SB 165: Prohibit denial of health insurance claim for certain factors

As Introduced

136th General Assembly Regular Session 2025-2026

S. B. No. 165

Senator Manchester

To amend sections 1753.28 and 3923.65 and to enact 1
sections 1753.29 and 3923.66 of the Revised Code 2
to prohibit a health insuring corporation or 3
sickness and accident insurer from reducing or 4
denying a claim based on certain factors. 5

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That sections 1753.28 and 3923.65 be amended 6
and sections 1753.29 and 3923.66 of the Revised Code be enacted 7
to read as follows: 8

Sec. 1753.28. (A) As used in this section: 9

(1) "Emergency medical condition" means a medical physical 10
or mental health condition that manifests itself by such acute 11
symptoms of sufficient severity, including severe pain, that a 12
prudent layperson with an average knowledge of health and 13
medicine could reasonably expect the absence of immediate 14
medical attention to result in any of the following: 15
(a) Placing the health of the individual or, with respect 16
to a pregnant woman, the health of the woman or her unborn 17
child, in serious jeopardy; 18

b) Serious impairment to bodily functions; 19

S. B. No. 165 As Introduced

(c) Serious dysfunction of any bodily organ or part. 20
(2) "Emergency services" means the following: 21
(a) A medical screening examination, as required by 22
federal law, that is within the capability of the emergency 23
department of a hospital, including ancillary services routinely 24
available to the emergency department, to evaluate an emergency 25
medical condition; 26
(b) Such further medical examination and treatment that 27
are required by federal law to stabilize an emergency medical 28
condition and are within the capabilities of the staff and 29
facilities available at the hospital, including any trauma and 30
burn center of the hospital. 31
(3)(a) "Stabilize" means the provision of such medical 32
treatment as may be necessary to assure, within reasonable 33
medical probability, that no material deterioration of an 34
individual's medical condition is likely to result from or occur 35
during a transfer, if the medical condition could result in any 36
of the following: 37
(i) Placing the health of the individual or, with respect 38
to a pregnant woman, the health of the woman or her unborn 39
child, in serious jeopardy; 40
(ii) Serious impairment to bodily functions; 41
(iii) Serious dysfunction of any bodily organ or part. 42
(b) In the case of a woman having contractions, 43
"stabilize" means such medical treatment as may be necessary to 44
deliver, including the placenta. 45
(4) "Transfer" has the same meaning as in section 1867 of 46
the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 47

S. B. No. 165 As Introduced

1395dd, as amended. 48
(B) A health insuring corporation policy, contract, or 49
agreement providing coverage of basic health care services shall 50
cover emergency services for enrollees with emergency medical 51
conditions without regard to the day or time the emergency 52
services are rendered or to whether the enrollee, the hospital's 53
emergency department where the services are rendered, or an 54
emergency physician treating the enrollee, obtained prior 55
authorization for the emergency services. 56
(C) A health insuring corporation policy, contract, or 57
agreement providing coverage of basic health care services shall 58
cover both of the following: 59
(1) Emergency services provided to an enrollee at a 60
participating hospital's emergency department if the enrollee 61
presents self with an emergency medical condition; 62
(2) Emergency services provided to an enrollee at a 63
nonparticipating hospital's emergency department if the enrollee 64
presents self with an emergency medical condition and one of the 65
following circumstances applies: 66
(a) Due to circumstances beyond the enrollee's control, 67
the enrollee was unable to utilize a participating hospital's 68
emergency department without serious threat to life or health. 69
(b) A prudent layperson with an average knowledge of 70
health and medicine would have reasonably believed that, under 71
the circumstances, the time required to travel to a 72
participating hospital's emergency department could result in 73
one or more of the adverse health consequences described in 74
division (A)(1) of this section. 75
(c) A person authorized by the health insuring corporation 76

S. B. No. 165 As Introduced

refers the enrollee to an emergency department and does not 77
specify a participating hospital's emergency department. 78
(d) An ambulance takes the enrollee to a nonparticipating 79
hospital other than at the direction of the enrollee. 80
(e) The enrollee is unconscious. 81
(f) A natural disaster precluded the use of a 82
participating emergency department. 83
(g) The status of a hospital changed from participating to 84
nonparticipating with respect to emergency services during a 85
contract year and no good faith effort was made by the health 86
insuring corporation to inform enrollees of this change. 87
(D) A health insuring corporation that provides coverage 88
for emergency services shall inform enrollees of all of the 89
following: 90
(1) The scope of coverage for emergency services; 91
(2) The appropriate use of emergency services, including 92
the use of the 9-1-1 system and any other telephone access 93
systems utilized to access prehospital emergency services; 94
(3) Any cost sharing provisions for emergency services; 95
(4) The procedures for obtaining emergency services and 96
other medical services, so that enrollees are familiar with the 97
location of the emergency departments of participating hospitals 98
and with the location and availability of other participating 99
facilities or settings at which they could receive medical 100
services; 101
(5) That enrollees are not required to self-diagnose. 102
Sec. 1753.29. (A) A health insuring corporation shall not 103

S. B. No. 165 As Introduced

reduce or deny a claim for reimbursement based solely on a 104
diagnosis code or impression, current ICD code, duration of an 105
appointment as deemed clinically necessary by the enrollee's 106
provider, or select procedure code relating to the enrollee's 107
condition included on a form submitted to the health insuring 108
corporation by a provider for reimbursement of a claim. 109

(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 126
to a pregnant woman, the health of the woman or her unborn 127
child, in serious jeopardy; 128
(b) Serious impairment to bodily functions; 129
(c) Serious dysfunction of any bodily organ or part. 130
(2) "Emergency services" means the following: 131

S. B. No. 165 As Introduced

(a) A medical screening examination, as required by 132
federal law, that is within the capability of the emergency 133
department of a hospital, including ancillary services routinely 134
available to the emergency department, to evaluate an emergency 135
medical condition; 136
(b) Such further medical examination and treatment that 137
are required by federal law to stabilize an emergency medical 138
condition and are within the capabilities of the staff and 139
facilities available at the hospital, including any trauma and 140
burn center of the hospitaland "emergency services" have the 141
same meanings as in section 1753.28 of the Revised Code. 142
(B) Every individual or group policy of sickness and 143
accident insurance that provides hospital, surgical, or medical 144
expense coverage shall cover emergency services without regard 145
to the day or time the emergency services are rendered or to 146
whether the policyholder, the hospital's emergency department 147
where the services are rendered, or an emergency physician 148
treating the policyholder, obtained prior authorization for the 149
emergency services. 150
(C) Every individual policy or certificate furnished by an 151
insurer in connection with any sickness and accident insurance 152
policy shall provide information regarding the following: 153
(1) The scope of coverage for emergency services; 154
(2) The appropriate use of emergency services, including 155
the use of the 9-1-1 system and any other telephone access 156
systems utilized to access prehospital emergency services; 157
(3) Any copayments for emergency services; 158
(4) That the covered person is not required to self- 159
diagnose. 160

S. B. No. 165 As Introduced

(D) This section does not apply to any individual or group 161
policy of sickness and accident insurance covering only 162
accident, credit, dental, disability income, long-term care, 163
hospital indemnity, medicare supplement, medicare, tricare, 164
specified disease, or vision care; coverage under a one- 165
timelimitedduration one-time-limited-duration policy that is 166
less than twelve months; coverage issued as a supplement to 167
liability insurance; insurance arising out of workers' 168
compensation or similar law; automobile medical payment 169
insurance; or insurance under which benefits are payable with or 170
without regard to fault and which is statutorily required to be 171
contained in any liability insurance policy or equivalent self- 172
insurance. 173
Sec. 3923.66. (A) A sickness and accident insurer shall 174
not reduce or deny a claim for reimbursement based solely on a 175
diagnosis code or impression, current ICD code, duration of an 176
appointment as deemed clinically necessary by the covered 177
person's provider, or select procedure code relating to the 178
covered person's condition included on a form submitted to the 179
sickness and accident insurer by a provider for reimbursement of 180
a claim. 181
(B) A sickness and accident insurer shall not reduce or 182
deny a claim for reimbursement based on the absence of an 183
emergency medical condition if a prudent layperson with an 184
average knowledge of health and medicine would have reasonably 185
expected the presence of an emergency medical condition. 186
(C) Nothing in this section shall be construed as 187
exempting a sickness and accident insurer from the prompt 188
payment requirements prescribed in sections 3901.381 to 189
3901.3814 of the Revised Code. 190

S. B. No. 165 As Introduced

Section 2. That existing sections 1753.28 and 3923.65 of 19
the Revised Code are hereby repealed. 19