The primary concern for our organization and physicians is the Ohio budget and the potential catastrophic impact on Ohioans, especially those in need. The two-year budget passed by the Ohio House of Representatives last week includes a provision that would enable the state to back out of the Kasich-era Medicaid expansion if federal funding is cut. This would put healthcare coverage at risk for nearly 800,000 Ohioans and especially impact children, children’s hospitals, and rural hospitals.

Take Action Today

The budget is now in the hands of the Ohio Senate. We ask that our members and partners reach out to their Senators today to ask that they remove this provision to ensure Ohio’s most vulnerable are protected. Find your Ohio Senator and call their office today!

Insurance Reform Legislation

There is positive news to report. Legislators in the 136th General Assembly have recently introduced a slew of legislation aimed at insurance reform in Ohio. Find a summary of the legislation below, and please consider contacting your representatives in support of these issues.

House Bill 214 - Prior Authorization “Gold Card”

•  Sponsor(s): Rep. Kevin Miller, (R) Newark
• Status: In the House Insurance Committee
• This bill would create a system that rewards healthcare providers who consistently receive a prior authorization approval rate for a specific service or treatment in a 12-month period by establishing a “gold card” exemption from prior authorization requirements. It also contains data sharing requirements which mirror federal CMS requirements set to go into effect in 2027. Insurers would be required to share certain program metrics, such as rates of approval/denial/approval after appeal of urgent and non-urgent requests, with the Ohio Department of Insurance and publicly on their websites.

Senate Bill 160 – Non-Medical Switching

• Sponsor(s): Sen. Beth Liston, MD, (D) Dublin, Sen. Terry Johnson, (R) McDermott
• Status: In the Senate Financial Institutions, Insurance, and Technology Committee
• This legislation would prohibit insurers from non-medical switching or making mid-year drug formulary changes which force patients to undergo abrupt and unwarranted treatment changes.

Senate Bill 165 – Automatic Downcoding

• Sponsor(s): Sen. Susan Manchester – (R) Waynesfield
• Status: In the Senate Financial Institutions, Insurance, and Technology Committee
• SB 165 contains prohibitions on downcoding for all providers, including prohibitions on limitations on reimbursement for time spent with patients. It would also strengthen Ohio’s prudent layperson standard in order to protect Ohioans from unexpected medical bills due to their insurer denying claims for emergency care after the care has been sought and provided.

House Bill 219 – Network Adequacy

• Sponsor(s): Rep. Kellie Deeter, (R) Norwalk
• Status: In the House Insurance Committee
• This bill would require the Ohio Department of Insurance to create network adequacy standards for commercial plans.

Senate Bill 162 – Takebacks/Clawbacks

• Sponsor(s): Sen. Bill Blessing, (R) Colerain Twp.
• Status: In the Senate Financial Institutions, Insurance, and Technology Committee
• This Senate bill would change Ohio’s current 24-month insurer takeback timeframe, decreasing it to the same timeframe given to a provider to submit a claim, and also prohibit insurers from changing these timeframes during a contract period. It would also prohibit insurers from charging a provider for appealing a determination of overpayment.

Senate Bill 166 – No Fees for EFTs

• Sponsors(s): Sen. Nathan Manning, (R) North Ridgeville
• Status: In the Senate Medicaid Committee
• SB 166 would prohibit insurers from imposing any charge, fee, or other payment requirement (including through withholding from payment), on any healthcare provider for electronic fund transfers or remittance advice transactions.

House Bill 220 – Prior Authorization

• Sponsor(s): Rep. Heidi Workman, (R) Rootstown
• Status: In the House Insurance Committee
• HB 220 would strengthen existing Ohio prior authorization laws passed in 2018 by ensuring retroactive denials only occur in the event of non-covered benefits or lack of coverage at the time of service, requiring identification of clinical peer conducting peer review in adverse determinations, prohibiting insurers from charging providers for appeals, and requiring insurers to account for dosage adjustments in drug prior authorizations to treat chronic conditions.

Senate Bill 164 – Transparency in Health Plan Use of AI

• Sponsor(s): Sen. Al Cutrona, (R) Canfield
• Status: In the Senate Financial Institutions, Insurance, and Technology Committee
• This proposed legislation would require insurer transparency in their use of AI tools in prior authorization determinations, specifically by requiring insurers to disclose use of AI and ensuring that prior authorization determinations are made through review of individual merits of claims by licensed clinical professionals.

Get Involved

The role of our Public Policy Committee and Advocacy Community is to monitor legislation that impacts physicians and assist them in getting their voices heard on the issues that matter most. If you’d like to get involved, go to the Advocacy page on our website and watch for updates on upcoming policy meetings.