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15.11 Medical Plans

Ohio Children’s Health Insurance Program​

The Children’s Health Insurance Program (CHIP) provides health coverage assistance to uninsured individuals under the age of 19 whose family income falls between 150% and 200% of the federal poverty level. The program is designed to help eligible children and adolescents gain access to essential healthcare services when their families do not qualify for Medicaid but cannot afford private health insurance coverage.

The Director of Job and Family Services may submit a request to the United States Secretary of Health and Human Services for a federal waiver to expand health assistance coverage to individuals under the age of 19 whose family income does not exceed 300% of the federal poverty level. Under the expanded program, eligible families may be required to pay a monthly premium of at least the following amounts:

  • $40 per month when coverage is provided for 1 family member
  • $80 per month when coverage is provided for 2 family members
  • $120 per month when coverage is provided for 3 or more family members

The Director of Job and Family Services may also submit a request for a federal waiver to provide health assistance coverage to an uninsured parent of a child under the age of 19 who resides with the parent and is enrolled in the Children’s Health Insurance Program (CHIP), provided the family income does not exceed 100% of the federal poverty level.

Cost Containment in Health Care Delivery​

Prior Authorization Procedures​

When a sickness and accident insurance policy or public employee benefit plan requires prior authorization, several procedural requirements must be followed:

  • The insurer or benefit plan must make prior authorization forms available to healthcare practitioners through the appropriate electronic software system and must accept requests submitted through secure electronic transmission.
  • A healthcare practitioner and an insurer may establish a contractual arrangement allowing prior authorization requests to be submitted through non-electronic methods. This alternative may be permitted when electronic submission would create a financial hardship for the practitioner or when adequate internet access is unavailable or limited in the practitioner’s location.
  • The insurer or benefit plan must issue a decision on prior authorization requests within required time limits. Requests related to urgent care services must receive a response within 48 hours after the request is received, while requests for non-urgent services must be answered within 10 calendar days after receipt.

Ohio Requirements (Individual and Group)​

Eligibility Requirements​

Dependent Child Coverage​

Every sickness and accident insurance policy issued for delivery or renewed by an insurer, public employee benefit plan, or health insuring corporation that provides coverage for an unmarried dependent child will terminate that dependent coverage when the child reaches the limiting age specified in the policy or contract.

Dependent Child Coverage​

Any sickness and accident insurance policy issued or renewed by an insurer, public employee benefit plan, or health insuring corporation that includes coverage for an unmarried dependent child will provide coverage only until the child reaches the limiting age stated in the policy or contract.

After an unmarried dependent child reaches the limiting age specified for dependent coverage, the insurer must, upon request, offer continued coverage for the child until the child reaches 26 years of age, provided all of the following conditions are met:

  • The child is the insured’s natural child, stepchild, or adopted child
  • The child is either a resident of Ohio or enrolled as a full-time student at an accredited public or private institution of higher education
  • The child is not employed by an employer that offers a health benefit plan for which the child is eligible
  • The child is not eligible for coverage under Medicaid or Medicare

Reaching the limiting age for dependent coverage does not terminate coverage for a dependent child who meets both of the following conditions:

  • The child is incapable of self-sustaining employment because of a mental or physical disability
  • The child is primarily dependent on the policyholder or certificate holder for financial support and maintenance

The policyholder must provide proof of the child’s incapacity and dependency within 31 days after the child reaches the limiting age for dependent coverage. After the initial 2-year period, the insurer may require ongoing satisfactory proof that the child remains incapacitated and dependent, but such proof may not be requested more than once each year.

This section does not require an insurance policy or employer to provide coverage for dependent children or for the children of an unmarried dependent child. If such coverage is made available, the employer is not obligated to contribute toward the premium cost for an unmarried dependent child who has reached the limiting age for dependent coverage.

Child Health Supervision Services​

Every employee benefit plan established or maintained within the state that provides coverage for an employee’s family members must include benefits for child health supervision services for covered children from birth through 9 years of age.

Copayments and deductibles must be set at reasonable levels and may not create barriers that prevent covered individuals from obtaining necessary child health supervision services.

Benefits provided for child health supervision services during a child’s first year of life may not exceed a maximum of $500, including coverage for hearing screening services. Of this amount, benefits for the hearing screening may not exceed $75. After the child reaches age 1, benefits for child health supervision services are limited to a maximum of $150 per year.

Newborn Child Coverage​

Every individual and group sickness and accident insurance policy that provides benefits on an expense-incurred basis must provide coverage for a newborn child beginning at the moment of birth. This coverage includes benefits for injury or sickness, as well as medically necessary care and treatment for diagnosed congenital defects and birth abnormalities.

The policyholder must submit proof of the child’s incapacity and dependency within 31 days after the child reaches the limiting age for dependent coverage. Following the initial 2-year period, the insurer may request continued satisfactory proof that the child remains incapacitated and dependent, but the insurer may not require such proof more than once per year.

This section does not obligate an insurance policy or employer to provide coverage for dependent children or for the children of an unmarried dependent child. When such coverage is offered, the employer is not required to contribute toward the premium for an unmarried dependent child who has exceeded the limiting age for dependent coverage.

Child Health Supervision Services​

Every employee benefit plan established or maintained within the state that provides coverage for an employee’s family members must include benefits for child health supervision services for covered children from birth through age 9.

Copayments and deductibles must remain reasonable in amount and may not prevent covered individuals from obtaining necessary child health supervision services.

Benefits for child health supervision services provided during a child’s first year of life are limited to a maximum of $500, which includes coverage for hearing screening services. Coverage for the hearing screening itself may not exceed $75. Beginning after the child reaches age 1, benefits for child health supervision services are limited to a maximum of $150 per year.

Newborn Child Coverage​

Every individual and group sickness and accident insurance policy that provides benefits on an expense-incurred basis must provide coverage for a newborn child beginning at birth. This coverage includes benefits for injury or sickness, as well as medically necessary care and treatment for diagnosed congenital defects and birth abnormalities.

If an additional premium is required to provide coverage for a newly added child, the insurer must be notified and the required premium must be paid within 31 days after the child’s birth for coverage to continue beyond that initial period.

Coverage of Adopted Children​

An adopted child is defined as an individual who is under the age of 18 on the date the adoption is finalized or the child is placed for adoption.

All accident and health insurance policies issued in Ohio must provide coverage for adopted children on the same terms and conditions that apply to other dependents. Coverage cannot be denied, limited, or restricted solely because the child has a pre-existing condition at the time the child otherwise becomes eligible for coverage under the plan.

Noncustodial Parent​

If a child is covered under the health insurance policy of a noncustodial parent, the insurer is required to:

  • Provide the custodial parent with any information necessary for the child to access benefits under the policy
  • Allow the custodial parent, or a health care provider acting with the custodial parent’s authorization, to submit claims for covered services without requiring approval from the noncustodial parent
  • Issue payment for approved claims directly to the custodial parent, the health care provider, or the Department of Job and Family Services, as applicable

Grandchildren​

A health plan may establish additional eligibility requirements for providing coverage to an insured’s grandchild. For example, the plan may require the insured to be the grandchild’s legal guardian or to claim the grandchild as a dependent for tax purposes.

Women’s Benefits​

Cytologic Screening and Mammography​

All accident and health insurance policies issued in Ohio are required to provide benefits for screening mammograms used to detect breast cancer and cytologic screenings used to detect cervical cancer. Required mammography coverage includes:

  • One screening mammogram for women between ages 35 and 39
  • One screening mammogram every 2 years for women between ages 40 and 49
  • One screening mammogram each year for women ages 40 through 49 when a licensed physician determines that the woman has risk factors for breast cancer
  • One screening mammogram annually for women between ages 50 and 64

The maximum benefit payable for a screening mammography may not exceed 130% of the reimbursement rate established by Medicare.

HIPAA​

Security Rule​

The HIPAA Security Rule establishes standards designed to protect individuals’ electronic protected health information (ePHI) that is created, received, maintained, or transmitted by covered entities. The rule requires covered entities to implement appropriate administrative, physical, and technical safeguards to maintain the confidentiality, integrity, and security of electronic protected health information.

The Affordable Care Act​

Provisions​

  • Insurers are prohibited from placing lifetime dollar limits on essential health benefits, such as hospital care, in newly issued policies
  • Dependents may remain covered under a parent’s health insurance plan until reaching age 26
  • Health insurance plans are required to provide coverage for pre-existing conditions
  • New health insurance plans must provide preventive care services and medical screenings without charging copayments, coinsurance, or deductibles
  • Insurers are prohibited from canceling or terminating coverage solely because a policyholder becomes ill
  • Insurers are required to disclose information regarding administrative costs and executive compensation expenditures
  • All new health plans must include an appeals process for coverage determinations and claim decisions
  • Insurers must spend at least 85% of premiums collected from large-group plans, and 80% of premiums collected from small-group and individual plans, on health care services or activities that improve health care quality. If these standards are not met, the insurer must provide rebates to policyholders for the difference
  • Funds from flexible spending accounts (FSAs), health reimbursement arrangements (HRAs), and health savings accounts (HSAs) generally may not be used to purchase over-the-counter medications unless the medication is insulin or is obtained with a prescription
  • Insurers are prohibited from discriminating against individuals or charging higher premiums based on pre-existing medical conditions
  • Health insurance plans are prohibited from imposing annual spending limits on covered benefits
  • Employers with more than 50 employees that fail to offer health insurance coverage to full-time employees may be subject to a tax penalty of $2,000 per employee
  • Annual deductibles are limited to a maximum of $2,000 for single coverage and $4,000 for plans covering more than one individual
  • Premium subsidies are available to individuals and families with incomes up to 400% of the federal poverty level, including eligible single adults
  • Health insurance companies are subject to an excise tax that is determined in part by their share of the insurance market
  • All health insurance plans are required to provide coverage for approved preventive care services and routine checkups without requiring copayments
  • A 40% excise tax is imposed on high-cost “Cadillac” health plans for coverage costs exceeding established thresholds of $27,500 for family coverage and $10,200 for individual coverage. Higher thresholds of $30,950 for family coverage and $11,850 for individual coverage apply to retirees and employees in high-risk occupations
  • Health insurers and employer-sponsored health plans must provide consumers with a standardized glossary of commonly used health insurance and medical terms to improve understanding of coverage and benefits

Plans on the Marketplace​

In Ohio, the health insurance marketplace is operated federally through HealthCare.gov. However, the state continues to maintain oversight of marketplace plans through a marketplace plan management exchange. This arrangement allows the state to use its regulatory authority to help ensure an efficient and consumer-friendly enrollment experience. The state is responsible for recommending plans for Qualified Health Plan (QHP) certification when those plans meet Affordable Care Act (ACA) requirements, including providing essential health benefits, complying with cost-sharing limitations, and satisfying other federal standards. In addition, the state oversees plan and rate approval processes and provides consumer assistance services.

Summary of Benefits and Coverage​

Insurers that offer individual or group health insurance coverage are required to provide applicants with a Summary of Benefits and Coverage (SBC). The SBC is designed to help consumers compare health insurance plans by providing a clear summary of covered benefits, cost-sharing features, and standardized examples of how coverage applies in common medical situations.

The Summary of Benefits and Coverage (SBC) must also include instructions for accessing the uniform glossary in either paper or electronic format. The uniform glossary is required to provide standardized definitions of commonly used health coverage and medical terms to help consumers better understand their insurance coverage.

Open Enrollment Period​

An open enrollment period is the designated timeframe during which eligible individuals may enroll in a Qualified Health Plan (QHP) through an Exchange. In Ohio, the health insurance Exchange is operated by the federal government through HealthCare.gov. For federally facilitated Exchange plans, the annual open enrollment period generally runs from November 1 through December 15 for coverage effective in the following plan year.

Special Enrollment Period​

A special enrollment period is a designated timeframe that allows an individual to enroll in a Qualified Health Plan (QHP) outside of the regular open enrollment period when a qualifying life event occurs. Examples of qualifying life events include marriage, divorce, the birth or adoption of a child, or loss of other health coverage. In the Individual Marketplace, the special enrollment period generally lasts 60 days from the date of the qualifying event. In the Small Business Health Options Program (SHOP) Marketplace, the special enrollment period typically lasts 30 days from the date of the qualifying event.

Adverse Benefit Determination​

This refers to a determination made by a health insurer to:

  • Deny, reduce, or terminate a requested health care service or payment, in whole or in part, based on a determination that:
    • The requested service does not satisfy the health plan’s standards for medical necessity or appropriateness, including services considered experimental or investigational; or
    • The service is not covered under the terms of the health benefit plan
  • Refuse to issue individual health insurance coverage to an applicant, including coverage offered through a nonemployer group arrangement
  • Rescind or cancel coverage under a health benefit plan

An insured has the right to request an external review of an adverse benefit determination. An adverse benefit determination may be submitted for internal appeal or external review regardless of the cost or value of the requested health care service.

Internal Appeal​

All health insurers are required to establish and maintain an internal appeal process that allows insureds to appeal adverse benefit determinations. This appeal process must comply with the requirements of the Affordable Care Act (ACA), along with all applicable state laws and federal regulations.

Insureds must receive written notice regarding:

  • All available internal appeal and external review procedures
  • Any assistance programs or consumer support services available through agencies and programs in Ohio
  • The requirement that, unless otherwise permitted, the insured must first exhaust the health plan’s internal appeal process before requesting a standard external review from the insurer

External Review​

Each health insurer is required to include, either within or attached to the evidence of coverage, a description of the insurer’s external review procedures. In addition, whenever an insurer issues notice of an adverse benefit determination, the insurer must provide the insured with written notice of the right to request an external review.

After receiving a request for an external review, a health insurer must submit all relevant documentation and information to the independent review organization within 5 days.

An external review may not be postponed solely because the health insurer fails to provide the required information within the specified timeframe. However, the independent review organization may allow the insurer additional time to submit the required documentation if the insurer requests an extension.

If an independent review organization reverses an adverse benefit determination, it must provide notice of the reversal to the insured, the health insurer, and the Superintendent within 1 business day.

An external review decision is binding on both the insurer and the insured, except to the extent that either party may pursue other remedies available under applicable state law or if the Superintendent determines that a second external review is necessary. An insured may not submit another request for external review regarding the same adverse benefit determination unless new medical or scientific evidence is provided to the insurer.

External reviews that are expedited or involve experimental or investigational treatments may be governed by separate requirements, procedures, and timeframes.

If an adverse benefit determination is made because the requested health care service is considered experimental or investigational, the insured may request an external review when the insured’s physician certifies that one of the following conditions exists:

  • Standard health care services have not successfully improved the insured’s condition
  • Standard health care services are not medically appropriate for the insured
  • No standard health care service covered by the insurer is available that would be more beneficial than the requested service

Expedited External Review​

An insured may request an expedited external review following an adverse benefit determination if both of the following conditions are met:

  • The insured’s physician certifies that waiting for the standard review process, including the timeframe required for an expedited internal review, could seriously jeopardize the insured’s life, health, or ability to regain maximum function
  • The insured has submitted a request for an expedited internal review

Once the insurer receives a complete and eligible request for an expedited external review, the insurer must immediately forward all required information to the independent review organization (IRO). The independent review organization is then required to issue a decision within 72 hours, either upholding or reversing the adverse benefit determination.

Penalty: A violation of these requirements is considered an unfair or deceptive act or practice. If, after providing notice and conducting a hearing, the Superintendent determines that a health insurer has violated laws relating to adverse benefit determinations, the Superintendent may impose one or more of the following penalties:

  • Suspend or revoke the insurer’s certificate of authority
  • Impose an administrative fine of up to $100,000 for each violation
  • Require the insurer to take corrective action to remedy any identified deficiency