4123-6-13 Payment to MCOs.

(A) The bureau shall determine fee payments to an MCO which is selected by or assigned to employers with zero payroll, noncomplying employers, employers who are no longer in business, new employers, and other employer situations in which the employer’s premium does not adequately account for an MCO’s medical management services.

(B) The bureau shall pay an MCO an administrative fee for its medical management and administrative services in a manner determined by the administrator. The administrative fee may be subject to a disincentive penalty based upon the failure of the MCO to meet predetermined performance criteria set forth in the MCO contract. The bureau may pay an MCO a performance payment and may pay an incentive payment.

(C) In establishing performance measures, the bureau shall evaluate an MCO’s performance based upon but not limited to:

(1) Quality performance measures that may include return to work rates and reinjury rates.

(2) Total cost measures that may include average total paid cost, average incurred cost, and lost-time claims to total claims ratio.

(3) Change in cost measures that may include change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.

(4) Customer satisfaction that may include in-network utilization rate and employee, employer, and provider satisfaction surveys.

R.C. 119.032 review dates: 10/27/2004 and 03/01/2009

Promulgated Under: 119.03

Statutory Authority: 4121.12, 4121.30, 4121.31, 4123.05

Rule Amplifies: 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates: 2/16/96, 1/1/99, 1/1/01