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HB 891

Enact the Fair Health Claims Act

136th Legislature (2025-2026) Introduced by Sean Brennan and 4 co-sponsors

The bill creates a state program to help consumers contest wrongfully denied health benefits and imposes penalties and stricter oversight on health plans.

Referred to committee
#commerce #insurance
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Bill Summary · HB 891

Overview

HB 891, introduced in the 136th Ohio General Assembly, is titled the Fair Health Claims Act. It seeks to create a Medical Claims Consumer Assistance Program, tighten protections against wrongful denial/reduction/termination of covered health care services or payments, and enhance reporting and oversight of adverse benefit determinations by health plan issuers. The bill would amend and add sections to the Revised Code and repeal certain existing sections related to insurance complaints and remedies.

Purpose and intent

  • Establish a state-run framework to prevent improper denials and to empower consumers who dispute health benefit determinations.
  • Create a medical claims consumer assistance program to help individuals navigate internal appeals, external reviews, and related processes.
  • Provide enhanced enforcement mechanisms and penalties for health plan issuers that wrongfully deny or reduce benefits.
  • Improve data collection and transparency on adverse benefit determinations and wrongful denials.

Key provisions

1) Prohibition on wrongful denials (Section 3901.216)

  • Health plan issuers may not wrongfully deny, reduce, or terminate a requested health care service or payment that is covered.
  • Violations fall under the enforcement framework of section 3901.22, with added remedies if the superintendent of insurance finds a violation.
  • If proven, courts may:
    • Order double payment to the covered person (double the wrongful amount) plus reasonable related professional expenses.
    • Impose compensatory damages and a civil penalty up to $25,000 per violation.
    • Impose additional penalties for repeated violations.
  • Penalties are adjusted annually beginning one year after the effective date, based on health insurance premium trends or inflation (whichever is higher).

2) Administrative and penalty framework (Section 3901.216; cross-referenced with 3901.22)

  • The superintendent may pursue state action via the attorney general.
  • Court-imposed penalties consider factors such as gravity, harm, cooperation, corrective action, bad faith, issuer financial status, number of affected consumers, frequency, and deterrence.

3) Medical claims consumer assistance program (Section 3901.97)

  • Establishes a program to assist health plan consumers with:
    • Information and assistance regarding internal appeals and external reviews.
    • Filing complaints and appeals, settling disputes, and assisting with premium tax credits.
    • Collecting and tracking consumer problems and inquiries.
    • Educating consumers about rights and responsibilities.
    • Assisting with enrollment and premium credits.
    • Providing outreach via electronic resources and a toll-free number.
  • May contract with a nonprofit administrator; health plan issuers or their affiliates cannot serve as the administrator.
  • Requires prominent plain-language notices about the program on health plan communications.

4) Assigned independent review organization considerations (Section 3922.07)

  • When reviewing adverse determinations, an independent review organization must consider:
    • Medical records, attending professional recommendations, supporting documents from all parties.
    • Plan terms and coverage.
    • Relevant clinical guidelines and evidence-based standards.
    • Applicable utilization review criteria.
    • The independent reviewer’s clinical opinion.
    • Evidence of intent to improperly deny or deny benefits.

5) Data reporting and transparency (Section 3922.171)

  • Health plan issuers must report adverse benefit determinations and related data to the superintendent.
  • The superintendent must annually publish a comprehensive report with:
    • Total adverse determinations by issuers.
    • The share deemed wrongful under 3901.216.
    • Data from the medical claims consumer assistance program.
    • Outcomes of investigations and any corrective actions.
  • The report is to be shared with key state leaders and posted publicly in machine-readable format.
  • The superintendent must review and update data annually and may highlight issuers whose wrongful determinations exceed median levels.

Affected entities and individuals

  • Health plan issuers and their subsidiaries/affiliates licensed under Title XXXIX.
  • Covered persons (enrollees/claimants) under health benefit plans.
  • Consumers utilizing the health care internal/external appeal processes.
  • The Ohio Department of Insurance (superintendent) and the Attorney General for enforcement.
  • Potential nonprofit entities contracted to administer the medical claims consumer assistance program.

Procedural and timeline aspects

  • Penalty adjustments begin one year after the act’s effective date and occur annually thereafter.
  • The act repeals sections 3901.22 and 3922.07 and enacts/addresses related provisions (3901.216, 3901.97, 3922.171) to consolidate enforcement and reporting.
  • The medical claims consumer assistance program is to be established by the superintendent, with implementation guided by provisions of the federal Patient Protection and Affordable Care Act where appropriate.
  • Annual reporting requirements commence after the initial data collection year, with ongoing collaboration across state agencies.

Potential impact

  • Strengthened protections against wrongful health benefit determinations.
  • Increased accountability for health plan issuers, including stronger penalties and reporting requirements.
  • Expanded consumer support through a dedicated medical claims consumer assistance program.
  • Greater transparency and data-driven oversight of adverse determinations and enforcement actions.
  • Potential administrative burden on health plans due to reporting and compliance obligations.

Compiled from official sources — confirm details with the bill’s official record.

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