Current through all regulations passed and filed through September 16, 2024
(A) An MCO, any individual, corporation, or
entity affiliated with the MCO as defined in rule
4123-6-03.9 of the
Administrative Code, or any other individual, corporation, or entity acting on
behalf of an MCO or for the benefit of an MCO, shall not:
(1) Pay, allow, or give, or offer to pay,
allow, or give, to any prospective employer or to any other person, firm, or
corporation not an employee or agent of the MCO, either directly or indirectly,
as an inducement to or in return for an employer's selection of the MCO, any
rebate, premium, or kickback, or any special favor or advantage, or any other
valuable consideration or inducement not provided for under Chapter 4123-6 of
the Administrative Code.
(2) Pay,
allow, or give, or offer to pay, allow, or give any commission, consideration,
money, or other thing of value to any person, firm, or corporation not an
employee or agent of the MCO for soliciting, negotiating, procuring, placing,
writing, renewing, forwarding, or transmitting to the bureau an employer's
selection of the MCO.
(B) Notwithstanding paragraph (A) of this
rule, the MCO may reimburse to a trade or business association certain expenses
in accordance with the following :
(1)
The trade or business association
meets the criteria for
being a sponsoring organization for group rating
pursuant to
section 4123.29 of the Revised Code and
rules 4123-17-61 to
4123-17-68 of the Administrative
Code.
(2) The MCO may reimburse to
the trade or business association only its actual and reasonable expenses
incurred in educating its member employers on bureau and MCO medical management
and cost containment services and related rules, policies, and
processes.
(3) The MCO may
reimburse to the trade or business association only its actual and reasonable
expenses incurred in marketing the MCO to its member employers, subject to the
limits set forth in paragraph (B)(4) of this rule.
(4) The reimbursement of a trade or business
association's actual and reasonable expenses incurred in marketing the MCO to
its member employers during a calendar year
cannot exceed sixteen one-hundredths
of one per cent of the premium of those employers that are members of the trade
or business association and that have selected the MCO.
(5) The MCO and
the trade or business association shall keep accurate records of all marketing
and education services provided to its member employers for a period of four
years from the date of performance of any such service
and provide the bureau with access
to such records within a reasonable time after a request for audit of such
records by the bureau.
(C) Except as provided in paragraph (B) of
this rule, no person, firm, or corporation not an employee or agent of the MCO
shall knowingly receive any payment, commission, rebate, premium or kickback,
or any other valuable consideration or thing of value
described in paragraph (A) of this rule.
(D) For purposes of this rule, "affiliated
with an MCO"
has the same meaning as in paragraph (B) of rule
4123-6-03.9 of the
Administrative Code.
(E) Agent of
the MCO.
(1) For purposes of this rule,
"agent" of the MCO means:
(a) An insurance
agent or broker contracted by the MCO and licensed by the Ohio department of
insurance pursuant to Title XXXIX of the Revised Code;
(b) A corporation or entity contracted by the
MCO to conduct non-telephonic marketing that has not had and does not
contemplate having activities of any nature with the Ohio workers' compensation
system so as to create a conflict of interest or the appearance of a conflict
of interest under rule
4123-6-03.9 of the
Administrative Code;
(c) A
telemarketer or telemarketing firm contracted by the MCO who has obtained a
certificate of registration from the Ohio attorney general in accordance with
Chapter 4719. of the Revised Code.
(2) "Agent" of the MCO does not include the
following:
(a) A third party administrator,
group rating sponsor, business or trade association;
(b) An individual, corporation, or entity
affiliated with the MCO that has had or contemplates having activities with the
Ohio workers' compensation system so as to create a conflict of interest or the
appearance of a conflict of interest under rule
4123-6-03.9 of the
Administrative Code.
