Bill Title: To require health insurers to provide coverage for prostheses.
Sponsorship: Strong Partisan Bill (Democrat 18-1)
Status: (Introduced - Dead) 2010-05-27 - Committee Report - S
[HB310 Detail]Download: Ohio-2009-HB310-Comm_Sub.html
As Reported by the House Health Committee
| 128th General Assembly | | Regular Session | | 2009-2010 |
| |
Representatives Garland, Driehaus
Cosponsors:
Representatives Murray, Hagan, Chandler, Okey, Stewart, Celeste, Harris, Harwood, Domenick, Fende, Brown, Yuko, Letson, Williams, B., Phillips, Pillich, Ujvagi
A BILL
| To amend section 1739.05 and to enact sections | 1 |
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1751.69 and 3923.85 of the Revised Code to require | 2 |
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health insurers to provide coverage for | 3 |
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
| Section 1. That section 1739.05 be amended and sections | 5 |
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1751.69 and 3923.85 of the Revised Code be enacted to read as | 6 |
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follows: | 7 |
| Sec. 1739.05. (A) A multiple employer welfare arrangement | 8 |
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that is created pursuant to sections 1739.01 to 1739.22 of the | 9 |
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Revised Code and that operates a group self-insurance program may | 10 |
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be established only if any of the following applies: | 11 |
| (1) The arrangement has and maintains a minimum enrollment of | 12 |
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three hundred employees of two or more employers. | 13 |
| (2) The arrangement has and maintains a minimum enrollment of | 14 |
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three hundred self-employed individuals. | 15 |
| (3) The arrangement has and maintains a minimum enrollment of | 16 |
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three hundred employees or self-employed individuals in any | 17 |
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combination of divisions (A)(1) and (2) of this section. | 18 |
| (B) A multiple employer welfare arrangement that is created | 19 |
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pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 20 |
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that operates a group self-insurance program shall comply with all | 21 |
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laws applicable to self-funded programs in this state, including | 22 |
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sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 23 |
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to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 24 |
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3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, | 25 |
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3923.80, 3923.85, 3924.031, 3924.032, and 3924.27 of the Revised | 26 |
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Code. | 27 |
| (C) A multiple employer welfare arrangement created pursuant | 28 |
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to sections 1739.01 to 1739.22 of the Revised Code shall solicit | 29 |
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enrollments only through agents or solicitors licensed pursuant to | 30 |
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Chapter 3905. of the Revised Code to sell or solicit sickness and | 31 |
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accident insurance. | 32 |
| (D) A multiple employer welfare arrangement created pursuant | 33 |
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to sections 1739.01 to 1739.22 of the Revised Code shall provide | 34 |
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benefits only to individuals who are members, employees of | 35 |
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members, or the dependents of members or employees, or are | 36 |
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eligible for continuation of coverage under section 1751.53 or | 37 |
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3923.38 of the Revised Code or under Title X of the "Consolidated | 38 |
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Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 39 |
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U.S.C.A. 1161, as amended. | 40 |
| Sec. 1751.69. (A) As used in this section, "prosthesis" means | 41 |
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an artificial leg, arm, or eye, including a replacement if | 42 |
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required because of a change in the patient's physical condition. | 43 |
| (B) Notwithstanding section 3901.71 of the Revised Code and | 44 |
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except as provided in division (D) of this section, each | 45 |
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individual or group health insuring corporation policy, contract, | 46 |
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or agreement providing basic health care services that is | 47 |
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delivered, issued for delivery, or renewed in this state shall | 48 |
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provide coverage for benefits for prostheses that are medically | 49 |
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necessary. In providing the coverage, all of the following apply: | 50 |
| (1) The coverage shall be at least equal to the coverage | 51 |
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provided under the medicare program pursuant to Title XVIII of the | 52 |
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"Social Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1395, as | 53 |
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amended. | 54 |
| (2) The coverage shall include coverage for benefits for the | 55 |
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repair or replacement of a prosthesis that is medically necessary. | 56 |
| (3) The policy, contract, or agreement may require prior | 57 |
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authorization for a prosthesis using the same prior authorization | 58 |
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process that is used for other covered benefits. | 59 |
| (4) The policy, contract, or agreement may impose a | 60 |
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deductible, copayment, coinsurance, or any combination thereof, on | 61 |
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a prosthesis. The amount imposed shall not exceed the amount of | 62 |
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the respective deductible, copayment, coinsurance, or combination | 63 |
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thereof, that is imposed for other health benefits under the | 64 |
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policy, contract, or agreement. | 65 |
| (5) The policy, contract, or agreement shall provide | 66 |
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reimbursement for a prosthesis in an amount equal to the fee | 67 |
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schedule amount for the prosthesis under the medicare | 68 |
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reimbursement schedule. | 69 |
| (6) The policy, contract, or agreement shall not impose any | 70 |
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annual or lifetime dollar maximum on the coverage for prostheses, | 71 |
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other than an annual or lifetime dollar maximum that applies in | 72 |
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the aggregate to all terms and services covered under the policy, | 73 |
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contract, or agreement. | 74 |
| (C) Nothing in division (B) of this section requires a | 75 |
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policy, contract, or agreement to provide reimbursement to a | 76 |
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health care provider or facility for providing, repairing, or | 77 |
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replacing prostheses if the provider or facility does not have a | 78 |
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health care contract with the health insuring corporation. | 79 |
| (D) Division (B) of this section does not apply to a contract | 80 |
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that a health insuring corporation enters into with the department | 81 |
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of job and family services under section 5111.17 of the Revised | 82 |
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Code. | 83 |
| Sec. 3923.85. (A) As used in this section, "prosthesis" means | 84 |
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an artificial leg, arm, or eye, including a replacement if | 85 |
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required because of a change in the patient's physical condition. | 86 |
| (B) Notwithstanding section 3901.71 of the Revised Code and | 87 |
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except as provided in division (D) of this section, each | 88 |
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individual or group policy of sickness and accident insurance that | 89 |
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is delivered, issued for delivery, or renewed in this state and | 90 |
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each public employee benefit plan that is established or modified | 91 |
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in this state shall provide coverage for benefits for prostheses | 92 |
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that are medically necessary. In providing the coverage, all of | 93 |
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the following apply: | 94 |
| (1) The coverage shall be at least equal to the coverage | 95 |
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provided under the medicare program pursuant to Title XVIII of the | 96 |
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"Social Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1395, as | 97 |
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amended. | 98 |
| (2) The coverage shall include coverage for benefits for the | 99 |
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repair or replacement of a prosthesis that is medically necessary. | 100 |
| (3) The policy or plan may require prior authorization for a | 101 |
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prosthesis using the same prior authorization process that is used | 102 |
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for other covered benefits. | 103 |
| (4) The policy or plan may impose a deductible, copayment, | 104 |
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coinsurance, or any combination thereof, on a prosthesis. The | 105 |
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amount imposed shall not exceed the amount of the respective | 106 |
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deductible, copayment, coinsurance, or combination thereof, that | 107 |
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is imposed for other health benefits under the policy or plan. | 108 |
| (5) The policy or plan shall provide reimbursement for a | 109 |
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prosthesis in an amount equal to the fee schedule amount for the | 110 |
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prosthesis under the medicare reimbursement schedule. | 111 |
| (6) The policy or plan shall not impose any annual or | 112 |
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lifetime dollar maximum on the coverage for prostheses, other than | 113 |
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an annual or lifetime dollar maximum that applies in the aggregate | 114 |
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to all terms and services covered under the policy or plan. | 115 |
| (C) Nothing in division (B) of this section requires a policy | 116 |
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or plan to provide reimbursement to a health care provider or | 117 |
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facility for providing, repairing, or replacing prostheses if the | 118 |
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provider or facility does not have a health care contract with the | 119 |
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sickness and accident insurer or public employee benefit plan. | 120 |
| (D) Division (B) of this section does not apply to the offer | 121 |
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or renewal of any individual or group policy of sickness and | 122 |
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accident insurance that provides coverage for specific diseases or | 123 |
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accidents only, or to any hospital indemnity, medicare supplement, | 124 |
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medicare, tricare, long-term care, disability income, one-time | 125 |
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limited duration policy of not longer than six months, or other | 126 |
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policy that offers only supplemental benefits. | 127 |
| Section 2. That existing section 1739.05 of the Revised Code | 128 |
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is hereby repealed. | 129 |
| Section 3. Section 1751.69 of the Revised Code shall apply | 130 |
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only to policies, contracts, and agreements that are delivered, | 131 |
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issued for delivery, or renewed in this state on or after the | 132 |
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effective date of this act. Section 3923.85 of the Revised Code | 133 |
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shall apply to policies of sickness and accident insurance on or | 134 |
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after the effective date of this act in accordance with section | 135 |
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3923.01 of the Revised Code and to public employee benefit plans | 136 |
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that are established or modified in this state on or after the | 137 |
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effective date of this act. | 138 |
