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hb888_00_IN
As Introduced
136th
General Assembly
Regular
Session
H. B. No. 888
2025-2026
Representatives White, E., Bryant
Bailey
Cosponsors: Representatives McNally,
Piccolantonio
To
amend section 1751.01 and to enact sections 3902.65 and 5164.11 of
the Revised Code
concerning
insurance and Medicaid coverage for specified infertility services.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
section 1751.01 be amended and sections 3902.65 and 5164.11 of the
Revised Code be enacted to read as follows:
Sec.
1751.01.
As
used in this chapter:
(A)(1)
"Basic health care services" means the following services
when medically necessary:
(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.
(4)
To the extent permitted under federal law, a health insuring
corporation that offers coverage for basic health care services shall
cover, as infertility services, diagnostic and exploratory procedures
to determine infertility and surgical procedures to correct a
medically diagnosed disease or condition of reproductive organs,
including endometriosis, collapsed or clogged fallopian tubes, and
testicular failure.
(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 Chapter 1705. 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.
3902.65.
(A)
As used in this section:
(1)
"Assisted reproductive technology" means any
fertility-related treatment in which eggs are surgically removed from
a woman's ovaries, combined with sperm in a laboratory, and
transferred back to that woman or a gestational carrier, including in
vitro fertilization, gamete intrafallopian transfer, or zygote
intrafallopian transfer. "Assisted reproductive technology"
does not include any treatment in which only sperm are handled, such
as intrauterine insemination or procedures in which a woman takes
medication to stimulate egg production without planning to have the
eggs surgically retrieved.
(2)
"Treatment for conditions that impact fertility" means any
treatment or procedure that seeks to remedy one or more medical
conditions or diagnoses that affect the male or female reproductive
system and result in the inability to conceive through sexual
intercourse, with the goal of achieving a successful pregnancy
without the use of assisted reproductive technology. "Treatment
for conditions that impact fertility" includes medications that
stimulate ovulation, intrauterine insemination, laparascopic surgery,
and treatment for any of the following:
(a)
Conditions that result in a failure to ovulate;
(b)
Issues in the menstrual cycle;
(c)
Structural problems of the male or female reproductive system;
(d)
Infections that impact fertility;
(e)
Conditions that result in the failure of an egg to mature properly;
(f)
Implantation failure;
(g)
Endometriosis;
(h)
Polycystic ovary syndrome;
(i)
Primary ovary insufficiency;
(j)
Uterine fibroids;
(k)
Autoimmune disorders that impact fertility;
(l)
Sperm disorders.
(B)
Notwithstanding section 3901.71 of the Revised Code, on and after the
effective date of this section, a health benefit plan that offers
coverage of basic health care services shall cover assisted
reproductive technology and treatment for conditions that impact
fertility to the same extent that the plan covers other medical
procedures and treatments for female reproductive care or male
infertility treatments and procedures. A cost-sharing requirement for
assisted reproductive technology and treatment for conditions that
impact fertility shall not exceed the cost-sharing requirement
imposed by the plan for other medical procedures and treatments for
female reproductive care or male infertility treatments and
procedures.
Sec.
5164.11.
(A)
As used in this section, "assisted reproductive technology"
and "treatment for conditions that impact fertility" have
the same meanings as in section 3902.65 of the Revised Code.
(B)
The medicaid program shall cover assisted reproductive technology and
treatment for conditions that impact fertility to the same extent
that the program covers other medical procedures and treatments for
female reproductive care or male infertility treatments and
procedures.
Section
2.
That
existing section 1751.01 of the Revised Code is hereby repealed.