4123-6-03.9 MCO participation in the HPP - MCO disclosure of relationship.

(A) If an MCO is affiliated with another individual, corporation, or entity that has had or contemplates activities of any nature with the Ohio workers' compensation system including but not limited to third party administrators, medical or vocational rehabilitation providers, professional employer organizations, and/or transitional work developers:

(1) To the extent such relationship creates or presents either the opportunity for a conflict of interest or preferential treatment or the appearance of a conflict of interest or preferential treatment for the managed care organization and/or the other individual, corporation, or entity, the MCO shall provide to the bureau a written description of the resolution of such opportunity for or the appearance of a conflict of interest satisfactory to the bureau; and shall disclose the potential conflict of interest and its resolution to the employers and injured workers assigned to the MCO.

(2) The MCO and the other affiliated corporation or entity shall implement complete separation of functions, offices, systems, and staff. Complete separation of staff shall include, but not be limited to, medical and vocational rehabilitation case management staff and marketing staff.

(B) For purposes of this rule, an individual, corporation, or entity is "affiliated with an MCO" when it:

(1) Owns, is owned by, or is under common ownership with an MCO, directly or indirectly through one or more intermediaries;

(2) Controls, is controlled by, or is under common control with an MCO, directly or indirectly through one or more intermediaries;

(3) Has a contractual or other business arrangement with an MCO;

(4) Has one or more owners, shareholders, partners, members, officers, directors or other persons who exercise operational or managerial control in common with the MCO.

Effective: 11/13/2015
Five Year Review (FYR) Dates: 08/26/2015 and 08/25/2020
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 2/16/96, 10/26/00, 2/1/10, 6/9/14