4123-6-54 Employer participation in the QHP system - QHP certification application.

(A) Upon request by an employer or health plan seeking certification, the bureau shall mail the employer or health plan seeking certification a QHP application for certification.

(B) The QHP application for certification shall include a list of bureau certified providers.

(C) The QHP application for certification shall include, at a minimum, the following provisions, as more fully detailed within the QHP certification application itself:

(1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit;

(2) Proof that a self-insured employer has been granted status as a self-insured employer in accordance with section 4123.35 of the Revised Code;

(3) A description of the geographic or regional area of the state of Ohio to be serviced by the QHP, taking into account the unique circumstances of the individual employer, such as multiple locations, and/or the need for a statewide network;

(4) A description of the role of each vendor that will be a component of the QHP including, but not limited to, the following: if an employer uses or anticipates using company-based providers, a description of the role of company-based providers as distinguished from QHP network providers; if an employer uses or anticipates using a third party administrator, a description of the role of the third party administrator;

(5) If an employer contemplates contracting with a vendor that has been certified by the bureau under Chapter 4123-6 of the Administrative Code to provide services under the employer's QHP, proof that certification has been granted by the bureau and that such certification is current;

(6) A description of the structure of the medical management component and the health care provider network to be offered by the QHP;

(7) A description of the QHP's plan and methodology for providing, at least annually, QHP network provider information, by provider type, and updated QHP network provider directories to employees;

(8) A description of the QHP's quality assurance program, including but not limited to, the proposed structure and operation and a description of the mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with the elements listed in paragraph (B) of rule 4123-6-53 of the Administrative Code;

(9) A description of the QHP's employee education program. The description shall include but shall not be limited to: a description of the process to be used to educate employees regarding their rights and responsibilities in the QHP system; a description of the process to be used to explain the time, place and manner of services to be delivered under the QHP; and a description of the process to be used to explain options available to injured workers, including the process for changing providers within the QHP and referral and transfer to the HPP; and

(10) A description of the plan satisfactory to the bureau to be implemented by the QHP in the event a final order to revoke certification, or to refuse to recertify a QHP is issued by the administrator, pursuant to rule 4123-6-55 of the Administrative Code, that includes, but is not limited to, a plan that describes continuation and continuity of care of injured workers; a plan that describes payment of providers for medical services rendered prior to revocation of certification or refusal to certify. The injured worker may continue receiving medical services from the same provider or may choose a provider in a new approved plan for delivery of medical services, both of whom shall accept medical management of the medical services through the employer's new approved plan.

(D) The bureau shall review the application for certification submitted by the health plan seeking certification. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(E) The bureau shall hold as confidential and proprietary the vendor's descriptions of process, methodology, policies, procedures and systems as required for the application for certification.

R.C. 119.032 review dates: 11/17/2009 and 11/01/2014

Promulgated Under: 119.03

Statutory Authority: 4121.12 , 4121.30 , 4121.31 , 4123.05

Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4121.442 , 4123.66

Prior Effective Dates: 9/5/96