Ohio Admin. Code 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 in the QHP's provider
network .
(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;
and 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, to the extent such qualify as a
"trade secret" under division (D) of section
1333.61 of the Revised
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: 09/05/1996
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(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 in the QHP 's provider network .
(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; and 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 , to the extent such qualify as a "trade secret" under division (D) of section 1333.61 of the Revised 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: 09/05/1996