Prohibit certain health insurance cost-sharing practices

hb937_00_IN

As Introduced

136th
General Assembly

Regular
Session
H. B. No. 937

2025-2026

Representatives Baker, Lorenz

To
amend sections 1751.12 and 1751.32 and to enact sections 3923.811 and
3959.21 of the Revised Code
to
prohibit certain health insurance cost-sharing practices.

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

Section
1.
That
sections 1751.12 and 1751.32 be amended and sections 3923.811 and
3959.21 of the Revised Code be enacted to read as follows:

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
either
of the following:

(a)
The annual limitation on cost sharing incurred under a health plan
under division (c) of 42 U.S.C. 18022;

(b)(i)
Except as otherwise provided in division (D)(5) of this section,

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

(ii)
As used in division (D)(2)(b) of this section, "
total
annual cost of providing a health care service

is
"
means
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

(iii)
A health insuring corporation
shall

be
demonstrated by
demonstrate
compliance with division (D)(2)(b) of this section through
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)

No
health insuring corporation shall directly or indirectly set, alter,
implement, or condition the terms of coverage, including benefit
design, based in full or in part on the availability or amount of
financial or product assistance for a prescription drug.

(4)
Except as otherwise provided in division (D)(5) of this section, when
calculating an enrollee's contribution to any applicable copayment
charges, coinsurance, cost sharing, deductible, or other similar
charges for a prescription drug, a health insuring corporation shall
include all amounts paid by the enrollee and on behalf of the
enrollee by another person, group, or organization.

(5)(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

for the purposes of division (D)(1) of this section
.

(b)
Division
(D)(2)
(D)(2)(b)

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 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.

(d)(i)
Division (D)(4)(a) of this section does not apply to copayment
charges, coinsurance, cost sharing, deductible, or similar charges
paid on behalf of an enrollee by another person, group, or
organization for a brand prescription drug for which there is a
medically appropriate generic equivalent, unless the prescriber
determines that the brand prescription drug is medically necessary.

(ii)
As used in division (D)(5)(d) of this section, "generic
equivalent" means a drug that is designated to be
therapeutically equivalent, as indicated by the United States food
and drug administration's publication titled approved drug products
with therapeutic equivalence evaluations.

(e)(i)
If a health insuring corporation's compliance with division (D)(2)(a)
of this section would result in an enrollee losing eligibility for
the federal income tax deduction, under 26 U.S.C. 223, for a health
savings account linked to a high deductible plan, then that division
applies only after the enrollee has met the minimum deductible
required by federal law;

(ii)
Division (D)(5)(e)(i) of this section does not apply with respect to
items or services that are considered preventive care pursuant to
division (c)(2)(C) of 26 U.S.C. 223, and the requirement of division
(D)(2)(a) of this section applies to such items or services
regardless of whether the minimum deductible under 26 U.S.C. 223 has
been met.

(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.
1751.32.
Each
health insuring corporation, annually, on or before the first day of
March, shall file a report with the superintendent of insurance,
covering the preceding calendar year.

The
report shall be verified by an officer of the health insuring
corporation, shall be in the form the superintendent prescribes, and
shall include:

(A)
A financial statement of the health insuring corporation, including
its balance sheet and receipts and disbursements for the preceding
year, which reflect, at a minimum:

(1)
All premium rate and other payments received for health care services
rendered;

(2)
Expenditures with respect to all categories of providers, facilities,
insurance companies, and other persons engaged to fulfill obligations
of the health insuring corporation arising out of its health care
policies, contracts, certificates, and agreements;

(3)
Expenditures for capital improvements or additions thereto,
including, but not limited to, construction, renovation, or purchase
of facilities and equipment.

(B)
A description of the enrollee population and composition, group and
nongroup;

(C)
A summary of enrollee written complaints and their disposition;

(D)
A statement of the number of subscriber policies, contracts,
certificates, and agreements that have been terminated by action of
the health insuring corporation, including the number of enrollees
affected;

(E)
A summary of the information compiled pursuant to division (A)(5) of
section 1751.04 of the Revised Code;

(F)
A current report of the names and addresses of the persons
responsible for the conduct of the affairs of the health insuring
corporation as required by section 1751.03 of the Revised Code.
Additionally, the report shall include the amount of wages, expense
reimbursements, and other payments to these persons for services to
the health insuring corporation, and shall include a full disclosure
of the financial interests related to the operations of the health
insuring corporation acquired by these persons during the preceding
year.

(G)
An actuarial opinion in the form prescribed by the superintendent by
rule;

(H)

Certification
as to whether the health insuring corporation has fully and
completely complied with division (D) of section 1751.12 of the
Revised Code during the preceding year.

(I)

Any
other information relating to the performance of the health insuring
corporation that is necessary to enable the superintendent to carry
out the superintendent's duties under this chapter.

Sec.
3923.811.
(A)
A sickness and accident insurer shall not impose copayment charges,
coinsurance, cost sharing, deductible, or other similar charges that
exceed the annual limitation on cost sharing incurred under a health
plan under division (c) of 42 U.S.C. 18022.

(B)
No sickness and accident insurer shall directly or indirectly set,
alter, implement, or condition the terms of coverage, including
benefit design, based in full or in part on the availability or
amount of financial or product assistance for a prescription drug.

(C)
Except as otherwise provided in division (D) of this section, when
calculating an insured's contribution to any applicable copayment
charges, coinsurance, cost sharing, deductible, or other similar
charges for a prescription drug, a sickness and accident insurer
shall include all amounts paid by the insured and on behalf of the
insured by another person, group, or organization.

(D)(1)
Division (C) of this section shall not apply to copayment charges,
coinsurance, cost sharing, deductible, or other similar charges paid
on behalf of an insured by another person, group, or organization for
a brand prescription drug for which there is a medically appropriate
generic equivalent, as defined in section 1751.12 of the Revised
Code, unless the prescriber determines that the brand prescription
drug is medically necessary.

(2)
If a sickness and accident insurer's compliance with division (C) of
this section would result in an insured losing eligibility for the
federal income tax deduction, under 26 U.S.C. 223, for a health
savings account linked to a high deductible plan, then that division
applies only after the insured has met the minimum deductible
required by federal law.

(3)
Division (D)(2) of this section does not apply with respect to items
or services that are considered preventive care pursuant to division
(c)(2)(C) of 26 U.S.C. 223, and the requirement of division (C) of
this section applies to such items or services regardless of whether
the minimum deductible under 26 U.S.C. 223 has been met.

(E)
On or before the first day of March each year, each sickness and
accident insurer operating in this state shall certify to the
superintendent of insurance whether the sickness and accident insurer
fully and completely complied with the requirements of this section
throughout the preceding calendar year.

Sec.
3959.21.
(A)
As used in this section:

(1)
Notwithstanding section 3959.01 of the Revised Code, "pharmacy
benefit manager" means any person or entity that, pursuant to a
contract or other relationship with an insurer, managed care
organization, employer, or other third party, either directly or
indirectly provides one or more pharmacy benefit management services
on behalf of a health benefit plan, and any agent, contractor,
intermediary, affiliate, subsidiary, or related entity of such person
that facilitates, provides, directs, or oversees the provision of
pharmacy benefit services.

(2)
"Pharmacy benefit management service" includes all the
following:

(a)
Negotiating the price of prescription drugs, including negotiating
and contracting for direct or indirect rebates, discounts, or other
price concessions;

(b)
Processing and payment of claims for covered prescription drugs;

(c)
Managing or providing data related to a prescription drug benefit;

(d)
Processing of drug prior authorization requests;

(e)
Adjudication of appeals or grievances related to the prescription
drug benefit;

(f)
Contracting with network pharmacies;

(g)
Controlling the cost of covered prescription drugs;

(h)
Arranging alternative access to or funding of prescription drugs;

(i)
Performing any administrative, managerial, clinical, pricing,
financial, reimbursement, data administration or reporting, or
billing services;

(j)
Performing any other duty directly or indirectly related to the
processing or payment of claims for covered prescription drugs.

(3)
"Health benefit plan" has the same meaning as in section
3922.01 of the Revised Code.

(B)(1)
Subject to the insurance laws and rules of this state, and subject to
the jurisdiction of the superintendent of insurance, a pharmacy
benefit manager, in the performance of contracted duties, shall
comply with all applicable requirements and limitations concerning
copayments, coinsurance, cost sharing, deductibles, or other similar
charges detailed in sections 1751.12 and 3923.811 of the Revised
Code.

(2)
If a pharmacy benefit manager's compliance with division (B)(1) of
this section would result in an enrollee or insured losing
eligibility for the federal income tax deduction, under 26 U.S.C.
223, for a health savings account linked to a high deductible plan,
then that division applies only after the enrollee or insured has met
the minimum deductible required by federal law;

(3)
Division (B)(2) of this section does not apply with respect to items
or services that are considered preventive care pursuant to division
(c)(2)(C) of 26 U.S.C. 223, and the requirement of division (B)(1) of
this section applies to such items or services regardless of whether
the minimum deductible under 26 U.S.C. 223 has been met.

(C)
No pharmacy benefit manager shall seek, conspire, or contract with a
health benefit plan to directly or indirectly set, alter, implement,
or condition the terms of the health plan coverage, including benefit
design, based in part or entirely on information about the
availability or amount of financial or product assistance available
for a prescription drug.

(D)
On or before the first day of March each year, each pharmacy benefit
manager operating in this state shall certify to the superintendent
of insurance whether the pharmacy benefit manager fully and
completely complied with the requirements of this section throughout
the preceding calendar year.

Section
2.
That
existing sections 1751.12 and 1751.32 of the Revised Code are hereby
repealed.

Section
3.
The
amendment or enactment by this act of sections 1751.12, 1751.32,
3923.811, and 3959.21 of the Revised Code 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 January 1,
2027.

Section
4.
Section
1751.12 of the Revised Code is presented in this act as a composite
of the section as amended by both H.B. 59 and H.B. 3 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.