Ohio Admin. Code 4123-6-05.3 - Employer access to the HPP - certain solicitation practices by MCOs prohibited
(A) An MCO, any individual, corporation, or
entity affiliated with the MCO as defined in rule 4123-6-03.9 of the
Administrative Code, or any other individual, corporation, or entity acting on
behalf of an MCO or for the benefit of an MCO, shall not:
(1) Pay, allow, or give, or offer to pay,
allow, or give, to any prospective employer or to any other person, firm, or
corporation not an employee or agent of the MCO, either directly or indirectly,
as an inducement to or in return for an employer's selection of the MCO, any
rebate, premium, or kickback, or any special favor or advantage, or any other
valuable consideration or inducement not provided for under Chapter 4123-6 of
the Administrative Code.
(2) Pay,
allow, or give, or offer to pay, allow, or give any commission, consideration,
money, or other thing of value to any person, firm, or corporation not an
employee or agent of the MCO for soliciting, negotiating, procuring, placing,
writing, renewing, forwarding, or transmitting to the bureau an employer's
selection of the MCO.
(B)
Notwithstanding paragraph (A) of this rule, the MCO may reimburse to a trade or
business association certain expenses in accordance with the following
requirements:
(1) The trade or business
association shall meet the requirements for being a sponsoring organization for
group rating under section
4123.29
of the Revised Code and rules
4123-17-61
to
4123-17-68
of the Administrative Code.
(2) The
MCO may reimburse to the trade or business association only its actual and
reasonable expenses incurred in educating its member employers on bureau and
MCO medical management and cost containment services and related rules,
policies, and processes.
(3) The
MCO may reimburse to the trade or business association only its actual and
reasonable expenses incurred in marketing the MCO to its member employers,
subject to the limits set forth in paragraph (B)(4) of this rule.
(4) The reimbursement of a trade or business
association's actual and reasonable expenses incurred in marketing the MCO to
its member employers during a calendar year shall not exceed sixteen
one-hundredths of one per cent of the premium of those employers that are
members of the trade or business association and that have selected the MCO.
The premium used in calculating allowable reimbursement under this rule shall
be the premium used by the bureau to calculate payments to the MCO under the
payment provisions of the MCO contract.
(5) The MCO and the trade or business
association shall keep accurate records of all marketing and education services
provided to its member employers for a period of four years from the date of
performance of any such service. The MCO and the trade or business association
shall provide the bureau with access to such records within a reasonable time
after a request for audit of such records by the bureau.
(C) Except as provided in paragraph (B) of
this rule, no person, firm, or corporation not an employee or agent of the MCO
shall knowingly receive any payment, commission, rebate, premium or kickback,
or any other valuable consideration or thing of value prohibited under
paragraph (A) of this rule.
(D) For
purposes of this rule, "affiliated with an MCO" shall have the same meaning as
in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.
(E) Agent of the MCO.
(1) For purposes of this rule, "agent" of the
MCO means:
(a) An insurance agent or broker
contracted by the MCO and licensed by the Ohio department of insurance pursuant
to Title XXXIX of the Revised Code;
(b) A corporation or entity contracted by the
MCO to conduct non-telephonic marketing that has not had and does not
contemplate having activities of any nature with the Ohio workers' compensation
system so as to create a conflict of interest or the appearance of a conflict
of interest under rule 4123-6-03.9 of the Administrative Code;
(c) A telemarketer or telemarketing firm
contracted by the MCO who has obtained a certificate of registration from the
Ohio attorney general in accordance with Chapter 4719. of the Revised
Code.
(2) "Agent" of the
MCO does not include the following:
(a) A
third party administrator, group rating sponsor, business or trade
association;
(b) An individual,
corporation, or entity affiliated with the MCO that has had or contemplates
having activities with the Ohio workers' compensation system so as to create a
conflict of interest or the appearance of a conflict of interest under rule
4123-6-03.9 of the Administrative Code.
Notes
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: 01/30/1998 (Emer.), 04/29/1998, 01/01/1999, 10/26/2000, 01/01/2001, 02/14/2005, 02/01/2010, 06/09/2014
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(A) An MCO , any individual, corporation, or entity affiliated with the MCO as defined in rule 4123-6-03.9 of the Administrative Code, or any other individual, corporation, or entity acting on behalf of an MCO or for the benefit of an MCO , shall not:
(1) Pay, allow, or give, or offer to pay, allow, or give, to any prospective employer or to any other person, firm, or corporation not an employee or agent of the MCO, either directly or indirectly, as an inducement to or in return for an employer's selection of the MCO, any rebate, premium, or kickback, or any special favor or advantage, or any other valuable consideration or inducement not provided for under Chapter 4123-6 of the Administrative Code.
(2) Pay, allow, or give, or offer to pay, allow, or give any commission, consideration, money, or other thing of value to any person, firm, or corporation not an employee or agent of the MCO for soliciting, negotiating, procuring, placing, writing, renewing, forwarding, or transmitting to the bureau an employer's selection of the MCO.
(B) Notwithstanding paragraph (A) of this rule, the MCO may reimburse to a trade or business association certain expenses in accordance with the following requirements:
(1) The trade or business association shall meet the requirements for being a sponsoring organization for group rating under section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.
(2) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in educating its member employers on bureau and MCO medical management and cost containment services and related rules, policies, and processes.
(3) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in marketing the MCO to its member employers, subject to the limits set forth in paragraph (B)(4) of this rule.
(4) The reimbursement of a trade or business association's actual and reasonable expenses incurred in marketing the MCO to its member employers during a calendar year shall not exceed sixteen one-hundredths of one per cent of the premium of those employers that are members of the trade or business association and that have selected the MCO . The premium used in calculating allowable reimbursement under this rule shall be the premium used by the bureau to calculate payments to the MCO under the payment provisions of the MCO contract.
(5) The MCO and the trade or business association shall keep accurate records of all marketing and education services provided to its member employers for a period of four years from the date of performance of any such service. The MCO and the trade or business association shall provide the bureau with access to such records within a reasonable time after a request for audit of such records by the bureau.
(C) Except as provided in paragraph (B) of this rule, no person, firm, or corporation not an employee or agent of the MCO shall knowingly receive any payment, commission, rebate, premium or kickback, or any other valuable consideration or thing of value prohibited under paragraph (A) of this rule.
(D) For purposes of this rule, "affiliated with an MCO " shall have the same meaning as in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.
(E) Agent of the MCO .
(1) For purposes of this rule, "agent" of the MCO means:
(a) An insurance agent or broker contracted by the MCO and licensed by the Ohio department of insurance pursuant to Title XXXIX of the Revised Code;
(b) A corporation or entity contracted by the MCO to conduct non-telephonic marketing that has not had and does not contemplate having activities of any nature with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code;
(c) A telemarketer or telemarketing firm contracted by the MCO who has obtained a certificate of registration from the Ohio attorney general in accordance with Chapter 4719. of the Revised Code.
(2) "Agent" of the MCO does not include the following:
(a) A third party administrator, group rating sponsor, business or trade association;
(b) An individual, corporation, or entity affiliated with the MCO that has had or contemplates having activities with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code.
Notes
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: 01/30/1998 (Emer.), 04/29/1998, 01/01/1999, 10/26/2000, 01/01/2001, 02/14/2005, 02/01/2010, 06/09/2014