Insurance Reform

Insurance Reform

Prioritizing Patients & Healthcare Providers Over Insurers

OSMA is thrilled to launch a major Insurance Reform Campaign to put patients interests over insurance companies—keeping medical decision-making in the hands of physicians, and shedding light on the massive burdens put on our healthcare system and providers by insurance companies. 

These newly-introduced bills (see details below) will bring much-needed transparency to the insurmountable power insurers have gained in the healthcare system, putting decisions about medical care back in the hands of the people who should be making them: expert physicians who are best at caring for their patients. 


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OSMA is thrilled to see commitment by members of both the House and Senate to put patients interests over insurance companies. Here are the 8 initiatives:

Prior Authorization “Gold Card”

HB 214  •  SPONSOR: Rep. Kevin Miller (R-Newark)  •  April 1, 2025

  • Would establish an exemption of prior authorization requirements and 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.
  • Also includes data collection provisions mirroring federal CMS requirements set to go into effect in 2027, which will require insurers to share program metrics (e.g.: percentage of urgent and non-urgent requests approved, denied, and approved after appeal) on their public websites and with ODI on an annual basis.

Automatic Downcoding

SB 165  •  SPONSOR: Sen. Susan Manchester (R-Waynesfield)  •  April 1, 2025

  • Contains prohibitions on downcoding for all providers, including prohibitions on limitations on reimbursement for time spent with patients.
  • Strengthens 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. This will help prevent patients from delaying seeking emergency care out of fear that their insurers will not cover it.

Non-Medical Switching

SB 160  •  SPONSOR: Sen. Terry Johnson (R-McDermott) and Sen. Beth Liston (D-Dublin)  •  April 1, 2025

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

Takebacks/Clawbacks

SB 162  •  SPONSOR: Sen. Bill Blessing (R-Colerain Twp.)  •  April 1, 2025

  • 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.
  • Would prohibit insurers from charging a provider for appealing a determination of overpayment.

Network Adequacy

HB 219  •  SPONSOR: Rep. Kellie Deeter (R-Norwalk)  •  April 1, 2025

  • Establish standards for creation and maintenance of networks by insurers and assure the adequacy, adequacy, accessibility, transparency and quality of healthcare services offered under a network plan.
  • Require insurers to maintain and follow access plans that consist of policies and procedures for assuring the ongoing sufficiency of provider networks.
  • Establish requirements for written agreements between insurers and participating providers regarding the standards, terms and provisions under which the participating provider will provide covered services to covered patients.

Prior Authorization: Retroactive Denials, Peer to Peer, Appeals

HB 220  •  SPONSOR: Rep. Heidi Workman (R-Rootstown)  •  April 1, 2025

  • Would ensure retroactive denial can only occur for non-covered benefits or lack of coverage at the time of service.
  • Would require prior authorization appeals to be between the healthcare provider and a clinical peer, and require identification of the clinical peer (plan clinician) making adverse determinations.
  • Would also prohibit insurers from charging providers to appeal rejected claims.
  • Would require insurers to account for dosage adjustments in drug prior authorizations to treat chronic conditions.

No Fees for EFTs

SB 166  •  SPONSOR: Sen. Nathan Manning (R-North Ridgeville)  •  April 1, 2025

  • 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.

Transparency in Health Plan Use of AI

SB 164  •  SPONSOR: Sen. Al Cutrona (R-Canfield)  •  April 1, 2025

  • Would require insurer transparency regarding their use of AI tools in prior authorization determinations, and ensure that determinations are made through review of individual merits of claims by licensed clinical professionals.