Ohio Code 1751.04 – Review of application and documents by superintendent
(A) Except as provided by division (D) of this section, upon the receipt by the superintendent of insurance of a complete application for a certificate of authority to establish or operate a health insuring corporation, which application sets forth or is accompanied by the information and documents required by division (A) of section 1751.03 of the Revised Code, the superintendent shall review the application and accompanying documents and make findings as to whether the applicant for a certificate of authority has done all of the following with respect to any basic health care services and supplemental health care services to be furnished:
Terms Used In Ohio Code 1751.04
- 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
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- 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.
- 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.
- Evidence of coverage: means any certificate, agreement, policy, or contract issued to a subscriber that sets out the coverage and other rights to which such person is entitled under a health care plan. See Ohio Code 1751.01
- 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
- 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
(1) Demonstrated the willingness and potential ability to ensure that all basic health care services and supplemental health care services described in the evidence of coverage will be provided to all its enrollees as promptly as is appropriate and in a manner that assures continuity;
(2) Made effective arrangements to ensure that its enrollees have reliable access to qualified providers in those specialties that are generally available in the geographic area or areas to be served by the applicant and that are necessary to provide all basic health care services and supplemental health care services described in the evidence of coverage;
(3) Made appropriate arrangements for the availability of short-term health care services in emergencies within the geographic area or areas to be served by the applicant, twenty-four hours per day, seven days per week, and for the provision of adequate coverage whenever an out-of-area emergency arises;
(4) Made appropriate arrangements for an ongoing evaluation and assurance of the quality of health care services provided to enrollees, including, if applicable, the development of a quality assurance program complying with the requirements of sections 1751.73 to 1751.75 of the Revised Code, and the adequacy of the personnel, facilities, and equipment by or through which the services are rendered;
(5) Developed a procedure to gather and report statistics relating to the cost and effectiveness of its operations, the pattern of utilization of its services, and the quality, availability, and accessibility of its services.
(B) Based upon the information provided in the application for issuance of a certificate of authority, the superintendent shall determine whether or not the applicant meets the requirements of division (A) of this section. If the superintendent determines that the applicant does not meet these requirements, the superintendent shall specify in what respects it is deficient. However, the superintendent shall not deny an application because the requirements of this section are not met unless the applicant has been given an opportunity for a hearing on that issue.
(C) If the applicant requests a hearing, the superintendent shall hold a hearing before denying an application because the applicant does not meet the requirements of this section. The hearing shall be held in accordance with Chapter 119 of the Revised Code.
(D) Nothing in this section requires the superintendent to review or make findings with regard to an application and accompanying documents to establish or operate any of the following:
(1) A health insuring corporation to cover solely medicaid recipients;
(2) A health insuring corporation to cover solely medicare beneficiaries;
(3) A health insuring corporation to cover solely medicaid recipients and medicare beneficiaries;
(4) A health insuring corporation to cover solely federal employees and other individuals eligible for coverage in the federal employees health benefits program pursuant to 5 U.S.C. § 8905.