Bill Text: OH HB511 | 2013-2014 | 130th General Assembly | Engrossed

Ohio House Bill 511 (Prior Session Legislation)

Bill Title: To clarify the status of volunteer firefighters for purposes of the Patient Protection and Affordable Care Act, to make changes regarding coverage for a dependent child under a parent's health insurance plan and the hours of work needed to qualify for coverage under a small employer health benefit plan, to make changes to the chemotherapy parity law, to make peace officers, firefighters, and emergency medical workers diagnosed with post-traumatic stress disorder arising from employment without an accompanying physical injury eligible for compensation and benefits under Ohio's Workers' Compensation Law, and to increase the duration of the health insurance considered to be short-term under certain insurance laws.

Spectrum: Partisan Bill (Republican 30-0)

Status: (Engrossed - Dead) 2014-12-09 - Passed 3rd Consideration Senate [HB511 Detail]

Download: Ohio-2013-HB511-Engrossed.html

As Passed by the Senate

130th General Assembly

Regular Session

2013-2014

Sub. H. B. No. 511

Representative Sears

Cosponsors: Representatives Boose, Grossman, Henne, Romanchuk, Smith, Wachtmann, Young, Amstutz, Beck, Blessing, Burkley, Conditt, Green, Hackett, Hill, Scherer, Thompson Speaker Batchelder
Senators Bacon, Balderson, Burke, Eklund, Hite, Hughes, Jones, LaRose, Patton, Schaffer, Seitz

A BILL

To amend sections 1739.061, 1751.14, 1751.69,

3923.022, 3923.24, 3923.241, 3923.281, 3923.57,

3923.58, 3923.601, 3923.65, 3923.83, 3923.85,

3924.01, 4123.01, 4123.026, and 4123.46, and to

enact sections 505.377, 737.082, and 737.222 of

the Revised Code to clarify the status of

volunteer firefighters for purposes of the Patient

Protection and Affordable Care Act, to make

changes regarding coverage for a dependent child

under a parent's health insurance plan and the

hours of work needed to qualify for coverage under

a small employer health benefit plan, to make

changes to the chemotherapy parity law, to make

peace officers, firefighters, and emergency

medical workers diagnosed with post-traumatic

stress disorder arising from employment without an

accompanying physical injury eligible for

compensation and benefits under Ohio's Workers'

Compensation Law, and to increase the duration of

the health insurance considered to be short-term

under certain insurance laws.

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

Section 1. That sections 1739.061, 1751.14, 1751.69,	22
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601,	23
3923.65, 3923.83, 3923.85, 3924.01, 4123.01, 4123.026, and 4123.46	24
be amended and sections 505.377, 737.082, and 737.222 of the	25
Revised Code be enacted to read as follows:	26

Sec. 505.377. A volunteer firefighter appointed pursuant to	27
this chapter is a bona fide volunteer and not an employee for	28
purposes of section 513 of the "Patient Protection and Affordable	29
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	30
providing those fire protection services, the volunteer receives	31
any of the benefits provided in Chapter 146., 4121., or 4123. or	32
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	33
Code.	34

Sec. 737.082. A volunteer firefighter appointed pursuant to	35
this chapter is a bona fide volunteer and not an employee for	36
purposes of section 513 of the "Patient Protection and Affordable	37
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	38
providing those fire protection services, the volunteer receives	39
any of the benefits provided in Chapter 146., 4121., or 4123. or	40
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	41
Code.	42

Sec. 737.222. A volunteer firefighter appointed pursuant to	43
this chapter is a bona fide volunteer and not an employee for	44
purposes of section 513 of the "Patient Protection and Affordable	45
Care Act," 124 Stat. 119 (2010), 26 U.S.C. 4980H, if, for	46
providing those fire protection services, the volunteer receives	47
any of the benefits provided in Chapter 146., 4121., or 4123. or	48
section 9.65, 505.23, 3333.26, 3923.13, or 4113.41 of the Revised	49
Code.	50

Sec. 1739.061. (A)(1) This section applies to both of the	51
following:	52

(a) A multiple employer welfare arrangement that issues or	53
requires the use of a standardized identification card or an	54
electronic technology for submission and routing of prescription	55
drug claims;	56

(b) A person or entity that a multiple employer welfare	57
arrangement contracts with to issue a standardized identification	58
card or an electronic technology described in division (A)(1)(a)	59
of this section.	60

(2) Notwithstanding division (A)(1) of this section, this	61
section does not apply to the issuance or required use of a	62
standardized identification card or an electronic technology for	63
the submission and routing of prescription drug claims in	64
connection with any of the following:	65

(a) Any program or arrangement covering only accident,	66
credit, dental, disability income, long-term care, hospital	67
indemnity, medicare supplement, medicare, tricare, specified	68
disease, or vision care; coverage under a	69
one-time-limited-duration policy ~~of not longer~~that is less than	70
~~six~~twelve months; coverage issued as a supplement to liability	71
insurance; insurance arising out of workers' compensation or	72
similar law; automobile medical payment insurance; or insurance	73
under which benefits are payable with or without regard to fault	74
and which is statutorily required to be contained in any liability	75
insurance policy or equivalent self-insurance.	76

(b) Coverage provided under the medicaid program.

(c) Coverage provided under an employer's self-insurance plan	78
or by any of its administrators, as defined in section 3959.01 of	79
the Revised Code, to the extent that federal law supersedes,	80
preempts, prohibits, or otherwise precludes the application of	81
this section to the plan and its administrators.	82

(B) A standardized identification card or an electronic	83
technology issued or required to be used as provided in division	84
(A)(1) of this section shall contain uniform prescription drug	85
information in accordance with either division (B)(1) or (2) of	86
this section.	87

(1) The standardized identification card or the electronic	88
technology shall be in a format and contain information fields	89
approved by the national council for prescription drug programs or	90
a successor organization, as specified in the council's or	91
successor organization's pharmacy identification card	92
implementation guide in effect on the first day of October most	93
immediately preceding the issuance or required use of the	94
standardized identification card or the electronic technology.	95

(2) If the multiple employer welfare arrangement or person	96
under contract with it to issue a standardized identification card	97
or an electronic technology requires the information for the	98
submission and routing of a claim, the standardized identification	99
card or the electronic technology shall contain any of the	100
following information:	101

(a) The name of the multiple employer welfare arrangement;

102

(b) The individual's name, group number, and identification	103
number;	104

(c) A telephone number to inquire about pharmacy-related	105
issues;	106

(d) The issuer's international identification number, labeled	107
as "ANSI BIN" or "RxBIN";	108

(e) The processor's control number, labeled as "RxPCN";

109

(f) The individual's pharmacy benefits group number if	110
different from the insured's medical group number, labeled as	111
"RxGrp."	112

(C) If the standardized identification card or the electronic	113
technology issued or required to be used as provided in division	114
(A)(1) of this section is also used for submission and routing of	115
nonpharmacy claims, the designation "Rx" is required to be	116
included as part of the labels identified in divisions (B)(2)(d)	117
and (e) of this section if the issuer's international	118
identification number or the processor's control number is	119
different for medical and pharmacy claims.	120

(D) Each multiple employer welfare arrangement described in	121
division (A) of this section shall annually file a certificate	122
with the superintendent of insurance certifying that it or any	123
person it contracts with to issue a standardized identification	124
card or electronic technology for submission and routing of	125
prescription drug claims complies with this section.	126

(E)(1) Except as provided in division (E)(2) of this section,	127
if there is a change in the information contained in the	128
standardized identification card or the electronic technology	129
issued to an individual, the multiple employer welfare arrangement	130
or person under contract with it to issue a standardized	131
identification card or an electronic technology shall issue a new	132
card or electronic technology to the individual.	133

(2) A multiple employer welfare arrangement or person under	134
contract with it is not required under division (E)(1) of this	135
section to issue a new card or electronic technology to an	136
individual more than once during a twelve-month period.	137

(F) Nothing in this section shall be construed as requiring a	138
multiple employer welfare arrangement to produce more than one	139
standardized identification card or one electronic technology for	140
use by individuals accessing health care benefits provided under a	141
multiple employer welfare arrangement.	142

Sec. 1751.14. (A) Notwithstanding section 3901.71 of the	143
Revised Code, any policy, contract, or agreement for health care	144
services authorized by this chapter that is issued, delivered, or	145
renewed in this state and that provides that coverage of an	146
unmarried dependent child will terminate upon attainment of the	147
limiting age for dependent children specified in the policy,	148
contract, or agreement, shall also provide in substance both of	149
the following:	150

(1) Once an unmarried child has attained the limiting age for	151
dependent children, as provided in the policy, contract, or	152
agreement, upon the request of the subscriber, the health insuring	153
corporation shall offer to cover the unmarried child until the	154
child attains ~~twenty-eight~~twenty-six years of age if all of the	155
following are true:	156

(a) The child is the natural child, stepchild, or adopted	157
child of the subscriber.	158

(b) The child is a resident of this state or a full-time	159
student at an accredited public or private institution of higher	160
education.	161

(c) The child is not employed by an employer that offers any	162
health benefit plan under which the child is eligible for	163
coverage.	164

(d) The child is not eligible for coverage under the medicaid	165
program or the medicare program.	166

(2) That attainment of the limiting age for dependent	167
children shall not operate to terminate the coverage of a	168
dependent child if the child is and continues to be both of the	169
following:	170

(a) Incapable of self-sustaining employment by reason of	171
mental retardation or physical handicap;	172

(b) Primarily dependent upon the subscriber for support and	173
maintenance.	174

(B) Proof of incapacity and dependence for purposes of	175
division (A)(2) of this section shall be furnished to the health	176
insuring corporation within thirty-one days of the child's	177
attainment of the limiting age. Upon request, but not more	178
frequently than annually, the health insuring corporation may	179
require proof satisfactory to it of the continuance of such	180
incapacity and dependency.	181

182

(1) Require that any policy, contract, or agreement offer	183
coverage for dependent children or provide coverage for an	184
unmarried dependent child's children as dependents on the policy,	185
contract, or agreement;	186

(2) Require an employer to pay for any part of the premium	187
for an unmarried dependent child that has attained the limiting	188
age for dependents, as provided in the policy, contract, or	189
agreement;	190

(3) Require an employer to offer health insurance coverage to	191
the dependents of any employee.	192

(D) This section does not apply to any health insuring	193
corporation policy, contract, or agreement offering only	194
supplemental health care services or specialty health care	195
services.	196

(E) As used in this section, "health benefit plan" has the	197
same meaning as in section 3924.01 of the Revised Code and also	198
includes both of the following:	199

(1) A public employee benefit plan;

200

(2) A health benefit plan as regulated under the "Employee	201
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	202

Sec. 1751.69. (A) As used in this section, "cost sharing"	203
means the cost to an individual insured under an individual or	204
group health insuring corporation policy, contract, or agreement	205
according to any coverage limit, copayment, coinsurance,	206
deductible, or other out-of-pocket expense requirements imposed by	207
the policy, contract, or agreement.	208

(B) Notwithstanding section 3901.71 of the Revised Code and	209
subject to division (D) of this section, no individual or group	210
health insuring corporation policy, contract, or agreement	211
providing basic health care services or prescription drug services	212
that is delivered, issued for delivery, or renewed in this state,	213
if the policy, contract, or agreement provides coverage for cancer	214
chemotherapy treatment, shall fail to comply with either of the	215
following:	216

(1) The policy, contract, or agreement shall not provide	217
coverage or impose cost sharing for a prescribed, orally	218
administered cancer medication on a less favorable basis than the	219
coverage it provides or cost sharing it imposes for intraveneously	220
administered or injected cancer medications.	221

(2) The policy, contract, or agreement shall not comply with	222
division (B)(1) of this section by imposing an increase in cost	223
sharing solely for orally administered, intravenously	224
administered, or injected cancer medications.	225

(C) Notwithstanding any provision of this section to the	226
contrary, an individual or group health insuring corporation	227
policy, contract, or agreement shall be deemed to be in compliance	228
with this section if the cost sharing imposed under such a policy,	229
contract, or agreement for orally administered cancer treatments	230
does not exceed one hundred dollars per prescription fill. The	231
cost sharing limit of one hundred dollars per prescription fill	232
shall apply to a high deductible plan, as defined in 26 U.S.C.	233
223, or a catastrophic plan, as defined in 42 U.S.C. 18022, only	234
after the deductible has been met.	235

(D) The prohibitions in division (B) of this section do not	236
preclude an individual or group health insuring corporation	237
policy, contract, or agreement from requiring an enrollee to	238
obtain prior authorization before orally administered cancer	239
medication is dispensed to the enrollee.	240

(E) A health insuring corporation that offers coverage for	241
basic health care services is not required to comply with division	242
(B) of this section if all of the following apply:	243

(1) The health insuring corporation submits documentation	244
certified by an independent member of the American academy of	245
actuaries to the superintendent of insurance showing that	246
compliance with division (B)(1) of this section for a period of at	247
least six months independently caused the health insuring	248
corporation's costs for claims and administrative expenses for the	249
coverage of basic health care services to increase by more than	250
one per cent per year.	251

(2) The health insuring corporation submits a signed letter	252
from an independent member of the American academy of actuaries to	253
the superintendent of insurance opining that the increase in costs	254
described in division (E)(1) of this section could reasonably	255
justify an increase of more than one per cent in the annual	256
premiums or rates charged by the health insuring corporation for	257
the coverage of basic health care services.	258

(3)(a) The superintendent of insurance makes the following	259
determinations from the documentation and opinion submitted	260
pursuant to divisions (E)(1) and (2) of this section:	261

(i) Compliance with division (B)(1) of this section for a	262
period of at least six months independently caused the health	263
insuring corporation's costs for claims and administrative	264
expenses for the coverage of basic health care services to	265
increase more than one per cent per year.	266

(ii) The increase in costs reasonably justifies an increase	267
of more than one per cent in the annual premiums or rates charged	268
by the health insuring corporation for the coverage of basic	269
health care services.	270

(b) Any determination made by the superintendent under	271
division (E)(3) of this section is subject to Chapter 119. of the	272
Revised Code.	273

Sec. 3923.022. (A) As used in this section:

274

(1)(a) "Administrative expense" means the amount resulting	275
from the following: the amount of premiums earned by the insurer	276
for sickness and accident insurance business plus the amount of	277
losses recovered from reinsurance coverage minus the sum of the	278
amount of claims for losses paid; the amount of losses incurred	279
but not reported; the amount incurred for state fees, federal and	280
state taxes, and reinsurance; and the incurred costs and expenses	281
related, either directly or indirectly, to the payment of	282
commissions, measures to control fraud, and managed care.	283

(b) "Administrative expense" does not include any amounts	284
collected, or administrative expenses incurred, by an insurer for	285
the administration of an employee health benefit plan subject to	286
regulation by the federal "Employee Retirement Income Security Act	287
of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended. "Amounts	288
collected or administrative expenses incurred" means the total	289
amount paid to an administrator for the administration and payment	290
of claims minus the sum of the amount of claims for losses paid	291
and the amount of losses incurred but not reported.	292

(2) "Insurer" means any insurance company authorized under	293
Title XXXIX of the Revised Code to do the business of sickness and	294
accident insurance in this state.	295

(3) "Sickness and accident insurance business" does not	296
include coverage provided by an insurer for specific diseases or	297
accidents only; any hospital indemnity, medicare supplement,	298
long-term care, disability income, one-time-limited-duration	299
policy ~~of no longer~~that is less than ~~six~~twelve months, or other	300
policy that offers only supplemental benefits; or coverage	301
provided to individuals who are not residents of this state.	302

(4) "Individual business" includes both individual sickness	303
and accident insurance and sickness and accident insurance made	304
available by insurers in the individual market to individuals,	305
with or without family members or dependents, through group	306
policies issued to one or more associations or entities.	307

(B) Notwithstanding section 3941.14 of the Revised Code, each	308
insurer shall have aggregate administrative expenses of no more	309
than twenty per cent of the premium income of the insurer, based	310
on the premiums earned in that year on the sickness and accident	311
insurance business of the insurer.	312

(C)(1) Each insurer, on the first day of January or within	313
sixty days thereafter, shall annually prepare, under oath, and	314
deposit in the office of the superintendent of insurance a	315
statement of the aggregate administrative expenses of the insurer,	316
based on the premiums earned in the immediately preceding calendar	317
year on the sickness and accident insurance business of the	318
insurer. The statement shall itemize and separately detail all of	319
the following information with respect to the insurer's sickness	320
and accident insurance business:	321

(a) The amount of premiums earned by the insurer both before	322
and after any costs related to the insurer's purchase of	323
reinsurance coverage;	324

(b) The total amount of claims for losses paid by the insurer	325
both before and after any reimbursement from reinsurance coverage;	326

(c) The amount of any losses incurred by the insurer but not	327
reported by the insurer in the current or prior year;	328

(d) The amount of costs incurred by the insurer for state	329
fees and federal and state taxes;	330

(e) The amount of costs incurred by the insurer for	331
reinsurance coverage;	332

(f) The amount of costs incurred by the insurer that are	333
related to the insurer's payment of commissions;	334

(g) The amount of costs incurred by the insurer that are	335
related to the insurer's fraud prevention measures;	336

(h) The amount of costs incurred by the insurer that are	337
related to managed care; and	338

(i) Any other administrative expenses incurred by the	339
insurer.	340

(2) The statement also shall include all of the information	341
required under division (C)(1) of this section separately detailed	342
for the insurer's individual business, small group business, and	343
large group business.	344

(D) No insurer shall fail to comply with this section.

345

(E) If the superintendent determines that an insurer has	346
violated this section, the superintendent, pursuant to an	347
adjudication conducted in accordance with Chapter 119. of the	348
Revised Code, may order the suspension of the insurer's license to	349
do the business of sickness and accident insurance in this state	350
until the superintendent is satisfied that the insurer is in	351
compliance with this section. If the insurer continues to do the	352
business of sickness and accident insurance in this state while	353
under the suspension order, the superintendent shall order the	354
insurer to pay one thousand dollars for each day of the violation.	355

(F) Any money collected by the superintendent under division	356
(E) of this section shall be deposited by the superintendent into	357
the state treasury to the credit of the department of insurance	358
operating fund.	359

(G) The statement of aggregate expenses filed pursuant to	360
this section separately detailing an insurer's individual, small	361
group, and large group business shall be considered work papers	362
resulting from the conduct of a market analysis of an entity	363
subject to examination by the superintendent under division (C) of	364
section 3901.48 of the Revised Code, except that the	365
superintendent may share aggregated market information that	366
identifies the premiums earned as reported under division	367
(C)(1)(a) of this section, the administrative expenses reported	368
under division (C)(1)(i) of this section, the amount of	369
commissions reported under division (C)(1)(f) of this section, the	370
amount of taxes paid as reported under division (C)(1)(d) of this	371
section, the total of the remaining benefit costs as reported	372
under divisions (C)(1)(b) and (c) of this section, and the amount	373
of fraud and managed care expenses reported under divisions	374
(C)(1)(g) and (h) of this section.	375

Sec. 3923.24. (A) Notwithstanding section 3901.71 of the	376
Revised Code, every certificate furnished by an insurer in	377
connection with, or pursuant to any provision of, any group	378
sickness and accident insurance policy delivered, issued for	379
delivery, renewed, or used in this state on or after January 1,	380
1972, every policy of sickness and accident insurance delivered,	381
issued for delivery, renewed, or used in this state on or after	382
January 1, 1972, and every multiple employer welfare arrangement	383
offering an insurance program, which provides that coverage of an	384
unmarried dependent child of a parent or legal guardian will	385
terminate upon attainment of the limiting age for dependent	386
children specified in the contract shall also provide in substance	387
both of the following:	388

(1) Once an unmarried child has attained the limiting age for	389
dependent children, as provided in the policy, upon the request of	390
the insured, the insurer shall offer to cover the unmarried child	391
until the child attains ~~twenty-eight~~twenty-six years of age if	392
all of the following are true:	393

(a) The child is the natural child, stepchild, or adopted	394
child of the insured.	395

(b) The child is a resident of this state or a full-time	396
student at an accredited public or private institution of higher	397
education.	398

(c) The child is not employed by an employer that offers any	399
health benefit plan under which the child is eligible for	400
coverage.	401

(d) The child is not eligible for the medicaid program or the	402
medicare program.	403

(2) That attainment of the limiting age for dependent	404
children shall not operate to terminate the coverage of a	405
dependent child if the child is and continues to be both of the	406
following:	407

(a) Incapable of self-sustaining employment by reason of	408
mental retardation or physical handicap;	409

(b) Primarily dependent upon the policyholder or certificate	410
holder for support and maintenance.	411

(B) Proof of such incapacity and dependence for purposes of	412
division (A)(2) of this section shall be furnished by the	413
policyholder or by the certificate holder to the insurer within	414
thirty-one days of the child's attainment of the limiting age.	415
Upon request, but not more frequently than annually after the	416
two-year period following the child's attainment of the limiting	417
age, the insurer may require proof satisfactory to it of the	418
continuance of such incapacity and dependency.	419

(C) Nothing in this section shall require an insurer to cover	420
a dependent child who is mentally retarded or physically	421
handicapped if the contract is underwritten on evidence of	422
insurability based on health factors set forth in the application,	423
or if such dependent child does not satisfy the conditions of the	424
contract as to any requirement for evidence of insurability or	425
other provision of the contract, satisfaction of which is required	426
for coverage thereunder to take effect. In any such case, the	427
terms of the contract shall apply with regard to the coverage or	428
exclusion of the dependent from such coverage. Nothing in this	429
section shall apply to accidental death or dismemberment benefits	430
provided by any such policy of sickness and accident insurance.	431

(D) Nothing in this section shall do any of the following:

432

(1) Require that any policy offer coverage for dependent	433
children or provide coverage for an unmarried dependent child's	434
children as dependents on the policy;	435

(2) Require an employer to pay for any part of the premium	436
for an unmarried dependent child that has attained the limiting	437
age for dependents, as provided in the policy;	438

(3) Require an employer to offer health insurance coverage to	439
the dependents of any employee.	440

(E) This section does not apply to any policies or	441
certificates covering only accident, credit, dental, disability	442
income, long-term care, hospital indemnity, medicare supplement,	443
specified disease, or vision care; coverage under a	444
one-time-limited-duration policy ~~of not longer~~that is less than	445
~~six~~twelve months; coverage issued as a supplement to liability	446
insurance; insurance arising out of a workers' compensation or	447
similar law; automobile medical-payment insurance; or insurance	448
under which benefits are payable with or without regard to fault	449
and that is statutorily required to be contained in any liability	450
insurance policy or equivalent self-insurance.	451

(F) As used in this section, "health benefit plan" has the	452
same meaning as in section 3924.01 of the Revised Code and also	453
includes both of the following:	454

(1) A public employee benefit plan;

455

(2) A health benefit plan as regulated under the "Employee	456
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	457

Sec. 3923.241. (A) Notwithstanding section 3901.71 of the	458
Revised Code, any public employee benefit plan that provides that	459
coverage of an unmarried dependent child will terminate upon	460
attainment of the limiting age for dependent children specified in	461
the plan shall also provide in substance both of the following:	462

(1) Once an unmarried child has attained the limiting age for	463
dependent children, as provided in the plan, upon the request of	464
the employee, the public employee benefit plan shall offer to	465
cover the unmarried child until the child attains ~~twenty-eight~~	466
twenty-six years of age if all of the following are true:	467

(a) The child is the natural child, stepchild, or adopted	468
child of the employee.	469

(b) The child is a resident of this state or a full-time	470
student at an accredited public or private institution of higher	471
education.	472

(c) The child is not employed by an employer that offers any	473
health benefit plan under which the child is eligible for	474
coverage.	475

(d) The child is not eligible for the medicaid program or the	476
medicare program.	477

(2) That attainment of the limiting age for dependent	478
children shall not operate to terminate the coverage of a	479
dependent child if the child is and continues to be both of the	480
following:	481

(a) Incapable of self-sustaining employment by reason of	482
mental retardation or physical handicap;	483

(b) Primarily dependent upon the plan member for support and	484
maintenance.	485

(B) Proof of incapacity and dependence for purposes of	486
division (A)(2) of this section shall be furnished to the public	487
employee benefit plan within thirty-one days of the child's	488
attainment of the limiting age. Upon request, but not more	489
frequently than annually, the public employee benefit plan may	490
require proof satisfactory to it of the continuance of such	491
incapacity and dependency.	492

493

(1) Require that any public employee benefit plan offer	494
coverage for dependent children or provide coverage for an	495
unmarried dependent child's children as dependents on the public	496
employee benefit plan;	497

(2) Require an employer to pay for any part of the premium	498
for an unmarried dependent child that has attained the limiting	499
age for dependents, as provided in the plan;	500

(3) Require an employer to offer health insurance coverage to	501
the dependents of any employee.	502

(D) This section does not apply to any public employee	503
benefit plan covering only accident, credit, dental, disability	504
income, long-term care, hospital indemnity, medicare supplement,	505
specified disease, or vision care; coverage under a	506
one-time-limited-duration policy ~~of not longer~~that is less than	507
~~six~~twelve months; coverage issued as a supplement to liability	508
insurance; insurance arising out of a workers' compensation or	509
similar law; automobile medical-payment insurance; or insurance	510
under which benefits are payable with or without regard to fault	511
and which is statutorily required to be contained in any liability	512
insurance policy or equivalent self-insurance.	513

(E) As used in this section, "health benefit plan" has the	514
same meaning as in section 3924.01 of the Revised Code and also	515
includes both of the following:	516

(1) A public employee benefit plan;

517

(2) A health benefit plan as regulated under the "Employee	518
Retirement Income Security Act of 1974," 29 U.S.C. 1001, et seq.	519

Sec. 3923.281. (A) As used in this section:

520

(1) "Biologically based mental illness" means schizophrenia,	521
schizoaffective disorder, major depressive disorder, bipolar	522
disorder, paranoia and other psychotic disorders,	523
obsessive-compulsive disorder, and panic disorder, as these terms	524
are defined in the most recent edition of the diagnostic and	525
statistical manual of mental disorders published by the American	526
psychiatric association.	527

(2) "Policy of sickness and accident insurance" has the same	528
meaning as in section 3923.01 of the Revised Code, but excludes	529
any hospital indemnity, medicare supplement, long-term care,	530
disability income, one-time-limited-duration policy ~~of not longer~~	531
that is less than ~~six~~twelve months, supplemental benefit, or	532
other policy that provides coverage for specific diseases or	533
accidents only; any policy that provides coverage for workers'	534
compensation claims compensable pursuant to Chapters 4121. and	535
4123. of the Revised Code; and any policy that provides coverage	536
to medicaid recipients.	537

(B) Notwithstanding section 3901.71 of the Revised Code, and	538
subject to division (E) of this section, every policy of sickness	539
and accident insurance shall provide benefits for the diagnosis	540
and treatment of biologically based mental illnesses on the same	541
terms and conditions as, and shall provide benefits no less	542
extensive than, those provided under the policy of sickness and	543
accident insurance for the treatment and diagnosis of all other	544
physical diseases and disorders, if both of the following apply:	545

(1) The biologically based mental illness is clinically	546
diagnosed by a physician authorized under Chapter 4731. of the	547
Revised Code to practice medicine and surgery or osteopathic	548
medicine and surgery; a psychologist licensed under Chapter 4732.	549
of the Revised Code; a professional clinical counselor,	550
professional counselor, or independent social worker licensed	551
under Chapter 4757. of the Revised Code; or a clinical nurse	552
specialist licensed under Chapter 4723. of the Revised Code whose	553
nursing specialty is mental health.	554

(2) The prescribed treatment is not experimental or	555
investigational, having proven its clinical effectiveness in	556
accordance with generally accepted medical standards.	557

(C) Division (B) of this section applies to all coverages and	558
terms and conditions of the policy of sickness and accident	559
insurance, including, but not limited to, coverage of inpatient	560
hospital services, outpatient services, and medication; maximum	561
lifetime benefits; copayments; and individual and family	562
deductibles.	563

(D) Nothing in this section shall be construed as prohibiting	564
a sickness and accident insurance company from taking any of the	565
following actions:	566

(1) Negotiating separately with mental health care providers	567
with regard to reimbursement rates and the delivery of health care	568
services;	569

(2) Offering policies that provide benefits solely for the	570
diagnosis and treatment of biologically based mental illnesses;	571

(3) Managing the provision of benefits for the diagnosis or	572
treatment of biologically based mental illnesses through the use	573
of pre-admission screening, by requiring beneficiaries to obtain	574
authorization prior to treatment, or through the use of any other	575
mechanism designed to limit coverage to that treatment determined	576
to be necessary;	577

(4) Enforcing the terms and conditions of a policy of	578
sickness and accident insurance.	579

(E) An insurer that offers any policy of sickness and	580
accident insurance is not required to provide benefits for the	581
diagnosis and treatment of biologically based mental illnesses	582
pursuant to division (B) of this section if all of the following	583
apply:	584

(1) The insurer submits documentation certified by an	585
independent member of the American academy of actuaries to the	586
superintendent of insurance showing that incurred claims for	587
diagnostic and treatment services for biologically based mental	588
illnesses for a period of at least six months independently caused	589
the insurer's costs for claims and administrative expenses for the	590
coverage of all other physical diseases and disorders to increase	591
by more than one per cent per year.	592

(2) The insurer submits a signed letter from an independent	593
member of the American academy of actuaries to the superintendent	594
of insurance opining that the increase described in division	595
(E)(1) of this section could reasonably justify an increase of	596
more than one per cent in the annual premiums or rates charged by	597
the insurer for the coverage of all other physical diseases and	598
disorders.	599

(3) The superintendent of insurance makes the following	600
determinations from the documentation and opinion submitted	601
pursuant to divisions (E)(1) and (2) of this section:	602

(a) Incurred claims for diagnostic and treatment services for	603
biologically based mental illnesses for a period of at least six	604
months independently caused the insurer's costs for claims and	605
administrative expenses for the coverage of all other physical	606
diseases and disorders to increase by more than one per cent per	607
year.	608

(b) The increase in costs reasonably justifies an increase of	609
more than one per cent in the annual premiums or rates charged by	610
the insurer for the coverage of all other physical diseases and	611
disorders.	612

Any determination made by the superintendent under this	613
division is subject to Chapter 119. of the Revised Code.	614

Sec. 3923.57. Notwithstanding any provision of this chapter,	615
every individual policy of sickness and accident insurance that is	616
delivered, issued for delivery, or renewed in this state is	617
subject to the following conditions, as applicable:	618

(A) Pre-existing conditions provisions shall not exclude or	619
limit coverage for a period beyond twelve months following the	620
policyholder's effective date of coverage and may only relate to	621
conditions during the six months immediately preceding the	622
effective date of coverage.	623

(B) In determining whether a pre-existing conditions	624
provision applies to a policyholder or dependent, each policy	625
shall credit the time the policyholder or dependent was covered	626
under a previous policy, contract, or plan if the previous	627
coverage was continuous to a date not more than thirty days prior	628
to the effective date of the new coverage, exclusive of any	629
applicable service waiting period under the policy.	630

(C)(1) Except as otherwise provided in division (C) of this	631
section, an insurer that provides an individual sickness and	632
accident insurance policy to an individual shall renew or continue	633
in force such coverage at the option of the individual.	634

(2) An insurer may nonrenew or discontinue coverage of an	635
individual in the individual market based only on one or more of	636
the following reasons:	637

(a) The individual failed to pay premiums or contributions in	638
accordance with the terms of the policy or the insurer has not	639
received timely premium payments.	640

(b) The individual performed an act or practice that	641
constitutes fraud or made an intentional misrepresentation of	642
material fact under the terms of the policy.	643

(c) The insurer is ceasing to offer coverage in the	644
individual market in accordance with division (D) of this section	645
and the applicable laws of this state.	646

(d) If the insurer offers coverage in the market through a	647
network plan, the individual no longer resides, lives, or works in	648
the service area, or in an area for which the insurer is	649
authorized to do business; provided, however, that such coverage	650
is terminated uniformly without regard to any health	651
status-related factor of covered individuals.	652

(e) If the coverage is made available in the individual	653
market only through one or more bona fide associations, the	654
membership of the individual in the association, on the basis of	655
which the coverage is provided, ceases; provided, however, that	656
such coverage is terminated under division (C)(2)(e) of this	657
section uniformly without regard to any health status-related	658
factor of covered individuals.	659

An insurer offering coverage to individuals solely through	660
membership in a bona fide association shall not be deemed, by	661
virtue of that offering, to be in the individual market for	662
purposes of sections 3923.58 and 3923.581 of the Revised Code.	663
Such an insurer shall not be required to accept applicants for	664
coverage in the individual market pursuant to sections 3923.58 and	665
3923.581 of the Revised Code unless the insurer also offers	666
coverage to individuals other than through bona fide associations.	667

(3) An insurer may cancel or decide not to renew the coverage	668
of a dependent of an individual if the dependent has performed an	669
act or practice that constitutes fraud or made an intentional	670
misrepresentation of material fact under the terms of the coverage	671
and if the cancellation or nonrenewal is not based, either	672
directly or indirectly, on any health status-related factor in	673
relation to the dependent.	674

(D)(1) If an insurer decides to discontinue offering a	675
particular type of health insurance coverage offered in the	676
individual market, coverage of such type may be discontinued by	677
the insurer if the insurer does all of the following:	678

(a) Provides notice to each individual provided coverage of	679
this type in such market of the discontinuation at least ninety	680
days prior to the date of the discontinuation of the coverage;	681

(b) Offers to each individual provided coverage of this type	682
in such market, the option to purchase any other individual health	683
insurance coverage currently being offered by the insurer for	684
individuals in that market;	685

(c) In exercising the option to discontinue coverage of this	686
type and in offering the option of coverage under division	687
(D)(1)(b) of this section, acts uniformly without regard to any	688
health status-related factor of covered individuals or of	689
individuals who may become eligible for such coverage.	690

(2) If an insurer elects to discontinue offering all health	691
insurance coverage in the individual market in this state, health	692
insurance coverage may be discontinued by the insurer only if both	693
of the following apply:	694

(a) The insurer provides notice to the department of	695
insurance and to each individual of the discontinuation at least	696
one hundred eighty days prior to the date of the expiration of the	697
coverage.	698

(b) All health insurance delivered or issued for delivery in	699
this state in such market is discontinued and coverage under that	700
health insurance in that market is not renewed.	701

(3) In the event of a discontinuation under division (D)(2)	702
of this section in the individual market, the insurer shall not	703
provide for the issuance of any health insurance coverage in the	704
market and this state during the five-year period beginning on the	705
date of the discontinuation of the last health insurance coverage	706
not so renewed.	707

(E) Notwithstanding divisions (C) and (D) of this section, an	708
insurer may, at the time of coverage renewal, modify the health	709
insurance coverage for a policy form offered to individuals in the	710
individual market if the modification is consistent with the law	711
of this state and effective on a uniform basis among all	712
individuals with that policy form.	713

(F) Such policies are subject to sections 2743 and 2747 of	714
the "Health Insurance Portability and Accountability Act of 1996,"	715
Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and	716
300gg-47, as amended.	717

(G) Sections 3924.031 and 3924.032 of the Revised Code shall	718
apply to sickness and accident insurance policies offered in the	719
individual market in the same manner as they apply to health	720
benefit plans offered in the small employer market.	721

In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of	722
this section also apply to all group sickness and accident	723
insurance policies that are not sold in connection with an	724
employment-related group health plan and that provide more than	725
short-term, limited duration coverage.	726

In applying divisions (C) to (G) of this section with respect	727
to health insurance coverage that is made available by an insurer	728
in the individual market to individuals only through one or more	729
associations, the term "individual" includes the association of	730
which the individual is a member.	731

For purposes of this section, any policy issued pursuant to	732
division (C) of section 3923.13 of the Revised Code in connection	733
with a public or private college or university student health	734
insurance program is considered to be issued to a bona fide	735
association.	736

As used in this section, "bona fide association" has the same	737
meaning as in section 3924.03 of the Revised Code, and "health	738
status-related factor" and "network plan" have the same meanings	739
as in section 3924.031 of the Revised Code.	740

This section does not apply to any policy that provides	741
coverage for specific diseases or accidents only, or to any	742
hospital indemnity, medicare supplement, long-term care,	743
disability income, one-time-limited-duration policy ~~of no longer~~	744
that is less than ~~six~~twelve months, or other policy that offers	745
only supplemental benefits.	746

Sec. 3923.58. (A) As used in sections 3923.58 and 3923.59 of	747
the Revised Code:	748

(1) "Base rate" means, as to any health benefit plan that is	749
issued by a carrier in the individual market, the lowest premium	750
rate for new or existing business prescribed by the carrier for	751
the same or similar coverage under a plan or arrangement covering	752
any individual with similar case characteristics.	753

(2) "Carrier," "health benefit plan," and "MEWA" have the	754
same meanings as in section 3924.01 of the Revised Code.	755

(3) "Network plan" means a health benefit plan of a carrier	756
under which the financing and delivery of medical care, including	757
items and services paid for as medical care, are provided, in	758
whole or in part, through a defined set of providers under	759
contract with the carrier.	760

(4) "Ohio health care basic and standard plans" means those	761
plans established under section 3924.10 of the Revised Code.	762

(5) "Pre-existing conditions provision" means a policy	763
provision that excludes or limits coverage for charges or expenses	764
incurred during a specified period following the insured's	765
effective date of coverage as to a condition which, during a	766
specified period immediately preceding the effective date of	767
coverage, had manifested itself in such a manner as would cause an	768
ordinarily prudent person to seek medical advice, diagnosis, care,	769
or treatment or for which medical advice, diagnosis, care, or	770
treatment was recommended or received, or a pregnancy existing on	771
the effective date of coverage.	772

(B) Beginning in January of each year, carriers in the	773
business of issuing health benefit plans to individuals and	774
nonemployer groups, except individual health benefit plans issued	775
pursuant to sections 1751.16 and 3923.122 of the Revised Code,	776
shall accept applicants for open enrollment coverage, as set forth	777
in this division, in the order in which they apply for coverage	778
and subject to the limitation set forth in division (G) of this	779
section. Carriers shall accept for coverage pursuant to this	780
section individuals to whom both of the following conditions	781
apply:	782

(1) The individual is not applying for coverage as an	783
employee of an employer, as a member of an association, or as a	784
member of any other group.	785

(2) The individual is not covered, and is not eligible for	786
coverage, under any other private or public health benefits	787
arrangement, including the medicare program established under	788
Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42	789
U.S.C.A. 301, as amended, or any other act of congress or law of	790
this or any other state of the United States that provides	791
benefits comparable to the benefits provided under this section,	792
any medicare supplement policy, or any continuation of coverage	793
policy under state or federal law.	794

(C) A carrier shall offer to any individual accepted under	795
this section the Ohio health care basic and standard plans or	796
health benefit plans that are substantially similar to the Ohio	797
health care basic and standard plans in benefit plan design and	798
scope of covered services.	799

A carrier may offer other health benefit plans in addition	800
to, but not in lieu of, the plans required to be offered under	801
this division. A basic health benefit plan shall provide, at a	802
minimum, the coverage provided by the Ohio health care basic plan	803
or any health benefit plan that is substantially similar to the	804
Ohio health care basic plan in benefit plan design and scope of	805
covered services. A standard health benefit plan shall provide, at	806
a minimum, the coverage provided by the Ohio health care standard	807
plan or any health benefit plan that is substantially similar to	808
the Ohio health care standard plan in benefit plan design and	809
scope of covered services.	810

For purposes of this division, the superintendent of	811
insurance shall determine whether a health benefit plan is	812
substantially similar to the Ohio health care basic and standard	813
plans in benefit plan design and scope of covered services.	814

(D)(1) Health benefit plans issued under this section may	815
establish pre-existing conditions provisions that exclude or limit	816
coverage for a period of up to twelve months following the	817
individual's effective date of coverage and that may relate only	818
to conditions during the six months immediately preceding the	819
effective date of coverage. A health insuring corporation may	820
apply a pre-existing condition provision for any basic health care	821
service related to a transplant of a body organ if the transplant	822
occurs within one year after the effective date of an enrollee's	823
coverage under this section except with respect to a newly born	824
child who meets the requirements for coverage under section	825
1751.61 of the Revised Code.	826

(2) In determining whether a pre-existing conditions	827
provision applies to an insured or dependent, each policy shall	828
credit the time the insured or dependent was covered under a	829
previous policy, contract, or plan if the previous coverage was	830
continuous to a date not more than sixty-three days prior to the	831
effective date of the new coverage, exclusive of any applicable	832
service waiting period under the policy.	833

(E) Premiums charged to individuals under this section may	834
not exceed the amounts specified below:	835

(1) For calendar years 2010 and 2011, an amount that is two	836
times the base rate for coverage offered to any other individual	837
to which the carrier is currently accepting new business, and for	838
which similar copayments and deductibles are applied;	839

(2) For calendar year 2012 and every year thereafter, an	840
amount that is one and one-half times the base rate for coverage	841
offered to any other individual to which the carrier is currently	842
accepting new business and for which similar copayments and	843
deductibles are applied, unless the superintendent of insurance	844
determines that the amendments by this act to this section and	845
section 3923.581 of the Revised Code, have resulted in the	846
market-wide average medical loss ratio for coverage sold to	847
individual insureds and nonemployer group insureds in this state,	848
including open enrollment insureds, to increase by more than five	849
and one quarter percentage points during calendar year 2010. If	850
the superintendent makes that determination, the premium limit	851
established by division (E)(1) of this section shall remain in	852
effect. The superintendent's determination shall be supported by a	853
signed letter from a member of the American academy of actuaries.	854

(F) In offering health benefit plans under this section, a	855
carrier may require the purchase of health benefit plans that	856
condition the reimbursement of health services upon the use of a	857
specific network of providers.	858

(G)(1) A carrier shall not be required to accept new	859
applicants under this section if the total number of the carrier's	860
current insureds with open enrollment coverage issued under this	861
section calculated as of the immediately preceding thirty-first	862
day of December and excluding the carrier's medicare supplement	863
policies and conversion or continuation of coverage policies under	864
state or federal law and any policies described in division (L) of	865
this section meets the following limits:	866

(a) For calendar years 2010 and 2011, four per cent of the	867
carrier's total number of individual or nonemployer group insureds	868
in this state;	869

(b) For calendar year 2012 and every year thereafter, eight	870
per cent of the carrier's total number of insured individuals and	871
nonemployer group insureds in this state, unless the	872
superintendent of insurance determines that the amendments by this	873
act to this section and section 3923.581 of the Revised Code, have	874
resulted in the market-wide average medical loss ratio for	875
coverage sold to individual insureds and nonemployer group	876
insureds in this state, including open enrollment insureds, to	877
increase by more than five and one quarter percentage points	878
during calendar year 2010. If the superintendent makes that	879
determination, the enrollment limit established by division	880
(G)(1)(a) of this section shall remain in effect. The	881
superintendent's determination shall be supported by a signed	882
letter from a member of the American academy of actuaries.	883

(2) An officer of the carrier shall certify to the department	884
of insurance when it has met the enrollment limit set forth in	885
division (G)(1) of this section. Upon providing such	886
certification, the carrier shall be relieved of its open	887
enrollment requirement under this section as long as the carrier	888
continues to meet the open enrollment limit. If the total number	889
of the carrier's current insureds with open enrollment coverage	890
issued under this section falls below the enrollment limit, the	891
carrier shall accept new applicants. A carrier may establish a	892
waiting list if the carrier has met the open enrollment limit and	893
shall notify the superintendent if the carrier has a waiting list	894
in effect.	895

(H) A carrier shall not be required to accept under this	896
section applicants who, at the time of enrollment, are confined to	897
a health care facility because of chronic illness, permanent	898
injury, or other infirmity that would cause economic impairment to	899
the carrier if the applicants were accepted. A carrier shall not	900
be required to make the effective date of benefits for individuals	901
accepted under this section earlier than ninety days after the	902
date of acceptance, except that when the individual had prior	903
coverage with a health benefit plan that was terminated by a	904
carrier because the carrier exited the market and the individual	905
was accepted for open enrollment under this section within	906
sixty-three days of that termination, the effective date of	907
benefits shall be the date of enrollment.	908

(I) The requirements of this section do not apply to any	909
carrier that is currently in a state of supervision, insolvency,	910
or liquidation. If a carrier demonstrates to the satisfaction of	911
the superintendent that the requirements of this section would	912
place the carrier in a state of supervision, insolvency, or	913
liquidation, or would otherwise jeopardize the carrier's economic	914
viability overall or in the individual market, the superintendent	915
may waive or modify the requirements of division (B) or (G) of	916
this section. The actions of the superintendent under this	917
division shall be effective for a period of not more than one	918
year. At the expiration of such time, a new showing of need for a	919
waiver or modification by the carrier shall be made before a new	920
waiver or modification is issued or imposed.	921

(J) No hospital, health care facility, or health care	922
practitioner, and no person who employs any health care	923
practitioner, shall balance bill any individual or dependent of an	924
individual for any health care supplies or services provided to	925
the individual or dependent who is insured under a policy issued	926
under this section. The hospital, health care facility, or health	927
care practitioner, or any person that employs the health care	928
practitioner, shall accept payments made to it by the carrier	929
under the terms of the policy or contract insuring or covering	930
such individual as payment in full for such health care supplies	931
or services.	932

As used in this division, "hospital" has the same meaning as	933
in section 3727.01 of the Revised Code; "health care practitioner"	934
has the same meaning as in section 4769.01 of the Revised Code;	935
and "balance bill" means charging or collecting an amount in	936
excess of the amount reimbursable or payable under the policy or	937
health care service contract issued to an individual under this	938
section for such health care supply or service. "Balance bill"	939
does not include charging for or collecting copayments or	940
deductibles required by the policy or contract.	941

(K) A carrier may pay an agent a commission in the amount of	942
not more than five per cent of the premium charged for initial	943
placement or for otherwise securing the issuance of a policy or	944
contract issued to an individual under this section, and not more	945
than four per cent of the premium charged for the renewal of such	946
a policy or contract. The superintendent may adopt, in accordance	947
with Chapter 119. of the Revised Code, such rules as are necessary	948
to enforce this division.	949

(L) This section does not apply to any policy that provides	950
coverage for specific diseases or accidents only, or to any	951
hospital indemnity, medicare supplement, long-term care,	952
disability income, one-time-limited-duration policy ~~of no longer~~	953
that is less than ~~six~~twelve months, or other policy that offers	954
only supplemental benefits.	955

(M) If a carrier offers a health benefit plan in the	956
individual market through a network plan, the carrier may do both	957
of the following:	958

(1) Limit the individuals that may apply for such coverage to	959
those who live, work, or reside in the service area of the network	960
plan;	961

(2) Within the service area of the network plan, deny the	962
coverage to individuals if the carrier has demonstrated both of	963
the following to the superintendent:	964

(a) The carrier will not have the capacity to deliver	965
services adequately to any additional individuals because of the	966
carrier's obligations to existing group contract holders and	967
individuals.	968

(b) The carrier is applying division (M)(2) of this section	969
uniformly to all individuals without regard to any health	970
status-related factors of those individuals.	971

(N) A carrier that, pursuant to division (M)(2) of this	972
section, denies coverage to an individual in the service area of a	973
network plan, shall not offer coverage in the individual market	974
within that service area for at least one hundred eighty days	975
after the date the carrier denies the coverage.	976

Sec. 3923.601. (A)(1) This section applies to both of the	977
following:	978

(a) A sickness and accident insurer that issues or requires	979
the use of a standardized identification card or an electronic	980
technology for submission and routing of prescription drug claims	981
pursuant to a policy, contract, or agreement for health care	982
services;	983

(b) A person that a sickness and accident insurer contracts	984
with to issue a standardized identification card or an electronic	985
technology described in division (A)(1)(a) of this section.	986

(2) Notwithstanding division (A)(1) of this section, this	987
section does not apply to the issuance or required use of a	988
standardized identification card or an electronic technology for	989
the submission and routing of prescription drug claims in	990
connection with any of the following:	991

(a) Any individual or group policy of sickness and accident	992
insurance covering only accident, credit, dental, disability	993
income, long-term care, hospital indemnity, medicare supplement,	994
medicare, tricare, specified disease, or vision care; coverage	995
under a one-time-limited-duration policy ~~of not longer~~that is	996
less than ~~six~~twelve months; coverage issued as a supplement to	997
liability insurance; insurance arising out of workers'	998
compensation or similar law; automobile medical payment insurance;	999
or insurance under which benefits are payable with or without	1000
regard to fault and which is statutorily required to be contained	1001
in any liability insurance policy or equivalent self-insurance.	1002

(b) Coverage provided under the medicaid program.

1003

(c) Coverage provided under an employer's self-insurance plan	1004
or by any of its administrators, as defined in section 3959.01 of	1005
the Revised Code, to the extent that federal law supersedes,	1006
preempts, prohibits, or otherwise precludes the application of	1007
this section to the plan and its administrators.	1008

(B) A standardized identification card or an electronic	1009
technology issued or required to be used as provided in division	1010
(A)(1) of this section shall contain uniform prescription drug	1011
information in accordance with either division (B)(1) or (2) of	1012
this section.	1013

(1) The standardized identification card or the electronic	1014
technology shall be in a format and contain information fields	1015
approved by the national council for prescription drug programs or	1016
a successor organization, as specified in the council's or	1017
successor organization's pharmacy identification card	1018
implementation guide in effect on the first day of October most	1019
immediately preceding the issuance or required use of the	1020
standardized identification card or the electronic technology.	1021

(2) If the insurer or person under contract with the insurer	1022
to issue a standardized identification card or an electronic	1023
technology requires the information for the submission and routing	1024
of a claim, the standardized identification card or the electronic	1025
technology shall contain any of the following information:	1026

(a) The insurer's name;

1027

(b) The insured's name, group number, and identification	1028
number;	1029

(c) A telephone number to inquire about pharmacy-related	1030
issues;	1031

(d) The issuer's international identification number, labeled	1032
as "ANSI BIN" or "RxBIN";	1033

(e) The processor's control number, labeled as "RxPCN";

1034

(f) The insured's pharmacy benefits group number if different	1035
from the insured's medical group number, labeled as "RxGrp."	1036

(C) If the standardized identification card or the electronic	1037
technology issued or required to be used as provided in division	1038
(A)(1) of this section is also used for submission and routing of	1039
nonpharmacy claims, the designation "Rx" is required to be	1040
included as part of the labels identified in divisions (B)(2)(d)	1041
and (e) of this section if the issuer's international	1042
identification number or the processor's control number is	1043
different for medical and pharmacy claims.	1044

(D) Each sickness and accident insurer described in division	1045
(A) of this section shall annually file a certificate with the	1046
superintendent of insurance certifying that it or any person it	1047
contracts with to issue a standardized identification card or	1048
electronic technology for submission and routing of prescription	1049
drug claims complies with this section.	1050

(E)(1) Except as provided in division (E)(2) of this section,	1051
if there is a change in the information contained in the	1052
standardized identification card or the electronic technology	1053
issued to an insured, the insurer or person under contract with	1054
the insurer to issue a standardized identification card or an	1055
electronic technology shall issue a new card or electronic	1056
technology to the insured.	1057

(2) An insurer or person under contract with the insurer is	1058
not required under division (E)(1) of this section to issue a new	1059
card or electronic technology to an insured more than once during	1060
a twelve-month period.	1061

(F) Nothing in this section shall be construed as requiring	1062
an insurer to produce more than one standardized identification	1063
card or one electronic technology for use by insureds accessing	1064
health care benefits provided under a policy of sickness and	1065
accident insurance.	1066

Sec. 3923.65. (A) As used in this section:

1067

(1) "Emergency medical condition" means a medical condition	1068
that manifests itself by such acute symptoms of sufficient	1069
severity, including severe pain, that a prudent layperson with	1070
average knowledge of health and medicine could reasonably expect	1071
the absence of immediate medical attention to result in any of the	1072
following:	1073

(a) Placing the health of the individual or, with respect to	1074
a pregnant woman, the health of the woman or her unborn child, in	1075
serious jeopardy;	1076

(b) Serious impairment to bodily functions;

1077

1078

(2) "Emergency services" means the following:

1079

(a) A medical screening examination, as required by federal	1080
law, that is within the capability of the emergency department of	1081
a hospital, including ancillary services routinely available to	1082
the emergency department, to evaluate an emergency medical	1083
condition;	1084

(b) Such further medical examination and treatment that are	1085
required by federal law to stabilize an emergency medical	1086
condition and are within the capabilities of the staff and	1087
facilities available at the hospital, including any trauma and	1088
burn center of the hospital.	1089

(B) Every individual or group policy of sickness and accident	1090
insurance that provides hospital, surgical, or medical expense	1091
coverage shall cover emergency services without regard to the day	1092
or time the emergency services are rendered or to whether the	1093
policyholder, the hospital's emergency department where the	1094
services are rendered, or an emergency physician treating the	1095
policyholder, obtained prior authorization for the emergency	1096
services.	1097

(C) Every individual policy or certificate furnished by an	1098
insurer in connection with any sickness and accident insurance	1099
policy shall provide information regarding the following:	1100

(1) The scope of coverage for emergency services;

1101

(2) The appropriate use of emergency services, including the	1102
use of the 9-1-1 system and any other telephone access systems	1103
utilized to access prehospital emergency services;	1104

(3) Any copayments for emergency services.

1105

(D) This section does not apply to any individual or group	1106
policy of sickness and accident insurance covering only accident,	1107
credit, dental, disability income, long-term care, hospital	1108
indemnity, medicare supplement, medicare, tricare, specified	1109
disease, or vision care; coverage under a one-time limited	1110
duration policy ~~of no longer~~that is less than ~~six~~twelve months;	1111
coverage issued as a supplement to liability insurance; insurance	1112
arising out of workers' compensation or similar law; automobile	1113
medical payment insurance; or insurance under which benefits are	1114
payable with or without regard to fault and which is statutorily	1115
required to be contained in any liability insurance policy or	1116
equivalent self-insurance.	1117

Sec. 3923.83. (A)(1) This section applies to both of the	1118
following:	1119

(a) A public employee benefit plan that issues or requires	1120
the use of a standardized identification card or an electronic	1121
technology for submission and routing of prescription drug claims	1122
pursuant to a policy, contract, or agreement for health care	1123
services;	1124

(b) A person or entity that a public employee benefit plan	1125
contracts with to issue a standardized identification card or an	1126
electronic technology described in division (A)(1)(a) of this	1127
section.	1128

(2) Notwithstanding division (A)(1) of this section, this	1129
section does not apply to the issuance or required use of a	1130
standardized identification card or an electronic technology for	1131
the submission and routing of prescription drug claims in	1132
connection with either of the following:	1133

(a) Any individual or group policy of insurance covering only	1134
accident, credit, dental, disability income, long-term care,	1135
hospital indemnity, medicare supplement, medicare, tricare,	1136
specified disease, or vision care; coverage under a	1137
one-time-limited-duration policy ~~of not longer~~that is less than	1138
~~six~~twelve months; coverage issued as a supplement to liability	1139
insurance; insurance arising out of workers' compensation or	1140
similar law; automobile medical payment insurance; or insurance	1141
under which benefits are payable with or without regard to fault	1142
and which is statutorily required to be contained in any liability	1143
insurance policy or equivalent self-insurance.	1144

(b) Coverage provided under the medicaid program.

1145

(B) A standardized identification card or an electronic	1146
technology issued or required to be used as provided in division	1147
(A)(1) of this section shall contain uniform prescription drug	1148
information in accordance with either division (B)(1) or (2) of	1149
this section.	1150

(1) The standardized identification card or the electronic	1151
technology shall be in a format and contain information fields	1152
approved by the national council for prescription drug programs or	1153
a successor organization, as specified in the council's or	1154
successor organization's pharmacy identification card	1155
implementation guide in effect on the first day of October most	1156
immediately preceding the issuance or required use of the	1157
standardized identification card or the electronic technology.	1158

(2) If the public employee benefit plan or person under	1159
contract with the plan to issue a standardized identification card	1160
or an electronic technology requires the information for the	1161
submission and routing of a claim, the standardized identification	1162
card or the electronic technology shall contain any of the	1163
following information:	1164

(a) The plan's name;

1165

(b) The insured's name, group number, and identification	1166
number;	1167

(c) A telephone number to inquire about pharmacy-related	1168
issues;	1169

(d) The issuer's international identification number, labeled	1170
as "ANSI BIN" or "RxBIN";	1171

(e) The processor's control number, labeled as "RxPCN";

1172

(f) The insured's pharmacy benefits group number if different	1173
from the insured's medical group number, labeled as "RxGrp."	1174

(C) If the standardized identification card or the electronic	1175
technology issued or required to be used as provided in division	1176
(A)(1) of this section is also used for submission and routing of	1177
nonpharmacy claims, the designation "Rx" is required to be	1178
included as part of the labels identified in divisions (B)(2)(d)	1179
and (e) of this section if the issuer's international	1180
identification number or the processor's control number is	1181
different for medical and pharmacy claims.	1182

(D)(1) Except as provided in division (D)(2) of this section,	1183
if there is a change in the information contained in the	1184
standardized identification card or the electronic technology	1185
issued to an insured, the public employee benefit plan or person	1186
under contract with the plan to issue a standardized	1187
identification card or electronic technology shall issue a new	1188
card or electronic technology to the insured.	1189

(2) A public employee benefit plan or person under contract	1190
with the plan is not required under division (D)(1) of this	1191
section to issue a new card or electronic technology to an insured	1192
more than once during a twelve-month period.	1193

(E) Nothing in this section shall be construed as requiring a	1194
public employee benefit plan to produce more than one standardized	1195
identification card or one electronic technology for use by	1196
insureds accessing health care benefits provided under a health	1197
benefit plan.	1198

Sec. 3923.85. (A) As used in this section, "cost sharing"	1199
means the cost to an individual insured under an individual or	1200
group policy of sickness and accident insurance or a public	1201
employee benefit plan according to any coverage limit, copayment,	1202
coinsurance, deductible, or other out-of-pocket expense	1203
requirements imposed by the policy or plan.	1204

(B) Notwithstanding section 3901.71 of the Revised Code and	1205
subject to division (D) of this section, no individual or group	1206
policy of sickness and accident insurance that is delivered,	1207
issued for delivery, or renewed in this state and no public	1208
employee benefit plan that is established or modified in this	1209
state shall fail to comply with either of the following:	1210

(1) The policy or plan shall not provide coverage or impose	1211
cost sharing for a prescribed, orally administered cancer	1212
medication on a less favorable basis than the coverage it provides	1213
or cost sharing it imposes for intraveneously administered or	1214
injected cancer medications.	1215

(2) The policy or plan shall not comply with division (B)(1)	1216
of this section by imposing an increase in cost sharing solely for	1217
orally administered, intravenously administered, or injected	1218
cancer medications.	1219

(C) Notwithstanding any provision of this section to the	1220
contrary, a policy or plan shall be deemed to be in compliance	1221
with this section if the cost sharing imposed under such a policy	1222
or plan for orally administered cancer treatments does not exceed	1223
one hundred dollars per prescription fill. The cost sharing limit	1224
of one hundred dollars per prescription fill shall apply to a high	1225
deductible plan, as defined in 26 U.S.C. 223, or a catastrophic	1226
plan, as defined in 42 U.S.C. 18022, only after the deductible has	1227
been met.	1228

(D)(1) The prohibitions in division (B) of this section do	1229
not preclude an individual or group policy of sickness and	1230
accident insurance or public employee benefit plan from requiring	1231
an insured or plan member to obtain prior authorization before	1232
orally administered cancer medication is dispensed to the insured	1233
or plan member.	1234

(2) Division (B) of this section does not apply to the offer	1235
or renewal of any individual or group policy of sickness and	1236
accident insurance that provides coverage for specific diseases or	1237
accidents only, or to any hospital indemnity, medicare supplement,	1238
disability income, or other policy that offers only supplemental	1239
benefits.	1240

(E) An insurer that offers any sickness and accident	1241
insurance or any public employee benefit plan that offers coverage	1242
for basic health care services is not required to comply with	1243
division (B) of this section if all of the following apply:	1244

(1) The insurer or plan submits documentation certified by an	1245
independent member of the American academy of actuaries to the	1246
superintendent of insurance showing that compliance with division	1247
(B)(1) of this section for a period of at least six months	1248
independently caused the insurer or plan's costs for claims and	1249
administrative expenses for the coverage of basic health care	1250
services to increase by more than one per cent per year.	1251

(2) The insurer or plan submits a signed letter from an	1252
independent member of the American academy of actuaries to the	1253
superintendent of insurance opining that the increase in costs	1254
described in division (E)(1) of this section could reasonably	1255
justify an increase of more than one per cent in the annual	1256
premiums or rates charged by the insurer or plan for the coverage	1257
of basic health care services.	1258

(3)(a) The superintendent of insurance makes the following	1259
determinations from the documentation and opinion submitted	1260
pursuant to divisions (E)(1) and (2) of this section:	1261

(i) Compliance with division (B)(1) of this section for a	1262
period of at least six months independently caused the insurer or	1263
plan's costs for claims and administrative expenses for the	1264
coverage of basic health care services to increase more than one	1265
per cent per year.	1266

(ii) The increase in costs reasonably justifies an increase	1267
of more than one per cent in the annual premiums or rates charged	1268
by the insurer or plan for the coverage of basic health care	1269
services.	1270

(b) Any determination made by the superintendent under	1271
division (E)(3) of this section is subject to Chapter 119. of the	1272
Revised Code.	1273

Sec. 3924.01. As used in sections 3924.01 to 3924.14 of the	1274
Revised Code:	1275

(A) "Actuarial certification" means a written statement	1276
prepared by a member of the American academy of actuaries, or by	1277
any other person acceptable to the superintendent of insurance,	1278
that states that, based upon the person's examination, a carrier	1279
offering health benefit plans to small employers is in compliance	1280
with sections 3924.01 to 3924.14 of the Revised Code. "Actuarial	1281
certification" shall include a review of the appropriate records	1282
of, and the actuarial assumptions and methods used by, the carrier	1283
relative to establishing premium rates for the health benefit	1284
plans.	1285

(B) "Adjusted average market premium price" means the average	1286
market premium price as determined by the board of directors of	1287
the Ohio health reinsurance program either on the basis of the	1288
arithmetic mean of all carriers' premium rates for an OHC plan	1289
sold to groups with similar case characteristics by all carriers	1290
selling OHC plans in the state, or on any other equitable basis	1291
determined by the board.	1292

(C) "Base premium rate" means, as to any health benefit plan	1293
that is issued by a carrier and that covers at least two but no	1294
more than fifty employees of a small employer, the lowest premium	1295
rate for a new or existing business prescribed by the carrier for	1296
the same or similar coverage under a plan or arrangement covering	1297
any small employer with similar case characteristics.	1298

(D) "Carrier" means any sickness and accident insurance	1299
company or health insuring corporation authorized to issue health	1300
benefit plans in this state or a MEWA. A sickness and accident	1301
insurance company that owns or operates a health insuring	1302
corporation, either as a separate corporation or as a line of	1303
business, shall be considered as a separate carrier from that	1304
health insuring corporation for purposes of sections 3924.01 to	1305
3924.14 of the Revised Code.	1306

(E) "Case characteristics" means, with respect to a small	1307
employer, the geographic area in which the employees work; the age	1308
and sex of the individual employees and their dependents; the	1309
appropriate industry classification as determined by the carrier;	1310
the number of employees and dependents; and such other objective	1311
criteria as may be established by the carrier. "Case	1312
characteristics" does not include claims experience, health	1313
status, or duration of coverage from the date of issue.	1314

(F) "Dependent" means the spouse or child of an eligible	1315
employee, subject to applicable terms of the health benefits plan	1316
covering the employee.	1317

(G) "Eligible employee" means an employee who works a normal	1318
work week of ~~twenty-five~~thirty or more hours. "Eligible employee"	1319
does not include a temporary or substitute employee, or a seasonal	1320
employee who works only part of the calendar year on the basis of	1321
natural or suitable times or circumstances.	1322

(H) "Health benefit plan" means any hospital or medical	1323
expense policy or certificate or any health plan provided by a	1324
carrier, that is delivered, issued for delivery, renewed, or used	1325
in this state on or after the date occurring six months after	1326
November 24, 1995. "Health benefit plan" does not include policies	1327
covering only accident, credit, dental, disability income,	1328
long-term care, hospital indemnity, medicare supplement, specified	1329
disease, or vision care; coverage under a	1330
one-time-limited-duration policy ~~of no longer~~that is less than	1331
~~six~~twelve months; coverage issued as a supplement to liability	1332
insurance; insurance arising out of a workers' compensation or	1333
similar law; automobile medical-payment insurance; or insurance	1334
under which benefits are payable with or without regard to fault	1335
and which is statutorily required to be contained in any liability	1336
insurance policy or equivalent self-insurance.	1337

(I) "Late enrollee" means an eligible employee or dependent	1338
who enrolls in a small employer's health benefit plan other than	1339
during the first period in which the employee or dependent is	1340
eligible to enroll under the plan or during a special enrollment	1341
period described in section 2701(f) of the "Health Insurance	1342
Portability and Accountability Act of 1996," Pub. L. No. 104-191,	1343
110 Stat. 1955, 42 U.S.C.A. 300gg, as amended.	1344

(J) "MEWA" means any "multiple employer welfare arrangement"	1345
as defined in section 3 of the "Federal Employee Retirement Income	1346
Security Act of 1974," 88 Stat. 832, 29 U.S.C.A. 1001, as amended,	1347
except for any arrangement which is fully insured as defined in	1348
division (b)(6)(D) of section 514 of that act.	1349

(K) "Midpoint rate" means, for small employers with similar	1350
case characteristics and plan designs and as determined by the	1351
applicable carrier for a rating period, the arithmetic average of	1352
the applicable base premium rate and the corresponding highest	1353
premium rate.	1354

(L) "Pre-existing conditions provision" means a policy	1355
provision that excludes or limits coverage for charges or expenses	1356
incurred during a specified period following the insured's	1357
enrollment date as to a condition for which medical advice,	1358
diagnosis, care, or treatment was recommended or received during a	1359
specified period immediately preceding the enrollment date.	1360
Genetic information shall not be treated as such a condition in	1361
the absence of a diagnosis of the condition related to such	1362
information.	1363

For purposes of this division, "enrollment date" means, with	1364
respect to an individual covered under a group health benefit	1365
plan, the date of enrollment of the individual in the plan or, if	1366
earlier, the first day of the waiting period for such enrollment.	1367

(M) "Service waiting period" means the period of time after	1368
employment begins before an employee is eligible to be covered for	1369
benefits under the terms of any applicable health benefit plan	1370
offered by the small employer.	1371

(N)(1) "Small employer" means, in connection with a group	1372
health benefit plan and with respect to a calendar year and a plan	1373
year, an employer who employed an average of at least two but no	1374
more than fifty eligible employees on business days during the	1375
preceding calendar year and who employs at least two employees on	1376
the first day of the plan year.	1377

(2) For purposes of division (N)(1) of this section, all	1378
persons treated as a single employer under subsection (b), (c),	1379
(m), or (o) of section 414 of the "Internal Revenue Code of 1986,"	1380
100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one	1381
employer. In the case of an employer that was not in existence	1382
throughout the preceding calendar year, the determination of	1383
whether the employer is a small or large employer shall be based	1384
on the average number of eligible employees that it is reasonably	1385
expected the employer will employ on business days in the current	1386
calendar year. Any reference in division (N) of this section to an	1387
"employer" includes any predecessor of the employer. Except as	1388
otherwise specifically provided, provisions of sections 3924.01 to	1389
3924.14 of the Revised Code that apply to a small employer that	1390
has a health benefit plan shall continue to apply until the plan	1391
anniversary following the date the employer no longer meets the	1392
requirements of this division.	1393

(O) "OHC plan" means an Ohio health care plan, which is the	1394
basic, standard, or carrier reimbursement plan for small employers	1395
and individuals established in accordance with section 3924.10 of	1396
the Revised Code.	1397

Sec. 4123.01. As used in this chapter:

1398

(A)(1) "Employee" means:

1399

(a) Every person in the service of the state, or of any	1400
county, municipal corporation, township, or school district	1401
therein, including regular members of lawfully constituted police	1402
and fire departments of municipal corporations and townships,	1403
whether paid or volunteer, and wherever serving within the state	1404
or on temporary assignment outside thereof, and executive officers	1405
of boards of education, under any appointment or contract of hire,	1406
express or implied, oral or written, including any elected	1407
official of the state, or of any county, municipal corporation, or	1408
township, or members of boards of education.	1409

As used in division (A)(1)(a) of this section, the term	1410
"employee" includes the following persons when responding to an	1411
inherently dangerous situation that calls for an immediate	1412
response on the part of the person, regardless of whether the	1413
person is within the limits of the jurisdiction of the person's	1414
regular employment or voluntary service when responding, on the	1415
condition that the person responds to the situation as the person	1416
otherwise would if the person were on duty in the person's	1417
jurisdiction:	1418

(i) Off-duty peace officers~~. As used in division (A)(1)(a)(i)~~	1419
~~of this section, "peace officer" has the same meaning as in~~	1420
~~section 2935.01 of the Revised Code.~~;	1421

(ii) Off-duty firefighters~~, whether paid or volunteer, of a~~	1422
~~lawfully constituted fire department.~~;	1423

(iii) Off-duty ~~first responders, emergency medical~~	1424
~~technicians-basic, emergency medical technicians-intermediate, or~~	1425
~~emergency medical technicians-paramedic, whether paid or~~	1426
~~volunteer,~~emergency medical workers of an ambulance service	1427
organization or emergency medical service organization ~~pursuant to~~	1428
~~Chapter 4765. of the Revised Code~~.	1429

(b) Every person in the service of any person, firm, or	1430
private corporation, including any public service corporation,	1431
that (i) employs one or more persons regularly in the same	1432
business or in or about the same establishment under any contract	1433
of hire, express or implied, oral or written, including aliens and	1434
minors, household workers who earn one hundred sixty dollars or	1435
more in cash in any calendar quarter from a single household and	1436
casual workers who earn one hundred sixty dollars or more in cash	1437
in any calendar quarter from a single employer, or (ii) is bound	1438
by any such contract of hire or by any other written contract, to	1439
pay into the state insurance fund the premiums provided by this	1440
chapter.	1441

(c) Every person who performs labor or provides services	1442
pursuant to a construction contract, as defined in section 4123.79	1443
of the Revised Code, if at least ten of the following criteria	1444
apply:	1445

(i) The person is required to comply with instructions from	1446
the other contracting party regarding the manner or method of	1447
performing services;	1448

(ii) The person is required by the other contracting party to	1449
have particular training;	1450

(iii) The person's services are integrated into the regular	1451
functioning of the other contracting party;	1452

(iv) The person is required to perform the work personally;

1453

(v) The person is hired, supervised, or paid by the other	1454
contracting party;	1455

(vi) A continuing relationship exists between the person and	1456
the other contracting party that contemplates continuing or	1457
recurring work even if the work is not full time;	1458

(vii) The person's hours of work are established by the other	1459
contracting party;	1460

(viii) The person is required to devote full time to the	1461
business of the other contracting party;	1462

(ix) The person is required to perform the work on the	1463
premises of the other contracting party;	1464

(x) The person is required to follow the order of work set by	1465
the other contracting party;	1466

(xi) The person is required to make oral or written reports	1467
of progress to the other contracting party;	1468

(xii) The person is paid for services on a regular basis such	1469
as hourly, weekly, or monthly;	1470

(xiii) The person's expenses are paid for by the other	1471
contracting party;	1472

(xiv) The person's tools and materials are furnished by the	1473
other contracting party;	1474

(xv) The person is provided with the facilities used to	1475
perform services;	1476

(xvi) The person does not realize a profit or suffer a loss	1477
as a result of the services provided;	1478

(xvii) The person is not performing services for a number of	1479
employers at the same time;	1480

(xviii) The person does not make the same services available	1481
to the general public;	1482

(xix) The other contracting party has a right to discharge	1483
the person;	1484

(xx) The person has the right to end the relationship with	1485
the other contracting party without incurring liability pursuant	1486
to an employment contract or agreement.	1487

Every person in the service of any independent contractor or	1488
subcontractor who has failed to pay into the state insurance fund	1489
the amount of premium determined and fixed by the administrator of	1490
workers' compensation for the person's employment or occupation or	1491
if a self-insuring employer has failed to pay compensation and	1492
benefits directly to the employer's injured and to the dependents	1493
of the employer's killed employees as required by section 4123.35	1494
of the Revised Code, shall be considered as the employee of the	1495
person who has entered into a contract, whether written or verbal,	1496
with such independent contractor unless such employees or their	1497
legal representatives or beneficiaries elect, after injury or	1498
death, to regard such independent contractor as the employer.	1499

(2) "Employee" does not mean:

1500

(a) A duly ordained, commissioned, or licensed minister or	1501
assistant or associate minister of a church in the exercise of	1502
ministry;	1503

(b) Any officer of a family farm corporation;

1504

1505

(d) An individual who otherwise is an employee of an employer	1506
but who signs the waiver and affidavit specified in section	1507
4123.15 of the Revised Code on the condition that the	1508
administrator has granted a waiver and exception to the	1509
individual's employer under section 4123.15 of the Revised Code.	1510

Any employer may elect to include as an "employee" within	1511
this chapter, any person excluded from the definition of	1512
"employee" pursuant to division (A)(2) of this section. If an	1513
employer is a partnership, sole proprietorship, individual	1514
incorporated as a corporation, or family farm corporation, such	1515
employer may elect to include as an "employee" within this	1516
chapter, any member of such partnership, the owner of the sole	1517
proprietorship, the individual incorporated as a corporation, or	1518
the officers of the family farm corporation. In the event of an	1519
election, the employer shall serve upon the bureau of workers'	1520
compensation written notice naming the persons to be covered,	1521
include such employee's remuneration for premium purposes in all	1522
future payroll reports, and no person excluded from the definition	1523
of "employee" pursuant to division (A)(2) of this section,	1524
proprietor, individual incorporated as a corporation, or partner	1525
shall be deemed an employee within this division until the	1526
employer has served such notice.	1527

For informational purposes only, the bureau shall prescribe	1528
such language as it considers appropriate, on such of its forms as	1529
it considers appropriate, to advise employers of their right to	1530
elect to include as an "employee" within this chapter a sole	1531
proprietor, any member of a partnership, an individual	1532
incorporated as a corporation, the officers of a family farm	1533
corporation, or a person excluded from the definition of	1534
"employee" under division (A)(2) of this section, that they should	1535
check any health and disability insurance policy, or other form of	1536
health and disability plan or contract, presently covering them,	1537
or the purchase of which they may be considering, to determine	1538
whether such policy, plan, or contract excludes benefits for	1539
illness or injury that they might have elected to have covered by	1540
workers' compensation.	1541

(B) "Employer" means:

1542

(1) The state, including state hospitals, each county,	1543
municipal corporation, township, school district, and hospital	1544
owned by a political subdivision or subdivisions other than the	1545
state;	1546

(2) Every person, firm, professional employer organization,	1547
and private corporation, including any public service corporation,	1548
that (a) has in service one or more employees or shared employees	1549
regularly in the same business or in or about the same	1550
establishment under any contract of hire, express or implied, oral	1551
or written, or (b) is bound by any such contract of hire or by any	1552
other written contract, to pay into the insurance fund the	1553
premiums provided by this chapter.	1554

All such employers are subject to this chapter. Any member of	1555
a firm or association, who regularly performs manual labor in or	1556
about a mine, factory, or other establishment, including a	1557
household establishment, shall be considered an employee in	1558
determining whether such person, firm, or private corporation, or	1559
public service corporation, has in its service, one or more	1560
employees and the employer shall report the income derived from	1561
such labor to the bureau as part of the payroll of such employer,	1562
and such member shall thereupon be entitled to all the benefits of	1563
an employee.	1564

(C) "Injury" includes any injury, whether caused by external	1565
accidental means or accidental in character and result, received	1566
in the course of, and arising out of, the injured employee's	1567
employment. "Injury" does not include:	1568

(1) Psychiatric conditions except ~~where~~as follows:

1569

(a) Where the claimant's psychiatric conditions have arisen	1570
from an injury or occupational disease sustained by that claimant	1571
~~or where~~;	1572

(b) Where the claimant's psychiatric conditions have arisen	1573
from sexual conduct in which the claimant was forced by threat of	1574
physical harm to engage or participate;	1575

(c) Where the claimant is a peace officer, firefighter, or	1576
emergency medical worker and is diagnosed with post-traumatic	1577
stress disorder that has been received in the course of, and has	1578
arisen out of, the claimant's employment as a peace officer,	1579
firefighter, or emergency medical worker.	1580

(2) Injury or disability caused primarily by the natural	1581
deterioration of tissue, an organ, or part of the body;	1582

(3) Injury or disability incurred in voluntary participation	1583
in an employer-sponsored recreation or fitness activity if the	1584
employee signs a waiver of the employee's right to compensation or	1585
benefits under this chapter prior to engaging in the recreation or	1586
fitness activity;	1587

(4) A condition that pre-existed an injury unless that	1588
pre-existing condition is substantially aggravated by the injury.	1589
Such a substantial aggravation must be documented by objective	1590
diagnostic findings, objective clinical findings, or objective	1591
test results. Subjective complaints may be evidence of such a	1592
substantial aggravation. However, subjective complaints without	1593
objective diagnostic findings, objective clinical findings, or	1594
objective test results are insufficient to substantiate a	1595
substantial aggravation.	1596

(D) "Child" includes a posthumous child and a child legally	1597
adopted prior to the injury.	1598

(E) "Family farm corporation" means a corporation founded for	1599
the purpose of farming agricultural land in which the majority of	1600
the voting stock is held by and the majority of the stockholders	1601
are persons or the spouse of persons related to each other within	1602
the fourth degree of kinship, according to the rules of the civil	1603
law, and at least one of the related persons is residing on or	1604
actively operating the farm, and none of whose stockholders are a	1605
corporation. A family farm corporation does not cease to qualify	1606
under this division where, by reason of any devise, bequest, or	1607
the operation of the laws of descent or distribution, the	1608
ownership of shares of voting stock is transferred to another	1609
person, as long as that person is within the degree of kinship	1610
stipulated in this division.	1611

(F) "Occupational disease" means a disease contracted in the	1612
course of employment, which by its causes and the characteristics	1613
of its manifestation or the condition of the employment results in	1614
a hazard which distinguishes the employment in character from	1615
employment generally, and the employment creates a risk of	1616
contracting the disease in greater degree and in a different	1617
manner from the public in general.	1618

(G) "Self-insuring employer" means an employer who is granted	1619
the privilege of paying compensation and benefits directly under	1620
section 4123.35 of the Revised Code, including a board of county	1621
commissioners for the sole purpose of constructing a sports	1622
facility as defined in section 307.696 of the Revised Code,	1623
provided that the electors of the county in which the sports	1624
facility is to be built have approved construction of a sports	1625
facility by ballot election no later than November 6, 1997.	1626

(H) "Private employer" means an employer as defined in	1627
division (B)(2) of this section.	1628

(I) "Professional employer organization" has the same meaning	1629
as in section 4125.01 of the Revised Code.	1630

(J) "Public employer" means an employer as defined in	1631
division (B)(1) of this section.	1632

(K) "Sexual conduct" means vaginal intercourse between a male	1633
and female; anal intercourse, fellatio, and cunnilingus between	1634
persons regardless of gender; and, without privilege to do so, the	1635
insertion, however slight, of any part of the body or any	1636
instrument, apparatus, or other object into the vaginal or anal	1637
cavity of another. Penetration, however slight, is sufficient to	1638
complete vaginal or anal intercourse.	1639

(L) "Other-states' insurer" means an insurance company that	1640
is authorized to provide workers' compensation insurance coverage	1641
in any of the states that permit employers to obtain insurance for	1642
workers' compensation claims through insurance companies.	1643

(M) "Other-states' coverage" means both of the following:

1644

(1) Insurance coverage secured by an eligible employer for	1645
workers' compensation claims of employees who are in employment	1646
relationships localized in a state other than this state or those	1647
employees' dependents;	1648

(2) Insurance coverage secured by an eligible employer for	1649
workers' compensation claims that arise in a state other than this	1650
state where an employer elects to obtain coverage through either	1651
the administrator or an other-states' insurer.	1652

(N) "Limited other-states coverage" means insurance coverage	1653
provided by the administrator to an eligible employer for workers'	1654
compensation claims of employees who are in an employment	1655
relationship localized in this state but are temporarily working	1656
in a state other than this state, or those employees' dependents.	1657

(O) "Peace officer" has the same meaning as in section	1658
2935.01 of the Revised Code.	1659

(P) "Firefighter" means a firefighter, whether paid or	1660
volunteer, of a lawfully constituted fire department.	1661

(Q) "Emergency medical worker" means a first responder,	1662
emergency medical technician-basic, emergency medical	1663
technician-intermediate, or emergency medical	1664
technician-paramedic, certified under Chapter 4765. of the Revised	1665
Code, whether paid or volunteer.	1666

Sec. 4123.026. ~~(A)~~ The administrator of workers'	1667
compensation, or a self-insuring public employer for the peace	1668
officers, firefighters, and emergency medical workers employed by	1669
or volunteering for that self-insuring public employer, shall pay	1670
the costs of conducting post-exposure medical diagnostic services,	1671
consistent with the standards of medical care existing at the time	1672
of the exposure, to investigate whether an injury or occupational	1673
disease was sustained by a peace officer, firefighter, or	1674
emergency medical worker when coming into contact with the blood	1675
or other body fluid of another person in the course of and arising	1676
out of the peace officer's, firefighter's, or emergency medical	1677
worker's employment, or when responding to an inherently dangerous	1678
situation in the manner described in, and in accordance with the	1679
conditions specified under, division (A)(1)(a) of section 4123.01	1680
of the Revised Code, through any of the following means:	1681

~~(1)~~(A) Splash or spatter in the eye or mouth, including when	1682
received in the course of conducting mouth-to-mouth resuscitation;	1683

~~(2)~~(B) A puncture in the skin;

1684

~~(3)~~(C) A cut in the skin or another opening in the skin such	1685
as an open sore, wound, lesion, abrasion, or ulcer.	1686

~~(B) As used in this section:~~

1687

~~(1) "Peace officer" has the same meaning as in section~~	1688
~~2935.01 of the Revised Code.~~	1689

~~(2) "Firefighter" means a firefighter, whether paid or~~	1690
~~volunteer, of a lawfully constituted fire department.~~	1691

~~(3) "Emergency medical worker" means a first responder,~~	1692
~~emergency medical technician-basic, emergency medical~~	1693
~~technician-intermediate, or emergency medical~~	1694
~~technician-paramedic, certified under Chapter 4765. of the Revised~~	1695
~~Code, whether paid or volunteer.~~	1696

Sec. 4123.46. (A)(1) Except as provided in division (A)(2)	1697
of this section, the bureau of workers' compensation shall	1698
disburse the state insurance fund to employees of employers who	1699
have paid into the fund the premiums applicable to the classes to	1700
which they belong when the employees have been injured in the	1701
course of their employment, wherever the injuries have occurred,	1702
and provided the injuries have not been purposely self-inflicted,	1703
or to the dependents of the employees in case death has ensued.	1704

(2) As long as injuries have not been purposely	1705
self-inflicted, the bureau shall disburse the surplus fund created	1706
under section 4123.34 of the Revised Code to off-duty peace	1707
officers, firefighters, and emergency medical ~~technicians, and~~	1708
~~first responders~~workers, or to their dependents if death ensues,	1709
who are injured while responding to inherently dangerous	1710
situations that call for an immediate response on the part of the	1711
person, regardless of whether the person was within the limits of	1712
the person's jurisdiction when responding, on the condition that	1713
the person responds to the situation as the person otherwise would	1714
if the person were on duty in the person's jurisdiction.	1715

As used in division (A)(2) of this section, "peace officer,"	1716
"firefighter," and "emergency medical ~~technician," "first~~	1717
~~responder~~worker," ~~and "jurisdiction"~~ have the same meanings as in	1718
section 4123.01 of the Revised Code.	1719

(B) All self-insuring employers, in compliance with this	1720
chapter, shall pay the compensation to injured employees, or to	1721
the dependents of employees who have been killed in the course of	1722
their employment, unless the injury or death of the employee was	1723
purposely self-inflicted, and shall furnish the medical, surgical,	1724
nurse, and hospital care and attention or funeral expenses as	1725
would have been paid and furnished by virtue of this chapter under	1726
a similar state of facts by the bureau out of the state insurance	1727
fund if the employer had paid the premium into the fund.	1728

If any rule or regulation of a self-insuring employer	1729
provides for or authorizes the payment of greater compensation or	1730
more complete or extended medical care, nursing, surgical, and	1731
hospital attention, or funeral expenses to the injured employees,	1732
or to the dependents of the employees as may be killed, the	1733
employer shall pay to the employees, or to the dependents of	1734
employees killed, the amount of compensation and furnish the	1735
medical care, nursing, surgical, and hospital attention or funeral	1736
expenses provided by the self-insuring employer's rules and	1737
regulations.	1738

(C) Payment to injured employees, or to their dependents in	1739
case death has ensued, is in lieu of any and all rights of action	1740
against the employer of the injured or killed employees.	1741

Section 2. That existing sections 1739.061, 1751.14, 1751.69,	1742
3923.022, 3923.24, 3923.241, 3923.281, 3923.57, 3923.58, 3923.601,	1743
3923.65, 3923.83, 3923.85, 3924.01, 4123.01, 4123.026, and 4123.46	1744
of the Revised Code are hereby repealed.	1745

Section 3. Section 1751.14 and division (G) of section	1746
3924.01 of the Revised Code, as amended by this act, apply only to	1747
policies, contracts, and agreements that are delivered, issued for	1748
delivery, or renewed in this state on or after January 1, 2016.	1749
Division (A)(1) of section 3923.24 and division (A)(1) of section	1750
3923.241 of the Revised Code, as amended by this act, apply only	1751
to policies of sickness and accident insurance delivered, issued	1752
for delivery, or renewed in this state and public employee benefit	1753
plans or multiple employer welfare arrangement contracts and	1754
certificates that are established or modified in this state on or	1755
after January 1, 2016.	1756

Section 4. The General Assembly declares that the amendments	1757
made to section 3923.58 of the Revised Code by this act are not to	1758
supersede the suspension of the operation of this section enacted	1759
by Section 3 of Sub. S.B. 9 of the 130th General Assembly. Rather,	1760
it is the intent of the General Assembly to ensure consistency in	1761
Ohio Insurance Law should this suspension be nullified.	1762

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Bill Text: OH HB511 | 2013-2014 | 130th General Assembly | Engrossed

Ohio House Bill 511 (Prior Session Legislation)

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