Chapter 123-6 School Employees Health Care Board
Chapter 3306-2 of the Administrative Code establishes minimum best practice standards to be used by health plan sponsors in the selection and implementation of health care plans offered to public school district employees and the rules for the enforcement of health care plan sponsors' compliance with the best practice standards adopted by the school employees health care board. This chapter is applicable to all public school districts within the state of Ohio.
(A) "Board" means the school employees health care board of the state of Ohio.
(B) "Health plan sponsor" means a public school district, a consortium of public school districts, or a council of governments, which sponsors a health care plan.
(C) "Health care plan" includes group policies, contracts, and agreements entered into by a health plan sponsor that provide hospital, surgical, or medical expense coverage, including self-insured plans. A health care plan does not include a plan offered to individual employees of a public school district or a plan that provides coverage only for specific disease or accidents, or a hospital indemnity, Medicare supplement, or other plan that provides only supplemental benefits, paid for by the employees of a public school district.
(D) "Public school district" means a city, local, exempted village, or joint vocational school district, and includes the educational service centers associated with those districts. Charter schools are not included in this definition.
(E) "Best practice standards" means procedures, programs, activities or actions that the Board has determined to demonstrate effectiveness in assuring the provision of quality health care and improving the health status of a particular population. The goals of best practices are to derive the greatest value in purchasing health insurance and health care and improve the health of public school district employees and their families.
(F) "Wellness or healthy lifestyle program" means a program that consists of a combination of activities designed to increase awareness, assess risks, educate, and promote voluntary behavior change to improve the health of an individual, encourage modifications of his or her health status, and enhance his or her personal well-being and productivity, with a goal of preventing illness and injury.
(G) "Disease management" means a program that includes both education and support activities designed to increase individuals' awareness and understanding of their disease(s), promote voluntary behavior change, improve self-care, with the goal of preventing or managing complications associated with targeted chronic diseases.
(H) "Clinically superior healthcare" means a medically necessary procedure, process, activity or treatment plan that has demonstrated greater effectiveness than competing procedures or treatment plans in producing positive clinical outcomes and financial results.
(I) "Health information" means personally identifiable information collected through a wellness or healthy lifestyle program, including demographic information, and relates to the past, present or anticipated future medical condition of an individual.
(J) "Dependent eligibility audit" means a process which reviews the eligibility requirements of a health care plan and verifies the eligibility of all dependents currently receiving benefits under the health care plan.
(K) "Maintenance drugs" means medications prescribed for chronic, long-term conditions that are taken on a regular, recurring basis, including but not limited to medicine for: high blood pressure, high cholesterol, and diabetes.
(L) "Joint purchasing arrangement" means an entity that is organized under Chapter 167. of the Revised Code, section 9.833 of the Revised Code, an entity that is organized as a multi-employer welfare arrangement as defined by 29 USC 1002, or an entity that is organized as a voluntary employee benefits arrangement under IRC 501(c)(9).
All health care plans shall include a wellness or healthy lifestyle program.
(A) The required components of an acceptable wellness or healthy lifestyle program under this rule specifically include but are not limited to:
(1) Conducting an initial evaluation of historical claims experience if available to specifically identify health conditions that are modifiable and preventable through health improvement, health management, and patient compliance.
(2) A personal health assessment tool capable of providing an accurate and comprehensive baseline of population health status. The personal health assessment must:
(a) Be available in multiple formats including both online and paper media;
(b) Be reasonable in length;
(c) Capture modifiable and non-modifiable risk factors;
(d) Assess an individual's confidence and readiness to change his or her lifestyle, potential barriers to change, and include quality of life measures;
(e) Capture current contact information and preferred means of contact;
(f) Generate a personalized report for the individual that addresses lifestyle changes they can make to improve their health and reduce risks.
(3) Conduct a biometric screening at the health plan sponsor location(s) of choice.
This screening must include:
(a) Cholesterol levels;
(b) Diabetic risk assessment;
(c) Blood pressure;
(d) Body mass index (BMI), including recording of height and weight and body composition.
(4) Provide proactive, ongoing support and education for individuals with lifestyle health risks, such as tobacco use, obesity, high blood pressure, high cholesterol, and high stress. This support and education must:
(a) Include access to personalized health coaching;
(b) Be available in multiple formats, including telephone, email and the internet;
(c) Be provided by qualified professionals.
(5) Include processes or programs that encourage the highest levels of participation possible at the onset of the program, make it attractive to enroll in the program at any time and to keep participants engaged throughout the duration of the program.
(6) Provide regularly scheduled reports to the health plan sponsor demonstrating the impact of the program in aggregate, including:
(a) Personal health assessment completion rates;
(b) Outcome-oriented metrics such as reductions in BMI, smoking cessation rates and other quantifiable improvements in behavior.
(B) The use and disclosure of health information collected through health risk assessments shall respect patient confidentiality and may not be used or disclosed for any purpose other than allowed by state or federal law to improve the health status of participating members.
All health care plans shall include a disease management program.
(A) The required components of an acceptable disease management program under this rule specifically include:
(1) An initial evaluation of plan history and claims if available to specifically identify the prevalence of diseases amenable to disease management interventions;
(2) Identification, classification and tracking of defined patient populations;
(3) Patient education and involvement in self-care techniques:
(4) Drug management and protocol adherence:
(5) Feedback to physicians on the progress of patients in the program:
(6) Integration of the services provided and the sharing of information with the health plan's employee wellness or healthy lifestyle program.
(B) A disease management program offered under this rule shall address chronic diseases, including but not limited to:
(3) Chronic obstructive pulmonary disease;
(4) Morbid obesity If such diseases have been identified as being prevalent in the population being served.
(C) A disease management program under this rule must provide the health plan sponsor with regular reports documenting the impact of the program in aggregate, specifically including but not limited to:
(1) Participation rates and satisfaction;
(2) Disease-specific clinical outcomes;
(3) Financial outcomes.
(D) All health care plans shall include access to institutions and providers offering demonstrated clinically superior health care for complex medical conditions.
(1) Complex medical conditions may include but need not be limited to:
(a) Transplantation (solid organ, blood and bone marrow);
(c) Chronic kidney disease;
(d) Congenital heart disease;
(e) Infertility (if a covered condition);
(g) Morbid obesity;
(h) High risk pregnancy.
(2) All health care plans offered to employees by a school district shall be required to use objective, measurable criteria to evaluate participating institutions and providers.
(3) All health care plans offered to employees by a school district shall provide the health plan sponsor access to the evaluations of all participating institutions and providers so long as the release of specific information is not in breach of any agreement between an institution or provider and the health care plan.
(A) All health care plans offered to health plan sponsors shall be evaluated, negotiated, procured, and administered in a transparent manner. Transparency requires public disclosure of all costs a health care plan or a health plan sponsor pays to or receives from any person or entity related to the designing, procuring, administering, and evaluating a public school district's health care plan.
(B) Any school district that is a member of a joint purchasing arrangement shall:
(1) Only participate in a joint purchasing arrangement that is audited at least biannually in accordance with the "Generally Accepted Government Auditing Standards" (GAGAS) in the United States and submits such information to the board; and
(2) Only enter into an agreement with any joint purchasing arrangement that holds cash and cash equivalents in a separate interest-bearing account in a financial institution authorized to do business in the state of Ohio; and
(3) Only participate in a joint purchasing arrangement that invests its funds in accordance with the requirements of Chapter 135. of the Revised Code; and
(4) Only participate in a joint purchasing arrangement that requires plan fiduciaries to be trained as such at least triennially.
(A) Each school district or educational service center that procures its health care plans independently or each joint purchasing arrangement that procures health care plans on behalf of school districts or educational service centers shall participate in a formal, competitive procurement process for health insurance coverage and, if appropriate, health consulting services no less than every three years (except in cases of financial exigency) and no more than every five years.
(B) Each health plan sponsor shall:
(1) Employ a tiered pharmacy plan incorporating a drug formulary;
(2) Include in their health care plans that generic drugs must be dispensed where applicable in order for the health care plan provisions to apply, unless:
(a) A less expensive option is available; or
(b) A physician has indicated that the prescription is to be dispensed as written and that drug is a covered drug under the benefit plan.
(C) Each health plan sponsor shall establish or maintain a labor-management health benefits committee. The committee will have the responsibility of reviewing all health benefits related issues including but not limited to benefits design, costs, and communications to district personnel. The committee will make recommendations to the superintendent, all school employees and school employee organizations regarding health benefits and costs. The committee will consist of certified, classified, and administrative personnel. The committee shall receive labor-management health benefits committee training triennially by the board or a board approved training organization.
(D) All health plan sponsors that maintain a self-insured health care plan shall reserve funds as advised, in writing, by an actuary who has achieved the designation of member of the academy of actuaries. The reserve amounts will include "Incurred But Not Reported" (IBNR) claims plus no more than thirty per cent of expected annual claims. Amounts over the aforementioned reserve levels shall be returned to the member districts in accordance with the governing documents for the health care plan. Amounts under the aforementioned reserve levels shall be billed to the member districts in accordance with the governing documents for the health care plan. The specific methodology for setting reserve levels must be disclosed to the board by providing a copy of the actuary's report as required by rule 3306-3-01 of the Administrative Code.
(E) Each health plan sponsor shall undertake periodic dependent eligibility audits. The aggregate results of each dependent eligibility audit shall be furnished by each health plan sponsor to the school employees health care board.
(A) Each health plan sponsor offering health care benefits to persons employed with the public school districts of this state shall furnish to the "Board" evidence of its compliance with all best practices as established by this chapter. Upon ascertaining compliance with the criteria as set forth, the "Board" shall certify the compliance of the health plan sponsor.
(B) Any health care plan or vendor providing programs or services to employees of public school districts of this state pursuant to best practices as required by these rules shall provide health plan sponsors with evidence that such programs or services meet the minimum criteria as set forth in this rule within sixty days after receiving a written request for such information from the health plan sponsor.
(C) Each health plan sponsor that provides health insurance through a self-insured plan shall provide, at least once every other fiscal year, to the "Board" a copy of an audit and a report of an actuary on the reserves required in paragraph (D) of rule 3306-2-04 of the Administrative Code.
Each public school district shall file annually, on or before the first day of July, a written report, on a form prescribed by the "Board," which describes the progress made to reduce the rate of increase in insurance premiums and employee out of pocket expenses and the progress made to improve the health status of public school district employees and their allowable dependents. The report shall also document the implementation of the best practice standards adopted by the public school district. The report shall be verified by an officer of the public school district and shall be filed with the "Board." The "Board" shall prepare and disseminate to the public an annual report on the status of each health plan sponsors' effectiveness in reducing the rate of increase in insurance premiums and employee out of pocket expenses and the progress made to improve the health status of public school district employees and their allowable dependents.
The "Board" shall review the annual status report received from each public school district and determine whether best practice standards have been implemented and utilized to reduce the rate of increase in insurance premiums and employee out of pocket expenses and to improve the health status of school district employees and allowable dependents in accordance with this chapter. The "Board" may request the school board of any public school district that has not adopted all best practice standards to submit a written report which shall document the reason that omitted best practice standards should not be applied to the public school district or, in the alternative, documents the school board's corrective action plan to ensure that all best practice standards are implemented within one hundred eighty days. The report of the school board shall be submitted to the "Board" within ninety days of the request by the "Board."