Ohio Health Plan Reimbursement: The Pro Rata Statute and Made-Whole

By the FigureMyTax Editorial Team · How we calculate

Notwithstanding any contract, if less than the full value of your Ohio injury claim is recovered, a subrogee's claim is diminished in the same proportion as your interest. The statute covers insurers, self-funded plans and anyone claiming subrogation by contract or common law.

What the statute says

R.C. 2323.44 applies to insurers doing business in the state, self-funded health, sickness or disability plans, provider-sponsored organizations and anyone claiming subrogation by contract or common law. If less than the full value of the tort action is recovered because of comparative negligence, a party's limited share of liability, or collectability from limited liability insurance or any other cause, the subrogee's claim is diminished in the same proportion as your interest. Either side may bring a declaratory action over a distribution dispute.

What a compendium reports

A law-firm compilation of Ohio subrogation law reports that subrogation of medical benefits is allowed, that the common fund rule applies, and that a policy or plan can disclaim made-whole. We did not read the decisions. A self-funded plan under federal law may not be reached by a state statute; ask for the plan document.

A worked example

Say a health plan paid $9,000, your claim is worth $200,000 and you recover $100,000. You recover 50 percent of the full value, so the plan's claim is diminished to $4,500. If you recover the full value, the plan can claim the full $9,000. The Ohio medical lien calculator applies that proportion and offers a full-claim upper bound.

Medicaid is different

Medicaid has its own statute with a one-third fee deduction and a presumption of one-half of the remainder (R.C. 5160.37). See the Medicare and Medicaid post.

What to do

Ask for an itemized claim and the plan document, ask whether the plan is insured or self-funded, and ask it to reduce its claim by the proportion you were shorted. See how provider bills differ from liens.

This is general information, not legal advice, and the state comparisons above are illustrative, not an exhaustive survey. Confirm how Ohio's rules apply to your specific case with a licensed Ohio attorney.