Ohio Revised Code
Chapter 3923 | Sickness and Accident Insurance
Section 3923.57 | Pre-Existing Conditions Provisions.

Effective: March 23, 2015
Latest Legislation: House Bill 201 - 130th General Assembly
Notwithstanding any provision of this chapter, every individual policy of sickness and accident insurance that is delivered, issued for delivery, or renewed in this state is subject to the following conditions, as applicable:
(A) Pre-existing conditions provisions shall not exclude or limit coverage for a period beyond twelve months following the policyholder's effective date of coverage and may only relate to conditions during the six months immediately preceding the effective date of coverage.
(B) In determining whether a pre-existing conditions provision applies to a policyholder or dependent, each policy shall credit the time the policyholder or dependent was covered under a previous policy, contract, or plan if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable service waiting period under the policy.
(C)(1) Except as otherwise provided in division (C) of this section, an insurer that provides an individual sickness and accident insurance policy to an individual shall renew or continue in force such coverage at the option of the individual.
(2) An insurer may nonrenew or discontinue coverage of an individual in the individual market based only on one or more of the following reasons:
(a) The individual failed to pay premiums or contributions in accordance with the terms of the policy or the insurer has not received timely premium payments.
(b) The individual performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the policy.
(c) The insurer is ceasing to offer coverage in the individual market in accordance with division (D) of this section and the applicable laws of this state.
(d) If the insurer offers coverage in the market through a network plan, the individual no longer resides, lives, or works in the service area, or in an area for which the insurer is authorized to do business; provided, however, that such coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
(e) If the coverage is made available in the individual market only through one or more bona fide associations, the membership of the individual in the association, on the basis of which the coverage is provided, ceases; provided, however, that such coverage is terminated under division (C)(2)(e) of this section uniformly without regard to any health status-related factor of covered individuals.
An insurer offering coverage to individuals solely through membership in a bona fide association shall not be deemed, by virtue of that offering, to be in the individual market for purposes of sections 3923.58 and 3923.581 of the Revised Code. Such an insurer shall not be required to accept applicants for coverage in the individual market pursuant to sections 3923.58 and 3923.581 of the Revised Code unless the insurer also offers coverage to individuals other than through bona fide associations.
(3) An insurer may cancel or decide not to renew the coverage of a dependent of an individual if the dependent has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage and if the cancellation or nonrenewal is not based, either directly or indirectly, on any health status-related factor in relation to the dependent.
(D)(1) If an insurer decides to discontinue offering a particular type of health insurance coverage offered in the individual market, coverage of such type may be discontinued by the insurer if the insurer does all of the following:
(a) Provides notice to each individual provided coverage of this type in such market of the discontinuation at least ninety days prior to the date of the discontinuation of the coverage;
(b) Offers to each individual provided coverage of this type in such market, the option to purchase any other individual health insurance coverage currently being offered by the insurer for individuals in that market;
(c) In exercising the option to discontinue coverage of this type and in offering the option of coverage under division (D)(1)(b) of this section, acts uniformly without regard to any health status-related factor of covered individuals or of individuals who may become eligible for such coverage.
(2) If an insurer elects to discontinue offering all health insurance coverage in the individual market in this state, health insurance coverage may be discontinued by the insurer only if both of the following apply:
(a) The insurer provides notice to the department of insurance and to each individual of the discontinuation at least one hundred eighty days prior to the date of the expiration of the coverage.
(b) All health insurance delivered or issued for delivery in this state in such market is discontinued and coverage under that health insurance in that market is not renewed.
(3) In the event of a discontinuation under division (D)(2) of this section in the individual market, the insurer shall not provide for the issuance of any health insurance coverage in the market and this state during the five-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.
(E) Notwithstanding divisions (C) and (D) of this section, an insurer may, at the time of coverage renewal, modify the health insurance coverage for a policy form offered to individuals in the individual market if the modification is consistent with the law of this state and effective on a uniform basis among all individuals with that policy form.
(F) Such policies are subject to sections 2743 and 2747 of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-43 and 300gg-47, as amended.
(G) Sections 3924.031 and 3924.032 of the Revised Code shall apply to sickness and accident insurance policies offered in the individual market in the same manner as they apply to health benefit plans offered in the small employer market.
In accordance with 45 C.F.R. 148.102, divisions (C) to (G) of this section also apply to all group sickness and accident insurance policies that are not sold in connection with an employment-related group health plan and that provide more than short-term, limited duration coverage.
In applying divisions (C) to (G) of this section with respect to health insurance coverage that is made available by an insurer in the individual market to individuals only through one or more associations, the term "individual" includes the association of which the individual is a member.
For purposes of this section, any policy issued pursuant to division (C) of section 3923.13 of the Revised Code in connection with a public or private college or university student health insurance program is considered to be issued to a bona fide association.
As used in this section, "bona fide association" has the same meaning as in section 3924.03 of the Revised Code, and "health status-related factor" and "network plan" have the same meanings as in section 3924.031 of the Revised Code.
This section does not apply to any policy that provides coverage for specific diseases or accidents only, or to any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy that is less than twelve months, or other policy that offers only supplemental benefits.
Last updated November 23, 2021 at 3:54 PM

Structure Ohio Revised Code

Ohio Revised Code

Title 39 | Insurance

Chapter 3923 | Sickness and Accident Insurance

Section 3923.01 | Policy of Sickness and Accident Insurance Defined.

Section 3923.011 | Sickness and Accident Insurance Definitions.

Section 3923.02 | Form of Policy Filed With Superintendent.

Section 3923.021 | Approval or Disapproval of Premium Rates.

Section 3923.022 | Maximum Aggregate Administrative Expenses.

Section 3923.03 | Necessary Provisions.

Section 3923.04 | Policy Standard Provisions.

Section 3923.041 | Policies With Prior Authorization Requirement Provisions.

Section 3923.05 | Provisions to Conform to Prescribed Wording.

Section 3923.06 | Order of Presentation of Policy Provisions.

Section 3923.061 | Interest on Proceeds Payable Due to Death by Sickness or Accident.

Section 3923.07 | Omission or Substitution of Provisions.

Section 3923.071 | Policies, Applications, Riders or Indorsements Issued Prior to 10-1-53.

Section 3923.08 | Nonconflicting Provisions Permitted in Policy.

Section 3923.09 | Validity of Nonconforming Policy.

Section 3923.10 | Industrial Sickness and Accident Insurance.

Section 3923.11 | Sickness and Accident Insurance on a Franchise Plan.

Section 3923.12 | Group Sickness and Accident Insurance.

Section 3923.121 | Association of Insurers to Provide Basic Medical Coverage to Persons 65 or Older.

Section 3923.122 | [Suspended Eff. 1/1/2014 to 1/1/2026, per Section 3 of s.b. 9 of the 130th General Assembly, as Amended] Option for Conversion From Group Policy to Individual Policy.

Section 3923.123 | Association of Insurers to Provide Group Health Coverage to Qualified Unemployed Persons.

Section 3923.13 | Blanket Sickness and Accident Insurance.

Section 3923.14 | False Statement in Application - Alteration of Written Application.

Section 3923.141 | Agent of the Insurer.

Section 3923.15 | Unfair Discrimination Prohibited.

Section 3923.16 | Misleading or Deceptive Advertising Prohibited.

Section 3923.161 | Describing Cancellability and Renewability Provisions Clearly and With Prominence or Emphasis.

Section 3923.17 | Prohibition of Rebates Not to Prohibit Commissions or Dividends.

Section 3923.18 | Rights of Insurer in Defense of Claim Not Waived.

Section 3923.19 | Benefits Exempt From Legal Process - Exception.

Section 3923.20 | Exemptions for Certain Insurance Policies.

Section 3923.21 | Prohibition Against Delivery of Policy on Disapproved Insurance Form.

Section 3923.22 | Appeal - Applicability of Administrative Procedure Sections.

Section 3923.23 | Reimbursement for Services of Licensed Osteopath, Optometrist, Chiropractor or Podiatrist.

Section 3923.231 | Reimbursement for Services of Licensed Psychologist.

Section 3923.232 | Reimbursement for Services of Licensed Dentist.

Section 3923.233 | Reimbursement for Services of Certified Nurse-Midwife Performing Service in Collaboration With Licensed Physician.

Section 3923.234 | Reimbursement for Services of Certified Mechanotherapist.

Section 3923.24 | Continuing Coverage for Dependent Children.

Section 3923.241 | Public Employee Benefit Plans - Continuing Coverage for Dependent Children.

Section 3923.25 | Kidney Dialysis Benefits.

Section 3923.26 | Coverage for Newly Born Children From the Moment of Birth.

Section 3923.27 | Hospitalization Coverage for Mental Illness.

Section 3923.28 | Outpatient Coverage for Mental or Emotional Disorders.

Section 3923.281 | Sickness and Accident Policies - Biologically Based Mental Illness.

Section 3923.282 | Health Coverage Plans - Biologically Based Mental Illness.

Section 3923.29 | Outpatient, Inpatient, and Intermediate Primary Care Benefits for Alcoholism.

Section 3923.30 | Requiring Provision of Coverage of Treatment of Mental or Nervous Disorders and Alcoholism.

Section 3923.301 | Requiring Provision of Coverage for Services of Certified Nurse-Midwife Performing Service in Collaboration With Licensed Physician.

Section 3923.31 | Right to Rescind Individual Policy of Sickness and Accident Insurance.

Section 3923.32 | Right of Family Member to Continue Coverage After Subscriber's Death or Upon Change in Marital Relation to Subscriber.

Section 3923.33 | Medicare Supplement Policy Definitions.

Section 3923.331 | Statutes Applicable to Medicare Supplement Policies.

Section 3923.332 | Standards for Policy Provisions of Medicare Supplement Policies and Certificates.

Section 3923.333 | Benefits to Be Reasonable in Relation to Premium Charged.

Section 3923.334 | Outline of Coverage Delivered at Time Application Is Made.

Section 3923.335 | Right to Return Policy or Certificate and Have Premium Refunded.

Section 3923.336 | Review and Approval of Advertisement by Superintendent.

Section 3923.337 | Rules.

Section 3923.338 | Orders of Superintendent.

Section 3923.339 | Severability.

Section 3923.36 | Excluding Coverage of Illness or Injury Covered by Workers' Compensation.

Section 3923.37 | Prohibiting Exclusion or Reduction of Benefits Because of Benefits Payable Under Supplemental Policy.

Section 3923.38 | Continuing Policy Upon Termination of Employment.

Section 3923.381 | Continuing Coverage Under Group Policy When Reservist Is Called or Ordered to Active Duty.

Section 3923.382 | Continuing Coverage Under Group Plan When Reservist Is Called or Ordered to Active Duty.

Section 3923.39 | Consolidated Corporation Cancelling Individual Policy for Nonpayment.

Section 3923.40 | Coverage of Adopted Children.

Section 3923.41 | Long-Term Care Insurance Definitions.

Section 3923.42 | Citing Provisions - Applicability.

Section 3923.43 | Evidence to Be Filed by Long-Term Care Insurance Association.

Section 3923.44 | Standards for Full and Fair Disclosure for Sale of Long-Term Care Insurance Policies.

Section 3923.441 | Rescission of Long-Term Care Policy for Misrepresentation.

Section 3923.442 | Offer of Nonforfeiture Benefit Option With Long-Term Care Policy.

Section 3923.443 | Training Required for Agents Selling Long-Term Care Policies.

Section 3923.444 | Compensation of Agents Selling Long-Term Care Policies.

Section 3923.45 | Forms.

Section 3923.46 | Rates for Individual Policy.

Section 3923.47 | Rules.

Section 3923.48 | Violation Is Unfair and Deceptive Insurance Practice.

Section 3923.49 | Establishing Outreach Program to Educate Consumers.

Section 3923.50 | Notifying Department of Job and Family Services of Long-Term Care Insurance Policies That Comply With Insurance Department Requirements.

Section 3923.51 | Group Contracts of Sickness and Accident Insurance Persons Under Nineteen Who Are Members of Impoverished Families.

Section 3923.52 | Screening Mammography and Cytologic Screening Benefits.

Section 3923.53 | Public Employee Benefit Plan - Breast Cancer and Cervical Cancer Screening.

Section 3923.54 | Employee Health Care Benefit Plan.

Section 3923.55 | Policy to Include Benefits for Child Health Supervision Services From Moment of Birth Until Age Nine.

Section 3923.56 | Plan to Include Benefits for Child Health Supervision Services From Moment of Birth Until Age Nine.

Section 3923.57 | Pre-Existing Conditions Provisions.

Section 3923.571 | Conditions Applying to Group Policies of Sickness and Accident Insurance Sold in Connection With Employment-Related Group Health Plan.

Section 3923.58 | [Suspended Eff. 1/1/2014 to 1/1/2026, per Section 3 of s.b. 9 of the 130th General Assembly, as Amended] Open Enrollment Coverage - Insurers in the Business of Issuing Individual Policies of Sickness and Accident Insurance.

Section 3923.581 | [Suspended Eff. 1/1/2014 to 1/1/2026, per Section 3 of s.b. 9 of the 130th General Assembly, as Amended] Open Enrollment Coverage - Carriers in the Business of Issuing Health Benefit Plans to Individuals or Nonemployer Groups.

Section 3923.582 | [Suspended Eff. 1/1/2014 to 1/1/2026, per Section 3 of s.b. 9 of the 130th General Assembly, as Amended] Open Enrollment Coverage - Responsibilities of Superintendent of Insurance.

Section 3923.59 | [Suspended Eff. 1/1/2014 to 1/1/2026, per Section 3 of s.b. 9 of the 130th General Assembly, as Amended] Open Enrollment Reinsurance Program.

Section 3923.60 | Standard Medical Reference Compendia for Coverage of Prescription Drugs.

Section 3923.601 | Standardized Prescription Identification Information - Pharmacy Benefits to Be Included.

Section 3923.602 | Medication Synchronization for Insured.

Section 3923.61 | Public Employee Benefit Plans - Prescription Drugs.

Section 3923.62 | Disclosing Determination of Usual and Customary Fee for Dental Benefits.

Section 3923.63 | Coverage of Inpatient Care and Follow-Up Care for Mother and Her Newborn.

Section 3923.64 | Public Employee Benefit Plans - Maternity Benefits.

Section 3923.65 | Coverage for Emergency Services.

Section 3923.80 | Denial of Coverage to Cancer Clinical Trial Participant.

Section 3923.81 | Covered Person's Payments Not to Exceed Insurer Payments.

Section 3923.82 | Coverage for Alcohol or Drug Related Losses or Expenses.

Section 3923.83 | Standardized Prescription Identification Information - Pharmacy Benefits to Be Included - Public Employee Benefit Plan.

Section 3923.84 | Coverage for Autism Spectrum Disorder.

Section 3923.85 | Cancer Medication; Coverage for Orally and Intravenously Administered Treatments.

Section 3923.851 | Prior Authorization Requirements or Other Utilization Review Measures as Conditions of Providing Coverage of an Opioid Analgesic Prescribed for Treatment of Chronic Pain; Exceptions.

Section 3923.86 | Statement Provided to Insureds Under Vision Policy.

Section 3923.87 | Compliance With Section 3959.20.

Section 3923.89 | Payment or Reimbursement to Pharmacist.

Section 3923.90 | Teledentistry to Be Included in Coverage.

Section 3923.99 | Penalty.