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.
Cite as Ohio Admin. Code 123-6-04