Continuity of Stabilizing Treatment Act (Ohio)

The Continuity of Stabilizing Treatment Act is a state-level legislative proposal designed to ensure uninterrupted access to medically necessary stabilizing treatment within Ohio-regulated health plans.

The proposal establishes a continuity-first standard for treatment initiation while preserving insurer utilization review authority and protecting patients from retroactive financial liability arising from administrative disputes. Rather than eliminating oversight, the Act modifies the sequencing of review in continuity-critical situations to prevent avoidable clinical destabilization.

Under the framework, patients receiving treatment from in-network providers are guaranteed initial access to therapies that, if delayed or interrupted, pose a predictable risk of physiological deterioration. Post-dispensing review remains permissible, and financial reconciliation may occur between insurers and providers, but patients are insulated from recoupment disputes.

The Act applies strictly within Ohio’s regulatory authority and does not attempt to regulate self-funded employer plans governed by federal ERISA law.

By reinforcing stabilization as the foundational principle of time-sensitive care, the proposal seeks to reduce avoidable escalation, preserve insurer oversight mechanisms, and strengthen patient protection within existing insurance structures.

Health insurance utilization review processes are designed to manage cost, ensure medical necessity, and maintain actuarial balance. However, when administrative review occurs prior to initiation of clinically necessary stabilizing treatment, it may unintentionally delay therapy in circumstances where interruption or postponement increases the risk of physiological deterioration.

In time-sensitive clinical contexts, treatment delay can contribute to avoidable escalation, including emergency department utilization, inpatient admission, or higher-intensity intervention. Patients receiving care from insurer-credentialed in-network providers reasonably rely on continuity of prescribed therapy and may lack the ability to navigate or expedite complex authorization processes during medically vulnerable periods.

Existing insurance regulations in Ohio preserve insurer oversight authority but do not uniformly prioritize continuity sequencing in situations where stabilization risk is present. As a result, administrative review may function as a barrier to stabilization rather than a safeguard of appropriate care.

The structural challenge is to preserve insurer utilization management authority while modifying review sequencing in narrowly defined continuity-critical circumstances, ensuring that necessary stabilization is not interrupted while administrative processes proceed.

The Continuity of Stabilizing Treatment Act is designed for structured implementation within existing Ohio insurance regulatory authority.

Phase I — Statutory Enactment and Regulatory Guidance

Upon enactment, the Ohio Department of Insurance shall issue guidance clarifying:

• Documentation standards for continuity-critical determinations

• Reporting requirements for participating insurers

• Compliance monitoring procedures

• Patient notification and protection standards

Guidance shall emphasize that the Act modifies review sequencing without eliminating utilization review authority.

Phase II — Insurer Operational Adjustment

Health plans regulated under Ohio law shall adjust internal authorization workflows to ensure:

• Immediate dispensing for continuity-critical medications

• Post-dispensing review conducted without treatment interruption

• Internal tracking of review outcomes for compliance reporting

Insurers may develop standardized review protocols consistent with statutory definitions and existing medical necessity criteria.

Phase III — Oversight and Reporting

The Ohio Department of Insurance shall:

• Monitor compliance

• Establish complaint resolution mechanisms

• Review aggregate data regarding continuity-critical determinations

• Issue periodic public summaries as appropriate

Oversight shall focus on ensuring that stabilization protections are upheld while preserving insurer contractual authority.

Title II Activation (Separate Track)

Implementation of Title II (stabilizing treatments and therapies) shall occur only after issuance of structured administrative guidance defining:

• Qualifying treatment categories

• Documentation standards

• Operational readiness benchmarks

This staged approach ensures system clarity before expansion beyond medication-based continuity protections.

Compliance and Review

The Department may review:

• Frequency of continuity-critical determinations

• Rate of post-dispensing reversals

• Patterns of dispute resolution

• Escalation trends involving emergency utilization

The purpose of review is to evaluate continuity performance, not to interfere with individualized clinical judgment.

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Fiscal and Actuarial Framework

Fiscal and Actuarial Considerations

The following fiscal considerations are provided to support legislative evaluation of the Act's potential operational and market impacts.

The Continuity of Stabilizing Treatment Act is designed to operate within existing insurance regulatory structures and does not mandate expansion of covered benefits beyond medically necessary treatment already eligible for coverage under plan terms.

The proposal modifies the sequencing of utilization review for continuity-critical treatment but does not eliminate utilization management authority or remove insurer cost-control mechanisms.

Because the Act addresses the timing of review rather than the scope of covered services, systemic cost expansion attributable to new benefit mandates is not expected.

Cost Stabilization Considerations

Interruptions in clinically necessary stabilizing treatment may increase the likelihood of emergency department utilization, hospitalization, or other high-acuity interventions.

A continuity-first sequencing model allows stabilizing therapy to begin immediately while administrative review proceeds.

Where escalation events are avoided, total episode-of-care costs may be lower than those associated with delayed or interrupted treatment pathways.

Actuarial Predictability

The population affected by the Act is structurally limited because continuity protections apply only when:

• Treatment is prescribed by an in-network provider

• Therapy meets the statutory definition of continuity-critical

• Medical necessity standards remain satisfied

Claims exposure therefore remains bounded by existing plan coverage parameters.

Actuarial modeling conducted during legislative review may examine:

• Frequency of continuity-critical determinations

• Post-dispensing review outcomes

• Emergency utilization trends associated with treatment interruption

• Potential cost-offset effects related to avoided escalation of care

State Fiscal Impact

Oversight and reporting responsibilities assigned to the Ohio Department of Insurance are expected to operate within existing administrative authority.

Any incremental regulatory costs associated with monitoring compliance or producing summary reports are anticipated to be absorbed through standard departmental operations or existing insurance regulatory assessment mechanisms.

The Act does not establish a new state program, entitlement, or direct public expenditure.

Market Stability

By preserving utilization review authority and limiting application to defined stabilizing contexts, the Act avoids disruption to actuarial underwriting models used by insurers operating in Ohio.

The proposal modifies administrative sequencing but does not alter risk pool composition, premium rating structures, or underlying benefit mandates.

Accordingly, the Act is structured to support predictable premium development while strengthening patient stability protections.

American Medical Association. 2023 AMA Prior Authorization Physician Survey.

This national survey of practicing physicians reports that prior authorization requirements frequently delay medically necessary care and may lead to negative clinical outcomes when treatment initiation is postponed.

American Medical Association. Fix Prior Authorization Reform Toolkit.

The AMA documents how administrative barriers associated with prior authorization can interrupt continuity of care and contribute to delays in medically necessary treatment.

Centers for Medicare & Medicaid Services. Improving Prior Authorization Processes.

CMS has recognized that delays associated with prior authorization may interfere with timely access to medically necessary care and has encouraged reforms to improve patient access.

Health Affairs. Administrative Barriers and Health Care Utilization.

Research published in Health Affairs has examined how delays in treatment authorization can contribute to increased emergency utilization and higher-cost care episodes.

Agency for Healthcare Research and Quality (AHRQ). Care Coordination and Patient Safety.

Federal research on care coordination highlights the importance of continuity of treatment in preventing avoidable escalation of care and improving patient outcomes.

Ohio Department of Insurance. Health Insurance Regulatory Authority Overview.

Ohio law grants the Department of Insurance authority to regulate fully insured health plans and enforce consumer protections applicable to state-regulated insurance markets.

Institutional Note

This proposal was developed and published by Public Reason Institute as part of its independent research and legislative development program. The draft is offered for public discussion and potential consideration by policymakers.