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As Introduced
136th
General Assembly
Regular
Session
S. B. No. 165
2025-2026
Senator Manchester
To
amend sections 1753.28 and 3923.65 and to enact sections 1753.29 and
3923.66 of the Revised Code
to prohibit a health insuring corporation or sickness and accident
insurer from reducing or denying a claim based on certain factors.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
sections 1753.28 and 3923.65 be amended and sections 1753.29 and
3923.66 of the Revised Code be enacted to read as follows:
Sec.
1753.28.
(A)
As used in this section:
(1)
"Emergency medical condition" means a
medical
physical
or mental health
condition
that manifests itself by such acute symptoms of sufficient severity,
including severe pain, that a prudent layperson with an average
knowledge of health and medicine could reasonably expect the absence
of immediate medical attention to result in any of the following:
(a)
Placing the health of the individual or, with respect to a pregnant
woman, the health of the woman or her unborn child, in serious
jeopardy;
(b)
Serious impairment to bodily functions;
(c)
Serious dysfunction of any bodily organ or part.
(2)
"Emergency services" means the following:
(a)
A medical screening examination, as required by federal law, that is
within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department, to evaluate an emergency medical condition;
(b)
Such further medical examination and treatment that are required by
federal law to stabilize an emergency medical condition and are
within the capabilities of the staff and facilities available at the
hospital, including any trauma and burn center of the hospital.
(3)(a)
"Stabilize" means the provision of such medical treatment
as may be necessary to assure, within reasonable medical probability,
that no material deterioration of an individual's medical condition
is likely to result from or occur during a transfer, if the medical
condition could result in any of the following:
(i)
Placing the health of the individual or, with respect to a pregnant
woman, the health of the woman or her unborn child, in serious
jeopardy;
(ii)
Serious impairment to bodily functions;
(iii)
Serious dysfunction of any bodily organ or part.
(b)
In the case of a woman having contractions, "stabilize"
means such medical treatment as may be necessary to deliver,
including the placenta.
(4)
"Transfer" has the same meaning as in section 1867 of the
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A.
1395dd, as amended.
(B)
A health insuring corporation policy, contract, or agreement
providing coverage of basic health care services shall cover
emergency services for enrollees with emergency medical conditions
without regard to the day or time the emergency services are rendered
or to whether the enrollee, the hospital's emergency department where
the services are rendered, or an emergency physician treating the
enrollee, obtained prior authorization for the emergency services.
(C)
A health insuring corporation policy, contract, or agreement
providing coverage of basic health care services shall cover both of
the following:
(1)
Emergency services provided to an enrollee at a participating
hospital's emergency department if the enrollee presents self with an
emergency medical condition;
(2)
Emergency services provided to an enrollee at a nonparticipating
hospital's emergency department if the enrollee presents self with an
emergency medical condition and one of the following circumstances
applies:
(a)
Due to circumstances beyond the enrollee's control, the enrollee was
unable to utilize a participating hospital's emergency department
without serious threat to life or health.
(b)
A prudent layperson with an average knowledge of health and medicine
would have reasonably believed that, under the circumstances, the
time required to travel to a participating hospital's emergency
department could result in one or more of the adverse health
consequences described in division (A)(1) of this section.
(c)
A person authorized by the health insuring corporation refers the
enrollee to an emergency department and does not specify a
participating hospital's emergency department.
(d)
An ambulance takes the enrollee to a nonparticipating hospital other
than at the direction of the enrollee.
(e)
The enrollee is unconscious.
(f)
A natural disaster precluded the use of a participating emergency
department.
(g)
The status of a hospital changed from participating to
nonparticipating with respect to emergency services during a contract
year and no good faith effort was made by the health insuring
corporation to inform enrollees of this change.
(D)
A health insuring corporation that provides coverage for emergency
services shall inform enrollees of all of the following:
(1)
The scope of coverage for emergency services;
(2)
The appropriate use of emergency services, including the use of the
9-1-1 system and any other telephone access systems utilized to
access prehospital emergency services;
(3)
Any cost sharing provisions for emergency services;
(4)
The procedures for obtaining emergency services and other medical
services, so that enrollees are familiar with the location of the
emergency departments of participating hospitals and with the
location and availability of other participating facilities or
settings at which they could receive medical services
;
(5)
That enrollees are not required to self-diagnose
.
Sec.
1753.29.
(A)
A health insuring corporation shall not reduce or deny a claim for
reimbursement based solely on a diagnosis code or impression, current
ICD code, duration of an appointment as deemed clinically necessary
by the enrollee's provider, or select procedure code relating to the
enrollee's condition included on a form submitted to the health
insuring corporation by a provider for reimbursement of a claim.
(B)
A health insuring corporation shall not reduce or deny reimbursement
for a claim based on the absence of an emergency medical condition if
a prudent layperson with an average knowledge of health and medicine
would have reasonably expected the presence of an emergency medical
condition.
(C)
Nothing in this section shall be construed as exempting a health
insuring corporation from the prompt payment requirements prescribed
in sections 3901.381 to 3901.3814 of the Revised Code.
Sec.
3923.65.
(A)
As used in this section
:
(1)
"Emergency
,
"emergency
medical
condition"
means
a medical condition that manifests itself by such acute symptoms of
sufficient severity, including severe pain, that a prudent layperson
with average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in any of the
following:
(a)
Placing the health of the individual or, with respect to a pregnant
woman, the health of the woman or her unborn child, in serious
jeopardy;
(b)
Serious impairment to bodily functions;
(c)
Serious dysfunction of any bodily organ or part.
(2)
"Emergency services" means the following:
(a)
A medical screening examination, as required by federal law, that is
within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department, to evaluate an emergency medical condition;
(b)
Such further medical examination and treatment that are required by
federal law to stabilize an emergency medical condition and are
within the capabilities of the staff and facilities available at the
hospital, including any trauma and burn center of the hospital
and
"emergency services" have the same meanings as in section
1753.28 of the Revised Code
.
(B)
Every individual or group policy of sickness and accident insurance
that provides hospital, surgical, or medical expense coverage shall
cover emergency services without regard to the day or time the
emergency services are rendered or to whether the policyholder, the
hospital's emergency department where the services are rendered, or
an emergency physician treating the policyholder, obtained prior
authorization for the emergency services.
(C)
Every individual policy or certificate furnished by an insurer in
connection with any sickness and accident insurance policy shall
provide information regarding the following:
(1)
The scope of coverage for emergency services;
(2)
The appropriate use of emergency services, including the use of the
9-1-1 system and any other telephone access systems utilized to
access prehospital emergency services;
(3)
Any copayments for emergency services
;
(4)
That the covered person is not required to self-diagnose
.
(D)
This section does not apply to any individual or group policy of
sickness and accident insurance covering only accident, credit,
dental, disability income, long-term care, hospital indemnity,
medicare supplement, medicare, tricare, specified disease, or vision
care; coverage under a
one-timelimitedduration
one-time-limited-duration
policy
that is less than twelve months; 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.
Sec.
3923.66.
(A)
A sickness and accident insurer shall not reduce or deny a claim for
reimbursement based solely on a diagnosis code or impression, current
ICD code, duration of an appointment as deemed clinically necessary
by the covered person's provider, or select procedure code relating
to the covered person's condition included on a form submitted to the
sickness and accident insurer by a provider for reimbursement of a
claim.
(B)
A sickness and accident insurer shall not reduce or deny a claim for
reimbursement based on the absence of an emergency medical condition
if a prudent layperson with an average knowledge of health and
medicine would have reasonably expected the presence of an emergency
medical condition.
(C)
Nothing in this section shall be construed as exempting a sickness
and accident insurer from the prompt payment requirements prescribed
in sections 3901.381 to 3901.3814 of the Revised Code.
Section
2.
That
existing sections 1753.28 and 3923.65 of the Revised Code are hereby
repealed.