CMA State Policy Update

State Budget

The following provisions are included in the Senate-passed version of the state operating budget for state fiscal years 2026-2027 (beginning July 1, 2025). The budget bill will next head to a House-Senate Conference Committee where the content of the bill will change again, meaning some or all of the provisions described below may be changed or eliminated and not become codified in law. You can educate yourself about the provisions of the bill by accessing the bill here and contacting your state legislators, including members of the Conference Committee.

R.C. 9.05 Sex Recognition

What is it?

• Establishes a state policy recognizing only two sexes, male and female, which “are not changeable and are grounded in fundamental and incontrovertible reality”.
  

What does it mean?

• The ability of people who do not identify as male or female or whose sex has changed or will change to access affirming health care will be challenged, as will the ability of health care professionals to provide appropriate healthcare.

R.C. 3701.511 Genetic Services Funds for Abortion Referral or Counsel

What is it?

• Eliminates the availability of Ohio Department of Health Genetic Services funds to counsel or refer for abortion in the case of a medical emergency.
  

What does it mean?

• Medical professionals will be prohibited from using Genetic Services funds to counsel or refer a patient for an abortion. 

R.C. 3701.79, 2919.171 Abortion Reporting Changes

What is it?

• Requires the abortion report to be completed by an attending physician when an abortion is performed surgically or through abortion-inducing drugs. Also requires that the pregnant woman’s state of residence and her zip code be reported. 
  

What does it mean?

• This requirement could result in additional administrative work for attending physicians, but the abortion report is already required, so there may no be real effect for physicians.

R.C. 3705.16, 4731.22 Medical Certificate of Death

What is it?

• Clarifies that the coroner or medical examiner certifies a death when a decedent dies of criminal or other violent means, while an attending physician certifies the cause of death in all other circumstances. Authorizes the physician who last examined or treated a decedent to certify the decedent’s cause of death and complete and sign the medical certificate of death, but only in the cases where the decedent did not have an attending physician in charge of a patient’s care for the illness or condition that resulted in the patient’s death. Extends the timeline by which a medical certificate of death must be completed and signed, from 48 hours after death to 48 hours after notice of death. Revises existing law provisions that apply when a decedent’s cause of death remains pending. 
  

What does it mean?

• Clarifies responsibilities related to medical certificates of death.

R.C. 3748.13 Inspection Fees

What is it?

• Increases inspection fees for radiation-generating equipment used in facilities operated by medical practitioners or medical practitioner groups
  

What does it mean?

• Inspection fees for dental x-ray tube, medical x-ray tube, ionizing radiation-generating equipment, and nonionizing radiation-generating equipment will increase.

R.C. 4730.25, 4731.22, 4759.07, 4760.13, 4761.09, 4762.13, 4772.20, 4774.13, and 4778.14 Summary Suspensions

What is it?

• Revises the law authorizing  the State Medical Board of Ohio to issue summary suspensions against its license holders by:
  • Eliminating provisions specifying that an order is not subject to suspension by a court before the State Medical Board of Ohio issues its final adjudicative order and, instead, specifies the following: (a) that a summary suspension is not a final appealable order and is not an adjudication that may be appealed under the Administrative Procedure Act and (b) that once a final adjudicative order has been issued, any party adversely affected by it may file an appeal in accordance with the requirements of the Administrative Procedure Act.
  • Eliminating provisions specifying that the period during which a summary suspension is in effect applies unless reversed on appeal.

R.C. 333.13 Social Gender Transition

What is it?

• Prohibits Medicaid reimbursement for mental health services that promote or affirm social gender transition.

What does it mean?

• Individuals will lose access to mental health services, and providers will be tasked with complying with a law that is vague.
  

R.C. 5163.11 Medicaid Group VIII Eligibility Redeterminations

What is it?

• Requires the Ohio Department of Medicaid to conduct eligibility requirements for Group VIII enrollees (i.e., the Medicaid expansion population) every six months.

What does it mean?

• Every six months, Group VIII enrollees’ coverage will be threatened if they are unable to meet Medicaid eligibility requirements, meaning more people will become uninsured. Providers’ population of Medicaid patients is likely to decline, while their population of uninsured patients is likely to increase. 
  

State Miscellaneous 

OSMA Insurance Reform Effort

The Ohio State Medical Association (OSMA) is launching an Insurance Reform Campaign that seeks to reduce burdens placed on physicians by insurers. According to the OSMA, these bills (House Bills 214, 219, 220 and Senate Bills 160, 162, 164, 165, 166) “will bring much-needed transparency to the insurmountable power insurers have at dictating medical care—power that too often disrupts the ability of physicians to effectively provide patient care, and can lead to patients facing delays and denials of medically-necessary and even life-saving treatments”.  Right now, the call to action is to educate yourself about these bills and be prepared to advocate for them when the time is right.

HB 214 Require Medicaid, Health Insurers Report on Prior Authorization

What is it?

• Requires health insurers to make prior authorization data available on their websites in a readily accessible format and submit such data in a report to the Ohio Department of Insurance which, in turn, must provide the data to the General Assembly. 
• Requires health insurers and the Ohio Department of Medicaid (ODM) to exempt a healthcare provider from prior authorization when at least 90% of the provider’s requests for a service, device, or drug within the prior 12 months have been approved.  
• Permits providers to request evidence from a health insurer or ODM that supports the insurer’s or ODM’s decision to deny an exception, and to appeal that exception. Providers would not be required to initiate a request as a condition of receiving an exemption. Exemptions are to be reviewed after a year. Establishes guidelines for the exception of the review process and permits a provider to appeal an exemption revocation.

HB 219 Establish Network Adequacy Standards for Health Insurers

What is it?

• Requires health plan issuers to establish and maintain adequate provider networks to ensure all covered benefits are accessible to covered persons. 
• Requires a health plan issuer to establish and maintain a process to ensure covered persons are able to obtain covered benefits at an in-network level from an out-of-network provider whenever there are not a sufficient number of in-network providers.
• Requires a health plan issuer to establish and maintain adequate arrangements to ensure all covered persons have reasonable access to in-network providers near the covered person’s home or place of employment. 
• Requires a health plan issuer to monitor the ability, clinical capacity, and legal authority of in-network providers to furnish covered benefits under the network plan. 
• Prohibits a health plan issuer from delivering, issuing for delivery, or using a network plan before a copy of the plan, premium rates, and an access arrangement are filed with the Ohio Department of Insurance (ODI). 
• Requires a health plan issuer to notify the Superintendent of any material change to a network plan or access arrangement within 15 business days of the change or implementation of the change. 
• Requires a health plan issuer to provide covered persons a directory that identifies which providers and facilities belong to each network and which networks are applicable to each specific plan offered in Ohio. 

HB 220 Regards Health Insurance, Medicaid Prior Authorization 

What is it?

• Requires health insurers and the Department of Medicaid (ODM) to honor a prior authorization approval if a provider prescribes a change in dosage of an approved drug. 
• Requires that the name, specialty, and relevant qualifications of the clinical peer, who is required by continuing law to review prior authorization appeals, to be identified. 
• Prohibits health insurers from charging a fee for appealing an adverse prior authorization determination. 
• Prohibits health insurers and ODM from retroactively denying a prior authorization for mental health or substance use disorder treatment. 
  
   

SB 160 Regards Prescription Drugs and Medication Switching

What is it?

• Prohibits insurers from making mid-year drug formulary changes to avoid abrupt and unwarranted treatment changes that disrupt a physician’s ability to exercise their medical expertise to help their patients.

SB 162 Regards Timing of Health Insurer Recoupment from Providers

What is it?

•  Shortens the time period in which a payment made by a third-party payer to a provider shall be considered final. 
  

SB 164 Regulate the Use of Artificial Intelligence by Health Insurers

What is it?

•  Requires health plan issuers to annually file a report with the Superintendent of insurance covering a variety of information including: each provider in the health plan issuer’s network, the number of covered persons enrolled in health benefit plans issued by the health plan issuer, whether the health plan issuer is using, or will use artificial intelligence-based algorithms in utilization review processes for those health benefit plans, and much more information as listed in the bill. 
  
• Prohibits health plan issuers from making a decision regarding the care of a covered person, including the decision to deny, delay, or modify health care services based on medical necessity, based solely on results derived from the use or application of artificial intelligence.
  

SB 165 Prohibit Denial of Health Insurance Claim for Certain Factors, SB 166 Prohibit Health Insurance, Medicaid Electronic Claim Fees

What is it?

• Prohibits insurers from imposing any charge, fee, or other payment requirement (including through withholding from payment), on any provider for electronic fund transfers or remittance advice transactions. 
  

HB 172 Prohibit Mental Health Service to Minors Without Parental Consent

• Prohibits the provision of mental health services by mental health professionals (including psychiatrists) to minors without parental consent

• More limited access to mental health services for minors and a greater administrative burden for providers. 
  

• The bill was introduced in the House in March and referred to the House Health Committee in March. Interested parties can read more about the bill here and contact the bill sponsor to weigh in.

HB 277 Health Care Workers’ Employment Status

• Specifies conditions under which a health care worker providing services to patients is not an employee of a healthcare worker platform or a healthcare facility for purposes of state overtime and minimum wage requirements, the Bimonthly Pay Law, the Workers’ Compensation Law, the Unemployment Compensation Law, and the Income Tax Law.
  

• Strengthens a health care worker’s ability to be treated as an independent contractor when the health care worker seeks work through a healthcare worker platform. 

• The bill was introduced in the House in May and referred to the House Commerce and Labor Committee in May. Interested parties can read more about the bill here and contact the bill sponsor to weigh in.