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15.12 Health Insuring Corporations

General Characteristics​

A Health Insuring Corporation (HIC) operates similarly to a Health Maintenance Organization (HMO) and is considered a managed health care system that provides a broad range of medical services on a prepaid basis. This arrangement generally results in minimal or no out-of-pocket expenses for members.

Individuals enrolled in managed care plans are referred to as subscribers rather than insureds. Subscribers are required to reside within a designated geographic region known as the service area. The HIC contracts with health care providers located within this service area, and subscribers must obtain medical treatment from these participating providers in order for services to be covered. Services received outside the service area are generally not covered, except in emergency situations.

Although Health Insuring Corporations (HICs) provide health care services on a prepaid basis, subscribers are typically still required to pay copayments for services such as office visits and hospital care. These copayments are considered administrative fees and are not determined by the actual cost of the services received. Copayments are intended to help control unnecessary use of medical services, such as the inappropriate use of emergency room facilities for nonemergency treatment.

Health Insuring Corporations (HICs) function as both a health care financing system and a health care delivery system. Their primary goals are to control and reduce medical costs by emphasizing preventive care, decreasing unnecessary hospital admissions and extended hospital stays, minimizing duplication of benefits and services, and lowering administrative expenses.

HIC Services​

Basic Health Services​

Basic health care services include the following medically necessary services:

  • Physician services, except when the services are considered supplemental
  • Inpatient hospital services
  • Outpatient medical services
  • Emergency health services, which must be available 24 hours a day and include coverage for emergency care received outside the service area
  • Urgent care services
  • Diagnostic laboratory services, as well as diagnostic and therapeutic radiologic services
  • Diagnostic and treatment services for biologically based mental illnesses, excluding prescription drug services
  • Preventive health care services, including but not limited to voluntary family planning, infertility treatment, periodic physical examinations, prenatal and obstetrical care, and well-child care
  • Routine patient care services provided to individuals participating in an eligible cancer clinical trial

Basic health care services do not include experimental or investigational procedures.

Supplemental Health Care Services​

Any health care services that are not classified as basic health care services are considered supplemental health care services. Supplemental services may be offered independently or together with basic health care services or other supplemental benefits. Examples of supplemental health care services include:

  • Intermediate care and long-term care facilities
  • Dental care services
  • Vision care services
  • Podiatric or foot care services
  • Mental health services, excluding diagnostic and treatment services for biologically based mental illnesses
  • Short-term outpatient mental health services and crisis intervention services
  • Treatment for alcohol or drug abuse and addiction
  • Home health care services
  • Prescription drug coverage
  • Nursing care services
  • Dietitian or nutritional counseling services
  • Physical therapy services
  • Chiropractic care services

If a Health Insuring Corporation (HIC) provides prescription drug coverage, the coverage must include prescription medications used to treat biologically based mental illnesses under the same terms, conditions, and limitations that apply to prescription drug coverage for physical illnesses and disorders.

Specialty Health Care Services​

When a Health Insuring Corporation (HIC) provides supplemental health care services exclusively on an outpatient basis and not together with other supplemental health care services, those services are classified as specialty health care services.

Closed Panel Plans​

Closed panel plans are health care plans that require enrollees to obtain medical services from participating or network providers in order for coverage to apply.

HIC Certification and Regulation​

Solicitation Documents​

Each prospective applicant must receive a solicitation document containing all information necessary to make an informed decision about enrolling in the Health Insuring Corporation (HIC). The document must include a detailed description of the health care services available, as well as the approximate number and types of participating medical providers and practitioners.

Any revisions to a Health Insuring Corporation’s (HIC’s) solicitation document must be filed with the Superintendent at least 30 days before the revised document is used. The Superintendent may disapprove a rate by providing the health insuring corporation with written notice at least 30 days in advance.

Advertising​

A Health Insuring Corporation (HIC) is prohibited from using advertisements or engaging in activities that are unfair, false, misleading, or deceptive.

All solicitation documents and advertisements must clearly identify the name of the Health Insuring Corporation (HIC). An HIC may not use a name that is deceptively similar to the name of any insurance or surety corporation authorized to conduct business in Ohio.

The use of words, symbols, or physical materials that suggest or imply an affiliation with a federal or state government agency is prohibited in solicitation documents and advertisements.

A Health Insuring Corporation (HIC) that provides basic health care services may use the term “Health Maintenance Organization” or the abbreviation “HMO” in its marketing name, advertisements, solicitation materials, marketing literature, or in connection with the phrase “doing business as” (DBA).

Confidentiality of Medical and Health Information​

Any medical information obtained from an enrollee must be maintained in strict confidence and may not be disclosed to another person unless the disclosure is:

  • Required by law enforcement authorities or a court order
  • Necessary for claim-related litigation
  • Required to administer or enforce insurance laws
  • Specifically authorized or consented to by the enrollee

Member Rights​

An enrollee has the right to appeal any action or decision made by a Health Insuring Corporation (HIC). To begin the appeal process, the enrollee must submit a written complaint to the HIC. If the enrollee is dissatisfied with the HIC’s written response, the enrollee may file an appeal with the Superintendent within 30 days after receiving the response.

Health Insuring Corporations (HICs) are required to establish and maintain procedures for resolving written complaints submitted by subscribers or enrollees. The HIC must also provide a timely written response to each complaint received.

Copies of complaints, responses, and any related medical records must be maintained and made available to the Superintendent for inspection for a period of 3 years. Any document or information containing medical records is considered confidential and is not classified as a public record.

The Superintendent may disclose confidential information when necessary for the investigation of suspected criminal activity, provided that the receiving party agrees to preserve the confidentiality of the information.

Evidence of Coverage​

Each subscriber must receive an identification card that displays the name of the Health Insuring Corporation (HIC) and includes toll-free telephone numbers that provide:

  • 24-hour, 7-day-a-week access to information regarding how to obtain health care services
  • Access during normal business hours to information about specific coverage details and the internal and external review procedures

The identification card must also contain a clear, concise, and complete explanation of the following:

  • The health care services, insurance coverage, and other benefits available to the enrollee
  • Any exclusions or limitations on coverage, including applicable copayments and deductibles
  • The enrollee’s financial responsibility for services that are not covered under the plan
  • The premium rate for individual and conversion contracts, as well as applicable copayment and deductible provisions for all contracts
  • The procedures used to resolve enrollee complaints
  • The utilization review process, along with the internal review and external review procedures

Each Health Insuring Corporation (HIC) must provide subscribers with information describing the corporation, its methods of operation, service area, current provider directory, complaint procedures, and its utilization review, internal review, and external review processes. This information must be distributed annually by HICs that provide basic health care services and every 2 years by HICs that provide specialty health care services.

Renewal​

A Health Insuring Corporation (HIC) may not cancel or refuse to renew an enrollee’s coverage based on the enrollee’s health condition or need for health care services. Coverage also may not be canceled or nonrenewed because of an enrollee’s race, color, sex, age, religion, or military status.

A Health Insuring Corporation (HIC) may cancel or refuse to renew an enrollee’s coverage if the enrollee has engaged in fraud or made a material misrepresentation.