123-6-06 Cost containment best practice.

(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.

Effective: 03/19/2011
R.C. 119.032 review dates: 03/19/2016
Promulgated Under: 119.03
Statutory Authority: 9.901
Rule Amplifies: 9.901