In order to establish, operate, or perform the services of a HIC in Ohio, a corporation formed by or on behalf of a publicly owned, operated, or funded hospital or health care facility must first obtain a Certificate of Authority from the Director. Corporations domiciled in another state that does not have HIC regulations similar to those in Ohio must first form a domestic corporation prior to applying for a Certificate of Authority.

Insurers that offer an open panel plan are not required to obtain a HIC Certificate of Authority, as long as the providers and health care facilities participating in the open panel are compensated directly from the insurer. Additionally, intermediary organizations are not required to obtain a Certificate of Authority, as long as the organization maintains ultimate responsibility to assure delivery of health care services.

Though health delivery networks doing business in Ohio are not required to obtain a Certificate of Authority, including those functioning as an intermediary organization, the network must provide the Director with a signed statement containing the network’s full name, address, and an acknowledgement that the network does not maintain a Certificate of Authority. The statement must be provided to the Director annually, no later than July 1.

Any changes in a health insuring corporation’s solicitation document must be filed with the Director 30 days prior to use. The Director then has 60 days to approve or disapprove any solicitation document or amendment on any grounds.

The solicitation document must contain all information necessary to enable a consumer to make an informed choice as to whether or not to enroll in the HIC. The information must include a specific description of health services and the approximate number and type of full-time equivalent medical practitioners. It must also be presented in a manner that is clear, concise, and intelligible to prospective applicants in the proposed service area.

Health insuring corporations (or their agents, employees, or representatives) may not use any advertisement or solicitation document or engage in any activity that is unfair, untrue, misleading, or deceptive.

HICs may not use names that are deceptively similar to the name or description of any insurance company or surety corporation doing business in Ohio.

A health insuring corporation that provides basic health care services may use the phrase “health maintenance organization” or the abbreviation “HMO” in its marketing name, advertising, solicitation documents, or marketing literature, or in reference to the phrase “doing business as” or the abbreviation “DBA.”

Any information pertaining to the diagnosis, treatment or health condition of an HIC enrollee or applicant must be held confidential and cannot be disclosed to any person except under one of the following circumstances:

• With the enrollee’s consent;
• If required by a court order as evidence;
• In the event of claim litigation between the enrollee and the HIC.

Health insuring corporations are required to hold an open enrollment period at least once during each 12-month period in order to accept new members, assuming that the HICs have not reached maximum capacity. These open enrollment periods must last at least 30 days. In certain cases, the Director may waive the requirements for an open enrollment period or authorize enrollment underwriting restrictions as deemed necessary. The open enrollment period requirement does not apply to HICs that offer only supplemental health care services, or that offer plans only through Medicare, Medicaid, or federal health care programs.

Evidence of coverage means any certificate, agreement, policy or contract issued to a subscriber that sets out the coverage to which the person is entitled under a health care plan. Every subscriber of a health insuring corporation is entitled to an evidence of coverage in the form of an identification card or a similar document.

The evidence of coverage card must specify the health insuring corporation’s name and provide at least one toll-free telephone number that provides the subscriber with access to information on a 24-hour, 7-days-a-week basis, as to how health care services may be obtained.

The card must also list at least one telephone number that, during normal business hours, allows the subscriber access to information on the coverage available under the subscriber’s health care plan and information on the health care plan’s internal and external review process.

Each insurer must provide to its policyholders and subscribers the following information:

• A description of the health insurance company;
• Methods of operation;
• Current service area, and the most recent providers list;
• Complaint procedure process; and
• A description of how the insurer determines the need for future services.

At the request of the subscriber, an insurer may provide this information electronically or in hard copy by mail. A health insurance corporation may also satisfy this requirement by providing the subscribers a web site with access to all required information.

This information will be provided to the insured annually unless the insurer is a specialty health care insurer only in which case the information will be provided biennially.

Health insuring corporation may not cancel or fail to renew the coverage of a subscriber or enrollee because of any health status-related factor in relation to the subscriber or enrollee, the subscriber’s or enrollee’s requirements for health care services, or for any other reason designated under rules adopted by the Director.

Health status-related factor refers to any of the following:

• Health status;
• Medical condition, including both physical and mental illnesses;
• Claims experience;
• Receipt of health care;
• Medical history;
• Genetic information;
• Evidence of insurability, including conditions arising out of acts of domestic violence; and/or
• Disability.

A health insuring corporation may cancel or decide not to renew the coverage of an enrollee if the enrollee has performed an act or practice that constitutes fraud or intentional misrepresentation of material fact under the terms of the coverage and if the cancellation or nonrenewal is not based on any health status-related factor in relation to the enrollee.