(A) No health benefit plan offered or provided by an insurer to a small employer under a qualified alliance program is subject to any law that does any of the following:

Terms Used In Ohio Code 1731.06

  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • 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.
  • Health benefit plan: means any hospital or medical expense policy of insurance or a health care plan provided by an insurer, including a health insuring corporation plan, provided by or through an insurer, or any combination thereof. See Ohio Code 1731.01
  • Insurer: means an insurance company authorized to do the business of sickness and accident insurance in this state or, for the purposes of this chapter, a health insuring corporation authorized to issue health care plans in this state. See Ohio Code 1731.01
  • Provider: means a hospital, urgent care facility, nursing home, physician, podiatrist, dentist, pharmacist, chiropractor, certified registered nurse anesthetist, dietitian, or other health care provider licensed by this state, or group of such health care providers. See Ohio Code 1731.01
  • Qualified alliance program: means an alliance program under which health care benefits are provided to one thousand or more participants. See Ohio Code 1731.01

(1) Inhibits the insurer from selectively contracting with providers or groups of providers with respect to health care service or benefits;

(2) Imposes any restrictions on the ability of the insurer to negotiate with providers regarding the level or method of reimbursing for care or services;

(3) Requires the insurer either to include a specific provider or class of providers, or to exclude any class of providers that are generally authorized by law to provide such care, in connection with health care services or benefits under such health benefit plan;

(4) Limits the financial incentives that a health benefit plan may require a beneficiary to pay when a nonplan provider is used on a nonemergency basis;

(5) Prohibits utilization review of any or all treatments and conditions;

(6) Requires the use of specified standards of health care practice in such reviews or requires the disclosure of the specific criteria used in such reviews;

(7) Requires payments to providers for the expenses of responding to utilization review requests;

(8) Imposes liability for delays in performing such review.

(B) Notwithstanding division (A) of this section, every health benefit plan offered or provided by an insurer, other than a health insuring corporation, to a small employer under a qualified alliance program is subject to sections 3923.23, 3923.231, 3923.232, 3923.233, and 3923.234 of the Revised Code and any other provision of the Revised Code that requires the reimbursement, utilization, or consideration of a specific category of licensed or certified health care practitioner.

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