Ohio Code 1751.17 – [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 to a contract issued on a direct-payment basis
(A) As used in this section, “nongroup contract” means a contract issued by a health insuring corporation to an individual who makes direct application for coverage under the contract and who, if required by the health insuring corporation, submits to medical underwriting. “Nongroup contract” does not include group conversion coverage, coverage obtained through open enrollment, or coverage issued on the basis of membership in a group.
Terms Used In Ohio Code 1751.17
- Basic health care services: means the following services when medically necessary:
(a) Physician's services, except when such services are supplemental under division (B) of this section;
(b) Inpatient hospital services;
(c) Outpatient medical services;
(d) Emergency health services;
(e) Urgent care services;
(f) Diagnostic laboratory services and diagnostic and therapeutic radiologic services;
(g) Diagnostic and treatment services, other than prescription drug services, for biologically based mental illnesses;
(h) Preventive health care services, including, but not limited to, voluntary family planning services, infertility services, periodic physical examinations, prenatal obstetrical care, and well-child care;
(i) Routine patient care for patients enrolled in an eligible cancer clinical trial pursuant to section 3923. See Ohio Code 1751.01
- Child: includes child by adoption. See Ohio Code 1.59
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- Dependent: A person dependent for support upon another.
- Enrollee: means any natural person who is entitled to receive health care benefits provided by a health insuring corporation. See Ohio Code 1751.01
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care services: means basic, supplemental, and specialty health care services. See Ohio Code 1751.01
- Health insuring corporation: means a corporation, as defined in division (H) of this section, that, pursuant to a policy, contract, certificate, or agreement, pays for, reimburses, or provides, delivers, arranges for, or otherwise makes available, basic health care services, supplemental health care services, or specialty health care services, or a combination of basic health care services and either supplemental health care services or specialty health care services, through either an open panel plan or a closed panel plan. See Ohio Code 1751.01
- Premium rate: means any set fee regularly paid by a subscriber to a health insuring corporation. See Ohio Code 1751.01
- state: means the state of Ohio. See Ohio Code 1.59
- Subscriber: means a person who is responsible for making payments to a health insuring corporation for participation in a health care plan, or an enrollee whose employment or other status is the basis of eligibility for enrollment in a health insuring corporation. See Ohio Code 1751.01
- Supplemental health care services: means any health care services other than basic health care services that a health insuring corporation may offer, alone or in combination with either basic health care services or other supplemental health care services, and includes:
(a) Services of facilities for intermediate or long-term care, or both;
(b) Dental care services;
(c) Vision care and optometric services including lenses and frames;
(d) Podiatric care or foot care services;
(e) Mental health services, excluding diagnostic and treatment services for biologically based mental illnesses;
(f) Short-term outpatient evaluative and crisis-intervention mental health services;
(g) Medical or psychological treatment and referral services for alcohol and drug abuse or addiction;
(h) Home health services;
(i) Prescription drug services;
(j) Nursing services;
(k) Services of a dietitian licensed under Chapter 4759 of the Revised Code;
(l) Physical therapy services;
(m) Chiropractic services;
(n) Any other category of services approved by the superintendent of insurance. See Ohio Code 1751.01
- United States: includes all the states. See Ohio Code 1.59
(B) Except as provided in division (C) of this section, every nongroup contract that is issued by a health insuring corporation and that makes available basic health care services shall provide an option for conversion to a contract issued on a direct-payment basis to an enrollee covered by the nongroup contract. The option for conversion shall be available:
(1) Upon the death of the subscriber, to the surviving spouse with respect to the spouse or dependents who were then covered by the nongroup contract;
(2) Upon the divorce, dissolution, or annulment of the marriage of the subscriber, to the divorced spouse, or, in the event of annulment, to the former spouse of the subscriber;
(3) To a child solely with respect to the child, upon the child’s attaining the limiting age of coverage under the nongroup contract while covered as a dependent under the contract.
(C) The direct payment contract offered pursuant to division (B) of this section shall not be made available to an enrollee if any of the following applies:
(1) The enrollee is, or is eligible to be, covered for benefits at least comparable to the nongroup contract under any of the following:
(a) Medicaid;
(b) Medicare;
(c) Any act of congress or law under this or any other state of the United States providing coverage at least comparable to the benefits offered under division (C)(1)(a) or (b) of this section.
(2) The nongroup contract under which the enrollee was covered was terminated due to nonpayment of a premium rate.
(3) The enrollee is eligible for group coverage provided by, or available through, an employer or association and the group coverage provides benefits comparable to the benefits provided under a direct payment contract.
(D) The direct payment contract offered pursuant to division (B) of this section shall provide benefits that are at least comparable to the benefits provided by the nongroup contract under which the enrollee was covered at the time of the occurrence of any of the events set forth in division (B) of this section. The coverage provided under the direct payment contract shall be continuous, provided that the enrollee makes the required premium rate payment within the thirty-day period immediately following the occurrence of the event, and may be terminated for nonpayment of any required premium rate payment.
(E) The evidence of coverage of every nongroup contract shall contain notice that an option for conversion to a contract issued on a direct-payment basis is available, in accordance with this section, to any enrollee covered by the contract.
(F) Benefits otherwise payable to an enrollee under a direct payment contract shall be reduced by the amount of any benefits available to the enrollee under any applicable group health insuring corporation contract or group sickness and accident insurance policy.
(G) Nothing in this section shall be construed as requiring a health insuring corporation to offer nongroup contracts.
(H) This section does not apply to any nongroup contract offering only supplemental health care services or specialty health care services.
Last updated March 23, 2022 at 10:26 AM