Ohio

SUMMARY

Ohio has been relatively inactive during the 2017 legislation on healthcare price transparency, cost, or markets. Ohio introduced bills that aimed at lowering prescription drug costs, increasing insurance plan transparency and providing universal healthcare coverage.  However, none of these bills had bipartisan support and all failed in committee.

On the price transparency front, an Ohio law enacted in 2015 (HB 52) to increase health care price transparency in the state still has not been enforced because of an ongoing legal challenge from health care providers. The Healthcare Price Transparency Law, which was scheduled to take effect in January 2017, requires providers to supply patients with a “good faith” estimate of how much non-emergency, elective health care services would cost individuals after accounting for health insurance. The law would mandate that providers must give the cost information to patients before they begin treatment. Providers argue that the law’s requirements are too broad and would delay patient care by requiring physicians to make cost estimates before beginning treatment. As of February 2018, the hearing on the lawsuit has been delayed indefinitely.

 

LEGISLATION/REGULATION

Legislative Calendar

Ohio’s current regular legislative session runs from 1/2/2018 – 12/31/2018.

 

Recent Legislative Developments

Healthcare Transparency

2018 HB 479 Disclose Drug Price Information to Patients: Seeks to reduce the administrative burden placed on pharmacists by Pharmacy Benefit Managers (PBMs), which act as third-party intermediaries between pharmacies and insurers. By requiring that patients are informed of the most affordable payment option for their prescriptions, PBMs or other administrators will be limited in the amount they may charge a patient. Active –Referred to Committee.
2017 SB 227

 

Requiring health insurers to release group plan information: Authorizes a health plan issuer, beginning in 2019, to release the following to a requesting group policyholder: net claims data paid by month, monthly enrollment, the claims reserve amount, and, for claims over $10,000, the amount paid toward each claim, which claims are unpaid or outstanding, and claimant health condition. Failed.

 

Healthcare Cost

2018 SB 253 Establish Requirements for Rx Drugs and Med Equipment Pricing: The department of administrative services shall create a state medical item formulary. The formulary shall contain all prescription drugs and items of medical equipment on the VA national formulary. The state medical item formulary also shall specify the per unit price that the United States department of veterans affairs pays, reimburses, or otherwise provides benefits for each drug or item on the VA national formulary Active – Referred to Health, Human Services and Medicaid Committee on 3/21/18.
2017 SB 215 Create Ohio Pharmaceutical Assistance Program: Creates a pharmaceutical assistance program under the Ohio Department of Insurance. The program creates three saving components including the Ohio supreme RX savings, Ohio veterans, and the Ohio bronze RX savings. To receive assistance from the program, the individual must be an Ohio state resident, is at least 65 years of age or disabled, and has an income lower than the state’s poverty line. Failed.


Healthcare Markets

2018 HB 546 Prohibit Health Insurer Discrimination Involving Telemedicine: Requires a health benefit plan to provide coverage for telemedicine services on the same basis and to the same extent that the plan provides coverage for the provision of in-person health care services. Active – Referred to Health Committee on 3/20/18.
HB 536 Prohibit Selective Emergency Services Insurance Coverage: A health plan issuer shall not implement any form of selective emergency services coverage in regards to any health benefit plan. Active – Referred to Insurance Committee on 3/6/18.
SB 265 Permit Health Insurers to Cover Pharmacist Provided Benefits: Notwithstanding any provision of a policy of sickness and accident insurance that is delivered, issued for delivery, or renewed in this state, whenever the policy provides for reimbursement of any service that may be legally performed by a pharmacist who holds a current, valid license under Chapter 4729. of the Revised Code, reimbursement under the policy shall not be denied to the pharmacist performing the service. Active – Referred to Insurance and Financial Institutions Committee on 3/21/18.
2017 HB 440

 

Provide Universal Healthcare Coverage to Ohioans: Creates the Ohio healthcare plan, which shall be administered by the Ohio health care agency under the direction of the Ohio health care board. The Ohio health care plan will provide universal and affordable health care coverage for all Ohio residents, consisting of a comprehensive benefit package that includes benefits for prescription drugs. Failed.

 

Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

Transparency in Healthcare

  • Ohio Rev. Code Ann. § 3727.33 through 40 requires hospitals to periodically submit information on certain inpatient and outpatient service measures and performance indicators regardless of who pays for the services. The information submitted pursuant to these sections is made available to the public on the internet by the Director of Health, with the stipulation that the information be presented in such a way so as to enable the public to compare the performance of hospitals.
  • Ohio Rev. Code Ann. § 3727.42 requires that every hospital compile and make publically available (both in paper and online at no cost) a current price information list containing the usual and customary charges for the specified services, including the following: room and board, nursing care rates, the thirty most common radiological procedures, the thirty most common laboratory procedures, emergency room service rates, and operating room service rates, among others.
  • Ohio Rev. Code Ann. § 4729.361 requires retail sellers of dangerous drugs to disclose price information regarding that drug verbally to all persons on the premises and by telephone to all persons maintaining a valid prescription.
  • Ohio Rev. Code Ann. § 5162.80 (Healthcare Price Transparency Law – suspended pending legal challenge) requires health care providers to supply patients with a “good faith” estimate of how much non-emergency, elective health care services would cost individuals after accounting for health insurance. The law mandates that providers must give the cost information to patients before they begin treatment.

 

Healthcare Contracting

  • Ohio Rev. Code Ann. § 3963.03 specifies the required form of contracts between a health care provider and an insurer.
  • Ohio Rev. Code Ann. § 3963.11 prohibits most-favored nation (MFN) clauses in a contract between a health insurance carrier and a health care provider. A most-favored nation clause is a type of contractual provision that requires that the provider give the health carrier a rate equal to or lower than the most favorable rate between the provider and any other health insurance carrier. A most-favored nation clause in a healthcare contract can prevent smaller insurance carriers with less market power from competing on price.

 

Healthcare Markets

  • Ohio Rev. Code Ann. 3702.11 et seq. prohibits health care providers from developing, relocating, or adding additional beds to a long-term care facility, except in specified circumstances, without the prior approval of the Department of Health through the state’s Certificate of Need process. A Certificate of Need regime aims to reduce healthcare overheard by reducing unnecessary or duplicative services, but can be anticompetitive by increasing regulatory barriers for new entrants.
  • Ohio Rev. Code Ann. §§ 3923.02, 3923.021 requires that an insurer issuing a group or individual benefits plan obtain prior approval for forms and premium rates. Premium rates may be disapproved if the benefits provided are unreasonable in relation to the premium charged.
  • Ohio Rev. Code Ann. § 3924.04 provides that subject to certain exceptions and variations, premium rates offered by a carrier “for a rating period for the same or similar coverage under a health benefit plan covering any small employer with similar case characteristics shall not vary from the applicable midpoint rate by more than forty percent.”
  • Ohio Rev. Code Ann. § 3924.21 penalizes hospitals for charging more than the usual and customary charge by requiring them to refund to the beneficiary 15% of the overcharged amount if the beneficiary notifies the third-party payer of such overcharge 30 days after the making of a payment and the hospital is not able to show documentation that they were already in the process of correcting that error.

 

FY 2018-2019 BUDGET

Ohio enacts budgets on a two-year cycle, beginning July 1 of each odd-numbered year. Ohio’s new Biennial Budget will take effect on July 1, 2017 and is valid through June 30, 2019. To view Ohio’s FY 2018-2019 Budget, click here.

 

LITIGATION/ENFORCEMENT

  • On April 22, 2014, the Sixth Circuit affirmed the FTC administrative order requiring ProMedica Health System of Toledo, OH, to divest acquired hospital St. Luke’s. The FTC originally challenged the August 2010 merger in January 2011 on the basis that the transaction would adversely affect competition, in violation of the Clayton Act. ProMedica has stated that it will appeal the case to the U.S. Supreme Court.
  • Ohio’s Healthcare Price Transparency Law, passed in June 2015 (HB 52) by the Ohio Legislature, has been challenged by health care providers arguing that the law’s requirements are too broad and would delay patient care. The law requires providers to supply patients with a “good faith” estimate of how much non-emergency, elective health care services would cost individuals after accounting for health insurance. The price transparency law was scheduled to take effect in January 2017 but has been suspended from enforcement pending the legal challenge. As of February 2018, the hearing on the lawsuit has been delayed indefinitely.

 

KEY RESOURCES

Ohio Legislature

Ohio Attorney General

Ohio Department of Insurance

Health Policy Institute of Ohio