Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-54 - Employer participation in the QHP system - QHP certification application

Current through all regulations passed and filed through July 1, 2024
(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.