3924.031
of the Revised Code, relating to such members or to individuals
eligible for coverage through a member; does not make health
insurance coverage offered through the association available other
than in connection with a member of the association; and meets any
other requirement imposed by the superintendent. To maintain its
status as a "bona fide association," each association shall
annually certify to the superintendent that it meets the requirements
of this paragraph.

Sec.
3924.033.
(A)
Each carrier, in connection with the offering of a health benefit
plan to a small employer, shall disclose to the employer, as part of
its solicitation and sales materials, the following information:

(1)
The provisions of the plan concerning the carrier's right to change
premium rates and the factors that may affect changes in premium
rates;

(2)
The provisions of the plan relating to renewability of coverage;

(3)

The
provisions of the plan relating to any pre-existing condition
exclusion;

(4)

The
benefits and premiums available under all health benefit plans for
which the employer is qualified.

(B)
The information described in division (A) of this section shall be
provided in a manner determined to be understandable by the average
small employer, and in a manner sufficient to reasonably inform a
small employer regarding the employer's rights and obligations under
the health benefit plan.

(C)
Nothing in this section requires a carrier to disclose any
information that is by law proprietary and trade secret information.

Sec.
3924.51.
(A)
As used in this section:

(1)
"Child" means, in connection with any adoption or placement
for adoption of the child, an individual who has not attained age
eighteen as of the date of the adoption or placement for adoption.

(2)
"Health insurer" has the same meaning as in section 3924.41
of the Revised Code.

(3)
"Placement for adoption" means the assumption and retention
by a person of a legal obligation for total or partial support of a
child in anticipation of the adoption of the child. The child's
placement with a person terminates upon the termination of that legal
obligation.

(B)
If an individual or group health plan of a health insurer makes
coverage available for dependent children of participants or
beneficiaries, the plan shall provide benefits to dependent children
placed with participants or beneficiaries for adoption under the same
terms and conditions as apply to the natural, dependent children of
the participants and beneficiaries, irrespective of whether the
adoption has become final.

(C)
A health plan described in division (B) of this section shall not
restrict coverage under the plan of any dependent child adopted by a
participant or beneficiary, or placed with a participant or
beneficiary for adoption, solely on the basis of a pre-existing
condition of the child at the time that the child would otherwise
become eligible for coverage under the plan, if the adoption or
placement for adoption occurs while the participant or beneficiary is
eligible for coverage under the plan.

Sec.
4125.041.
A
shared employee under a professional employer organization agreement
shall not, solely as a result of being a shared employee, be
considered an employee of the professional employer organization for
purposes of general liability insurance, fidelity bonds, surety
bonds, employer liability not otherwise covered by Chapters 4121. and
4123. of the Revised Code, or liquor liability insurance carried by
the professional employer organization, unless the professional
employer organization agreement and applicable prearranged employment
contract, insurance contract, or bond specifically states otherwise.

A
shared employee shall be considered an employee of the professional
employer organization for purposes of determining whether a
professional employer organization who sponsors a group health
benefit plan is a small employer under division
(M)(1)
(L)(1)

of section 3924.01 of the Revised Code. A fully insured health
benefit plan sponsored by a professional employer organization is not
subject to sections 3924.01 to 3924.06 of the Revised Code if the
professional employer organization is not a small employer for
purposes of those sections.

Section
2.
That
existing sections 1731.04, 1751.01, 1751.06, 1751.12, 1751.18,
1751.58, 1751.69, 3902.50, 3922.01, 3923.57, 3923.571, 3923.85,
3924.01, 3924.02, 3924.03, 3924.033, 3924.51, and 4125.041 of the
Revised Code are hereby repealed.

Section
3.
This
act shall apply to health benefit plans, as defined in section
3922.01 of the Revised Code, delivered, issued for delivery,
modified, or renewed on or after the effective date of this act.

Section
4.
This
act shall be known as the Fair Access to Medical Insurance for Local
Youth and Families (FAMILY) Act.

Section
5.
Section
1751.12 of the Revised Code is presented in this act as a composite
of the section as amended by both H.B. 3 and H.B. 59 of the 130th
General Assembly. The General Assembly, applying the principle stated
in division (B) of section 1.52 of the Revised Code that amendments
are to be harmonized if reasonably capable of simultaneous operation,
finds that the composite is the resulting version of the section in
effect prior to the effective date of the section as presented in
this act.