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Rights – Laws

Health insurance laws in Ohio are similar to much of the nation, with a few key federal regulations governing how insurers can issue health plans, and the rest is determined at the state level. Ohio health insurance companies on the private market are no longer permitted certain liberties in underwriting that make the process of getting insured more difficult if you have a flawed medical history or health status. Whether your BMI is over the normal limit, you’ve beaten cancer, or you’re pregnant, individual health insurance is not a challenge to obtain in Ohio under the Affordable Care Act. Once the ACA was completely implemented, conditions, gender, occupation and other personal factors cannot determine your premium rate. Additional freedoms have also been granted to policyholders under Obamacare.

Your rights as a health plan member are increasing under the ACA, and several laws before this one have also helped provide people with certain benefits and privileges. Apart from your protections, you may experience some confusion with your insurer regarding a claim or have an issue with your plan, and use your right to file a complaint. Appeals and complaints (which can be found though the Ohio Department of Insurance) help us understand which insurers are running their business smoothly and keeping members content, so you’re doing others a favor if your health plan raises a legitimate concern.

There are several laws to keep in mind as a policyholder to help you know what your plan can and cannot do. Federal and state laws prevent you from losing your coverage, allow you to get certain types of care, and permit insurers to set limits on what they cover.


Guaranteed Renewability

Under this provision, insurance companies are not permitted to drop you from a health plan for any reason that is not sensible. In the past, insurers would rescind policies if a person applied for coverage, was accepted, then acquired an illness, alleging the individual was dishonest on their application. Now, rescissions can only occur if you actually do lie on your application and turn out to have a condition, or you do not pay your premiums, or you commit fraud. Seems more logical than allowing insurers to cancel benefits just because someone suddenly becomes a risk. This is not a usual scenario, but you are protected against it regardless by chance you do get sick. This law also guarantees your health plan will offer to renew your coverage at the end of each year.


Rate Adjustments & Conditions

Prior to the healthcare law, Ohio insurers could increase your premiums, exclude benefits, or decide against selling you a plan if you were too high-risk. Pre-existing conditions comprised a wide range of health problems, and insurers could ask you about your medical history up to 6 months (which was incredibly short compared to many states) before applying. Insurers could request information that dates back further if you have any conditions. If you were accepted for a plan, insurers had the right to not cover certain benefits for your illness for up to 12 months with an exclusion period. They could also choose not to cover them at all, or for a longer period of time with an elimination rider. However, if you had a solid record of coverage in the past, you could use your previous plan as a credit to pay for care during the exclusion period in Ohio.

Under health reform, insurers cannot discriminate against people with health conditions by declining applicants, increasing rates, or issuing exclusions. The ACA only allows insurers to increase premiums based on age, location and tobacco use.


Mandatory Benefits

Certain health plans in Ohio are required to include a number of benefits, when applicable, to the insured, according to state and federal laws. These benefits include types of coverage offered to dependents, forms of care to prevent cancer, and other necessary services. Some of these state laws parallel the health reform requirement for essential health benefits, though the EHB requirement is more broad in some cases, requesting insurers to cover categories of care. Presently, insurers in Ohio must cover the following:

  • Alcoholism treatment
  • Ambulance services
  • Cervical cancer screening
  • Continuation of benefits for employees
  • Coverage for adopted children and newborns under parent’s plan
  • Coverage for dependents with disabilities under parent’s plan
  • Coverage for dependents until age 26 under parent’s plan
  • Kidney dialysis
  • Mammography
  • Maternity care and hospital stay
  • Mental health care
  • OB/GYN
  • Prescription drugs
  • Well-child services





1. Kaiser State Health Facts. Individual Market Portability Rules.

2. The Bureau of National Affairs. Ohio Mandatory Health Benefits.