3.1 Ohio Health Insurance Policy Requirements
Key Takeaways
- Individual accident and sickness policies in Ohio carry a 10-day free look under Revised Code Chapter 3923; the buyer returns the policy for a full refund.
- ORC 3923.04 fixes mandatory standard provisions: grace periods of 7/10/31 days, 20-day notice of claim, and 60-day wait before legal action.
- Ohio uses the federally-facilitated marketplace (HealthCare.gov); the Ohio Department of Insurance keeps regulatory authority over carriers and producers.
- ACA-compliant individual and small-group plans must cover all ten essential health benefits and apply guaranteed issue and guaranteed renewal.
- Mental health and substance-use benefits must meet federal parity (MHPAEA): no harsher copays, deductibles, or treatment limits than medical benefits.
Who Regulates Health Coverage in Ohio
Health, accident, and sickness insurance in Ohio is governed by Revised Code Chapter 3923 (Sickness and Accident Insurance) and enforced by the Ohio Department of Insurance (ODI). Federal rules from the Affordable Care Act (ACA) and the Centers for Medicare & Medicaid Services overlay the individual and small-group markets. The exam expects you to know which layer controls a given fact.
| Layer | Authority | What it controls |
|---|---|---|
| ODI | ORC Title 39, Chapters 3901/3923 | Policy forms, standard provisions, producer licensing, market conduct |
| CMS / HealthCare.gov | ACA, federal regulation | Marketplace enrollment, premium tax credits, metal tiers |
| ORC 3923.04 | Ohio statute | Mandatory standard policy provisions (see below) |
A frequent trap: Ohio runs a federally-facilitated exchange, so buyers enroll at HealthCare.gov, but Ohio did not abandon regulation. ODI still licenses every carrier and producer and enforces state law on those plans.
The Free Look Period
Ohio gives the owner of an individual accident and sickness policy a 10-day free look beginning the day the policy is delivered. Within those 10 days the owner may return the policy and receive a full refund of premium, no questions asked. Memorize the contrast tested constantly:
- Individual health / accident-sickness: 10 days
- Medicare Supplement (Medigap) and long-term care: 30 days
- Replacement of life insurance for an Ohio senior age 65+: 30 days
Do not confuse free look (return the issued policy) with the time-limit-on-certain-defenses clause (after two years a carrier cannot contest the policy except for fraud).
ORC 3923.04 Standard Provisions
Every individual sickness-and-accident policy delivered in Ohio must contain the statutory standard provisions. The exact numbers are high-value test points.
| Provision | Ohio requirement |
|---|---|
| Grace period | 7 days (weekly premium), 10 days (monthly), 31 days (all other modes) |
| Reinstatement | Lapsed policy may be reinstated; sickness covered after 10 days |
| Notice of claim | Within 20 days after loss begins, or as soon as reasonably possible |
| Proof of loss | Within 90 days of the loss |
| Time of payment of claims | Periodic indemnities at least monthly; balance promptly on proof |
| Legal actions | No suit sooner than 60 days after proof of loss; none after 3 years |
| Physical exam / autopsy | Insurer may examine the insured and, where not forbidden, order autopsy |
Worked example: an insured is hurt March 1. Under 3923.04 she has until roughly March 21 to file notice of claim and until about May 30 to submit proof of loss. If the carrier denies, she must wait 60 days from proof before suing and cannot sue at all after three years.
Essential Health Benefits
ACA-compliant individual and small-group plans sold in Ohio must cover the ten essential health benefits (EHBs). The exam may ask which categories are mandatory.
- Ambulatory (outpatient) patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance-use-disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic-disease management
- Pediatric services, including oral and vision care
Preventive services (immunizations, screenings, well-woman visits) must be covered with no cost sharing when in-network.
Guaranteed Issue and Guaranteed Renewal
- Guaranteed issue: carriers must accept all applicants in the individual and small-group markets during open or special enrollment, regardless of health status. Pre-existing condition exclusions are prohibited in these markets.
- Guaranteed renewal: the carrier cannot refuse to renew except for: non-payment of premium, fraud or intentional misrepresentation, the insured moving out of the service area, or discontinuance of the plan with proper notice.
| Market segment | Pre-existing exclusion allowed? |
|---|---|
| Individual (ACA) | No |
| Small group | No |
| Large group | No for new plans |
| Medicare Supplement | Limited (6-month look-back outside open enrollment) |
Mental Health Parity
Under the federal Mental Health Parity and Addiction Equity Act (MHPAEA), plans that cover behavioral health may not impose copays, deductibles, visit limits, or treatment limits on mental health or substance-use care that are more restrictive than those applied to comparable medical and surgical benefits. There can be no separate annual or lifetime dollar limits for mental health. Tested conditions include major depression, bipolar disorder, schizophrenia, anxiety disorders, eating disorders, autism spectrum disorder, and substance-use disorders.
The Marketplace and Subsidies
Ohioans buy individual ACA coverage at HealthCare.gov.
- Metal tiers set actuarial value: Bronze ~60%, Silver ~70%, Gold ~80%, Platinum ~90%.
- Advance premium tax credits lower monthly premiums based on household income relative to the federal poverty level.
- Cost-sharing reductions lower deductibles and copays but apply only to Silver-tier plans.
- Open enrollment runs roughly November 1 through mid-January; outside it, a qualifying life event (marriage, birth, loss of other coverage, move) triggers a 60-day special enrollment period.
Common trap: cost-sharing reductions attach to Silver only, while premium tax credits can apply to any metal level the buyer chooses.
An insured suffers a covered loss on June 1. Under the Ohio standard provisions in Revised Code 3923.04, by when must written notice of claim normally be given?
Which statement about cost-sharing reductions (CSRs) on the Ohio marketplace is correct?
How long is the free look period on an individual accident and sickness policy delivered in Ohio?