Current through all regulations passed and filed through December 16, 2024
(A) Purpose
The purpose of this rule
is to
set the requirements that third party payers shall follow if the third
party payer receives any discount from billed charges from a health care
provider.
(B) Authority
This rule is
promulgated pursuant to the authority vested in
the superintendent of insurance under
sections
3901.041
and
3901.19 to
3901.22
of the Revised
Code.
(C)
Definitions
(1) "Discount" means any
negotiated reduction or variation from the schedule of billed charges
(including capitation) that a health care provider otherwise would require a
patient and/or the patient's third party payer to pay to that health care
provider.
(2) "Billed charges"
means the non-discounted schedule of charges for services that the health care
provider would use to invoice a patient for services rendered.
(3) "Third party payer" means any of the
following:
(a) An insurance company;
(b) A preferred provider
organization;
(c) A labor
organization;
(d) An
employer;
(e) An administrator
subject to sections 3959.01 to
3959.16 of the Revised
Code;
(f) A multiple employer
welfare arrangement subject to sections
1739.01 to
1739.99 of the Revised
Code.
(g) Any other person that is
obligated pursuant to a benefits contract to reimburse for covered health care
services to beneficiaries under such contract, except that "third party payer"
does not include a health insuring corporation licensed pursuant to Chapter
1751. of the Revised Code.
(4) "Reasonable cash value" means the amount
the third party payer would reimburse the patient or health care provider in
the absence of a capitation agreement.
(D) Prohibited activity
No third party payer that has a negotiated discount with a
health care provider, shall do the following:
(1) Fail to disclose the existence of such
discount to any policy holder, certificate holder, subscriber or enrollee who
has purchased health care coverage from the third party payer. Such disclosure
shall be contained in the body of the insurance contract, and the certificate
if the contract is a group insurance program. Only disclosure of the existence
of such discount is required, disclosure of the extent of the discount is not
required.
(2) Fail to calculate any
annual or lifetime maximums only on the basis of actual payments made to
non-capitated health care providers. For capitated health care providers the
reasonable cash value of the services provided shall be used to calculate
annual or lifetime maximums.
(3)
Fail to maintain adequate records of the compliance with this rule.
(E) Penalties
Failure to comply with the requirements of paragraph (D) of
this rule is an unfair and deceptive practice within the meaning of section
3901.21 of the Revised
Code.
(F) Severability
If any portion of this rule or the
application thereof to any person or circumstance is held invalid, the
invalidity does not affect other provisions or applications of the rule or
related rules which can be given effect without the invalid portion or
application, and to this end the provisions of this rule are
severable.
