State RegulationsOH specificDifficulty 1/5
Under the adverse-benefit-determination framework reflected in ORC 3922.01-.23, which of the following is an adverse benefit determination?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
An adverse benefit determination is a decision that harms the member's benefits — a denial, reduction, or termination of a benefit, or a failure to provide or make payment for one. Ohio's framework at ORC 3922.01-.23 builds the consumer-protection structure around such decisions, requiring notice and appeal rights. Routine filings, directory updates, and ordinary renewals are not adverse determinations.
Why the other options are wrong
- A) A premium rate notice affects price, not a benefit decision, and is not an adverse benefit determination.
- B) A directory update changes which providers are listed; it is not a denial, reduction, or termination of a benefit.
- D) Renewal at the same benefit level leaves benefits intact, so it is not adverse.
Memory hook
Adverse = the plan says no, less, or later.