Enact SHIELD Act

As Introduced

136th
General Assembly

Regular
Session
H. B. No. 795

2025-2026

Representative Williams

To
enact sections 5164.40, 5164.401, 5164.402, 5164.403, 5164.404,
5164.405, and 5164.406 of the Revised Code
to
require the Department of Medicaid to establish electronic
verification systems that promote program integrity for certain
components of the Medicaid program and to name this act the
Safeguarding Healthcare Integrity through Electronic Location Data
(SHIELD) Act.

BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section
1.
That
sections 5164.40, 5164.401, 5164.402, 5164.403, 5164.404, 5164.405,
and 5164.406 of the Revised Code be enacted to read as follows:

Sec.
5164.40.
As
used in sections 5164.40 to 5164.406 of the Revised Code:

(A)
"Breadcrumb location data" means data that provides a
geographical position during a designated time period allowing the
movements of a user to be tracked.

(B)
"Electronic verification system" means an electronic system
capable of recording and verifying data elements related to the
delivery of health care services covered by the medicaid program.

(C)
"GPS-based verification" means real-time satellite location
data that can be used to confirm the physical presence of a person or
device in a specified location.

(D)
"Nonemergency medical transportation" means transportation
for which immediate response is not needed for the provision of
medical treatment and is provided to a medicaid recipient in
accordance with 42 C.F.R. 431.53.

(E)
"Personal care services" has the same meaning as in 42
C.F.R. 440.167.

Sec.
5164.401.
(A)
The department of medicaid shall develop, procure, certify, or
approve one or more systems for the electronic verification of
nonemergency medical transportation services and in-home personal
care services provided under the medicaid program to medicaid
recipients. In developing, procuring, certifying, or approving a
system under this section, the department may do any of the
following:

(1)
Establish an internal electronic verification system;

(2)
Contract with one or more vendors to establish an electronic
verification system;

(3)
Integrate with existing electronic verification systems utilized by
the department.

(B)
A system or systems developed, procured, certified, or approved in
accordance with this section shall do all of the following:

(1)
For claims submitted by a nonemergency medical transportation service
provider:

(a)
Utilize a ride dispatch system that is similar to other private
transportation services;

(b)
Utilize GPS-based verification to track a provider's arrival at a
pickup location, initiation of a transport, arrival at a drop-off
location, and completion of a transport;

(c)
Capture breadcrumb location data throughout the duration of a
transport;

(d)
Record timestamps, route data, and total distance traveled during a
transport;

(e)
Be capable of transmitting data directly to the department as a
condition of payment.

(2)
For claims submitted by an in-home personal care services provider:

(a)
Require personal care service providers to clock in and clock out
when physically present at the location where services are being
provided;

(b)
Utilize GPS-based verification to track when a provider clocks in and
clocks out;

(c)
Capture breadcrumb location data throughout the duration of service
delivery;

(d)
Record timestamps and the total duration of delivered services;

(e)
Be capable of transmitting data directly to the department for
integration with other claims submissions.

(C)(1)
An electronic verification system developed, procured, certified, or
approved in accordance with this section shall be used to ensure
payment integrity within the medicaid program, compliance with state
and federal requirements, and serve as a fraud prevention measure
within the medicaid program. No data transmitted or stored by an
electronic verification system shall be used to conduct unrelated
surveillance of medicaid providers or for enforcement purposes
unrelated to the medicaid program.

(2)
All data transmitted or stored by an electronic verification system
shall be encrypted, be subject to role-based access controls and
audit logs, and comply with all requirements under state and federal
law regarding the protection of patient information.

(D)
The department shall integrate any electronic verification system
developed, procured, certified, or approved under this section with
the department's existing claims and encounters database and systems.
If necessary, the department shall coordinate with medicaid managed
care organizations and seek any necessary federal approval to
facilitate coordination with electronic verification systems in the
medicare program.

(E)(1)
Not later than six months after the effective date of this section,
the department shall develop technical standards and a plan for
implementing the requirement of this section and sections 5164.402 to
5164.406 of the Revised Code. The department shall submit a copy of
the plan to the general assembly in accordance with section 101.68 of
the Revised Code.

(2)
Not later than twelve months after the effective date of this
section, the department shall establish a pilot program under which
certain medicaid providers must utilize the electronic verification
systems established under this section.

(3)
Beginning not later than eighteen months after the effective date of
this section, the department shall require all nonemergency medical
transportation service providers to utilize an electronic
verification system established under division (B)(1) of this
section.

(4)
Beginning not later than twenty-four months after the effective date
of this section, the department shall require all in-home personal
care service providers to utilize an electronic verification system
established under division (B)(2) of this section.

(F)
In establishing and requiring utilization of electronic visit
verification systems under this section, the department shall ensure
that medicaid recipients are not denied medically necessary services
solely on the basis of a provider's failure to utilize a required
system. The department shall further ensure that any transition
periods that are the result of implementing the requirements of this
section do not impact the continuity of care for medicaid recipients.
The department shall provide training and technical support to
providers to ensure compliance with this section.

Sec.
5164.402.
(A)
Upon full implementation of the electronic verification systems
developed, procured, certified, or approved in accordance with
section 5164.401 of the Revised Code, no nonemergency medical
transportation service provider or in-home personal care service
provider shall be eligible to receive medicaid payment for
transportation or personal care services provided to a medicaid
recipient unless the provider submits all necessary data through an
electronic verification system. The department of medicaid shall pay
a claim for transportation or personal care services submitted
through an electronic verification system if all of the following
conditions are satisfied:

(1)
All required GPS-based verification and timestamp data are present.

(2)
The breadcrumb location data utilized by an electronic verification
system is consistent with the billed services.

(3)
No unresolved discrepancies about the claim exist.

(B)
The department shall establish a process by which a nonemergency
medical transportation service provider may seek an exemption from
utilizing an electronic verification system. The department may
permit an exemption for any of the following reasons:

(1)
Equipment failure or network unavailability, including rural
connectivity issues;

(2)
Emergencies;

(3)
Concerns for the safety of the medicaid recipient.

(C)
Before granting an exemption under division (B) of this section, the
department shall require a nonemergency medical transportation
service provider to submit written documentation detailing why an
exemption should be granted. The department shall routinely monitor
the number of exemptions requested by a provider.

Sec.
5164.403.
(A)
Not later than five years after the effective date of this section,
the department of medicaid shall develop and implement a system by
which data received from a nonemergency medical transportation
service provider through an electronic verification system developed,
procured, certified, or approved under section 5164.401 of the
Revised Code may be cross-referenced with claims for medicaid payment
submitted to the department by other medicaid providers. The system
established in accordance with this section shall be capable of
verifying all of the following:

(1)
The medicaid recipient who received the nonemergency medical
transportation services was transported for the purpose of receiving
a medicaid service.

(2)
The medicaid recipient who received the nonemergency medical
transportation services was transported to a medicaid provider with
an active and valid provider agreement at the time of transport.

(3)
The records are received by the department within an allowable
timeframe established under division (B) of this section and reflect
an encounter, claim, or billing activity for a service described in
division (A)(1) or (2) of this section.

(B)
The department shall establish an allowable timeframe under which
claims for medicaid payment for transportation claims may be
cross-referenced and matched against claims for other medicaid
services. The allowable timeframe shall account for documented
exceptions that create delays including provider cancellations,
appointment rescheduling, emergency diversions, delayed billing, and
administrative errors.

Sec.
5164.404.
(A)
The department of medicaid shall develop and implement automated
fraud-detection tools to assist with identifying fraud through the
use of the electronic verification systems developed, procured,
certified, or approved under section 5164.401 of the Revised Code.
Any fraud-detection tools shall be capable of flagging irregular
patterns of activity by medicaid providers that are required to
utilize the electronic verification systems, including all of the
following:

(1)
The seeking and approval of repeated exceptions under section
5164.402 of the Revised Code;

(2)
Anomalous and irregular route patterns taken by nonemergency medical
transportation service providers;

(3)
Discrepancies between location data and submitted claims.

(B)
The department shall conduct periodic audits and investigations
concerning data collected through use of the electronic verification
systems developed, procured, certified, or approved under section
5164.401 of the Revised Code and fraud-detection tools implemented
under this section. The department may suspend a medicaid provider's
provider agreement for failing to comply with an audit or
investigation conducted under this section.

(C)
If an audit or investigation conducted in accordance with this
section results in a credible allegation of fraud as defined in
section 5164.36 of the Revised Code, the department shall handle the
credible allegation in accordance with that section and refer the
credible allegation to the attorney general for investigation.

Sec.
5164.405.
Annually,
the department of medicaid shall submit a report to the general
assembly detailing electronic verification systems developed,
procured, certified, or approved under section 5164.401 of the
Revised Code. The report shall be submitted to the general assembly
in accordance with section 101.68 of the Revised Code and detail all
of the following:

(A)
The verified number of service claims submitted through electronic
verification systems;

(B)
The number of claims denied or recouped;

(C)
The number of cases of fraud referred to the medicaid fraud control
unit as a result of electronic verification systems;

(D)
The number of provider sanctions issued as a result of electronic
verification system data;

(E)
The total amount of cost savings to the medicaid program achieved as
a result of electronic verification systems;

(F)
Any impacts to medicaid recipient access to medicaid services that
result from the use of electronic verification systems;

(G)
Any additional information or data the department considers relevant
concerning electronic verification systems.

Sec.
5164.406.
The
department of medicaid shall adopt rules in accordance with Chapter
119. of the Revised Code to implement sections 5164.40 to 5164.406 of
the Revised Code. The rules shall address all of the following:

(A)
Technical standards for electronic verification systems developed,
procured, certified, or approved under section 5164.401 of the
Revised Code including GPS intervals, breadcrumb location data
parameters, and criteria for certification of electronic verification
systems;

(B)
Procedures by which a provider may seek an exemption from electronic
verification requirements under section 5164.402 of the Revised Code;

(C)
Protocols by which the department will conduct audits and enforcement
of electronic verification requirements under section 5164.404 of the
Revised Code;

(D)
Other standards and procedures as necessary to implement sections
5164.40 through 5164.406 of the Revised Code.

Section
2.
Not
later than thirty days after the effective date of this section, the
Department of Medicaid shall submit a report to the General Assembly
with a cost estimate to implement this act. The report shall include
a comparison of state funds and expected matching federal funds
necessary to develop, procure, certify, or approve electronic
verification systems described in section 5164.401 of the Revised
Code. The report shall also analyze expected cost savings for the
Medicaid program that result from implementation of electronic
verification systems.

Section
3.
This
act shall be known as the Safeguarding Healthcare Integrity through
Electronic Location Data (SHIELD) Act.