Effective: October 16, 2009
Latest Legislation: House Bill 1 - 128th General Assembly
(A) As used in this section:
(1) "Base rate" means, as to any health benefit plan that is issued by a carrier in the individual market, the lowest premium rate for new or existing business prescribed by the carrier for the same or similar coverage under a plan or arrangement covering any individual with similar case characteristics.
(2) "Carrier," "health benefit plan," "MEWA," and "pre-existing conditions provision" have the same meanings as in section 3924.01 of the Revised Code.
(3) "Federally eligible individual" means an eligible individual as defined in 45 C.F.R. 148.103.
(4) "Health status-related factor" means any of the following:
(a) Health status;
(b) Medical condition, including both physical and mental illnesses;
(c) Claims experience;
(d) Receipt of health care;
(e) Medical history;
(f) Genetic information;
(g) Evidence of insurability, including conditions arising out of acts of domestic violence;
(h) Disability.
(5) "Network plan" means a health benefit plan of a carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier.
(6) "Ohio health care basic and standard plans" means those plans established under section 3924.10 of the Revised Code.
(B) Beginning in January of each year, carriers in the business of issuing health benefit plans to individuals or nonemployer groups shall accept federally eligible individuals for open enrollment coverage, as provided in this section, in the order in which they apply for coverage and subject to the limitation set forth in division (J) of this section.
(C) No carrier shall do either of the following:
(1) Decline to offer such coverage to, or deny enrollment of, such individuals;
(2) Apply any pre-existing conditions provision to such coverage.
(D) A carrier shall offer to federally eligible individuals the Ohio health care basic and standard plans or plans substantially similar to the basic and standard plans in benefit design and scope of covered services. For purposes of this division, the superintendent of insurance shall determine whether a plan is substantially similar to the basic or standard plan in benefit design and scope of covered services.
(E) Premiums charged to individuals under this section may not exceed the amounts specified below:
(1) For calendar years 2010 and 2011, an amount that is two times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business, and for which similar copayments and deductibles are applied;
(2) For calendar year 2012 and every calendar year thereafter, an amount that is one and one-half times the base rate for coverage offered to any other individual to which the carrier is currently accepting new business and for which similar copayments and deductibles are applied, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.58 of the Revised Code, have resulted in a market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the premium limit established by division (E)(1) of this section shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.
(F) If a carrier offers a health benefit plan in the individual market through a network plan, the carrier may do both of the following:
(1) Limit the federally eligible individuals that may apply for such coverage to those who live, work, or reside in the service area of the network plan;
(2) Within the service area of the network plan, deny the coverage to federally eligible individuals if the carrier has demonstrated both of the following to the superintendent:
(a) The carrier will not have the capacity to deliver services adequately to any additional individuals because of the carrier's obligations to existing group contract holders and individuals.
(b) The carrier is applying division (F)(2) of this section uniformly to all federally eligible individuals without regard to any health status-related factor of those individuals.
(G) A carrier that, pursuant to division (F)(2) of this section, denies coverage to an individual in the service area of a network plan, shall not offer coverage in the individual market within that service area for at least one hundred eighty days after the date the coverage is denied.
(H) A carrier may refuse to issue health benefit plans to federally eligible individuals if the carrier has demonstrated both of the following to the superintendent:
(1) The carrier does not have the financial reserves necessary to underwrite additional coverage.
(2) The carrier is applying division (H) of this section uniformly to all federally eligible individuals in this state consistent with the applicable laws and rules of this state and without regard to any health status-related factor relating to those individuals.
(I) A carrier that, pursuant to division (H) of this section, refuses to issue health benefit plans to federally eligible individuals, shall not offer health benefit plans in the individual market in this state for at least one hundred eighty days after the date the coverage is denied or until the carrier has demonstrated to the superintendent that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later.
(J)(1) Except as provided in division (J)(2) of this section, a carrier shall not be required to accept new applicants under this section if the total number of the carrier's current insureds with open enrollment coverage issued under this section calculated as of the immediately preceding thirty-first day of December and excluding the carrier's medicare supplement policies and conversion or continuation of coverage policies under state or federal law and any policies described in division (L) of section 3923.58 of the Revised Code meets the following limits:
(a) For calendar years 2010 and 2011, four per cent of the carrier's total number of individual or nonemployer group insureds in this state;
(b) For calendar year 2012 and every year thereafter, eight per cent of the carrier's total number of insured individuals and nonemployer group insureds in this state, unless the superintendent of insurance determines that the amendments by this act to this section and section 3923.58 of the Revised Code, have resulted in the market-wide average medical loss ratio for coverage sold to individual insureds and nonemployer group insureds in this state, including open enrollment insureds, to increase by more than five and one quarter percentage points during calendar year 2010. If the superintendent makes that determination, the enrollment limit established by division (J)(1)(a) shall remain in effect. The superintendent's determination shall be supported by a signed letter from a member of the American academy of actuaries.
(2) An officer of the carrier shall certify to the department of insurance when it has met the enrollment limit set forth in division (J)(1) of this section. Upon providing such certification, the carrier shall be relieved of its open enrollment requirement under this section for as long as the carrier continues to meet the open enrollment limit. If the total number of the carrier's current insureds with open enrollment coverage issued under this section falls below the enrollment limit, the carrier shall accept new applicants. A carrier may establish a waiting list if the carrier has met the open enrollment limit and shall notify the superintendent if the carrier has a waiting list in effect. In the event that all the carriers subject to this section have individually met the enrollment limit set forth in division (J)(1) of this section in a calendar year, carriers shall again accept applicants for open enrollment coverage pursuant to this section, subject to an additional enrollment limit equal to one-half of the limitation set forth in division (J)(1) of this section.
(K) The superintendent may provide for the application of this section on a service-area-specific basis.
(L) The requirements of this section do not apply to any health benefit plan described in division (L) of section 3923.58 of the Revised Code.
(M) A carrier may pay an agent a commission in the amount of not more than five per cent of the premium charged for initial placement or for otherwise securing the issuance of a policy or contract issued to an individual under this section, and not more than four per cent of the premium charged for the renewal of such a policy or contract. The superintendent may adopt, in accordance with Chapter 119. of the Revised Code, such rules as are necessary to enforce this division.
Last updated March 23, 2022 at 10:29 AM
Structure Ohio Revised Code
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 3923.13 | 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 3923.17 | 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 3923.231 | Reimbursement for Services of Licensed Psychologist.
Section 3923.232 | Reimbursement for Services of Licensed Dentist.
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 3923.31 | Right to Rescind Individual Policy of Sickness and Accident Insurance.
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 3923.338 | Orders of Superintendent.
Section 3923.339 | Severability.
Section 3923.36 | Excluding Coverage of Illness or Injury Covered by Workers' Compensation.
Section 3923.38 | Continuing Policy Upon Termination of Employment.
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 3923.441 | 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 3923.46 | Rates for Individual Policy.
Section 3923.48 | Violation Is Unfair and Deceptive Insurance Practice.
Section 3923.49 | Establishing Outreach Program to Educate Consumers.
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 3923.57 | Pre-Existing Conditions Provisions.
Section 3923.60 | Standard Medical Reference Compendia for Coverage of Prescription Drugs.
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 3923.84 | Coverage for Autism Spectrum Disorder.
Section 3923.85 | Cancer Medication; Coverage for Orally and Intravenously Administered Treatments.
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.