Effective: July 1, 2021
Latest Legislation: Senate Bill 9 - 133rd General Assembly
(A) As used in this section:
(1) "Full-time employee" means an employee working an average of at least thirty hours of service per week during a calendar month, or at least one hundred thirty hours of service during the calendar month.
(2) "Group policyholder" means a policyholder for a health insurance policy covering fifty or more full-time employees. "Group policyholder" includes an authorized representative of a group policyholder.
(3) "Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.
(B)(1)(a) A health plan issuer shall, upon request, release to each group policyholder monthly claims data and shall provide this data within thirty business days of receipt of the request.
(b) A health plan issuer shall not be required to release claims information as required in division (B)(1)(a) of this section more than once per calendar year per group policyholder.
(2) The data released shall include all of the following with regard to the policy in question for the policy period immediately preceding or the current policy period, as requested by the policyholder:
(a) The net claims paid or incurred by month;
(b)(i) If the group policyholder is an employer, the monthly enrollment data by employee only, employee and spouse, and employee and family;
(ii) If the group policyholder is not an employer, the monthly enrollment data shall be provided and organized in a relevant manner.
(c) Monthly prescription claims information;
(d) Paid claims over thirty thousand dollars, including claim identifier other than name and the date of occurrence, the amount paid toward each claim, and claimant health condition or diagnosis.
(C) A health plan issuer that discloses data or information in compliance with division (B) of this section may condition any such disclosure upon the execution of an agreement with the policyholder absolving the health plan issuer from civil liability related to the use of such data or information.
(D) A health plan issuer that provides data or information in compliance with division (B) of this section shall be immune from civil liability for any acts or omissions of any person's subsequent use of such data or information.
(E) This section shall not be construed as authorizing the disclosure of the identity of a particular individual covered under the group policy, nor the disclosure of any covered individual's particular health insurance claim, condition, or diagnosis, which would violate federal or state law.
(F) A group policyholder is entitled to receive protected health information under this section only after an appropriately authorized representative of the group policyholder makes to the health plan issuer a certification substantially similar to the following:
"I hereby certify and have demonstrated that the plan documents comply with the requirements of 45 C.F.R. 164.504(f)(2) and that the group policyholder will safeguard and limit the use and disclosure of protected health information that the policyholder may receive from the group health plan to perform plan administration functions."
(G) A group policyholder that does not provide the certification required in division (F) of this section is not entitled to receive the protected health information described in division (B)(2)(d) of this section, but is entitled to receive a report of claim information that includes the other information described under division (B) of this section.
(H) Committing a series of violations of this section that, taken together, constitute a practice or pattern shall be considered an unfair or deceptive practice under sections 3901.19 to 3901.26 of the Revised Code.
(I) Nothing in this section shall be construed as prohibiting a health plan issuer from disclosing additional claims information beyond what is required by this section.
Structure Ohio Revised Code
Chapter 3901 | Superintendent of Insurance
Section 3901.01 | Department of Insurance.
Section 3901.011 | Superintendent of Insurance - Powers and Duties.
Section 3901.02 | Appointment or Hiring of Employees.
Section 3901.021 | Department of Insurance Operating Fund.
Section 3901.03 | Warden - Duties - Office of Warden.
Section 3901.04 | Superintendent - Specific Powers.
Section 3901.041 | Rule-Making and Adjudicating Powers of Superintendent.
Section 3901.042 | Service and Transaction Fees.
Section 3901.043 | Fees for Services or Transactions Performed by Department of Insurance.
Section 3901.044 | Rules for Implementing Health Insurance Portability and Accountability Act.
Section 3901.045 | Receiving Confidential or Privileged Documents and Information.
Section 3901.046 | Electronic Signatures.
Section 3901.05 | Deputy Superintendent - Duties.
Section 3901.051 | Assistant Superintendent - Duties.
Section 3901.052 | Application for Innovative Waiver.
Section 3901.06 | Instruments Under Seal of the Superintendent.
Section 3901.07 | Examination of Financial Affairs of Insurer.
Section 3901.071 | Superintendent's Examination Fund.
Section 3901.072 | Corporate Governance Annual Disclosure Act.
Section 3901.073 | Corporate Governance Annual Disclosure.
Section 3901.074 | Format of Disclosure.
Section 3901.075 | Documents Deemed Proprietary.
Section 3901.076 | Retention of Third-Party Consultant.
Section 3901.08 | Information From Banks.
Section 3901.09 | Duty of Bank Officers.
Section 3901.10 | Deficiency of Company Assets.
Section 3901.11 | Acquisition of Stock of Other Insurers.
Section 3901.12 | Interlocking Directorate.
Section 3901.13 | Hearing by Superintendent.
Section 3901.14 | Record and Report of Superintendent.
Section 3901.15 | Application of Law.
Section 3901.17 | Personal Jurisdiction Over Foreign or Alien Insurer.
Section 3901.18 | Requirements for Unauthorized Foreign or Alien Insurer to Enter an Appearance.
Section 3901.19 | Unfair and Deceptive Practices Definitions.
Section 3901.20 | Prohibition Against Unfair or Deceptive Acts.
Section 3901.21 | Unfair and Deceptive Acts or Practices in Business of Insurance Defined.
Section 3901.211 | Lending of Money, Extension of Credit - Prohibited Acts.
Section 3901.212 | Consumer Protection Rules.
Section 3901.213 | Unfair and Deceptive Practices - Exceptions.
Section 3901.214 | Applicability of Prohibition on Inducements.
Section 3901.215 | Intent to Promote Innovation and Maintain Strong Consumer Protection.
Section 3901.22 | Hearings on Violation - Orders - Administrative Remedies.
Section 3901.221 | Cease-and-Desist Orders.
Section 3901.23 | Self-Incrimination.
Section 3901.24 | Unlawful Advertising.
Section 3901.241 | List of Top Twenty per Cent of Services and Expected Contributions.
Section 3901.25 | Action by Superintendent Against Insurer.
Section 3901.27 | Adoption of Emergency Bylaws.
Section 3901.28 | Provisions Effective if No Emergency Bylaws.
Section 3901.29 | Succession List.
Section 3901.30 | Emergency Business Location.
Section 3901.31 | Filing Statements Indicating Ownership.
Section 3901.32 | Insurance Holding Company System Definitions.
Section 3901.321 | Mergers and Acquisitions of Domestic Insurers.
Section 3901.322 | Procedure for Violations.
Section 3901.323 | Jurisdiction.
Section 3901.341 | Prior Review of Proposed Transactions.
Section 3901.35 | Requiring Production of Records.
Section 3901.351 | Participation in Supervisory College.
Section 3901.352 | Group-Wide Supervisor for Internationally Active Insurance Group.
Section 3901.36 | Confidential and Privileged Treatment of Documents and Information - Exceptions.
Section 3901.37 | Suspension, Revocation or Refusal to Renew License - Civil Forfeiture.
Section 3901.371 | Purpose of Sections 3901.371 to 3901.378.
Section 3901.372 | Definitions.
Section 3901.373 | Risk Management Framework.
Section 3901.374 | Own Risk and Solvency Assessment.
Section 3901.375 | Summary Report.
Section 3901.376 | Exemptions.
Section 3901.377 | Form and Content of Report; Review.
Section 3901.378 | Confidentiality.
Section 3901.38 | Prompt Payments to Health Care Providers Definitions.
Section 3901.381 | Third-Party Payers Processing Claims for Payment for Health Care Services.
Section 3901.382 | Electronic Submission of Claims.
Section 3901.383 | Contractual Agreements for Payments by Third-Party Payers.
Section 3901.384 | Untimely Claim Process.
Section 3901.385 | Third-Party Payer - Prohibited Acts.
Section 3901.387 | Duplicative Claims - Claim Information System.
Section 3901.388 | Payments Considered Final - Overpayment.
Section 3901.389 | Computation of Interest.
Section 3901.3810 | Complaints by Provider or Beneficiary - Retaliation by Payer.
Section 3901.3811 | Failure to Comply by Third-Party Payer.
Section 3901.3812 | Administrative Remedies.
Section 3901.3814 | Exceptions to Provisions.
Section 3901.40 | Payment or Reimbursement to Unlicensed or Unaccredited Hospital Prohibited.
Section 3901.41 | Applicability of Uniform Electronics Transactions Act; Automated Transactions.
Section 3901.42 | Annual Filing With National Association of Insurance Commissioners.
Section 3901.44 | Records of Insurance Fraud Investigation.
Section 3901.45 | Effect of Sexual Orientation, Hiv, or AIDS or Related Condition.
Section 3901.46 | Requiring HIV Testing.
Section 3901.47 | Administration of Claims Unpaid Due to Insolvency of Insurer.
Section 3901.48 | Disclosing Work Papers Resulting From Conduct of Audit.
Section 3901.491 | Genetic Screening or Testing.
Section 3901.501 | Genetic Screening or Testing for Self-Insurance Plans.
Section 3901.51 | Uncertified Securities as Deposits Definitions.
Section 3901.53 | Placement of Securities Shall Satisfy Deposit Requirements.
Section 3901.54 | Securities May Not Be Used for Other Purposes.
Section 3901.56 | Rewards or Incentives for Insurer Wellness or Health Improvement Programs.
Section 3901.61 | Credit for Reinsurance Ceded Definitions.
Section 3901.621 | Suspension or Revocation of Reinsurer's Accreditation or Certification.
Section 3901.63 | Credit for Reinsurance Ceded as Reduction of Liability.
Section 3901.631 | Management of Reinsurance Recoverables by Domestic Ceding Insurer.
Section 3901.64 | Terms of Reinsurance or Security Agreement.
Section 3901.67 | Disclosure of Material Transactions Model Act Definitions.
Section 3901.68 | Provisions Application.
Section 3901.69 | Insurer to Report Material Transactions.
Section 3901.70 | Confidentiality of Reports - Exceptions.
Section 3901.71 | Application of Mandated Health Benefits.
Section 3901.72 | Money Advanced to Insurance Company or Health Insuring Corporation.
Section 3901.73 | Department to Forward Copy of Late Filing Notice to Board of Directors.
Section 3901.74 | Notice of Life Insurance Company Discontinuing Business.
Section 3901.75 | Notice of Insurance Companies Other Than Life Discontinuing Business.
Section 3901.76 | Security Valuation Expense Fund.
Section 3901.77 | Forms, Instructions, Manuals - Determination of Accounting Practices and Methods.
Section 3901.78 | Certificate of Compliance.
Section 3901.80 | Discriminating Against Living Organ Donors.
Section 3901.81 | Definitions.
Section 3901.811 | Pharmacy Audits.
Section 3901.812 | Rights of Pharmacy.
Section 3901.813 | Proceedings After Audit.
Section 3901.814 | Appeal Process.
Section 3901.815 | Applicability of Provisions.
Section 3901.82 | Restatement of the Law, Liability Insurance.
Section 3901.83 | Definitions for Sections 3901.83 to 3901.833.
Section 3901.831 | Implementation of Step Therapy Protocol.
Section 3901.832 | Step Therapy Exemption.
Section 3901.833 | Adoption of Rules.
Section 3901.86 | Retaliatory Provisions - Moneys Collected Paid to State Fire Marshal's Fund.
Section 3901.87 | No Coverage for Nontherapeutic Abortion.
Section 3901.88 | Actuarial Study Regarding Costs of Health Care Mandates.
Section 3901.89 | Health Plan Issuers Release Claim Information to Group Plan policyholders..
Section 3901.90 | Education on Mental Health and Addiction Services Insurance Parity.
Section 3901.91 | Adoption or Amendment of Rules Related to Insurance Rating Agencies.
Section 3901.95 | Direct Primary Care Agreement Not to Be Considered Insurance.