Ohio health insurance laws for employers start with a fact that surprises many business owners: no Ohio statute requires any employer to offer health coverage. The requirement, when it applies, comes from the federal Affordable Care Act and hits employers with 50 or more full-time equivalent workers. What Ohio does is layer its own rules on top for businesses that offer coverage voluntarily or that must offer it under federal law. Those rules govern how carriers price small group plans, what benefits fully insured policies must include, and how continuation coverage works at companies too small for federal COBRA.
Who Has to Offer Coverage
The ACA’s Employer Shared Responsibility provisions apply to businesses that employed an average of at least 50 full-time employees during the prior calendar year, counting full-time equivalents calculated from part-time hours. Seasonal workers don’t push a business over the threshold if the excess lasts 120 days or fewer and the extra headcount was seasonal.1Office of the Law Revision Counsel. 26 U.S. Code 4980H – Shared Responsibility for Employers Regarding Health Coverage
Businesses below 50 full-time equivalents have no legal obligation to offer coverage under federal or Ohio law.2Internal Revenue Service. Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act If they choose to offer it, they enter Ohio’s small group market and pick up the rules described in the next section.
2026 Penalty Amounts
Two separate penalties apply when an applicable large employer falls short, and both went up for 2026 under Revenue Procedure 2025-26.3Internal Revenue Service. Rev. Proc. 2025-26
If an employer doesn’t offer minimum essential coverage to at least 95 percent of full-time employees and at least one employee receives a premium tax credit on the Marketplace, the penalty is $3,340 per full-time employee per year, minus the first 30 employees. If the employer does offer coverage but it fails the affordability or minimum value standards, the penalty is $5,010 per year for each full-time employee who actually receives a Marketplace subsidy. The second penalty is capped so it never exceeds what the first formula would have produced.2Internal Revenue Service. Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act
Ohio Small Group Market Protections
Ohio Revised Code Chapter 3924 governs the small group market, defined as employers with 2 to 50 eligible employees.4Ohio Legislative Service Commission. Ohio Code 3924.01 – Small Employer Health Benefit Plans Definitions Two protections matter most.
First, guaranteed issue. Carriers operating in Ohio’s small group market must offer every health benefit plan they actively market to any small employer that applies.5Ohio Legislative Service Commission. Ohio Code 3924.03 – Health Benefit Plans Covering Small Employers An insurer cannot refuse a business because one or more employees have preexisting conditions.
Second, rating limits. Insurers cannot use claims history, health status, or duration of coverage to set premiums.4Ohio Legislative Service Commission. Ohio Code 3924.01 – Small Employer Health Benefit Plans Definitions Under ACA community rating rules that overlay Ohio law, the only permissible rating factors are age, geographic area within Ohio, family composition, and tobacco use. A business with an employee in cancer treatment pays the same base rate as the shop down the street where everyone is healthy.
Benefits Ohio Requires on Fully Insured Plans
Ohio requires every fully insured individual and group health policy delivered or renewed in the state to include certain benefits. These mandates apply to plans purchased from a licensed Ohio insurer. Self-funded plans follow different rules.
Cancer Screening
ORC 3923.52 requires coverage for one annual screening mammography for adult women, including 3D mammography, along with cytologic screening to detect cervical cancer processed at a certified facility.6Ohio Legislative Service Commission. Ohio Code 3923.52 – Screening Mammography and Cytologic Screening Benefits
Autism Spectrum Disorder
ORC 3923.84 requires coverage for screening, diagnosis, and treatment of autism spectrum disorder. For children under 14, the minimum benefits include 20 visits per year each for speech and occupational therapy, up to 20 hours per week of clinical therapeutic intervention, and 30 visits per year for mental or behavioral health outpatient services. Treatment must be ordered by a developmental pediatrician or a psychologist trained in autism and found medically necessary.7Ohio Legislative Service Commission. Ohio Code 3923.84 – Coverage for Autism Spectrum Disorder
Maternity and Newborn Care
Plans covering maternity benefits must provide at least 48 hours of inpatient care after a vaginal delivery and 96 hours after a cesarean section, plus follow-up care that includes physical assessment of mother and newborn, feeding assistance, and home health visits when appropriate.8Ohio Legislative Service Commission. Ohio Code 3923.64 – Maternity Benefits Coverage
Self-Funded Plans Escape Most Ohio Mandates
When an employer self-funds its health plan rather than buying a policy, the federal Employee Retirement Income Security Act largely displaces Ohio insurance law. ERISA’s preemption clause blocks states from regulating self-funded plans as insurance.9Office of the Law Revision Counsel. 29 U.S. Code 1144 – Other Laws The practical result: Ohio’s mandates for mammography, autism treatment, and maternity minimum stays do not bind a self-insured employer.
A company that moves from a fully insured plan to a self-funded arrangement may find that benefits it assumed were legally required are actually optional under the new structure. Self-insured plans still must comply with federal rules, including ACA essential health benefit requirements for non-grandfathered plans, preventive care mandates, and mental health parity. The Ohio-specific mandates fall away.
Ohio Mini-COBRA for Smaller Employers
Federal COBRA requires employers with 20 or more employees to offer continuation coverage after a qualifying event.10Office of the Law Revision Counsel. 29 U.S. Code 1161 – Plans Must Provide Continuation Coverage Ohio fills the gap for smaller employers through ORC 3923.38.11Ohio Legislative Service Commission. Ohio Code 3923.38 – Continuing Policy Upon Termination of Employment
To qualify, the employee must have been continuously covered under the group policy or a predecessor policy for at least three months before employment ended. Employees who voluntarily quit or are terminated for gross misconduct are not eligible. The statute covers only termination of employment; it does not extend to divorce or a dependent aging out of coverage.
Eligible employees can continue their hospital, surgical, and medical coverage for up to 12 months, paying the full premium at no more than the group rate. The election windows are short. If the employer gives notice before coverage ends, the employee has 10 days from that notice to elect and pay. If notice comes after coverage ends, the employee has 10 days from that late notice. If the employer never gives notice, the employee still has only 31 days from the date coverage would otherwise have terminated.11Ohio Legislative Service Commission. Ohio Code 3923.38 – Continuing Policy Upon Termination of Employment Those windows are short enough that offboarding checklists, not memory, should drive the notification.
HRA Alternatives to Group Coverage
Ohio employers who are too small for the mandate or who find group coverage unaffordable have two federally created HRA options.
Individual Coverage HRA
An Individual Coverage HRA lets an employer of any size reimburse employees tax-free for premiums paid on individual health insurance, including Marketplace plans. There is no cap on annual reimbursement amounts. Each participant must receive a written notice at least 90 calendar days before the start of each plan year describing the terms, the maximum dollar amount available, and the effect on premium tax credit eligibility.12eCFR. 26 CFR 54.9802-4 – Special Rule Allowing Integration of Health Reimbursement Arrangements New hires who become eligible mid-year must receive the notice no later than the date the HRA can first take effect.
Qualified Small Employer HRA
A QSEHRA is available only to employers with fewer than 50 full-time equivalents that do not offer a group health plan. For 2026, the IRS caps annual reimbursements at $6,450 for self-only coverage and $13,100 for family coverage.13Internal Revenue Service. Rev. Proc. 2025-32 Amounts above these limits become taxable income to the employee. Reimbursements are distributed evenly across 12 months and prorated for employees who become eligible mid-year.
Mental Health Parity
The Mental Health Parity and Addiction Equity Act applies to any group health plan that covers both medical/surgical benefits and mental health or substance use disorder benefits. Financial requirements like copays and deductibles, and treatment limits like visit caps, cannot be more restrictive for behavioral health than the predominant limits applied to medical and surgical care.14Office of the Law Revision Counsel. 29 U.S. Code 1185a – Parity in Mental Health and Substance Use Disorder Benefits
Plans must also perform and document comparative analyses of nonquantitative treatment limitations, such as prior authorization or step therapy protocols, showing those restrictions are no stricter for behavioral health than for medical care. For plan years beginning on or after January 1, 2026, plans must additionally collect and evaluate claims data measuring the real-world impact of these limitations. If regulators request the analysis, the plan must produce it within 10 business days.
Self-funded employers bear direct responsibility for the analysis and should coordinate with their third-party administrator. Fully insured employers can look to the insurer to prepare it, but retain a fiduciary duty to monitor the process.
IRS Reporting for Applicable Large Employers
Every applicable large employer must file Forms 1094-C and 1095-C with the IRS annually and furnish Form 1095-C to each full-time employee. Form 1095-C reports whether the employer offered coverage, the employee’s share of the lowest-cost premium, and the months of coverage. Form 1094-C is the transmittal form. These filings are how the IRS determines whether an employer owes a penalty under Section 4980H.2Internal Revenue Service. Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act
Employers filing 10 or more information returns of any type during the calendar year must file electronically.15Internal Revenue Service. Who Must File Information Returns Electronically That threshold aggregates across nearly all return types, so most applicable large employers cross it easily. Errors and late filings on these forms are what typically trigger IRS penalty assessments.
Summary of Benefits and Coverage Delivery
Federal law requires group health plans and insurers to provide a Summary of Benefits and Coverage using a standardized template published by the Department of Labor.16U.S. Department of Labor. Summary of Benefits and Coverage and Uniform Glossary The timing depends on the situation:
- With open enrollment or application materials, or no later than the first date the participant is eligible to enroll if the plan doesn’t use written applications.
- At least 30 days before the first day of the new plan year on automatic renewal.
- Within 90 days of enrollment for new hires and special enrollment qualifying events.
- Within seven business days of a request.17GovInfo. 29 CFR 2590.715-2715 – Summary of Benefits and Coverage and Uniform Glossary
Electronic delivery is permitted only if the employee uses a computer as a regular part of their job duties, or affirmatively consents to electronic delivery in writing.18U.S. Department of Labor. Technical Release No. 2011-03 Emailing plan documents to warehouse workers or field staff who never use a computer at work does not meet the safe harbor, even if the email reaches a personal address. When in doubt, send paper by first-class mail.