The regulation of health insurance in Ohio
In Ohio, the responsibility for the administration, regulation and oversight of the private health insurance market is delegated to the Ohio Department of Insurance, led by Director Mary Jo Hudson. Several private health insurers operate in Ohio, including Anthem Blue Cross Blue Shield, a for-profit publicly-traded company the largest health plan company member of the national Blue Cross Blue Shield federation of private health insurers. Anthem Blue Cross Blue Shield is the trade name of Community Insurance Company in Ohio. For those applying for group health insurance, Ohio state law prohibits denial of coverage or increased premiums due to your current health status. Health insurance cannot be cancelled because you get sick, and all Ohio health plans must limit the way they exclude those with pre-existing medical conditions. In addition, a group health plan can only consider those pre-existing medical conditions that you received (or were recommended to receive) treatment, medical advice or a diagnosis for in the last six months.
If no supporting documentation is needed to process an insurance claim, private health insurance providers have 30 days from the receipt of the claim to process it. If supporting documentation is needed a 45-day period applies. Supporting documentation must be requested in the first 30 days following the receipt of the claim, and the 45-day period is suspended until the last piece of supporting documentation is received. If a claim is submitted over one year after the last date of receiving medical treatment as part of the claim, the private health insurer has 90 days to inform the patient of their decision, unless it chooses to pursue an alternative route as outlined in Ohio state law. If you are not satisfied with a private health insurer’s decision, you may begin the insurer’s internal appeals process. Details of this process may be found in your policy information material. If you are not satisfied by the outcome of the appeal, you may ask the Ohio State Department of Insurance or an independent review organization to review the decision, depending on the reason why your appeal was rejected. Independent review organizations are not aligned with any insurance company and are accredited by the Department of Insurance.
