Plan types (indemnity, HMO, PPO, POS, HDHP/HSA), cost sharing and the federal Affordable Care Act rules are covered in the national Medical Plans guide. This guide covers what Ohio adds: health insuring corporations, prompt pay, prior authorization and external review, mandated benefits and dependent coverage. Citations are to the Ohio Revised Code (R.C.).

Health insuring corporations (R.C. Chapter 1751)

• Ohio's HMO-type entities are health insuring corporations (HICs). They pay for, provide or arrange basic, supplemental or specialty health services through open panel or closed panel plans (R.C. 1751.01). A closed panel plan requires enrollees to use participating providers. An open panel plan gives incentives to use them but allows others.
• Basic health care services include physician, inpatient hospital, outpatient, emergency, urgent care, diagnostic, certain mental health and preventive services. Dental and vision are supplemental (R.C. 1751.01(A)(1)).
• An HIC may not cancel or nonrenew coverage because of any health status-related factor or need for care (R.C. 1751.18).
• HICs keep a toll-free number available 24/7 for information on getting services (R.C. 1751.11). Evidence of coverage forms must be filed before use. Marketing materials must show the HIC's name, and each prospective applicant gets an approved solicitation document at or before solicitation (R.C. 1751.20, 1751.31).
• Enrollee health information may be disclosed only as the law allows, such as with the enrollee's express consent (R.C. 1751.52).

Prompt pay (R.C. 3901.381)

Claims on the standard form are paid or denied within 30 days of receipt, or 45 days if the payer needs supporting documentation, with a specific reason for any denial.

Prior authorization and external review

• Prior authorization responses are due within 48 hours for urgent care and 10 calendar days for other requests (R.C. 3923.041). An approval for a drug is honored for the lesser of 12 months or the end of eligibility (R.C. 1751.72).
• External review is available for adverse benefit determinations (R.C. 3922.03). An independent review organization decides an expedited review within 72 hours (R.C. 3922.09). The Superintendent reviews denials based on a contract issue that doesn't involve medical judgment (R.C. 3922.11). The decision binds the insurer (R.C. 3922.12).

Mandated benefits

• Screening mammography once a year, including digital breast tomosynthesis, plus supplemental screening for women with dense breast tissue or higher risk (R.C. 3923.52).
• Child health supervision services from birth to age 9 (R.C. 3923.56).

Dependents and newborns

• Newborns are covered from the moment of birth, including congenital defects. The policy may require notice and premium within 31 days (R.C. 3923.26).
• Adopted children are covered on the same basis as other dependents (R.C. 3923.40).
• Insurers must offer coverage for an unmarried natural, step or adopted child to age 26 if the child lives in Ohio or is a full-time student, has no employer coverage, and isn't eligible for Medicaid or Medicare. Proof is due within 31 days of reaching the limiting age (R.C. 3923.24).
• Denying family coverage to a child solely because the child doesn't live in the insured's household is an unfair practice (R.C. 3901.21(S)).

Testing and underwriting limits

• Health insurers may not use genetic screening or test results in deciding insurability (R.C. 3901.491).
• An HIV test requires written consent and an explanation of its purpose, and may be required only along with tests for other conditions. An HIV test can't be required for group coverage, except under a membership organization policy (R.C. 3901.46).

Common exam traps

• HICs are Ohio's HMOs. Closed panel means network only.
• Prompt pay: 30 days, or 45 if documentation is needed.
• Prior authorization: 48 hours urgent, 10 days otherwise. Expedited external review: 72 hours.
• Newborn notice: 31 days.
• Annual mammograms, including tomosynthesis.