Current through all regulations passed and filed through September 16, 2024
(A) Upon request by
an employer or health plan seeking certification, the bureau shall mail the
employer or health plan seeking certification a QHP application for
certification.
(B) The QHP
application for certification shall include a list of bureau certified
providers in the QHP's provider
network.
(C) The QHP
application for certification shall include, at a minimum, the following
provisions, as more fully detailed within the QHP certification application
itself:
(1) A statement that the application
is without misrepresentation, misstatement, or omission of a relevant fact or
other acts involving dishonesty, fraud, or deceit;
(2) Proof that a self-insured employer has
been granted status as a self-insured employer in accordance with section
4123.35 of the Revised
Code;
(3) A description of the
geographic or regional area of the state of Ohio to be serviced by the QHP,
taking into account the unique circumstances of the individual employer, such
as multiple locations, and/or the need for a statewide network;
(4) A description of the role of each vendor
that will be a component of the QHP including, but not limited to, the
following: if an employer uses or anticipates using company-based providers, a
description of the role of company-based providers as distinguished from QHP
network providers; if an employer uses or anticipates using a third party
administrator, a description of the role of the third party
administrator;
(5) If an employer
contemplates contracting with a vendor that has been certified by the bureau
under Chapter 4123-6 of the Administrative Code to provide services under the
employer's QHP, proof that certification has been granted by the bureau and
that such certification is current;
(6) A description of the structure of the
medical management component and the health care provider network to be offered
by the QHP;
(7) A description of
the QHP's plan and methodology for providing, at least annually, QHP network
provider information, by provider type, and updated QHP network provider
directories to employees;
(8) A
description of the QHP's quality assurance program, including but not limited
to, the proposed structure and operation and a description of the mechanism for
monitoring and the methodology for measuring and improving the QHP's compliance
with the elements listed in paragraph (B) of rule
4123-6-53 of the Administrative
Code;
(9) A description of the
QHP's employee education program. The description shall include but shall not
be limited to: a description of the process to be used to educate employees
regarding their rights and responsibilities in the QHP system; a description of
the process to be used to explain the time, place and manner of services to be
delivered under the QHP; and a description of the process to be used to explain
options available to injured workers, including the process for changing
providers within the QHP and referral and transfer to the HPP; and
(10) A description of the plan satisfactory
to the bureau to be implemented by the QHP in the event a final order to revoke
certification, or to refuse to recertify a QHP is issued by the administrator,
pursuant to rule
4123-6-55 of the Administrative
Code, that includes, but is not limited to, a plan that describes continuation
and continuity of care of injured workers
and a plan that describes payment of providers
for medical services rendered prior to revocation of certification or refusal
to certify. The injured worker may continue receiving medical services from the
same provider or may choose a provider in a new approved plan for delivery of
medical services, both of whom shall accept medical management of the medical
services through the employer's new approved plan.
(D) The bureau shall review the application
for certification submitted by the health plan seeking certification. The
bureau reserves the right to cross-check data with other governmental agencies
or licensing or accrediting bodies.
(E) The bureau shall hold as confidential and
proprietary the vendor's descriptions of process, methodology, policies,
procedures and systems as required for the application for certification, to the extent such qualify as a "trade secret" under
division (D) of section
1333.61 of the Revised
Code.
