Bill Text: OH SB330 | 2013-2014 | 130th General Assembly | Introduced

Ohio Senate Bill 330 (Prior Session Legislation)

Introduced

Bill Title: To amend the law related to the prior authorization requirements of insurers and of the medical assistance programs administered by the Department of Medicaid.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Introduced - Dead) 2014-04-15 - To Insurance & Financial Institutions [SB330 Detail]

Download: Ohio-2013-SB330-Introduced.html

As Introduced

130th General Assembly

Regular Session

2013-2014

S. B. No. 330

Senator Cafaro

Cosponsors: Senators Brown, Smith

A BILL

To amend section 1739.05 and to enact sections

1751.72, 3901.90, 3923.251, and 5160.33 of the

Revised Code to amend the law related to the prior

authorization requirements of insurers and of the

medical assistance programs administered by the

Department of Medicaid.

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

Section 1. That section 1739.05 be amended and sections	7
1751.72, 3901.90, 3923.251, and 5160.33 of the Revised Code be	8
enacted to read as follows:	9

Sec. 1739.05. (A) A multiple employer welfare arrangement	10
that is created pursuant to sections 1739.01 to 1739.22 of the	11
Revised Code and that operates a group self-insurance program may	12
be established only if any of the following applies:	13

(1) The arrangement has and maintains a minimum enrollment of	14
three hundred employees of two or more employers.	15

(2) The arrangement has and maintains a minimum enrollment of	16
three hundred self-employed individuals.	17

(3) The arrangement has and maintains a minimum enrollment of	18
three hundred employees or self-employed individuals in any	19
combination of divisions (A)(1) and (2) of this section.	20

(B) A multiple employer welfare arrangement that is created	21
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	22
that operates a group self-insurance program shall comply with all	23
laws applicable to self-funded programs in this state, including	24
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	25
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	26
3923.24, 3923.251, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581,	27
3923.63, 3923.80, 3924.031, 3924.032, and 3924.27 of the Revised	28
Code.	29

(C) A multiple employer welfare arrangement created pursuant	30
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	31
enrollments only through agents or solicitors licensed pursuant to	32
Chapter 3905. of the Revised Code to sell or solicit sickness and	33
accident insurance.	34

(D) A multiple employer welfare arrangement created pursuant	35
to sections 1739.01 to 1739.22 of the Revised Code shall provide	36
benefits only to individuals who are members, employees of	37
members, or the dependents of members or employees, or are	38
eligible for continuation of coverage under section 1751.53 or	39
3923.38 of the Revised Code or under Title X of the "Consolidated	40
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	41
U.S.C.A. 1161, as amended.	42

Sec. 1751.72. (A) As used in this section:

(1) "Covered person" has the same meaning as in section	44
3901.90 of the Revised Code.	45

(2) "Prior authorization requirement" means any practice	46
implemented by a health insuring corporation in which coverage of	47
a health care service is dependent upon a covered person, or a	48
health care provider, notifying the health insuring corporation	49
that the service is going to be provided or requesting and	50
receiving approval from the health insuring corporation. "Prior	51
authorization" includes any precertification, notification, or	52
referral program, or a prospective or utilization review conducted	53
prior to providing a health care service.	54

(3) "Utilization review" has the same meaning as in section	55
1751.77 of the Revised Code.	56

(B) If a policy, contract, or agreement issued by a health	57
insuring corporation contains a prior authorization requirement,	58
then the health insuring corporation shall comply with both of the	59
following:	60

(1) The health insuring corporation shall use the prior	61
authorization form adopted in rule by the superintendent of	62
insurance under section 3901.90 of the Revised Code for all prior	63
authorization requests or notifications made under a prior	64
authorization requirement.	65

(2) If the prior authorization requirement stipulates that	66
the health insuring corporation must either respond to a request	67
for coverage or approve or deny a request for coverage, then the	68
health insuring corporation shall either respond to the request or	69
deny or authorize the request, as appropriate, within forty-eight	70
hours after the health insuring corporation receives the form.	71

(C) Failure to comply with division (B) of this section shall	72
be considered an unfair and deceptive practice under sections	73
3901.19 to 3901.26 of the Revised Code.	74

Sec. 3901.90. (A) As used in this section:

(1) "Covered person" means a person receiving coverage for	76
health services under a policy, contract, agreement, or plan	77
issued by a health plan issuer.	78

(2) "Health plan issuer" means a health insuring corporation,	79
a sickness and accident insurer, a public employee benefit plan,	80
or a multiple employer welfare arrangement.	81

(3) "Prior authorization requirement" means any practice	82
implemented by a health plan issuer in which coverage of a health	83
care service is dependent upon a covered person, or a health care	84
provider, notifying the health plan issuer that the service is	85
going to be provided or requesting and receiving approval from the	86
health plan issuer. "Prior authorization" includes any	87
precertification, notification, or referral program, or a	88
prospective or utilization review conducted prior to providing a	89
health care service.	90

(4) "Utilization review" has the same meaning as in section	91
1751.77 of the Revised Code.	92

(B) The superintendent shall adopt in rule a standard form by	93
which a covered person may request prior authorization under a	94
prior authorization requirement.	95

Sec. 3923.251. (A) As used in this section:

(1) "Covered person" has the same meaning as in section	97
3901.90 of the Revised Code.	98

(2) "Prior authorization requirement" means any practice	99
implemented by either a sickness and accident insurer or a public	100
employee benefit plan in which coverage of a health care service	101
is dependent upon a covered person, or the health care provider,	102
notifying the insurer or plan that the service is going to be	103
provided or requesting and receiving approval from the insurer or	104
plan. "Prior authorization requirement" includes any	105
precertification, notification, or referral program, or a	106
prospective or utilization review conducted prior to providing a	107
health care service.	108

(3) "Utilization review" has the same meaning as in section	109
1751.77 of the Revised Code.	110

(B) If a policy issued by a sickness and accident insurer or	111
a public employee benefit plan contains a prior authorization	112
requirement, then the insurer or plan shall comply with both of	113
the following:	114

(1) The insurer or plan shall use the prior authorization	115
form adopted in rule by the superintendent of insurance under	116
section 3901.90 of the Revised Code for all prior authorization	117
notifications or requests made under a prior authorization	118
requirement.	119

(2) If the prior authorization requirement stipulates that	120
the insurer or plan must either respond to a request for coverage	121
or approve or deny a request for coverage, then the insurer or	122
plan shall either respond to the request or deny or authorize the	123
request, as appropriate, within forty-eight hours after the	124
insurer or plan receives the form.	125

(C) Failure to comply with division (B) of this section shall	126
be considered an unfair and deceptive practice under sections	127
3901.19 to 3901.26 of the Revised Code.	128

Sec. 5160.33. The department of medicaid shall establish a	129
standardized form to be used by medical assistance recipients and	130
individuals acting on the behalf of medical assistance recipients	131
to request prior authorization for services that are covered by a	132
medical assistance program and require prior authorization. The	133
department may provide for the form to be completed and submitted	134
to the department or its designee through an electronic submission	135
process. To the extent possible, the form shall be modeled on the	136
standardized prior authorization form adopted by the	137
superintendent of insurance under section 3901.90 of the Revised	138
Code.	139

The department or its designee shall approve or deny a prior	140
authorization request made on the form established under this	141
section not later than forty-eight hours after the department or	142
its designee receives the form.	143