As Introduced
136th General Assembly
Regular Session H. B. No. 219
2025-2026
Representative Deeter
To enact section 3901.93 of the Revised Code to
establish network adequacy standards for health
insurers.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That section 3901.93 of the Revised Code be
enacted to read as follows:
Sec. 3901.93. (A) As used in this section:
(1) "Business day" has the same meaning as in section
3901.81 of the Revised Code.
(2) "Cost sharing" has the same meaning as in section
3902.50 of the Revised Code.
(3) "Covered benefit," "covered person," "health benefit
plan," and "health plan issuer" have the same meanings as in
section 3922.01 of the Revised Code.
(4) "Emergency services" has the same meaning as in
section 1753.28 of the Revised Code.
(5) "Material change" means any change to a network plan
or the population of covered persons that impacts the ability of
a health plan issuer to comply with this section.
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(6) "Network plan" means a health benefit plan under which
the financing and delivery of medical care, including items and
services paid for as medical care, are provided, in whole or in
part, through a defined set of providers under contract with the
health plan issuer.
(7) "Provider" has the same meaning as in section 1751.01
of the Revised Code.
(8) "Specialty health care services" means the delivery of
covered benefits in a manner that is physically accessible and
provides communication and accommodations needed by covered
persons with disabilities.
(B)(1) A health plan issuer that delivers, issues for
delivery, or uses a network plan in this state shall maintain a
network that ensures that all covered persons, including both
children and adults, have access to both of the following:
(a) A sufficient network of providers in terms of the
number and specialty, including providers that serve
predominantly low-income and medically underserved individuals,
to allow access to covered benefits without unreasonable travel
or delay;
(b) Emergency services that are available at all times.
(2) For tiered network plans, the adequacy of the network
is determined, for the purposes of this section, based on the
lowest cost sharing tier.
(C) The superintendent of insurance shall establish
reasonable criteria for the purpose of evaluating the adequacy
of a network plan under this section, taking into account all of
the following:
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(1) The ratio, for each specialty associated with a
covered benefit, of full-time equivalent providers, including
facility based providers, to covered persons;
(2) The ratio of full-time equivalent primary care
providers to covered persons;
(3) The geographic accessibility of providers, including
primary care providers, specialty providers, hospitals, and
facility-based providers;
(4) The geographic variation and population dispersion of
covered persons;
(5) Waiting times for an appointment with in-network
providers;
(6) Hours of operation of in-network providers;
(7) The ability of the network to meet the needs of
covered persons, including the following:
(a) Persons who are low-income;
(b) Children;
(c) Adults;
(d) Persons with serious, chronic, or complex health
conditions;
(e) Persons with physical or mental disabilities;
(f) Persons with limited English proficiency.
(8) The volume of technological and specialty care
services available to serve the needs of covered persons
requiring those services;
(9) The number of in-network providers accepting new
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patients.
(D) The superintendent shall establish requirements for
network plans to have a minimum number of providers within a
specified area, limits on travel distance to providers, and
limits on travel time to providers.
(E) The superintendent shall conduct periodic surveys of
covered persons and providers to assist the superintendent in
monitoring the adequacy of a network plan and shall publish the
results of those surveys on the department of insurance's web
site.
(F)(1) A health plan issuer shall establish and maintain a
process to assure that covered persons obtain covered benefits
at an in-network level, including in-network cost sharing, from
an out-of-network provider, or shall make other arrangements
acceptable to the superintendent, when either of the following
applies:
(a) The health plan issuer has a sufficient network but
does not have an appropriate in-network provider available to
provide the covered benefit to the covered person without
unreasonable travel or delay.
(b) The health plan issuer has an insufficient number or
type of appropriate in-network providers available to provide
the covered benefit to the covered person without unreasonable
travel or delay.
(2) The health plan issuer shall inform a covered person
who is diagnosed with a condition or disease that requires
specialty health care services of the process required by
division (E)(1) of this section when either of the following
apply:
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(a) The health plan issuer does not have an in-network
provider of the required specialty with the professional
training and expertise to treat or provide health care services
for the condition or disease.
(b) The health plan issuer cannot provide reasonable
access to an in-network provider with the required specialty
with the professional training and expertise to treat or provide
health care services for the condition or disease without
unreasonable travel or delay.
(3) The health plan issuer shall treat the health care
services the covered person receives from an out-of-network
provider under division (F) of this section as if the services
were provided by an in-network provider, including by counting
the covered person's cost sharing for such services toward the
maximum out-of-pocket limit applicable to services obtained from
in-network providers under the network plan.
(4) The health plan issuer shall address requests to
obtain a covered benefit from an out-of-network provider in a
timely fashion appropriate to the covered person's condition.
(5) The health plan issuer shall document all requests to
obtain a covered benefit from an out-of-network provider in
accordance with this section and shall provide such
documentation to the superintendent upon request.
(6) Nothing in division (F) of this section shall be
construed to absolve a health plan issuer from establishing and
maintaining an adequate network of providers in accordance with
this section or to allow covered persons to circumvent the use
of covered benefits available through a health plan issuer's in-
network providers.
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(G) A health plan issuer shall establish and maintain
adequate arrangements to ensure all covered persons have
reasonable access to in-network providers located near the
covered person's home or place of employment. In determining
whether the health plan issuer has complied with this division,
the superintendent shall give due consideration to the relative
availability of providers with the requisite expertise and
training in the service area under consideration.
(H) A health plan issuer shall monitor, on an ongoing
basis, the ability, clinical capacity, and legal authority of
in-network providers to furnish covered benefits under the
network plan.
(I) No health plan issuer shall deliver, issue for
delivery, or use a network plan in this state before a copy of
the plan, the premium rates, and an access arrangement are filed
with the department of insurance in a form and manner determined
by the superintendent. If the superintendent finds that the
network plan or the access arrangement does not meet the
requirements of this section, the superintendent shall provide
written notice of such finding to the health plan issuer, and
the health plan issuer shall not deliver, issue for delivery, or
use the network plan in this state. A health plan issuer shall
notify the superintendent of any material change to a network
plan or access arrangement approved under this division not
later than fifteen business days after the change occurs or is
implemented. An access arrangement submitted under this division
shall include all the following:
(1) The factors used by the health plan issuer to build
the provider network, including a description of the network and
the criteria used to select and tier providers;
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(2) The health plan issuer's procedures for making and
authorizing referrals within and outside the network;
(3) The health plan issuer's process for monitoring and
assuring, on an ongoing basis, the adequacy of the network to
meet the health care needs of covered persons;
(4) The health plan issuer's efforts to address the needs
of covered persons, including children, adults, persons with
limited English proficiency or illiteracy, diverse cultural or
ethnic backgrounds, physical or mental disabilities, and
serious, chronic, or complex medical conditions;
(5) The health plan issuer's methods for assessing the
health care needs of covered persons and the satisfaction of
covered persons with services;
(6) The health plan issuer's method of informing covered
persons of the covered benefits included in the network plan and
procedures for navigating the plan, such as:
(a) Grievance and appeals procedures;
(b) Processes for choosing and changing providers;
(c) Processes for updating provider directories;
(d) A statement of health care services offered, including
those services offered through preventive care benefit;
(e) Procedures for covering and approving emergency,
urgent, and specialty care.
(7) The health plan issuer's system for ensuring the
coordination and continuity of care for both of the following:
(a) Covered persons referred to specialty physicians;
(b) Covered persons using ancillary services, including
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social services and other community resources, and for ensuring
appropriate discharge planning.
(8) The health plan issuer's process for enabling covered
persons to change primary care professionals;
(9) The health plan issuer's proposed plan for providing
continuity of care in the event of contract termination between
the health plan issuer and any in-network providers or in the
event of the health plan issuer's insolvency or other inability
to continue operations, including an explanation of how covered
persons will be notified of the contract termination or the
health plan issuer's insolvency or other cessation of operations
and transitioned to other providers in a timely manner;
(10) The health plan issuer's process for monitoring
access to physician specialist services in emergency room care,
anesthesiology, radiology, hospitalist care, and pathology or
laboratory services at in-network hospitals;
(11) Any other information required by the superintendent
to determine compliance with this section.
(J) The health plan issuer shall make available to covered
persons a provider directory that clearly identifies which
providers and facilities belong to each network and which
networks are applicable to each specific plan offered in this
state. If a covered person receives care from an out-of-network
provider that is listed, incorrectly, as an in-network provider
in a directory provided under this division, the health plan
issuer shall compensate the provider at the provider's billed
rate at no expense to the covered person beyond the regular cost
sharing obligation for in-network services.
(K) The superintendent may adopt rules in accordance with
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Chapter 119. of the Revised Code to administer and enforce this
section.
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