As Introduced
136th General Assembly
Regular Session S. B. No. 165
2025-2026
Senator Manchester
To amend sections 1753.28 and 3923.65 and to enact
sections 1753.29 and 3923.66 of the Revised Code
to prohibit a health insuring corporation or
sickness and accident insurer from reducing or
denying a claim based on certain factors.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1753.28 and 3923.65 be amended
and sections 1753.29 and 3923.66 of the Revised Code be enacted
to read as follows:
Sec. 1753.28. (A) As used in this section:
(1) "Emergency medical condition" means a medical physical
or mental health condition that manifests itself by such acute
symptoms of sufficient severity, including severe pain, that a
prudent layperson with an average knowledge of health and
medicine could reasonably expect the absence of immediate
medical attention to result in any of the following:
(a) Placing the health of the individual or, with respect
to a pregnant woman, the health of the woman or her unborn
child, in serious jeopardy;
(b) Serious impairment to bodily functions;
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(c) Serious dysfunction of any bodily organ or part.
(2) "Emergency services" means the following:
(a) A medical screening examination, as required by
federal law, that is within the capability of the emergency
department of a hospital, including ancillary services routinely
available to the emergency department, to evaluate an emergency
medical condition;
(b) Such further medical examination and treatment that
are required by federal law to stabilize an emergency medical
condition and are within the capabilities of the staff and
facilities available at the hospital, including any trauma and
burn center of the hospital.
(3)(a) "Stabilize" means the provision of such medical
treatment as may be necessary to assure, within reasonable
medical probability, that no material deterioration of an
individual's medical condition is likely to result from or occur
during a transfer, if the medical condition could result in any
of the following:
(i) Placing the health of the individual or, with respect
to a pregnant woman, the health of the woman or her unborn
child, in serious jeopardy;
(ii) Serious impairment to bodily functions;
(iii) Serious dysfunction of any bodily organ or part.
(b) In the case of a woman having contractions,
"stabilize" means such medical treatment as may be necessary to
deliver, including the placenta.
(4) "Transfer" has the same meaning as in section 1867 of
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A.
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1395dd, as amended.
(B) A health insuring corporation policy, contract, or
agreement providing coverage of basic health care services shall
cover emergency services for enrollees with emergency medical
conditions without regard to the day or time the emergency
services are rendered or to whether the enrollee, the hospital's
emergency department where the services are rendered, or an
emergency physician treating the enrollee, obtained prior
authorization for the emergency services.
(C) A health insuring corporation policy, contract, or
agreement providing coverage of basic health care services shall
cover both of the following:
(1) Emergency services provided to an enrollee at a
participating hospital's emergency department if the enrollee
presents self with an emergency medical condition;
(2) Emergency services provided to an enrollee at a
nonparticipating hospital's emergency department if the enrollee
presents self with an emergency medical condition and one of the
following circumstances applies:
(a) Due to circumstances beyond the enrollee's control,
the enrollee was unable to utilize a participating hospital's
emergency department without serious threat to life or health.
(b) A prudent layperson with an average knowledge of
health and medicine would have reasonably believed that, under
the circumstances, the time required to travel to a
participating hospital's emergency department could result in
one or more of the adverse health consequences described in
division (A)(1) of this section.
(c) A person authorized by the health insuring corporation
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refers the enrollee to an emergency department and does not
specify a participating hospital's emergency department.
(d) An ambulance takes the enrollee to a nonparticipating
hospital other than at the direction of the enrollee.
(e) The enrollee is unconscious.
(f) A natural disaster precluded the use of a
participating emergency department.
(g) The status of a hospital changed from participating to
nonparticipating with respect to emergency services during a
contract year and no good faith effort was made by the health
insuring corporation to inform enrollees of this change.
(D) A health insuring corporation that provides coverage
for emergency services shall inform enrollees of all of the
following:
(1) The scope of coverage for emergency services;
(2) The appropriate use of emergency services, including
the use of the 9-1-1 system and any other telephone access
systems utilized to access prehospital emergency services;
(3) Any cost sharing provisions for emergency services;
(4) The procedures for obtaining emergency services and
other medical services, so that enrollees are familiar with the
location of the emergency departments of participating hospitals
and with the location and availability of other participating
facilities or settings at which they could receive medical
services;
(5) That enrollees are not required to self-diagnose .
Sec. 1753.29. (A) A health insuring corporation shall not
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reduce or deny a claim for reimbursement based solely on a
diagnosis code or impression, current ICD code, duration of an
appointment as deemed clinically necessary by the enrollee's
provider, or select procedure code relating to the enrollee's
condition included on a form submitted to the health insuring
corporation by a provider for reimbursement of a claim.
(B) A health insuring corporation shall not reduce or deny
reimbursement for a claim based on the absence of an emergency
medical condition if a prudent layperson with an average
knowledge of health and medicine would have reasonably expected
the presence of an emergency medical condition.
(C) Nothing in this section shall be construed as
exempting a health insuring corporation from the prompt payment
requirements prescribed in sections 3901.381 to 3901.3814 of the
Revised Code.
Sec. 3923.65. (A) As used in this section :
(1) "Emergency , "emergency medical condition" means a
medical condition that manifests itself by such acute symptoms
of sufficient severity, including severe pain, that a prudent
layperson with average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in any of the following:
(a) Placing the health of the individual or, with respect
to a pregnant woman, the health of the woman or her unborn
child, in serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.
(2) "Emergency services" means the following:
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(a) A medical screening examination, as required by
federal law, that is within the capability of the emergency
department of a hospital, including ancillary services routinely
available to the emergency department, to evaluate an emergency
medical condition;
(b) Such further medical examination and treatment that
are required by federal law to stabilize an emergency medical
condition and are within the capabilities of the staff and
facilities available at the hospital, including any trauma and
burn center of the hospital and "emergency services" have the
same meanings as in section 1753.28 of the Revised Code .
(B) Every individual or group policy of sickness and
accident insurance that provides hospital, surgical, or medical
expense coverage shall cover emergency services without regard
to the day or time the emergency services are rendered or to
whether the policyholder, the hospital's emergency department
where the services are rendered, or an emergency physician
treating the policyholder, obtained prior authorization for the
emergency services.
(C) Every individual policy or certificate furnished by an
insurer in connection with any sickness and accident insurance
policy shall provide information regarding the following:
(1) The scope of coverage for emergency services;
(2) The appropriate use of emergency services, including
the use of the 9-1-1 system and any other telephone access
systems utilized to access prehospital emergency services;
(3) Any copayments for emergency services ;
(4) That the covered person is not required to self-
diagnose.
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(D) This section does not apply to any individual or group
policy of sickness and accident insurance covering only
accident, credit, dental, disability income, long-term care,
hospital indemnity, medicare supplement, medicare, tricare,
specified disease, or vision care; coverage under a one-
timelimitedduration one-time-limited-duration policy that is
less than twelve months; coverage issued as a supplement to
liability insurance; insurance arising out of workers'
compensation or similar law; automobile medical payment
insurance; or insurance under which benefits are payable with or
without regard to fault and which is statutorily required to be
contained in any liability insurance policy or equivalent self-
insurance.
Sec. 3923.66. (A) A sickness and accident insurer shall
not reduce or deny a claim for reimbursement based solely on a
diagnosis code or impression, current ICD code, duration of an
appointment as deemed clinically necessary by the covered
person's provider, or select procedure code relating to the
covered person's condition included on a form submitted to the
sickness and accident insurer by a provider for reimbursement of
a claim.
(B) A sickness and accident insurer shall not reduce or
deny a claim for reimbursement based on the absence of an
emergency medical condition if a prudent layperson with an
average knowledge of health and medicine would have reasonably
expected the presence of an emergency medical condition.
(C) Nothing in this section shall be construed as
exempting a sickness and accident insurer from the prompt
payment requirements prescribed in sections 3901.381 to
3901.3814 of the Revised Code.
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Section 2. That existing sections 1753.28 and 3923.65 of
the Revised Code are hereby repealed.
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