What State Law Requires a Group Plan to Cover in Ohio

Ohio writes a good deal into a group policy, and the mandate names are a poor guide to what each one does. The contingent duties shape a benefit the plan already provides rather than adding one it does not. Several are parity rules, some are prohibitions, and one is carved out of this market altogether.

One more is an offer mandate rather than a benefit. And there is a gate standing in front of the modern ones, which is the right place to start.

Start with the gatekeeper, not the list

Ohio Revised Code 3901.71 does two things. It defines what a mandated health benefit is, and it suspends any such provision enacted after a cutoff date until the superintendent of insurance makes a determination. Quoted from https://codes.ohio.gov/ohio-revised-code/section-3901.71:

“(A) As used in this section, ‘mandated health benefits’ means any required coverage, or required offering of coverage, for the expenses of specified services, treatments, or diseases under any policy, contract, plan, or other arrangement providing sickness and accident or other health benefits to policyholders, subscribers, or members. (B) Any provision for mandated health benefits contained in a law enacted by the general assembly after January 14, 1993, shall not be applied to any policy, contract, plan, or other arrangement providing sickness and accident or other health benefits until the superintendent of insurance determines, pursuant to a hearing conducted in accordance with Chapter 119. of the Revised Code, that the provision can be applied fully and equally in all respects to employee benefit plans subject to regulation by the federal ‘Employee Retirement Income Security Act of 1974,’ 88 Stat. 832, 29 U.S.C.A. 1001, as amended, and to employee benefit plans established or modified by the state or any political subdivision of the state, or by any agency or instrumentality of the state or any political subdivision of the state.”

That is why so many Ohio mandates open with the words “Notwithstanding section 3901.71 of the Revised Code.” The General Assembly names the gatekeeper and overrides it, mandate by mandate. What that pattern proves about enforceability is a legal conclusion, and it is not one this page draws — not least because at least one long-standing Ohio duty carries no such clause and does not need one, its own operative date running from well before the cutoff.

Why “Ohio’s mandates include” is the only honest opening

Ohio’s duties are not confined to the sickness-and-accident chapter. Chapter 1751 carries parallel mandates for health insuring corporations — Ohio’s own statutory term for what most people call an HMO — and a small-group plan written as a health insuring corporation product is governed there. The only consolidated Ohio list that exists is federal, is more than a decade old, and its own citations span three separate chapters of the Revised Code.

So no number is given here. Not eight, not sixteen, not the count of sections in the chapter. Completeness has not been established and cannot be claimed, and a count would be the one thing on this page a reader could quote back with confidence and be wrong about.

Breast and cervical cancer screening: three duties in one section

Ohio Revised Code 3923.52(B) is free-standing — it does not wait on the plan to cover something first — and it reaches group policies expressly:

“Notwithstanding section 3901.71 of the Revised Code, every policy of individual or group sickness and accident insurance that is delivered, issued for delivery, or renewed in this state shall provide benefits for the expenses of all of the following: (1) To detect the presence of breast cancer in adult women, screening mammography; (2) To detect the presence of breast cancer in adult women meeting either of the conditions described in division (C)(2) of this section, supplemental breast cancer screening; (3) To detect the presence of cervical cancer, cytologic screening.”

Ohio’s mammography section therefore requires three things, and the middle one is narrower than it looks. Division (C)(2) limits supplemental screening to a woman whose screening mammography demonstrates that she has dense breast tissue, or who is at increased risk of breast cancer due to family history, prior personal history, ancestry, genetic predisposition, or other reasons as determined by her health care provider.

The contingent duties: rules about a benefit you already have

This is the largest group and the most misread. Each of these attaches only where the policy already covers something.

Kidney dialysis. Ohio Revised Code 3923.25 is a site-of-service parity rule, not a coverage mandate. Its operative clause reaches a policy “which provides for kidney dialysis benefits” and deems those benefits included on an equal basis if the dialysis is performed on an out-patient basis. It does not put dialysis into a plan that lacks it. It reaches group policies and, notably, the certificate furnished under a group policy — the instrument a covered employee actually holds.

A mother and her newborn. Ohio Revised Code 3923.63(A) applies to a policy “that provides maternity benefits,” and where it applies it requires coverage of inpatient care and follow-up care. The section then forecloses the reading every summary reaches for. Its own division (D)(2) says the section does not “require a mother or newborn to stay in a hospital or other inpatient setting for a fixed period of time following delivery.” The duty is to cover a minimum stay, not to impose one.

A newly born child. Ohio Revised Code 3923.26 applies to a group policy or certificate that “makes coverage available for family members of the insured,” and requires that benefits applicable for children be payable for a newly born child from the moment of birth, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. The section permits a notification-and-premium condition for continuing that coverage beyond a stated window; the window figure is not printed here.

Parity rules: equal treatment, not new coverage

Oral and intravenous cancer medication. Ohio Revised Code 3923.85(B) provides that a policy “shall not provide coverage or impose cost sharing for a prescribed, orally administered cancer medication on a less favorable basis than the coverage it provides or cost sharing it imposes for intraveneously administered or injected cancer medications.” The misspelling is the statute’s own. The section equalizes two delivery routes; it does not create cancer-drug coverage. And its division (E) is a genuine statutory route out of the duty: an insurer is not required to comply where an independent member of the American Academy of Actuaries certifies a cost increase above a stated threshold, an actuary opines that it justifies a premium increase above the same threshold, and the superintendent so determines. Whether any insurer has ever used it, I could not establish.

Biologically based mental illness. Ohio Revised Code 3923.281(B) requires benefits for the diagnosis and treatment of biologically based mental illnesses “on the same terms and conditions as, and … no less extensive than” those for all other physical diseases and disorders, subject to its own division (E) off-ramp. The crucial point is that the section defines its subject as a closed list:

“‘Biologically based mental illness’ means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.”

An employer told that Ohio requires parity for mental health generally has been told something broader than the statute says. The section names its conditions, and it preserves the insurer’s right to use prior authorization and other utilization management.

Two prohibitions rather than benefits

Routine care in a cancer clinical trial. Ohio Revised Code 3923.80(A) provides that no health benefit plan shall deny coverage for the costs of routine patient care administered to an insured participating in any stage of an eligible cancer clinical trial, if that care would be covered were the insured not in a trial. This one is tied to the small-employer vocabulary by cross-reference rather than inferred into it: division (C)(3) states that “health benefit plan” has the same meaning as in Ohio Revised Code 3924.01. It is also heavily conditioned — the coverage remains subject to every term, restriction and limitation applying to other coverage under the plan, and “eligible cancer clinical trial” is itself a multi-part test with an approving-body list.

Emergency services without prior authorization. Ohio Revised Code 3923.65(B) requires every individual or group policy providing hospital, surgical or medical expense coverage to cover emergency services without regard to the day or time they are rendered or to whether prior authorization was obtained. The statute defines emergency medical condition itself, by a prudent-layperson test, and that definition is the one to use.

Two duties that reach group policies only

Ohio Revised Code 3923.28(A) and Ohio Revised Code 3923.29(A)(1) are the clearest group-only mandates in the chapter, and the federal consolidated list classifies both as group. The first applies to a group policy “that provides coverage for mental or emotional disorders” and requires outpatient benefits for each eligible person residing in Ohio at an annual floor the statute sets. The second is free-standing and requires outpatient, inpatient and intermediate primary care benefits for alcoholism at a similar annual floor.

Both floors are withheld here, and not only because of how this site handles figures. They are annual minimums whose operative date runs from the late seventies. Printing them would tell you something true about the statute and misleading about your plan: these are old floors that a modern policy clears without noticing.

An offer mandate is not a benefit, and Ohio’s version has a federal problem

Ohio Revised Code 3923.24(A)(1) requires an insurer, on the insured’s request, to offer to cover an unmarried child past the policy’s limiting age “until the child attains twenty-six years of age” if four things are all true: the child is the natural, step or adopted child of the insured; is an Ohio resident or a full-time student at an accredited institution; is not employed by an employer offering a plan under which the child is eligible; and is not eligible for medicaid or medicare. An offer mandate obliges the insurer to make the offer. It does not put the benefit into the plan.

The federal dependent-coverage rule names the same factors as things a plan may not use:

“With respect to a child who has not attained age 26, a plan or issuer may not define dependent for purposes of eligibility for dependent coverage of children other than in terms of a relationship between a child and the participant … a plan or issuer may not deny or restrict dependent coverage for a child who has not attained age 26 based on the presence or absence of the child’s financial dependency …; residency with the participant … or with any other person; whether the child lives, works, or resides in an HMO’s service area or other network service area; marital status; student status; employment; eligibility for other coverage; or any combination of those factors.”

Both texts are current and they point in opposite directions on the conditions. This page states both and stops there. Which instrument governs a particular policy is a legal conclusion, and the one thing that would be actively harmful is to present Ohio’s four conditions to an Ohio parent as the limit of what their child is entitled to.

The mandate Ohio wrote and kept out of this market

Ohio requires coverage for the screening, diagnosis and treatment of autism spectrum disorder — and then, in the same division, excludes the market this site writes in. The third sentence of Ohio Revised Code 3923.84(A) reads: “Nothing in this section shall be applied to nongrandfathered plans in the individual and small group markets or to medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies.” The identical sentence appears on the health-insuring-corporation twin at Ohio Revised Code 1751.84.

Every ACA-compliant small-group plan sold in Ohio today is nongrandfathered. On the face of both statutes, this mandate does not reach it. It is a real Ohio mandate; it is not a coverage an Ohio small-group reader has by virtue of it.

What this page could not establish

Whether a superintendent’s determination under the gatekeeper section has ever been made, for any mandate, is unresolved: the departmental bulletin corpus could not be enumerated from the tools used here. Some of the sections above sit after the gatekeeper’s cutoff without a visible override clause, and their status against it is likewise unresolved. They are cited as what Ohio’s code provides.

If you want to know what your own policy actually carries rather than what the chapter requires, the certificate and schedule of benefits are the documents that answer it, and reading them is part of every Ohio group health case we handle and every renewal we take to market. There is more Ohio background on the Ohio page, and if a specific mandate matters to a specific employee, ask us.