Except as provided by divisions (A)(2) and (3) of this | 30 |
section in connection with the offering of coverage for diagnostic | 31 |
and treatment services for biologically based mental illnesses, a | 32 |
health insuring corporation shall not offer coverage for a health | 33 |
care service, defined as a basic health care service by this | 34 |
division, unless it offers coverage for all listed basic health | 35 |
care services. However, this requirement does not apply to the | 36 |
coverage of beneficiaries enrolled in medicare pursuant to a | 37 |
medicare contract, or to the coverage of beneficiaries enrolled in | 38 |
the federal employee health benefits program pursuant to 5 | 39 |
U.S.C.A. 8905, or to the coverage of medicaid recipients, or to | 40 |
the coverage of beneficiaries under any federal health care | 41 |
program regulated by a federal regulatory body, or to the coverage | 42 |
of beneficiaries under any contract covering officers or employees | 43 |
of the state that has been entered into by the department of | 44 |
administrative services. | 45 |
(2)(a) A health insuring corporation may offer coverage for | 46 |
diagnostic and treatment services for biologically based mental | 47 |
illnesses without offering coverage for all other basic health | 48 |
care services. A health insuring corporation may offer coverage | 49 |
for diagnostic and treatment services for biologically based | 50 |
mental illnesses alone or in combination with one or more | 51 |
supplemental health care services. However, a health insuring | 52 |
corporation that offers coverage for any other basic health care | 53 |
service shall offer coverage for diagnostic and treatment services | 54 |
for biologically based mental illnesses in combination with the | 55 |
offer of coverage for all other listed basic health care services. | 56 |
(b) Coverage for diagnostic and treatment services for | 57 |
biologically based mental illnesses related to pervasive | 58 |
developmental disorders shall include applied behavior analysis | 59 |
when provided or supervised by an analyst certified by the | 60 |
behavior analyst certification board or by a state licensed | 61 |
physician or psychologist, or a mental health professional, as | 62 |
defined in division (A)(1)(d) of section 2305.51 of the Revised | 63 |
Code, so long as the services performed are commensurate with the | 64 |
physician's, psychologist's, or mental health professional's | 65 |
training and supervised experience. Such coverage shall include | 66 |
the services of the personnel who work under the supervision of | 67 |
the analyst certified by the behavior analyst certification board | 68 |
or the licensed physician or psychologist or the mental health | 69 |
professional. | 70 |
(d) On and after January 1, 2014, to the extent that division | 74 |
(A)(2)(b) of this section results in the state paying the cost of | 75 |
benefits that exceed the essential health benefits specified under | 76 |
section 1302(b) of the "Patient Protection and Affordable Care | 77 |
Act," 42 U.S.C. 18022(b), as amended, those benefits that exceed | 78 |
the specified essential health benefits shall not be required of | 79 |
health benefit plans in the individual market or in the small | 80 |
group market that are offered by a health insuring corporation in | 81 |
this state either through or outside a health insurance exchange | 82 |
operated by the state or by the federal government. | 83 |
(e) "Applied behavior analysis" means the design, | 84 |
implementation, and evaluation of environmental modifications | 85 |
using behavioral stimuli and consequences to produce socially | 86 |
significant improvement in human behavior, that is delivered in a | 87 |
home or clinic setting to address core deficits resulting from a | 88 |
medical diagnosis of pervasive developmental disorder. "Applied | 89 |
behavior analysis" includes the use of direct observation, | 90 |
measurement, and functional analysis of the relationship between | 91 |
environment and behavior. | 92 |
(a) The health insuring corporation submits documentation | 98 |
certified by an independent member of the American academy of | 99 |
actuaries to the superintendent of insurance showing that incurred | 100 |
claims for diagnostic and treatment services for biologically | 101 |
based mental illnesses for a period of at least six months | 102 |
independently caused the health insuring corporation's costs for | 103 |
claims and administrative expenses for the coverage of basic | 104 |
health care services to increase by more than one per cent per | 105 |
year. | 106 |
(D) "Biologically based mental illnesses" means | 165 |
schizophrenia, schizoaffective disorder, major depressive | 166 |
disorder, bipolar disorder, paranoia and other psychotic | 167 |
disorders, obsessive-compulsive disorder, and panic disorder, as | 168 |
these terms are defined in the most recent edition of the | 169 |
diagnostic and statistical manual of mental disorders published by | 170 |
the American psychiatric association, and pervasive developmental | 171 |
disorders. | 172 |
(I) "Emergency health services" means those health care | 184 |
services that must be available on a seven-days-per-week, | 185 |
twenty-four-hours-per-day basis in order to prevent jeopardy to an | 186 |
enrollee's health status that would occur if such services were | 187 |
not received as soon as possible, and includes, where appropriate, | 188 |
provisions for transportation and indemnity payments or service | 189 |
agreements for out-of-area coverage. | 190 |
(L) "Health care facility" means any facility, except a | 198 |
health care practitioner's office, that provides preventive, | 199 |
diagnostic, therapeutic, acute convalescent, rehabilitation, | 200 |
mental health, mental retardation, intermediate care, or skilled | 201 |
nursing services. | 202 |
(O) "Health insuring corporation" means a corporation, as | 209 |
defined in division (H) of this section, that, pursuant to a | 210 |
policy, contract, certificate, or agreement, pays for, reimburses, | 211 |
or provides, delivers, arranges for, or otherwise makes available, | 212 |
basic health care services, supplemental health care services, or | 213 |
specialty health care services, or a combination of basic health | 214 |
care services and either supplemental health care services or | 215 |
specialty health care services, through either an open panel plan | 216 |
or a closed panel plan. | 217 |
"Health insuring corporation" does not include a limited | 218 |
liability company formed pursuant to Chapter 1705. of the Revised | 219 |
Code, an insurer licensed under Title XXXIX of the Revised Code if | 220 |
that insurer offers only open panel plans under which all | 221 |
providers and health care facilities participating receive their | 222 |
compensation directly from the insurer, a corporation formed by or | 223 |
on behalf of a political subdivision or a department, office, or | 224 |
institution of the state, or a public entity formed by or on | 225 |
behalf of a board of county commissioners, a county board of | 226 |
developmental disabilities, an alcohol and drug addiction services | 227 |
board, a board of alcohol, drug addiction, and mental health | 228 |
services, or a community mental health board, as those terms are | 229 |
used in Chapters 340. and 5126. of the Revised Code. Except as | 230 |
provided by division (D) of section 1751.02 of the Revised Code, | 231 |
or as otherwise provided by law, no board, commission, agency, or | 232 |
other entity under the control of a political subdivision may | 233 |
accept insurance risk in providing for health care services. | 234 |
However, nothing in this division shall be construed as | 235 |
prohibiting such entities from purchasing the services of a health | 236 |
insuring corporation or a third-party administrator licensed under | 237 |
Chapter 3959. of the Revised Code. | 238 |
(P) "Intermediary organization" means a health delivery | 239 |
network or other entity that contracts with licensed health | 240 |
insuring corporations or self-insured employers, or both, to | 241 |
provide health care services, and that enters into contractual | 242 |
arrangements with other entities for the provision of health care | 243 |
services for the purpose of fulfilling the terms of its contracts | 244 |
with the health insuring corporations and self-insured employers. | 245 |
(2) No health insuring corporation may offer an open panel | 262 |
plan, unless the health insuring corporation is also licensed as | 263 |
an insurer under Title XXXIX of the Revised Code, the health | 264 |
insuring corporation, on June 4, 1997, holds a certificate of | 265 |
authority or license to operate under Chapter 1736. or 1740. of | 266 |
the Revised Code, or an insurer licensed under Title XXXIX of the | 267 |
Revised Code is responsible for the out-of-network risk as | 268 |
evidenced by both an evidence of coverage filing under section | 269 |
1751.11 of the Revised Code and a policy and certificate filing | 270 |
under section 3923.02 of the Revised Code. | 271 |
(Z) "Premium rate" means any set fee regularly paid by a | 302 |
subscriber to a health insuring corporation. A "premium rate" does | 303 |
not include a one-time membership fee, an annual administrative | 304 |
fee, or a nominal access fee, paid to a managed health care system | 305 |
under which the recipient of health care services remains solely | 306 |
responsible for any charges accessed for those services by the | 307 |
provider or health care facility. | 308 |
(AA)(BB) "Provider" means any natural person or partnership | 316 |
of natural persons who are licensed, certified, accredited, or | 317 |
otherwise authorized in this state to furnish health care | 318 |
services, or any professional association organized under Chapter | 319 |
1785. of the Revised Code, provided that nothing in this chapter | 320 |
or other provisions of law shall be construed to preclude a health | 321 |
insuring corporation, health care practitioner, or organized | 322 |
health care group associated with a health insuring corporation | 323 |
from employing certified nurse practitioners, certified nurse | 324 |
anesthetists, clinical nurse specialists, certified nurse | 325 |
midwives, dietitians, physician assistants, dental assistants, | 326 |
dental hygienists, optometric technicians, or other allied health | 327 |
personnel who are licensed, certified, accredited, or otherwise | 328 |
authorized in this state to furnish health care services. | 329 |
(BB)(CC) "Provider sponsored organization" means a | 330 |
corporation, as defined in division (H) of this section, that is | 331 |
at least eighty per cent owned or controlled by one or more | 332 |
hospitals, as defined in section 3727.01 of the Revised Code, or | 333 |
one or more physicians licensed to practice medicine or surgery or | 334 |
osteopathic medicine and surgery under Chapter 4731. of the | 335 |
Revised Code, or any combination of such physicians and hospitals. | 336 |
Such control is presumed to exist if at least eighty per cent of | 337 |
the voting rights or governance rights of a provider sponsored | 338 |
organization are directly or indirectly owned, controlled, or | 339 |
otherwise held by any combination of the physicians and hospitals | 340 |
described in this division. | 341 |
(EE)(FF) "Urgent care services" means those health care | 351 |
services that are appropriately provided for an unforeseen | 352 |
condition of a kind that usually requires medical attention | 353 |
without delay but that does not pose a threat to the life, limb, | 354 |
or permanent health of the injured or ill person, and may include | 355 |
such health care services provided out of the health insuring | 356 |
corporation's approved service area pursuant to indemnity payments | 357 |
or service agreements. | 358 |
(1) "Biologically based mental illness" means schizophrenia, | 360 |
schizoaffective disorder, major depressive disorder, bipolar | 361 |
disorder, paranoia and other psychotic disorders, | 362 |
obsessive-compulsive disorder, and panic disorder, as these terms | 363 |
are defined in the most recent edition of the diagnostic and | 364 |
statistical manual of mental disorders published by the American | 365 |
psychiatric association, and pervasive developmental disorders. | 366 |
(2) "Policy of sickness and accident insurance" has the same | 367 |
meaning as in section 3923.01 of the Revised Code, but excludes | 368 |
any hospital indemnity, medicare supplement, long-term care, | 369 |
disability income, one-time-limited-duration policy of not longer | 370 |
than six months, supplemental benefit, or other policy that | 371 |
provides coverage for specific diseases or accidents only; any | 372 |
policy that provides coverage for workers' compensation claims | 373 |
compensable pursuant to Chapters 4121. and 4123. of the Revised | 374 |
Code; and any policy that provides coverage to beneficiaries | 375 |
enrolled in Title XIX of the "Social Security Act," 49 Stat. 620 | 376 |
(1935), 42 U.S.C.A. 301, as amended, known as the medical | 377 |
assistance program or medicaid, as provided by the Ohio department | 378 |
of job and family services under Chapter 5111. of the Revised | 379 |
Code. | 380 |
(3) "Applied behavior analysis" means the design, | 381 |
implementation, and evaluation of environmental modifications | 382 |
using behavioral stimuli and consequences to produce socially | 383 |
significant improvement in human behavior, that is delivered in a | 384 |
home or clinic setting to address core deficits resulting from a | 385 |
medical diagnosis of pervasive developmental disorder. "Applied | 386 |
behavior analysis" includes the use of direct observation, | 387 |
measurement, and functional analysis of the relationship between | 388 |
environment and behavior. | 389 |
(B)(1) Notwithstanding section 3901.71 of the Revised Code, | 399 |
and subject to division (E) of this section, every policy of | 400 |
sickness and accident insurance shall provide benefits for the | 401 |
diagnosis and treatment of biologically based mental illnesses on | 402 |
the same terms and conditions as, and shall provide benefits no | 403 |
less extensive than, those provided under the policy of sickness | 404 |
and accident insurance for the treatment and diagnosis of all | 405 |
other physical diseases and disorders, if both of the following | 406 |
apply: | 407 |
(1)(a) The biologically based mental illness is clinically | 408 |
diagnosed by a physician authorized under Chapter 4731. of the | 409 |
Revised Code to practice medicine and surgery or osteopathic | 410 |
medicine and surgery; a psychologist licensed under Chapter 4732. | 411 |
of the Revised Code; a professional clinical counselor, | 412 |
professional counselor, or independent social worker licensed | 413 |
under Chapter 4757. of the Revised Code; or a clinical nurse | 414 |
specialist licensed under Chapter 4723. of the Revised Code whose | 415 |
nursing specialty is mental health. | 416 |
(2) Coverage for diagnostic and treatment services for | 420 |
biologically based mental illnesses related to pervasive | 421 |
developmental disorders shall include applied behavior analysis | 422 |
when provided or supervised by an analyst certified by the | 423 |
behavior analyst certification board or by a state licensed | 424 |
physician or psychologist, or a mental health professional, as | 425 |
defined under division (A)(1)(d) of section 2305.51 of the Revised | 426 |
Code, so long as the services performed are commensurate with the | 427 |
physician's, psychologist's, or mental health professional's | 428 |
training and supervised experience. Such coverage shall include | 429 |
the services of the personnel who work under the supervision of | 430 |
the analyst certified by the behavior analyst certification board | 431 |
or the licensed physician or psychologist or the mental health | 432 |
professional. | 433 |
(4) On and after January 1, 2014, to the extent that the | 436 |
requirement of division (B)(2) of this section results in the | 437 |
state paying the cost of benefits that exceed the essential health | 438 |
benefits specified under section 1302(b) of the "Patient | 439 |
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as | 440 |
amended, the specific benefits that exceed the specified essential | 441 |
health benefits shall not be required of health benefit plans in | 442 |
the individual market or the small group market that are offered | 443 |
by a health care insurer in this state either through or outside a | 444 |
health insurance exchange operated by the state or by the federal | 445 |
government. | 446 |
(1) The insurer submits documentation certified by an | 474 |
independent member of the American academy of actuaries to the | 475 |
superintendent of insurance showing that incurred claims for | 476 |
diagnostic and treatment services for biologically based mental | 477 |
illnesses for a period of at least six months independently caused | 478 |
the insurer's costs for claims and administrative expenses for the | 479 |
coverage of all other physical diseases and disorders to increase | 480 |
by more than one per cent per year. | 481 |
(1) "Biologically based mental illness" means schizophrenia, | 505 |
schizoaffective disorder, major depressive disorder, bipolar | 506 |
disorder, paranoia and other psychotic disorders, | 507 |
obsessive-compulsive disorder, and panic disorder, as these terms | 508 |
are defined in the most recent edition of the diagnostic and | 509 |
statistical manual of mental disorders published by the American | 510 |
psychiatric association, and pervasive developmental disorders. | 511 |
(3) "Applied behavior analysis" means the design, | 517 |
implementation, and evaluation of environmental modifications | 518 |
using behavioral stimuli and consequences to produce socially | 519 |
significant improvement in human behavior, that is delivered in a | 520 |
home or clinic setting to address core deficits resulting from a | 521 |
medical diagnosis of pervasive developmental disorder. "Applied | 522 |
behavior analysis" includes the use of direct observation, | 523 |
measurement, and functional analysis of the relationship between | 524 |
environment and behavior. | 525 |
(B)(1) Notwithstanding section 3901.71 of the Revised Code, | 535 |
and subject to division (F) of this section, each plan of health | 536 |
coverage shall provide benefits for the diagnosis and treatment of | 537 |
biologically based mental illnesses on the same terms and | 538 |
conditions as, and shall provide benefits no less extensive than, | 539 |
those provided under the plan of health coverage for the treatment | 540 |
and diagnosis of all other physical diseases and disorders, if | 541 |
both of the following apply: | 542 |
(1)(a) The biologically based mental illness is clinically | 543 |
diagnosed by a physician authorized under Chapter 4731. of the | 544 |
Revised Code to practice medicine and surgery or osteopathic | 545 |
medicine and surgery; a psychologist licensed under Chapter 4732. | 546 |
of the Revised Code; a professional clinical counselor, | 547 |
professional counselor, or independent social worker licensed | 548 |
under Chapter 4757. of the Revised Code; or a clinical nurse | 549 |
specialist licensed under Chapter 4723. of the Revised Code whose | 550 |
nursing specialty is mental health. | 551 |
(2) Coverage for diagnostic and treatment services for | 555 |
biologically based mental illnesses related to pervasive | 556 |
developmental disorders shall include applied behavior analysis | 557 |
when provided or supervised by an analyst certified by the | 558 |
behavior analyst certification board or by a state licensed | 559 |
physician or psychologist, or a mental health professional, as | 560 |
defined under division (A)(1)(d) of section 2305.51 of the Revised | 561 |
Code, so long as the services performed are commensurate with the | 562 |
physician's, psychologist's, or mental health professional's | 563 |
training and supervised experience. Such coverage shall include | 564 |
the services of the personnel who work under the supervision of | 565 |
the analyst certified by the behavior analyst certification board | 566 |
or the licensed physician or psychologist or the mental health | 567 |
professional. | 568 |
(4) On and after January 1, 2014, to the extent that the | 571 |
requirement of division (B)(2) of this section results in the | 572 |
state paying the cost of benefits that exceed the essential health | 573 |
benefits specified under section 1302(b) of the "Patient | 574 |
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as | 575 |
amended, the specific benefits that exceed the specified essential | 576 |
health benefits shall not be required of health benefit plans in | 577 |
the individual market or small group market that are offered by a | 578 |
health care insurer in this state either through or outside a | 579 |
health insurance exchange operated by the state or by the federal | 580 |
government. | 581 |
(D) This section does not apply to a plan of health coverage | 587 |
if federal law supersedes, preempts, prohibits, or otherwise | 588 |
precludes its application to such plans. This section does not | 589 |
apply to long-term care, hospital indemnity, disability income, or | 590 |
medicare supplement plans of health coverage, or to any other | 591 |
supplemental benefit plans of health coverage. | 592 |
(1) The employer submits documentation certified by an | 613 |
independent member of the American academy of actuaries to the | 614 |
superintendent of insurance showing that incurred claims for | 615 |
diagnostic and treatment services for biologically based mental | 616 |
illnesses for a period of at least six months independently caused | 617 |
the employer's costs for claims and administrative expenses for | 618 |
the coverage of all other physical diseases and disorders to | 619 |
increase by more than one per cent per year. | 620 |