3901-8-02. Provider discounts

(A) Purpose

This rule sets the requirements that third party payers shall follow if the third party payer receives any discount from billed charges from a health care provider.

(B) Authority

This rule is issued pursuant to the authority vested in the superintendent of insurance under section 3901.041 of the Revised Code, general rule making authority; and sections 3901.19 to 3901.22 of the Revised Code, the unfair and deceptive acts statute.

(C) Definitions

(1) "Discount" means any negotiated reduction or variation from the schedule of billed charges (including capitation) that a health care provider otherwise would require a patient and/or the patient's third party payer to pay to that health care provider.

(2) "Billed charges" means the non-discounted schedule of charges for services that the health care provider would use to invoice a patient for services rendered.

(3) "Third party payer" means any of the following:

(a) An insurance company;

(b) A preferred provider organization;

(c) A labor organization;

(d) An employer;

(e) An administrator subject to sections 3959.01 to 3959.16 of the Revised Code;

(f) A multiple employer welfare arrangement subject to sections 1739.01 to 1739.99 of the Revised Code.

(g) Any other person that is obligated pursuant to a benefits contract to reimburse for covered health care services to beneficiaries under such contract, except that "third party payer" does not include a health insuring corporation licensed pursuant to Chapter 1751. of the Revised Code.

(4) "Reasonable cash value" means the amount the third party payer would reimburse the patient or health care provider in the absence of a capitation agreement.

(D) Prohibited activity

No third party payer that has a negotiated discount with a health care provider, shall do the following:

(1) Fail to disclose the existence of such discount to any policy holder, certificate holder, subscriber or enrollee who has purchased health care coverage from the third party payer. Such disclosure shall be contained in the body of the insurance contract, and the certificate if the contract is a group insurance program. Only disclosure of the existence of such discount is required, disclosure of the extent of the discount is not required.

(2) Fail to calculate any annual or lifetime maximums only on the basis of actual payments made to non-capitated health care providers. For capitated health care providers the reasonable cash value of the services provided shall be used to calculate annual or lifetime maximums.

(3) Fail to maintain adequate records of the compliance with this rule.

(E) Penalties

Failure to comply with the requirements of paragraph (D) of this rule is an unfair and deceptive practice within the meaning of section 3901.21 of the Revised Code.

(F) Severability

If any section, term or provision of this rule is judged invalid for any reason, such judgment shall not affect, impair or invalidate any other section, term or provision of this rule, but the remaining sections, terms and provisions shall be and continue in full force and effect.

Replaces: 3901-1-04

Five Year Review (FYR) Dates: 8/30/2018 and 08/30/2023
Promulgated Under: 119.03
Statutory Authority: 3901.041, 3901.21 to 3901.22
Rule Amplifies: 3901.19 to 3901.22
Prior Effective Dates: 04/01/1973, 06/01/1973, 09/26/1983, 11/14/2008

Prior History: (R.C. 119.032 review dates: 01/08/2014 and 08/31/2018
Promulgated Under: 119.03
Statutory Authority: 3901.041, 3901.21
Rule Amplifies: 3901.19 to 3901.22
Prior Effective Dates: 3/1/1999, 11/14/2008)