Enact the Enhanced Cybersecurity for SNAP Act

sb315_05_EN

(136th General Assembly)

(Substitute
Senate Bill Number 315)

AN
ACT

To amend sections 109.85,
117.10, 2903.216, 2913.40, 2923.31, 4113.52, 5101.542, 5164.32,
5164.33, 5164.36, 5164.57, 5167.03, and 5167.18 and to enact sections
103.413, 3901.93, 5101.5411, 5162.138, 5162.139, 5162.1311, 5162.17,
5162.19, 5162.90, 5163.05, 5164.11, 5164.12, 5164.13, 5164.292,
5164.302, 5164.303, 5164.304, 5164.305, 5164.331, 5164.332, 5164.40,
5164.401, 5164.402, 5164.403, 5164.404, 5164.405, 5164.406, 5164.41,
5164.42, 5164.421, 5164.43, and 5167.23 of the Revised Code regarding
program integrity for certain components of the Medicaid program,
regarding the authority of the Attorney General and Auditor of State,
to require Ohio's SNAP program to begin using chip-enabled EBT cards,
and to name section 5101.542 of the Revised Code as amended in this
act and section 5101.5411 of the Revised Code as enacted in this act
the Enhanced Cybersecurity for SNAP Act and to name the remainder of
this act the Ohio Medicaid Program Integrity and Fraud Prevention
Act.

Be
it enacted by the General Assembly of the State of Ohio:

Section
1.
That
sections 109.85, 117.10, 2903.216, 2913.40, 2923.31, 4113.52
,
5101.542
,
5164.32, 5164.33, 5164.36, 5164.57
,
5167.03
,
and 5167.18 be amended and sections 103.413, 3901.93
,
5101.5411
,
5162.138, 5162.139, 5162.1311, 5162.17, 5162.19
,
5162.90
,
5163.05
,
5164.11
,
5164.12, 5164.13, 5164.292, 5164.302, 5164.303, 5164.304, 5164.305,
5164.331, 5164.332, 5164.40, 5164.401, 5164.402, 5164.403, 5164.404,
5164.405, 5164.406, 5164.41, 5164.42, 5164.421, 5164.43, and 5167.23
of the Revised Code be enacted to read as follows:

Sec.
103.413.
Annually,
the standing committees of the house of representatives and the
senate that primarily consider legislation governing the medicaid
program shall meet jointly and conduct a review of one-quarter of the
medicaid waiver components as defined in section 5166.01 of the
Revised Code operating within the medicaid program. The review shall
focus on the waiver's purpose and evaluate the waiver's success at
achieving the desired purpose. The standing committees shall review
all medicaid waiver components within the medicaid program before
conducting a subsequent review of any medicaid waiver component.

Sec.
109.85.
(A)
Upon the written request of the governor, the general assembly, the
auditor of state, the medicaid director, the director of health, or
the director of budget and management, or upon the attorney general's
becoming aware of criminal or improper activity related to Chapter
3721.
of
the Revised Code

and the medicaid program, the attorney general shall investigate any
criminal or civil violation of law related to Chapter 3721. of the
Revised Code or the medicaid program.
In
any investigation conducted pursuant to this section the attorney
general may administer oaths, subpoena witnesses, adduce evidence,
and subpoena the production of any book, document, record, or other
relevant matter.

(B)
(B)(1)
If the attorney general under division (A) of this section subpoenas
the production of any relevant matter that is located outside this
state, the attorney general may designate a representative, including
an official of the state in which that relevant matter is located, to
inspect the relevant matter on the attorney general's behalf. The
attorney general may carry out similar requests received from
officials of other states.

(2)
Any person who is subpoenaed to produce relevant matter pursuant to
division (A) of this section shall make that relevant matter
available at a convenient location within this state or the state of
the representative designated under division (B)(1) of this section.

(C)
Any person who is subpoenaed as a witness or to produce relevant
matter pursuant to division (A) of this section may file in the court
of common pleas of Franklin county, the county in this state in which
the person resides, or the county in this state in which the person's
principal place of business is located a petition to extend for good
cause shown the date on which the subpoena is to be returned or to
modify or quash for good cause shown that subpoena. The person may
file the petition at any time prior to the date specified for the
return of the subpoena or within twenty days after the service of the
subpoena, whichever is earlier.

(D)
Any person who is subpoenaed as a witness or to produce relevant
matter pursuant to division (A) of this section shall comply with the
terms of the subpoena unless the court orders otherwise prior to the
date specified for the return of the subpoena or, if applicable, that
date as extended. If a person fails without lawful excuse to obey a
subpoena, the attorney general may apply to the same court of common
pleas as designated in division (C) of this section for an order that
does one or more of the following:

(1)
Compels the requested discovery;

(2)
Adjudges the person in contempt of court;

(3)
Grants other relief that may be required until the person obeys the
subpoena.

(E)
If the court finds that a person's failure to comply with a subpoena
issued under this section was in bad faith or for the purpose of
delay, it may order the person to pay to the attorney general the
reasonable expenses incurred in obtaining the order, including
attorney's fees, and may invoke the sanctions provided by Rule 37 of
the Rules of Civil Procedure.

(F)

When it appears to the attorney general, as a result of an
investigation under division (A) of this section, that there is cause
to prosecute for the commission of a crime or to pursue a civil
remedy, the attorney general may refer the evidence to the
prosecuting attorney having jurisdiction of the matter, or to a
regular grand jury drawn and impaneled pursuant to sections 2939.01
to 2939.24 of the Revised Code, or to a special grand jury drawn and
impaneled pursuant to section 2939.17 of the Revised Code, or the
attorney general may initiate and prosecute any necessary criminal or
civil actions in any court or tribunal of competent jurisdiction in
this state. When proceeding under this section, the attorney general,
and any assistant or special counsel designated by the attorney
general for that purpose, have all rights, privileges, and powers of
prosecuting attorneys. The attorney general shall have exclusive
supervision and control of all investigations and prosecutions
initiated by the attorney general under this section. The forfeiture
provisions of Chapter 2981. of the Revised Code apply in relation to
any such criminal action initiated and prosecuted by the attorney
general.

(C)
(G)

Nothing in this section shall prevent a county prosecuting attorney
from investigating and prosecuting criminal activity related to
Chapter 3721. of the Revised Code and the medicaid program. The
forfeiture provisions of Chapter 2981. of the Revised Code apply in
relation to any prosecution of criminal activity related to the
medicaid program undertaken by the prosecuting attorney.

Sec.
117.10.
(A)
The auditor of state shall audit all public offices as provided in
this chapter. The auditor of state also may audit the specific funds
or accounts of private institutions, associations, boards, and
corporations into which has been placed or deposited public money
from a public office and may require of them annual reports in such
form as the auditor of state prescribes. The auditor of state may
audit some or all of the other funds or accounts of a private
institution, association, board, or corporation that has received
public money from a public office only if one or more of the
following applies:

(1)
The audit is specifically required or authorized by the Revised Code;

(2)
The private institution, association, board, or corporation requests
that the auditor of state audit some or all of its other funds or
accounts;

(3)
All of the revenue of the private institution, association, board, or
corporation is composed of public money;

(4)
The private institution, association, board, or corporation failed to
separately and independently account for the public money in its
possession, in violation of section 117.431 of the Revised Code;

(5)
The auditor of state has a reasonable belief that the private
institution, association, board, or corporation illegally expended,
converted, misappropriated, or otherwise cannot account for the
public money it received from a public office and that it is
necessary to audit its other funds or accounts to make that
determination.

(B)
If the auditor of state performs or contracts for the performance of
an audit, including a special audit, of the public employees
retirement system, school employees retirement system, state teachers
retirement system, state highway patrol retirement system, or Ohio
police and fire pension fund, the auditor of state shall make a
timely report of the results of the audit to the Ohio retirement
study council.

(C)
The auditor of state may audit the accounts of any medicaid provider,
as defined in section 5164.01 of the Revised Code.

(D)
If a public office has been audited by an agency of the United States
government, the auditor of state may, if satisfied that the federal
audit has been conducted according to principles and procedures not
contrary to those of the auditor of state, use and adopt the federal
audit and report in lieu of an audit by the auditor of state's own
office.

(E)
Within thirty days after the creation or dissolution or the winding
up of the affairs of any public office, that public office shall
notify the auditor of state in writing that this action has occurred.

(F)

The
auditor of state may issue subpoenas compelling the production of
books, records, accounts, documents, electronically-stored
information, testimony, or other information relevant to any audit,
examination, special audit, investigation, or review within the
authority of the auditor of state under this chapter. Upon request of
the auditor of state, the attorney general shall bring an action in a
court of competent jurisdiction to enforce compliance with any
subpoena issued pursuant to this section.

(G)

Nothing
in this section precludes the auditor of state from issuing to a
private institution, association, board, or corporation a subpoena
and compulsory process for the attendance of witnesses or the
production of records under section 117.18 of the Revised Code if the
subpoena and compulsory process is in furtherance of an audit the
auditor of state is authorized by law to perform.

Sec.
2903.216.
(A)
As used in this section:

(1)
"Business entity" means any form of corporation,
partnership, association, cooperative, joint venture, business trust,
or sole proprietorship that conducts business in this state.

(2)
"Business of private investigation" and "private
investigator" have the same meanings as in section 4749.01 of
the Revised Code.

(3)
"Disabled adult" and "elderly person" have the
same meanings as in section 2913.01 of the Revised Code.

(4)
"Electronic monitoring" and "electronic monitoring
device" have the same meanings as in section 2929.01 of the
Revised Code.

(5)
"Law enforcement agency" means any organization or unit
comprised of law enforcement officers, and also includes any federal
or military law enforcement agency.

(6)
"Person" means an individual, but does not include a
business entity.

(7)
"Ohio protection order" means a protection order filed or
issued or a consent agreement approved pursuant to section 2919.26 or
3113.31 of the Revised Code, a protection order filed or issued
pursuant to section 2151.34, 2903.213, or 2903.214 of the Revised
Code, or a no contact order issued as any of the following:

(a)
As part of a person's sentence under a community control sanction
imposed under section 2929.16, 2929.17, 2929.26, or 2929.27 of the
Revised Code;

(b)
As a term or condition of a person's release under section 2929.20 of
the Revised Code;

(c)
As a post-release control sanction imposed as a condition of a
person's post-release control under section 2967.28 of the Revised
Code;

(d)
As a term of supervision for a person transferred to transitional
control under section 2967.26 of the Revised Code;

(e)
As a term or condition of the intervention plan of a person granted
intervention in lieu of conviction under section 2951.041 of the
Revised Code.

(8)
"Protection order issued by a court of another state" has
the same meaning as in section 2919.27 of the Revised Code.

(9)
"Tracking application" means any software program that
permits a person to remotely determine or track the position or
movement of another person or another person's property.

(10)
"Tracking device" means an electronic or mechanical device
that permits a person to remotely determine or track the position or
movement of another person or another person's property, including an
electronic monitoring device.

(B)
Except as otherwise provided in division (D) of this section, no
person shall knowingly do either of the following:

(1)
Install a tracking device or tracking application on another person's
property without the other person's consent or cause a tracking
device or tracking application to track the position or movement of
another person or another person's property without the other
person's consent;

(2)
If the person installed a tracking device or tracking application on
another's property with the other person's consent and the other
person subsequently revokes that consent, fail to remove or ensure
the removal of the device or application after the other person
revokes the consent.

(C)(1)
For purposes of this section, if a person has given consent for
another to install a tracking device or tracking application on the
consenting person's property, it is presumed that the consenting
person has revoked that consent if any of the following applies:

(a)
The consenting person and the person to whom consent was given are
lawfully married and one of them files a complaint for divorce or a
petition for dissolution of marriage from the other. Not later than
seventy-two hours after being served with a complaint for divorce or
a petition for dissolution of marriage, the person to whom consent
was given shall lawfully uninstall or discontinue use of the tracking
device or tracking application. If the person to whom consent was
given cannot lawfully uninstall or discontinue use of the tracking
device or tracking application, the person to whom consent was given
shall notify the court in which the complaint for divorce or the
petition for dissolution of marriage was filed in writing.

(b)
The consenting person or the person to whom consent was given files
an Ohio protection order against the other person or an Ohio
protection order is issued against the other person, and the person
to be protected under the order is the consenting person. Not later
than seventy-two hours after being served with the Ohio protection
order, the person to whom consent was given shall lawfully uninstall
or discontinue use of the tracking device or tracking application. If
the person to whom consent was given cannot lawfully uninstall or
discontinue use of the tracking device or tracking application, the
person to whom consent was given shall notify the court that issued
the Ohio protection order in writing that the person to whom consent
was given has installed or is using a tracking device or tracking
application on the previously consenting person's person or the
person's property and cannot uninstall or discontinue its use without
violating the Ohio protection order.

(2)
Revocation of consent under this division is effective upon the
service of the petition or motion or an Ohio protection order.

(D)
This section does not apply to any of the following:

(1)
A law enforcement officer, or any law enforcement agency, that
installs a tracking device or tracking application on another
person's property or causes a tracking device or tracking application
to track the position or movement of another person or another
person's property as part of a criminal investigation, or a probation
officer, parole officer, or employee of the department of
rehabilitation and correction, a halfway house, or a community-based
correctional facility when engaged in the lawful performance of the
officer's or employee's official duties;

(2)
A parent or legal guardian of a minor child who installs or uses a
tracking device or tracking application to track the minor child if
any of the following applies:

(a)
The parents or legal guardians of the child are lawfully married to
each other and are not separated or otherwise living apart, and
either of those parents or legal guardians consents to the
installation of the tracking device or tracking application;

(b)
The parent or legal guardian of the child is the sole surviving
parent or legal guardian of the child;

(c)
The parent or legal guardian of the child has sole custody of the
child;

(d)
The parents or legal guardians of the child are divorced, separated,
or otherwise living apart and neither parent has sole custody of the
child, and both consent to the installation of the tracking device or
tracking application;

(e)
The parents or legal guardians of the child are divorced, separated,
or otherwise living apart, neither parent has sole custody of the
child, and either only one parent consents to the installation of the
tracking device or tracking application or one parent revokes
consent, if the consenting parent only uses the tracking device or
tracking application during that parent's parenting or custodial time
and disables or removes the tracking device or application during the
nonconsenting parent's parenting or custodial time.

(3)
A caregiver of an elderly person or disabled adult, if the elderly
person's or disabled adult's treating physician certifies that the
installation of a tracking device or tracking application onto the
elderly person's or disabled adult's property is necessary to ensure
the safety of the elderly person or disabled adult;

(4)
A person acting in good faith on behalf of a business entity for a
legitimate business purpose, provided that this division does not
apply to a private investigator engaged in the business of private
investigation on behalf of another person;

(5)(a)
A private investigator or other person licensed under section 4749.03
of the Revised Code, who is acting in the normal course of the
investigator's business of private investigation on behalf of another
person and who has the consent of the owner of the property upon
which the tracking device or tracking application is installed, for
the purpose of obtaining information with reference to any of the
following:

(i)
Criminal offenses committed, threatened, or suspected against the
United States, a territory of the United States, a state, or any
person or legal entity;

(ii)
Locating an individual known to be a fugitive from justice;

(iii)
Locating lost or stolen property or other assets that have been
awarded by the court;

(iv)
Investigating claims related to workers' compensation.

(b)
This division does not apply if the person on whose behalf the
private investigator is working is the subject of an Ohio protection
order or a protection order issued by a court of another state or if
the private investigator knows or reasonably should know that the
person on whose behalf the private investigator is working seeks the
investigator's services to aid in the commission of a crime.

(6)
An owner or lessee of a motor vehicle who installs, or directs the
installation of, a tracking device or tracking application on the
vehicle during the period of ownership or lease, if any of the
following applies:

(a)
The tracking device or tracking application is removed before the
vehicle's title is transferred or the vehicle's lease expires;

(b)
The new owner of the vehicle, in the case of a sale, or the lessor of
the vehicle, in the case of an expired lease, consents in writing to
the non-removal of the tracking device or tracking application;

(c)
The owner of the vehicle at the time of the installation of the
tracking device or tracking application was the original manufacturer
of the vehicle.

(7)
A person who installs a tracking device or application on property in
which the person has an ownership or contractual interest, unless the
person is the subject of a protective order and the property is
likely to be used by the person who obtained the protective order;

(8)
A person or business entity that installs a tracking device or
tracking application on any fixed wing aircraft or rotorcraft
operated or managed by the person or business entity pursuant to 14
C.F.R. part 91 or part 135 to track the position or movement of the
fixed wing aircraft or rotorcraft;

(9)
A surety bail bond agent, or any employee or contractor of a surety
bail bond agent, that installs a tracking device or tracking
application on another person's property or causes a tracking device
or tracking application to track the position or movement of another
person or another person's property as part of the surety bail bond
agent's, employee's, or contractor's official responsibilities or
duties
;

(10)
The use of location verification technology by the department of
medicaid, a medicaid provider, a provider's employee or contractor,
or an electronic visit verification vendor when the technology is
used solely to comply with electronic visit verification requirements
under state or federal law including all of the following, provided
that verification technology is not used for continuous tracking
outside of the delivery of medicaid-covered services:

(a)
Verification of the beginning or ending of a medicaid-covered
service;

(b)
Validating a claim for medicaid payment;

(c)
Support for integrity of the medicaid program including audit,
investigation, payment, or recovery activities
.

(E)
For purposes of division (D)(1) of this section, a probation officer,
parole officer, or employee of the department of rehabilitation and
correction, a halfway house, or a community-based correctional
facility is engaged in the lawful performance of the officer's or
employee's duties if both of the following apply:

(1)
The court or the department of rehabilitation and correction imposes
electronic monitoring on a person.

(2)
The officer or employee installs or uses an electronic monitoring
device on that person in accordance with the court's or department's
imposition of electronic monitoring of that person.

(F)
Whoever violates this section is guilty of illegal use of a tracking
device or application.

(1)
Except as otherwise provided in division (F)(2) of this section,
illegal use of a tracking device or application is a misdemeanor of
the first degree.

(2)
Illegal use of a tracking device or application is a felony of the
fourth degree if any of the following applies:

(a)
The offender previously has been convicted of or pleaded guilty to a
violation of this section or section 2903.211 of the Revised Code.

(b)
At the time of the commission of the offense, the offender was the
subject of a protection order issued under section 2903.213 or
2903.214 of the Revised Code, regardless of whether the person to be
protected under the order is the victim of the offense or another
person.

(c)
Prior to committing the offense, the offender had been determined to
represent a substantial risk of physical harm to others as manifested
by evidence of then-recent homicidal or other violent behavior,
evidence of then-recent threats that placed another in reasonable
fear of violent behavior and serious physical harm, or other evidence
of then-present dangerousness.

(d)
The offender has a history of violence toward the victim or a history
of other violent acts towards the victim.

Sec.
2913.40.
(A)
As used in this section:

(1)
"Statement or representation" means any oral, written,
electronic, electronic impulse, or magnetic communication that is
used to identify an item of goods or a service for which
reimbursement may be made under the medicaid program or that states
income and expense and is or may be used to determine a rate of
reimbursement under the medicaid program.

(2)
"Provider" means any person who has signed a provider
agreement with the department of medicaid to provide goods or
services pursuant to the medicaid program or any person who has
signed an agreement with a party to such a provider agreement under
which the person agrees to provide goods or services that are
reimbursable under the medicaid program.

(3)
"Provider agreement" has the same meaning as in section
5164.01 of the Revised Code.

(4)
"Recipient" means any individual who receives goods or
services from a provider under the medicaid program.

(5)
"Records" means any medical, professional, financial, or
business records relating to the treatment or care of any recipient,
to goods or services provided to any recipient, or to rates paid for
goods or services provided to any recipient and any records that are
required by the rules of the medicaid director to be kept for the
medicaid program.

(6)
"Presumption that a prison term shall be imposed" means a
presumption, as described in division (D) of section 2929.13 of the
Revised Code, that a prison term is a necessary sanction for a felony
in order to comply with the purposes and principles of sentencing
under section 2929.11 of the Revised Code.

(B)
No person shall knowingly make or cause to be made a false or
misleading statement or representation for use in obtaining
reimbursement from the medicaid program.

(C)
No person, with purpose to commit fraud or knowing that the person is
facilitating a fraud, shall do either of the following:

(1)
Contrary to the terms of the person's provider agreement, charge,
solicit, accept, or receive for goods or services that the person
provides under the medicaid program any property, money, or other
consideration in addition to the amount of reimbursement under the
medicaid program and the person's provider agreement for the goods or
services and any cost-sharing expenses authorized by section 5162.20
of the Revised Code or rules adopted by the medicaid director
regarding the medicaid program.

(2)
Solicit, offer, or receive any remuneration, other than any
cost-sharing expenses authorized by section 5162.20 of the Revised
Code or rules adopted by the medicaid director regarding the medicaid
program, in cash or in kind, including, but not limited to, a
kickback or rebate, in connection with the furnishing of goods or
services for which whole or partial reimbursement is or may be made
under the medicaid program.

(D)
No person, having submitted a claim for or provided goods or services
under the medicaid program, shall do either of the following for a
period of at least six years after a reimbursement pursuant to that
claim, or a reimbursement for those goods or services, is received
under the medicaid program:

(1)
Knowingly alter, falsify, destroy, conceal, or remove any records
that are necessary to fully disclose the nature of all goods or
services for which the claim was submitted, or for which
reimbursement was received, by the person;

(2)
Knowingly alter, falsify, destroy, conceal, or remove any records
that are necessary to disclose fully all income and expenditures upon
which rates of reimbursements were based for the person.

(E)
Whoever violates this section is guilty of medicaid fraud. Except as
otherwise provided in this division, medicaid fraud is a
misdemeanor
of the first
felony
of the fifth
degree

and, notwithstanding section 2929.18 of the Revised Code, the court
shall impose as the fine for the offense a fine of one thousand
dollars
.

If

(1)
If
the
value of property, services, or funds obtained in violation of this
section is one thousand dollars or more and is less than seven
thousand five hundred dollars, medicaid fraud is a felony of the

fifth

fourth

degree

and, notwithstanding section 2929.18 of the Revised Code, the court
shall impose as the fine for the offense a fine of five thousand
dollars
.

If

(2)
If
the
value of property, services, or funds obtained in violation of this
section is seven thousand five hundred dollars or more and is less
than
one
hundred fifty
seventy-five

thousand
dollars, medicaid fraud is a felony of the
fourth

third

degree

and, notwithstanding section 2929.18 of the Revised Code, the court
shall impose as the fine for the offense a fine of twenty-five
thousand dollars
.

If

(3)
If
the
value of the property, services, or funds obtained in violation of
this section is
one
hundred fifty
seventy-five

thousand
dollars or more

and is less than one hundred fifty thousand dollars
,
medicaid fraud is a felony of the third degree

and there is a presumption for a prison term. Notwithstanding section
2929.18 of the Revised Code, the court shall impose as the fine for
the offense a fine of seventy-five thousand dollars
.

(4)
If the value of the property, services, or funds obtained in
violation of this section is one hundred fifty thousand dollars or
more and is less than seven hundred fifty thousand dollars, medicaid
fraud is a felony of the second degree and there is a presumption of
a prison term. Notwithstanding section 2929.18 of the Revised Code,
the court shall impose as the fine for the offense a fine of one
hundred fifty thousand dollars.

(5)
If the value of the property or services stolen is seven hundred
fifty thousand dollars or more, medicaid fraud is a felony of the
first degree and there is a presumption of a prison term.
Notwithstanding section 2929.18 of the Revised Code, the court shall
impose as the fine for the offense a fine of one hundred fifty
thousand dollars.

(F)
Upon application of the governmental agency, office, or other entity
that conducted the investigation and prosecution in a case under this
section, the court shall order any person who is convicted of a
violation of this section for receiving any reimbursement for
furnishing goods or services under the medicaid program to which the
person is not entitled to pay to the applicant its cost of
investigating and prosecuting the case. The costs of investigation
and prosecution that a defendant is ordered to pay pursuant to this
division shall be in addition to any other penalties for the receipt
of that reimbursement that are provided in this section, section
5164.35 of the Revised Code, or any other provision of law.

(G)
The provisions of this section are not intended to be exclusive
remedies and do not preclude the use of any other criminal or civil
remedy for any act that is in violation of this section.

Sec.
2923.31.
As
used in sections 2923.31 to 2923.36 of the Revised Code:

(A)
"Beneficial interest" means any of the following:

(1)
The interest of a person as a beneficiary under a trust in which the
trustee holds title to personal or real property;

(2)
The interest of a person as a beneficiary under any other trust
arrangement under which any other person holds title to personal or
real property for the benefit of such person;

(3)
The interest of a person under any other form of express fiduciary
arrangement under which any other person holds title to personal or
real property for the benefit of such person.

"Beneficial
interest" does not include the interest of a stockholder in a
corporation or the interest of a partner in either a general or
limited partnership.

(B)
"Costs of investigation and prosecution" and "costs of
investigation and litigation" mean all of the costs incurred by
the state or a county or municipal corporation under sections 2923.31
to 2923.36 of the Revised Code in the prosecution and investigation
of any criminal action or in the litigation and investigation of any
civil action, and includes, but is not limited to, the costs of
resources and personnel.

(C)
"Enterprise" includes any individual, sole proprietorship,
partnership, limited partnership, corporation, trust, union,
government agency, or other legal entity, or any organization,
association, or group of persons associated in fact although not a
legal entity. "Enterprise" includes illicit as well as
licit enterprises.

(D)
"Innocent person" includes any bona fide purchaser of
property that is allegedly involved in a violation of section 2923.32
of the Revised Code, including any person who establishes a valid
claim to or interest in the property in accordance with division (E)
of section 2981.04 of the Revised Code, and any victim of an alleged
violation of that section or of any underlying offense involved in an
alleged violation of that section.

(E)
"Pattern of corrupt activity" means two or more incidents
of corrupt activity, whether or not there has been a prior
conviction, that are related to the affairs of the same enterprise,
are not isolated, and are not so closely related to each other and
connected in time and place that they constitute a single event.

At
least one of the incidents forming the pattern shall occur on or
after January 1, 1986. Unless any incident was an aggravated murder
or murder, the last of the incidents forming the pattern shall occur
within six years after the commission of any prior incident forming
the pattern, excluding any period of imprisonment served by any
person engaging in the corrupt activity.

For
the purposes of the criminal penalties that may be imposed pursuant
to section 2923.32 of the Revised Code, at least one of the incidents
forming the pattern shall constitute a felony under the laws of this
state in existence at the time it was committed or, if committed in
violation of the laws of the United States or of any other state,
shall constitute a felony under the law of the United States or the
other state and would be a criminal offense under the law of this
state if committed in this state.

(F)
"Pecuniary value" means money, a negotiable instrument, a
commercial interest, or anything of value, as defined in section 1.03
of the Revised Code, or any other property or service that has a
value in excess of one hundred dollars.

(G)
"Person" means any person, as defined in section 1.59 of
the Revised Code, and any governmental officer, employee, or entity.

(H)
"Personal property" means any personal property, any
interest in personal property, or any right, including, but not
limited to, bank accounts, debts, corporate stocks, patents, or
copyrights. Personal property and any beneficial interest in personal
property are deemed to be located where the trustee of the property,
the personal property, or the instrument evidencing the right is
located.

(I)
"Corrupt activity" means engaging in, attempting to engage
in, conspiring to engage in, or soliciting, coercing, or intimidating
another person to engage in any of the following:

(1)
Conduct defined as "racketeering activity" under the
"Organized Crime Control Act of 1970," 84 Stat. 941, 18
U.S.C. 1961(1)(B), (1)(C), (1)(D), and (1)(E), as amended;

(2)
Conduct constituting any of the following:

(a)
A violation of section 1315.55, 1322.07, 2903.01, 2903.02, 2903.03,
2903.04, 2903.11, 2903.12, 2905.01, 2905.02, 2905.11, 2905.22,
2905.32 as specified in division (I)(2)(g) of this section, 2907.321,
2907.322, 2907.323, 2909.02, 2909.03, 2909.22, 2909.23, 2909.24,
2909.26, 2909.27, 2909.28, 2909.29, 2911.01, 2911.02, 2911.11,
2911.12, 2911.13, 2911.31, 2913.05, 2913.06, 2913.30, 2921.02,
2921.03, 2921.04, 2921.11, 2921.12, 2921.32, 2921.41, 2921.42,
2921.43, 2923.12, or 2923.17; division (F)(1)(a), (b), or (c) of
section 1315.53; division (A)(1) or (2) of section 1707.042; division
(B), (C)(4), (D), (E), or (F) of section 1707.44; division (A)(1) or
(2) of section 2923.20; division (E) or (G) of section 3772.99;
division (J)(1) of section 4712.02; section 4719.02, 4719.05, or
4719.06; division (C), (D), or (E) of section 4719.07; section
4719.08; or division (A) of section 4719.09 of the Revised Code.

(b)
Any violation of section 3769.11, 3769.15, 3769.16, or 3769.19 of the
Revised Code as it existed prior to July 1, 1996, any violation of
section 2915.02 of the Revised Code that occurs on or after July 1,
1996, and that, had it occurred prior to that date, would have been a
violation of section 3769.11 of the Revised Code as it existed prior
to that date, or any violation of section 2915.05 of the Revised Code
that occurs on or after July 1, 1996, and that, had it occurred prior
to that date, would have been a violation of section 3769.15,
3769.16, or 3769.19 of the Revised Code as it existed prior to that
date.

(c)
Any violation of section 2907.21, 2907.22, 2907.31, 2913.02, 2913.11,
2913.21, 2913.31, 2913.32, 2913.34,
2913.40,

2913.42,
2913.47, 2913.51, 2915.03, 2925.03, 2925.04, 2925.05, or 2925.37 of
the Revised Code, any violation of section 2925.11 of the Revised
Code that is a felony of the first, second, third, or fourth degree
and that occurs on or after July 1, 1996, any violation of section
2915.02 of the Revised Code that occurred prior to July 1, 1996, any
violation of section 2915.02 of the Revised Code that occurs on or
after July 1, 1996, and that, had it occurred prior to that date,
would not have been a violation of section 3769.11 of the Revised
Code as it existed prior to that date, any violation of section
2915.06 of the Revised Code as it existed prior to July 1, 1996, or
any violation of division (B) of section 2915.05 of the Revised Code
as it exists on and after July 1, 1996, when the proceeds of the
violation, the payments made in the violation, the amount of a claim
for payment or for any other benefit that is false or deceptive and
that is involved in the violation, or the value of the contraband or
other property illegally possessed, sold, or purchased in the
violation exceeds one thousand dollars, or any combination of
violations described in division (I)(2)(c) of this section when the
total proceeds of the combination of violations, payments made in the
combination of violations, amount of the claims for payment or for
other benefits that is false or deceptive and that is involved in the
combination of violations, or value of the contraband or other
property illegally possessed, sold, or purchased in the combination
of violations exceeds one thousand dollars;

(d)
Any violation of section 5743.112 of the Revised Code when the amount
of unpaid tax exceeds one hundred dollars;

(e)
Any violation or combination of violations of section 2907.32 of the
Revised Code involving any material or performance containing a
display of bestiality or of sexual conduct, as defined in section
2907.01 of the Revised Code, that is explicit and depicted with
clearly visible penetration of the genitals or clearly visible
penetration by the penis of any orifice when the total proceeds of
the violation or combination of violations, the payments made in the
violation or combination of violations, or the value of the
contraband or other property illegally possessed, sold, or purchased
in the violation or combination of violations exceeds one thousand
dollars;

(f)
Any combination of violations described in division (I)(2)(c) of this
section and violations of section 2907.32 of the Revised Code
involving any material or performance containing a display of
bestiality or of sexual conduct, as defined in section 2907.01 of the
Revised Code, that is explicit and depicted with clearly visible
penetration of the genitals or clearly visible penetration by the
penis of any orifice when the total proceeds of the combination of
violations, payments made in the combination of violations, amount of
the claims for payment or for other benefits that is false or
deceptive and that is involved in the combination of violations, or
value of the contraband or other property illegally possessed, sold,
or purchased in the combination of violations exceeds one thousand
dollars;

(g)
Any violation of section 2905.32 of the Revised Code to the extent
the violation is not based solely on the same conduct that
constitutes corrupt activity pursuant to division (I)(2)(c) of this
section due to the conduct being in violation of section 2907.21 of
the Revised Code.

(3)
Conduct constituting a violation of any law of any state other than
this state that is substantially similar to the conduct described in
division (I)(2) of this section, provided the defendant was convicted
of the conduct in a criminal proceeding in the other state;

(4)
Animal or ecological terrorism;

(5)(a)
Conduct constituting any of the following:

(i)
Organized retail theft;

(ii)
Conduct that constitutes one or more violations of any law of any
state other than this state, that is substantially similar to
organized retail theft, and that if committed in this state would be
organized retail theft, if the defendant was convicted of or pleaded
guilty to the conduct in a criminal proceeding in the other state.

(b)
By enacting division (I)(5)(a) of this section, it is the intent of
the general assembly to add organized retail theft and the conduct
described in division (I)(5)(a)(ii) of this section as conduct
constituting corrupt activity. The enactment of division (I)(5)(a) of
this section and the addition by division (I)(5)(a) of this section
of organized retail theft and the conduct described in division
(I)(5)(a)(ii) of this section as conduct constituting corrupt
activity does not limit or preclude, and shall not be construed as
limiting or precluding, any prosecution for a violation of section
2923.32 of the Revised Code that is based on one or more violations
of section 2913.02 or 2913.51 of the Revised Code, one or more
similar offenses under the laws of this state or any other state, or
any combination of any of those violations or similar offenses, even
though the conduct constituting the basis for those violations or
offenses could be construed as also constituting organized retail
theft or conduct of the type described in division (I)(5)(a)(ii) of
this section.

(J)
"Real property" means any real property or any interest in
real property, including, but not limited to, any lease of, or
mortgage upon, real property. Real property and any beneficial
interest in it is deemed to be located where the real property is
located.

(K)
"Trustee" means any of the following:

(1)
Any person acting as trustee under a trust in which the trustee holds
title to personal or real property;

(2)
Any person who holds title to personal or real property for which any
other person has a beneficial interest;

(3)
Any successor trustee.

"Trustee"
does not include an assignee or trustee for an insolvent debtor or an
executor, administrator, administrator with the will annexed,
testamentary trustee, guardian, or committee, appointed by, under the
control of, or accountable to a court.

(L)
"Unlawful debt" means any money or other thing of value
constituting principal or interest of a debt that is legally
unenforceable in this state in whole or in part because the debt was
incurred or contracted in violation of any federal or state law
relating to the business of gambling activity or relating to the
business of lending money at an usurious rate unless the creditor
proves, by a preponderance of the evidence, that the usurious rate
was not intentionally set and that it resulted from a good faith
error by the creditor, notwithstanding the maintenance of procedures
that were adopted by the creditor to avoid an error of that nature.

(M)
"Animal activity" means any activity that involves the use
of animals or animal parts, including, but not limited to, hunting,
fishing, trapping, traveling, camping, the production, preparation,
or processing of food or food products, clothing or garment
manufacturing, medical research, other research, entertainment,
recreation, agriculture, biotechnology, or service activity that
involves the use of animals or animal parts.

(N)
"Animal facility" means a vehicle, building, structure,
nature preserve, or other premises in which an animal is lawfully
kept, handled, housed, exhibited, bred, or offered for sale,
including, but not limited to, a zoo, rodeo, circus, amusement park,
hunting preserve, or premises in which a horse or dog event is held.

(O)
"Animal or ecological terrorism" means the commission of
any felony that involves causing or creating a substantial risk of
physical harm to any property of another, the use of a deadly weapon
or dangerous ordnance, or purposely, knowingly, or recklessly causing
serious physical harm to property and that involves an intent to
obstruct, impede, or deter any person from participating in a lawful
animal activity, from mining, foresting, harvesting, gathering, or
processing natural resources, or from being lawfully present in or on
an animal facility or research facility.

(P)
"Research facility" means a place, laboratory, institution,
medical care facility, government facility, or public or private
educational institution in which a scientific test, experiment, or
investigation involving the use of animals or other living organisms
is lawfully carried out, conducted, or attempted.

(Q)
"Organized retail theft" means the theft of retail property
with a retail value of one thousand dollars or more from one or more
retail establishments with the intent to sell, deliver, or transfer
that property to a retail property fence.

(R)
"Retail property" means any tangible personal property
displayed, held, stored, or offered for sale in or by a retail
establishment.

(S)
"Retail property fence" means a person who possesses,
procures, receives, or conceals retail property that was represented
to the person as being stolen or that the person knows or believes to
be stolen.

(T)
"Retail value" means the full retail value of the retail
property. In determining whether the retail value of retail property
equals or exceeds one thousand dollars, the value of all retail
property stolen from the retail establishment or retail
establishments by the same person or persons within any
one-hundred-eighty-day period shall be aggregated.

Sec.
3901.93.
(A)
As used in this section:

(1)
"Department" has the same meaning as in section 121.01 of
the Revised Code.

(2)
"Health plan issuer" has the same meaning as in section
3922.01 of the Revised Code.

(3)
"Medicaid managed care organization" has the same meaning
as in section 5167.01 of the Revised Code.

(4)
"Payer" includes a health plan issuer, a medicaid managed
care organization, the medicaid program, and the medicare program.

(B)(1)
Not later than one year after the effective date of this section, the
superintendent of insurance shall establish and administer an
all-payer claims database.

(2)
To the extent permitted by federal law and except as otherwise
provided in this division, each payer shall submit its claims to the
superintendent for inclusion in the database. Such claims shall be
submitted in the format and according to the schedule prescribed by
the superintendent in rule.

In
the case of a payer that is a health plan issuer, the requirement to
submit claims begins January 1, 2028.

(3)
The superintendent shall include in the database each claim the
superintendent receives.

(4)
The superintendent shall make claims information included in the
database available to any person or government entity. The
superintendent may require a person to obtain a subscription with the
department of insurance to access information included in the
database in accordance with section 149.43 of the Revised Code.

(C)
The superintendent shall adopt rules to implement this section,
including rules establishing standards and procedures for the
following:

(1)
Submitting claims for inclusion in the database, including the
prescribed format and schedule;

(2)
Maintaining the privacy and security of personal and health
information contained in claims;

(3)
Making available to persons or government entities claims information
from the database;

(4)
Imposing penalties when claims are not submitted.

The
superintendent may adopt any other rules the superintendent considers
necessary to implement this section. All rules shall be adopted in
accordance with Chapter 119. of the Revised Code.

(D)
Notwithstanding any provision of section 121.95 of the Revised Code
to the contrary, a regulatory restriction contained in a rule adopted
under division (C) of this section is not subject to sections 121.95
to 121.953 of the Revised Code.

Sec.
4113.52.
(A)(1)(a)
All state officials and employees employed by or appointed to a state
agency as defined in division (D) of section 121.41 of the Revised
Code shall report alleged fraud, theft in office, or the misuse or
misappropriation of public money by a state official or employee
to
the inspector general. All other state employees and elected
officials shall report fraud, theft in office, or the misuse or
misappropriation of public money
to
the auditor of state's fraud-reporting system under section 117.103
of the Revised Code
.
An official or employee of the auditor of state may report alleged
fraud, theft in office, or the misuse or misappropriation of public
money to the inspector general. Nothing in this division prohibits
the auditor of state or the inspector general from referring a report
to the other office when appropriate
.

(b)
A person is required to make a report under division (A)(1)(c) of
this section if the person meets any of the following:

(i)
The person is elected to local public office.

(ii)
The person is appointed to or within a local public office.

(iii)
The person has a fiduciary duty to a local public office.

(iv)
The person holds a supervisory position within a local public office.

(v)
The person is employed in the department or office responsible for
processing any revenue or expenses of the local public office.

(c)
If a person identified in division (A)(1)(b) of this section, during
the person's term of office or in the course of the person's
employment, becomes aware of fraud, theft in office, or the misuse or
misappropriation of public money, the person shall timely notify the
auditor of state via the auditor of state's fraud-reporting system
under section 117.103 of the Revised Code or via other means.

(d)
A person who serves as legal counsel, or who is employed as legal
counsel, for a local public office or a state official or employee
employed by or appointed to a state agency is not required to make a
report under division (A)(1)(a) or (c) of this section concerning any
communication received from a client in an attorney-client
relationship.

(e)
Divisions (A)(1)(a), (b), and (c) of this section do not apply to a
prosecuting attorney, director of law, village solicitor, or similar
chief legal officer of a municipal corporation, or to any employee of
the prosecuting attorney, director of law, village solicitor, or
similar chief legal officer of a municipal corporation.

(f)
If a person becomes aware in the course of the person's employment of
a violation of any state or federal statute or any ordinance or
regulation of a political subdivision that the person's employer has
authority to correct, and the person reasonably believes that the
violation is a criminal offense that is likely to cause an imminent
risk of physical harm to persons or a hazard to public health or
safety, a felony, or an improper solicitation for a contribution, the
person orally shall notify the person's supervisor or other
responsible officer of the person's employer of the violation and
subsequently shall file with that supervisor or officer a written
report that provides sufficient detail to identify and describe the
violation. If the employer does not correct the violation or make a
reasonable and good faith effort to correct the violation within
twenty-four hours after the oral notification or the receipt of the
report, whichever is earlier, the person may file a written report
that provides sufficient detail to identify and describe the
violation with the prosecuting authority of the county or municipal
corporation where the violation occurred, with a peace officer, with
the inspector general if the violation is within the inspector
general's jurisdiction, with the auditor of state's fraud-reporting
system under section 117.103 of the Revised Code if applicable, or
with any other appropriate public official or agency that has
regulatory authority over the employer and the industry, trade, or
business in which the employer is engaged.

(g)
If a person makes a report under division (A)(1)(f) of this section,
the employer, within twenty-four hours after the oral notification
was made or the report was received or by the close of business on
the next regular business day following the day on which the oral
notification was made or the report was received, whichever is later,
shall notify the person, in writing, of any effort of the employer to
correct the alleged violation or hazard or of the absence of the
alleged violation or hazard.

(2)
If a person becomes aware in the course of the person's employment of
a violation of Chapter 3704., 3734., 6109., or 6111. of the Revised
Code that is a criminal offense, the person directly may notify,
either orally or in writing, any appropriate public official or
agency that has regulatory authority over the employer and the
industry, trade, or business in which the employer is engaged.

(3)
If a person becomes aware in the course of the person's employment of
a violation by a fellow employee of any state or federal statute, any
ordinance or regulation of a political subdivision, or any work rule
or company policy of the person's employer and the person reasonably
believes that the violation is a criminal offense that is likely to
cause an imminent risk of physical harm to persons or a hazard to
public health or safety, a felony, or an improper solicitation for a
contribution, the person orally shall notify the person's supervisor
or other responsible officer of the person's employer of the
violation and subsequently shall file with that supervisor or officer
a written report that provides sufficient detail to identify and
describe the violation.

(4)
The reporting requirements under division (A) of this section are not
intended to infringe, and should not be interpreted as infringing on,
the constitutional right against self-incrimination.

(B)
Except as otherwise provided in division (C) of this section, no
employer shall take any disciplinary or retaliatory action against
an

a

person
for making any report authorized by division (A)(1) or (2) of this
section, or as a result of the person's having made any inquiry or
taken any other action to ensure the accuracy of any information
reported under either such division. No employer shall take any
disciplinary or retaliatory action against a person for making any
report authorized by division (A)(3) of this section if the person
made a reasonable and good faith effort to determine the accuracy of
any information so reported, or as a result of the person's having
made any inquiry or taken any other action to ensure the accuracy of
any information reported under that division. For purposes of this
division, disciplinary or retaliatory action by the employer
includes, without limitation, doing any of the following:

(1)
Removing or suspending the person from employment;

(2)
Withholding from the person salary increases or employee benefits to
which the person is otherwise entitled;

(3)
Transferring or reassigning the person;

(4)
Denying the person a promotion that otherwise would have been
received;

(5)
Reducing the person in pay or position.

(C)
A person shall make a reasonable and good faith effort to determine
the accuracy of any information reported under division (A)(1) or (2)
of this section. If the person who makes a report under either
division fails to make such an effort, the person may be subject to
disciplinary action by the person's employer, including suspension or
removal, for reporting information without a reasonable basis to do
so under division (A)(1) or (2) of this section.

(D)
If an employer takes any disciplinary or retaliatory action against

an

a

person
as a result of the person's having filed a report under division (A)
of this section, the person may bring a civil action for appropriate
injunctive relief or for the remedies set forth in division (E) of
this section, or both, within one hundred eighty days after the date
the disciplinary or retaliatory action was taken, in a court of
common pleas in accordance with the Rules of Civil Procedure. A civil
action under this division is not available to a person as a remedy
for any disciplinary or retaliatory action taken by an appointing
authority against the person as a result of the person's having filed
a report under division (A) of section 124.341 of the Revised Code.

(E)
The court, in rendering a judgment for the person in an action
brought pursuant to division (D) of this section, may order, as it
determines appropriate, reinstatement of the person to the same
position that the person held at the time of the disciplinary or
retaliatory action and at the same site of employment or to a
comparable position at that site, the payment of back wages, full
reinstatement of fringe benefits and seniority rights, or any
combination of these remedies. The court also may award the
prevailing party all or a portion of the costs of litigation and, if
the person who brought the action prevails in the action, may award
the prevailing person reasonable attorney's fees, witness fees, and
fees for experts who testify at trial, in an amount the court
determines appropriate. If the court determines that an employer
deliberately has violated division (B) of this section, the court, in
making an award of back pay, may include interest at the rate
specified in section 1343.03 of the Revised Code.

(F)
Any report filed with the inspector general under this section shall
be filed as a complaint in accordance with section 121.46 of the
Revised Code.

(G)
As used in this section:

(1)
"Contribution" has the same meaning as in section 3517.01
of the Revised Code.

(2)
"Improper solicitation for a contribution" means a
solicitation for a contribution that satisfies all of the following:

(a)
The solicitation violates division (B), (C), or (D) of section
3517.092 of the Revised Code;

(b)
The solicitation is made in person by a public official or by an
employee who has a supervisory role within the public office;

(c)
The public official or employee knowingly made the solicitation, and
the solicitation violates division (B), (C), or (D) of section
3517.092 of the Revised Code;

(d)
The employee reporting the solicitation is an employee of the same
public office as the public official or the employee with the
supervisory role who is making the solicitation.

(3)
"Misappropriation of public money" means knowingly using
public money or public property for an unauthorized, improper, or
unlawful purpose to serve a private or personal benefit or interest.

(4)
"Misuse of public money" means knowingly using public money
or public property in a manner not authorized by law.

(5)
"Public office" has the same meaning as in section 117.01
of the Revised Code.

(H)
Nothing in this section shall be construed to limit the authority of
an auditor to make inquiries or interview state or local government
employees or officials or otherwise perform audit procedures related
to fraud during the course of an audit or attestation engagement.

Sec.
5101.542.
(A)
Immediately following a county department of job and family services'
certification that a household determined under division (B) of
section 5101.54 of the Revised Code to be in immediate need of
nutrition assistance is eligible for the supplemental nutrition
assistance program, the department of job and family services shall
provide for the household to be sent by regular United States mail an
electronic benefit transfer card containing the amount of benefits
the household is eligible to receive under the program. The card
shall be sent to the member of the household in whose name
application for the supplemental nutrition assistance program was
made or that member's authorized representative.

(B)
Except as provided in division (C) of this section, the department
shall replace any electronic benefit transfer card that is reported
by a household to be lost, stolen, or damaged, within two business
days of receiving notice of the card's condition, in accordance with
7 C.F.R. 274.6(b).

(C)(1)
The department shall implement the option described in 7 C.F.R.
274.6(b)(5) and shall withhold a replacement electronic benefit
transfer card from a household that requests four or more replacement
cards during a twelve-month period until the requirements specified
in 7 C.F.R. 274.6(b)(5) have been satisfied.

(2)
The department shall not withhold a replacement card as described
under division (C)(1) of this section if the individual requesting
the replacement has a disability directly related to the loss of the
card.

(D)
The department shall establish a process as part of the department's
existing customer service telephone hotline that allows individuals
to lock or unlock an electronic benefit transfer card that has been
lost or stolen
.

(E)
On the effective date of this amendment, the department shall begin
the transition to chip-enabled supplemental nutrition assistance
program electronic benefit transfer cards. In implementing this
transition, the department shall ensure that all new electronic
benefit transfer cards that are issued are chip-enabled and shall
replace existing electronic benefit transfer cards with chip-enabled
cards under the department's ordinary timeframe for replacing
electronic benefit transfer cards
.

Sec.
5101.5411.
The
director of job and family services shall ensure that the department
of job and family services' web site contains a mechanism that allows
supplemental nutrition assistance program benefit recipients to
report alleged fraudulent transactions to the department.

Sec.
5162.138.
The
department of medicaid shall annually prepare and submit a report to
the chairpersons and ranking members of the committees of the house
of representatives and senate with jurisdiction over medicaid
detailing the department's efforts to ensure integrity within the
medicaid program.

Sec.
5162.139.
(A)
As used in this section, "electronic visit verification" or
"EVV" has the same meaning as in section 1903(l) of the
"Social Security Act," 42 U.S.C. 1903(l).

(B)
Not later than the first day of March annually, the medicaid director
shall submit a report to the governor, the speaker of the house of
representatives, the president of the senate, and the auditor of
state regarding electronic visit verification utilization and
compliance for the immediately preceding calendar year. The report
shall, at a minimum, include all of the following:

(1)
Provider utilization rates;

(2)
Provider compliance rates;

(3)
The number and percentage of claims or service visits with complete
EVV data;

(4)
The number and percentage of claims or service visits with missing,
incomplete, manually entered, modified, late, or unmatched EVV data;

(5)
The number of claims denied or paid due to EVV compliance status;

(6)
Compliance trends by provider type and geographic region;

(7)
Enforcement or corrective actions taken by the department;

(8)
Any recommendations to improve EVV utilization, compliance, payment
integrity, and fraud prevention.

(C)
The department of medicaid shall make the report publicly available
on the department's internet web site not later than thirty days
after submitting the report in accordance with division (B) of this
section, except that the department shall redact any information that
is confidential under state or federal law or would otherwise
compromise an ongoing audit, investigation, or enforcement action.

(D)
Nothing in this section shall be construed to limit the authority of
the auditor of state under Chapter 117. of the Revised Code.

Sec.
5162.1311.
The
department of medicaid shall prepare and submit an annual report to
the general assembly in accordance with section 101.68 of the Revised
Code that details any billing code that represents an increase or
decrease of greater than fifty per cent in the utilization rate or
total expenditures for a particular service from the previous state
fiscal year. As part of the report, the department shall also provide
data concerning any identified billing code or utilization rate or
expenditure data for an identified service from the five years
preceding the report.

Sec.
5162.17.
(A)
As used in this section:

(1)
"Electronic visit verification" or "EVV" has the
same meaning as in section 1903(l) of the "Social Security Act,"
42 U.S.C. 1396b(l).

(2)
"Provider" means a medicaid provider required by state or
federal law to utilize an electronic visit verification system as a
condition of payment for services provided under the medicaid
program.

(B)
The department of medicaid shall maintain a statewide electronic
visit verification performance dashboard. The dashboard shall include
all of the following information, updated not less than quarterly:

(1)
Statewide utilization rates of electronic visit verification;

(2)
Rates of successful matching between EVV records and submitted claims
for medicaid payment;

(3)
Provider compliance trends;

(4)
The percentage of claims that are supported by verified EVV
documentation;

(5)
Aggregate statistics regarding manually adjusted EVV entries;

(6)
Any other metrics the department determines appropriate for
monitoring compliance, fraud prevention, and program integrity.

(C)
The department shall make aggregate statewide data available to the
public on the department's internet web site.

(D)
The department shall use information collected and maintained under
this section to identify providers that may require technical
assistance, additional training, corrective action, or program
integrity review. The department may provide provider-specific
compliance information through a secure provider portal or dashboard.

(E)
The medicaid director may adopt rules under section 5162.02 of the
Revised Code to implement this section.

Sec.
5162.19.
(A)
As used in this section, "alternative primary insurance coverage
source" means an insurance coverage source that is not coverage
under the medicaid program, including coverage under the medicare
program or coverage under a health benefit plan as defined in section
3922.01 of the Revised Code.

(B)
Prior to the issuance of any payment on a claim for services provided
under either the fee-for-service component of the medicaid program or
the care management system established under Chapter 5167. of the
Revised Code, the department of medicaid shall require that all
claims be electronically evaluated to determine whether an
alternative primary insurance coverage source exists that is
responsible for payment of the claim.

(C)
An evaluation conducted under division (B) of this section shall use
automated algorithmic analysis and insurance discovery engines
capable of identifying alternative primary insurance coverage sources
associated with the medicaid recipient prior to any payment being
issued.

(D)
Neither the department nor a medicaid managed care organization shall
issue payment for a claim that has not been subjected to an
evaluation under this section.

(E)
If an alternative primary insurance coverage source is identified,
the claim shall be redirected to the identified alternative primary
insurance coverage source prior to any medicaid payment for the
claim, consistent with all medicaid payer-of-last-resort requirements
under state and federal law.

(F)
The department shall adopt rules in accordance with Chapter 119. of
the Revised Code as necessary to implement the requirements of this
section, including standards for approved insurance discovery
engines, claims processing timelines, and reporting requirements.

Sec.
5162.90.
(A)
As used in this section:

(1)
"Artificial intelligence" means a machine-based system
that, for explicit or implicit objectives, infers, from the input it
receives, how to generate outputs such as predictions, content,
recommendations, or decisions that can influence physical or virtual
environments. "Artificial intelligence" includes generative
artificial intelligence.

(2)
"Automated review tools" include artificial intelligence,
automated fraud detection tools, automated algorithmic analysis, or
any other electronic automated review tool, system, or service.

(3)
"Generative artificial intelligence" means an artificial
intelligence technology system that satisfies all of the following:

(a)
The system is trained on data.

(b)
The system is designed to simulate human conversation with a consumer
through text, audio, or visual communication.

(c)
The system generates nonscripted outputs similar to outputs created
by a human, with limited or no human oversight.

(B)
When implementing sections 5162.17 to 5162.19 of the Revised Code, if
the department of medicaid uses any automated review tools, all of
the following shall occur:

(1)
No action shall be taken automatically without human review as a
result of the automated review tool's determination or decision.

(2)
The appropriate department employee responsible for overseeing the
determination or decision shall review the findings of the automated
review tool to confirm the tool made the correct determination or
decision.

Sec.
5163.05.
No
individual is eligible to participate in the medicaid program in this
state unless that individual is eligible to participate in the
medicaid program under section 1903(v)(5) of the "Social
Security Act," 42 U.S.C. 1396b(v)(5).

Sec.
5164.11.
(A)
As used in this section:

(1)
"Artificial intelligence" means a machine-based system
that, for explicit or implicit objectives, infers, from the input it
receives, how to generate outputs such as predictions, content,
recommendations, or decisions that can influence physical or virtual
environments. "Artificial intelligence" includes generative
artificial intelligence.

(2)
"Automated review tools" mean artificial intelligence,
automated fraud detection tools, automated algorithmic analysis, or
any other electronic automated review tool, system, or service.

(3)
"Generative artificial intelligence" means an artificial
intelligence technology system that satisfies all of the following:

(a)
The system is trained on data.

(b)
The system is designed to simulate human conversation with a consumer
through text, audio, or visual communication.

(c)
The system generates nonscripted outputs similar to outputs created
by a human, with limited or no human oversight.

(B)
When implementing sections 5164.292, 5164.302, 5164.32, 5164.33 to
5164.332, 5164.36, 5164.40 to 5164.407, 5164.41 to 5164.43, 5164.54,
and 5164.57 of the Revised Code, if the department of medicaid uses
any automated review tools, all of the following shall occur:

(1)
No action shall be taken automatically without human review as a
result of the automated review tool's determination or decision.

(2)
The appropriate department employee responsible for overseeing the
determination or decision shall review the findings of the automated
review tool to confirm the tool made the correct determination or
decision.

Sec.
5164.12.
The
department of medicaid shall impose a prior authorization requirement
on all therapeutic behavioral services that are provided under the
medicaid program.

Sec.
5164.13.
(A)
As used in this section:

(1)
"Independent provider" has the same meaning as in section
5164.341 of the Revised Code.

(2)
"Personal care services" means any service reimbursed under
the medicaid program that assists a recipient who is not an inpatient
in a hospital or a resident of a nursing facility or ICF/IID with
activities of daily living, instrumental activities of daily living,
supervision, homemaker tasks, attendant care, personal support
services, or substantially similar in-home support services that are
not medical services.

(3)
"Prior authorization" means advance written approval issued
by the department of medicaid, a medicaid managed care organization,
or other entity contracted to perform utilization review functions
before medicaid payment may be made.

(4)
"Waiver agency" has the same meaning as in section 5164.342
of the Revised Code.

(B)
Subject to division (I) of this section, the department of medicaid
shall require prior authorization for personal care services provided
under the medicaid program when the personal care services that are
requested exceed the amount or scope of services described in a
written plan of care or individual service plan for an individual.

(C)(1)
To initiate a request for prior authorization under this section, an
independent provider shall submit a signed and dated request to the
department. An employee of a waiver agency shall submit a signed and
dated request to the waiver agency, and the waiver agency shall
submit the request to the department.

(2)
Included in a request, the independent provider or waiver agency
employee shall submit supporting documentation that provides evidence
that the requested services are medically necessary in accordance
with the standards established under division (E) of this section.

(3)
An independent provider or waiver agency employee shall include in a
request submitted under division (C)(1) of this section if the
services for which prior authorization is requested are urgent care
services for which a forty-eight hour determination is necessary
under division (D)(3) of this section.

(D)(1)
Within ten business days of receiving a request under division (C) of
this section, the department shall notify the independent provider or
waiver agency if additional information is needed to make a
determination. The independent provider or waiver agency shall submit
the additional information to the department within five business
days of receiving notification from the department.

(2)
The department shall review the request and make a determination
within ten business days of receiving all necessary information.

(3)
If an independent provider or waiver agency employee submits a
request for urgent care services under division (C)(3) of this
section, the department shall review the request and make a
determination within forty-eight hours of receiving all necessary
information.

(E)
When reviewing a request submitted under division (C) of this
section, the department shall determine whether the services for
which prior authorization is requested are medically necessary. The
department shall determine services to be medically necessary if the
services satisfy the following:

(1)
The services are appropriate for the individual's health and welfare
needs, living arrangement, circumstances, and expected outcomes.

(2)
The services are of an appropriate type, amount, duration, scope, and
intensity.

(3)
The services are the most efficient, effective, and lowest cost
alternative that, when combined with other services, ensure the
health and welfare of the individual receiving the services.

(4)
The services protect the individual from substantial harm expected to
occur if the requested services are not authorized.

(F)
After conducting a review of a request received under this section,
the department shall do one of the following:

(1)
Approve the request if the department finds that the services for
which prior authorization is requested meet the criteria established
under division (E) of this section;

(2)
Deny the request;

(3)
Approve the request in part if some of the criteria set forth in
division (E) of this section are satisfied.

(G)
When the department makes a determination regarding a request for
prior authorization, the department shall provide written
notification to the independent provider or waiver agency either
setting forth the reason for denial or indicating that prior
authorization has been approved. The department shall update the
prior authorization status to reflect its determination.

(H)
If a request for prior authorization is denied, an individual,
independent provider, or waiver agency may appeal the denial in
accordance with procedures established by the medicaid director under
rules adopted under division (J) of this section.

(I)
This section does not apply to personal care services provided under
a medicaid waiver component administered by the department of
developmental disabilities.

(J)
The medicaid director shall adopt rules in accordance with Chapter
119. of the Revised Code as necessary to implement this section.

Sec.
5164.292.
(A)
The department of medicaid shall require the providers and facilities
described in this section to provide the department or the
department's credentialing designee with the information described in
divisions (B) and (C) of this section every twenty-four months, or
sooner if required under division (D) of this section, as a condition
of continued participation in the medicaid program.

(B)(1)
Each of the following providers shall provide the department or the
department's credentialing designee with the information described in
division (B)(2) of this section as required by this section:

(a)
Physicians licensed under Chapter 4731. of the Revised Code to
practice medicine and surgery, osteopathic medicine and surgery, or
podiatric medicine and surgery;

(b)
Psychologists licensed under Chapter 4732. of the Revised Code;

(c)
Physician assistants licensed under Chapter 4730. of the Revised
Code;

(d)
Dentists licensed under Chapter 4715. of the Revised Code;

(e)
Optometrists licensed under Chapter 4725. of the Revised Code;

(f)
Pharmacists licensed under Chapter 4729. of the Revised Code;

(g)
Chiropractors licensed under Chapter 4734. of the Revised Code;

(h)
Acupuncturists licensed under Chapter 4762. of the Revised Code;

(i)
Clinical nurse specialists, certified nurse-midwives, or certified
nurse practitioners licensed under Chapter 4723. of the Revised Code;

(j)
Licensed independent social workers, licensed independent marriage
and family therapists, or licensed professional clinical counselors
licensed under Chapter 4757. of the Revised Code;

(k)
Licensed independent chemical dependency counselors licensed under
Chapter 4758. of the Revised Code;

(l)
Certified Ohio behavior analysts licensed under Chapter 4783. of the
Revised Code;

(m)
Audiologists and speech-language pathologists licensed under Chapter
4753. of the Revised Code;

(n)
Occupational therapists and physical therapists licensed under
Chapter 4755. of the Revised Code;

(o)
Dietitians licensed under Chapter 4759. of the Revised Code.

(2)
Providers described in division (B)(1) of this section shall provide
the department or department's credentialing designee with all of the
following about the provider in accordance with this section:

(a)
Access to the standard provider credentialing application form used
by the council for affordable quality healthcare in accordance with
section 3963.05 of the Revised Code within one hundred eighty days
prior to credentialing date;

(b)
Active provider licensing information;

(c)
Board certification, if applicable;

(d)
Educational background;

(e)
Clinical privileges, if applicable;

(f)
Medical malpractice insurance;

(g)
Drug enforcement administration certification, if applicable;

(h)
National practitioner data bank information regarding malpractice and
clinical privilege actions;

(i)
Sanctions or limitations on licensure;

(j)
Eligibility for participation in medicare and medicaid, if
applicable.

(C)(1)
Each of the following facilities shall provide the department or the
department's credentialing designee with the information described in
division (C)(2) of this section as required by this section:

(a)
Nursing facilities as defined in Chapter 5165. of the Revised Code;

(b)
Hospitals as defined in Chapter 3727. of the Revised Code;

(c)
Hospice care programs licensed under Chapter 3712. of the Revised
Code;

(d)
Home health agencies licensed by the department of health under
Chapter 3740. of the Revised Code;

(e)
Ambulatory surgical facilities as defined in section 3702.30 of the
Revised Code;

(f)
Community mental health services providers and community addiction
services providers as defined in Chapter 5119. of the Revised Code;

(g)
Freestanding dialysis centers and freestanding radiation therapy
centers licensed by the department of health under Chapter 3702. of
the Revised Code;

(h)
Residential facilities as defined in Chapter 5119. of the Revised
Code.

(2)
Facilities described in division (C)(1) of this section shall provide
the department or department's credentialing designee with all of the
following about the facility in accordance with this section:

(a)
The standardized credentialing form part B maintained by the
department of insurance;

(b)
Active provider licensing information;

(c)
Certification through an accrediting body or a site visit completed
by a state designated agency;

(d)
Eligibility for participation in medicare and medicaid, if
applicable;

(e)
Verification of good standing with applicable state and federal
bodies;

(f)
Active malpractice insurance.

(D)
The department of medicaid shall require a provider or facility to
provide the information described in this section to the department
or the department's credentialing designee sooner than every
twenty-four months if required under federal law or if the medicaid
director determines that a shorter time frame is necessary.

(E)
Nothing in this section prohibits the department from requesting
additional clarifying information at any time during the
credentialing or recredentialing process from a provider or facility.

Sec.
5164.302.
(A)
Before entering into a provider agreement with a medicaid provider
that seeks initial enrollment as a provider of home and
community-based services under the medicaid program, the department
of medicaid shall conduct an in-person review of the individual or
site inspection of the entity seeking enrollment as a provider. The
department shall thereafter conduct a subsequent in-person review or
site inspection every three years.

(B)
The department shall deny, refuse to revalidate, suspend, or
terminate a provider agreement if the department determines that an
individual or entity seeking enrollment as a provider of home and
community-based services under the medicaid program is principally
located at the same address as more than six other active home and
community-based services medicaid providers or is principally located
at the same address as another home and community-based services
medicaid provider when the address contains less than one thousand
square feet of space.

(C)
The department of medicaid shall make a referral to the auditor of
state whenever it is determined that a single address is the
principal place of business for more than six home and
community-based services medicaid providers.

Sec.
5164.303.
(A)
The department of medicaid shall coordinate with the attorney general
to create a disclaimer form that provides an affirmative and explicit
explanation of the penalties specified in section 2913.40 of the
Revised Code for medicaid fraud.

(B)
The department shall provide a copy of the disclaimer form to each
person or government entity seeking to participate in the medicaid
program as a provider. The department shall not enter into a provider
agreement with a person or government entity until the person or
government entity has signed and returned the disclaimer form to the
department, acknowledging that the person or government entity has
received and reviewed the form.

Sec.
5164.304.
The
department of medicaid shall establish a standardized onboarding
process for all providers with a valid provider agreement with the
department. The onboarding process shall provide a link to the
relevant administrative rules that describe the provider agreement
requirements for participation in the medicaid program.

Sec.
5164.305.
(A)
As a condition of entering into a provider agreement with the
department of medicaid or revalidating an existing provider
agreement, each person or government entity seeking to enroll in the
medicaid program as a provider or to revalidate an existing provider
agreement shall disclose to the department the identity of each
person with at least a five per cent direct or indirect ownership
interest in the person or entity.

(B)
The department shall verify all ownership disclosures under division
(A) of this section against the exclusion list maintained by the
United States department of health and human services office of
inspector general, prior medicaid sanctions imposed by another state,
and any prior convictions for fraud that a person may have.

(C)
The department shall enter into all agreements necessary to share
information and data obtained under this section with medicaid
managed care organizations to enable parallel verification by
medicaid managed care organizations. An agreement entered into
between the department and a medicaid managed care organization under
this section shall ensure confidentiality and privacy of the
information and data in accordance with state and federal law.

(D)
In implementing this section, the department may implement best
practices from other states' medicaid programs.

Sec.
5164.32.
(A)
Each medicaid provider agreement shall expire not later than
five

three

years
from its effective date

or sooner if determined necessary by the medicaid director
.

If
a provider agreement entered into before the effective date of this
amendment does not have a time limit, the department of medicaid
shall convert the agreement to a provider agreement with a time
limit.

(B)
The medicaid director shall adopt rules under section 5164.02 of the
Revised Code as necessary to implement this section. The rules shall
be consistent with subpart E of 42 C.F.R. Part 455 and include a
process for revalidating medicaid providers' continued enrollments as
providers. All of the following apply to the revalidation process:

(1)
The department shall refuse to revalidate a provider's provider
agreement when the provider fails to file a complete application for
revalidation within the time and in the manner required under the
revalidation process.

(2)
If a provider files a complete application for revalidation within
the time and in the manner required under the revalidation process,
but the provider agreement expires before the department acts on the
application or before the effective date of the department's decision
on the application, the provider, subject to division (B)(3) of this
section, may continue operating under the terms of the expired
provider agreement until the effective date of the department's
decision.

(3)
If a provider continues operating under the terms of an expired
provider agreement pursuant to division (B)(2) of this section and
the department denies the provider's application for revalidation,
medicaid payments shall not be made for services or items the
provider provides during the period beginning on the date the
provider agreement expired and ending on the effective date of a
subsequent provider agreement, if any, the department enters into
with the provider.

Sec.
5164.33.
(A)
(A)(1)

The medicaid director may do the following for any reason permitted
or required by federal law and when the director determines that the
action is in the best interests of medicaid recipients or the state:

(1)
(a)

Deny, refuse to revalidate, suspend, or terminate a provider
agreement;

(2)
(b)

Exclude an individual, provider of services or goods, or other entity
from participation in the medicaid program
;

(c)
Place a provider or entity at a high risk of fraud on heightened
scrutiny when suspension, termination, or exclusion of the provider
will result in access to care issues for medicaid recipients.
Heightened scrutiny shall include close monitoring of billing and
claims, increased compliance through corrective action plans, and the
potential for termination or exclusion if violations occur.

(d)
Deny an application for a provider agreement or refuse to revalidate
a provider agreement, including applications or revalidations where
the applicant is an owner of, or individual that resides with an
owner of, a current or former medicaid provider whose provider
agreement was terminated or suspended by the department
.

(2)
The medicaid director shall suspenda provider agreement of any
provider who has not submitted a claim for payment to the department
for a period of one year.

(3)
Whenever a temporary moratorium on the enrollment of new providers or
provider types is issued pursuant to 42 C.F.R. 424.570, the medicaid
director shall issue a similar moratorium and deny all pending
applications for provider agreements, including applications that
were pending prior to the issuance of the temporary moratorium and
were still awaiting approval when the moratorium was issued. In
issuing a moratorium under this section, the director shall comply
with the requirements specified in 42 C.F.R. 455.470.

(B)
No individual, provider, or entity excluded from participation in the
medicaid program under this section shall do any of the following:

(1)
Own, or provide services to, any other medicaid provider or risk
contractor;

(2)
Arrange for, render, or order services for medicaid recipients during
the period of exclusion;

(3)
During the period of exclusion, receive direct payments under the
medicaid program or indirect payments of medicaid funds in the form
of salary, shared fees, contracts, kickbacks, or rebates from or
through any other medicaid provider or risk contractor.

(C)
An individual, provider, or entity excluded from participation in the
medicaid program under this section may request a reconsideration of
the exclusion. The director shall adopt rules under section 5164.02
of the Revised Code governing the process for requesting a
reconsideration.

(D)
Nothing in this section limits the applicability of section 5164.38
of the Revised Code to a medicaid provider
.

(E)
To the extent permitted under state or federal law, the department of
medicaid shall share information concerning the director's decision
to deny, refuse to revalidate, suspend, or terminate a provider
agreement under this section with any other state board or commission
responsible for regulating a component of the health care industry.

(F)
The medicaid director may adopt rules under section 5164.02 of the
Revised Code as necessary to implement this section
.

Sec.
5164.331.
The
department of medicaid shall conduct an investigation if the
department determines that an individual or entity seeking initial
enrollment as a provider shares the same address or telephone number
as a current provider. If an investigation conducted by the
department determines it necessary, the department shall take the
actions described in section 5164.302 of the Revised Code with regard
to the individual or entity seeking initial enrollment as a provider.

Sec.
5164.332.
(A)
The department of medicaid shall impose a temporary suspension of
medicaid payments and conduct an investigation if the department
determines there is a suspicious increase in the number of claims for
payment submitted by a provider in the first sixty days of the
provider entering into a provider agreement with the department.

(B)
The department shall flag and investigate any time the department
determines that the number of claims for payment submitted by a
provider in a month increases by more than one hundred per cent
without a corresponding increase in the number of medicaid enrollees
receiving services from the provider.

Sec.
5164.36.
(A)
As used in this section:

(1)
"Credible allegation of fraud" has the same meaning as in
42 C.F.R. 455.2, except that for purposes of this section any
reference in that regulation to the "state" or the "state
medicaid agency" means the department of medicaid
.
A "credible allegation of fraud" includes falsified or fake
check-ins, forged paperwork, double billing for medicaid services,
identity misuse, impossible travel patterns, claims that overlap with
a hospital stay that are not provided in accordance with an
authorized individual service plan, and coordinated billing rings
.

(2)
"Disqualifying indictment" means an indictment of a
medicaid provider or its officer, authorized agent, associate,
manager, employee, or, if the provider is a noninstitutional
provider, its owner, if either of the following applies:

(a)
The indictment charges the person with committing an act to which
both of the following apply:

(i)
The act would be a felony or misdemeanor under the laws of this state
or the jurisdiction within which the act occurred.

(ii)
The act relates to or results from furnishing or billing for medicaid
services under the medicaid program or relates to or results from
performing management or administrative services relating to
furnishing medicaid services under the medicaid program.

(b)
The indictment charges the person with committing an act that would
constitute a disqualifying offense.

(3)
"Disqualifying offense" means any of the offenses listed or
described in divisions (A)(3)(a) to (e) of section 109.572 of the
Revised Code.

(4)
"Noninstitutional medicaid provider" means any person or
entity with a provider agreement other than a hospital, nursing
facility, or ICF/IID.

(5)
"Owner" means any person having at least five per cent
ownership in a noninstitutional medicaid provider.

(B)(1)
Except as provided in division (C) of this section and in rules
authorized by this section, the department of medicaid shall suspend
the provider agreement held by a medicaid provider on determining
either of the following:

(a)
There is a credible allegation of fraud against any of the following
for which an investigation is pending under the medicaid program:

(i)
The medicaid provider;

(ii)
The medicaid provider's owner, officer, authorized agent, associate,
manager, or employee.

(b)
A disqualifying indictment has been issued against any of the
following:

(i)
The medicaid provider;

(ii)
The medicaid provider's officer, authorized agent, associate,
manager, or employee;

(iii)
If the medicaid provider is a noninstitutional provider, its owner.

(2)
Subject to division (C) of this section, the department shall also
suspend all medicaid payments to a medicaid provider for services
rendered, regardless of the date that the services are rendered, when
the department suspends the provider's provider agreement under this
section.

(3)

Except as otherwise provided in 42 C.F.R. 455.23, when the attorney
general or auditor of state submits a credible allegation of fraud
with evidence to the department, the department shall take the
following actions:

(a)
Suspend medicaid payments to the provider in whole, in part, or as
applied to targeted payments;

(b)
Require pre-payment review of the provider's claims.

(4)

The suspension of a provider agreement
or
medicaid payments
shall
continue in effect until the latest of the following occurs:

(a)
If the suspension is the result of a credible allegation of fraud,
the department or a prosecuting authority determines that there is
insufficient evidence of fraud by the medicaid provider;

(b)
Regardless of whether the suspension is the result of a credible
allegation of fraud or a disqualifying indictment, the proceedings in
any related criminal case are completed through dismissal of the
indictment or through sentencing after conviction or entry of a
guilty plea or through finding of not guilty or, if the department
commences a process to terminate the suspended provider agreement,
the termination process is concluded;

(c)
The medicaid provider pays in full all fines and debts due and owing
to the department or makes arrangements satisfactory to the
department to fulfill those obligations;

(d)
A civil action related to a credible allegation of fraud or
disqualifying indictment is not pending against the medicaid
provider
;

(e)
If payments are suspended under division (B)(3) of this section,
until the completion of the administrative review described in
division (D)(2) of this section
.

(4)(a)
(5)(a)

When a provider agreement is suspended under this section, none of
the following shall take, during the period of the suspension, any of
the actions specified in division
(B)(4)(b)
(B)(5)(b)

of this section:

(i)
The medicaid provider;

(ii)
If the suspension is the result of an action taken by an officer,
authorized agent, associate, manager, or employee of the medicaid
provider, that person;

(iii)
If the medicaid provider is a noninstitutional provider and the
suspension is the result of an action taken by the owner of the
provider, the owner.

(b)
The following are the actions that persons specified in division

(B)(4)(a)
(B)(5)(a)

of this section cannot take during the suspension of a provider
agreement:

(i)
Own any other medicaid provider or risk contractor;

(ii)
Arrange, render, or order services on behalf of any other medicaid
provider or risk contractor;

(iii)
Arrange or order services for medicaid recipients or render services
to medicaid recipients;

(iv)
Receive direct payments under the medicaid program or indirect
payments of medicaid funds in the form of salary, shared fees,
contracts, kickbacks, or rebates from or through any other medicaid
provider or risk contractor.

(C)
The department shall not suspend a provider agreement or medicaid
payments under division (B) of this section if either of the
following is the case:

(1)
The medicaid provider or, if the provider is a noninstitutional
provider, the owner can demonstrate through the submission of written
evidence that the provider or owner did not directly or indirectly
sanction the action of its authorized agent, associate, manager, or
employee that resulted in the credible allegation of fraud or
disqualifying indictment.

(2)
The medicaid provider or, if the provider is a noninstitutional
provider, the owner can demonstrate that good cause exists not to
suspend the provider agreement or payments.

With
respect to the evidence described in division (C)(1) of this section,
the department shall grant, prior to suspension, the provider or
owner an opportunity to submit the written evidence to the
department.

With
respect to a demonstration of good cause described in division (C)(2)
of this section, the department shall specify in rules adopted under
section 5164.02 of the Revised Code what constitutes good cause and
the information, documents, or other evidence that must be submitted
to the department as part of the demonstration.

(D)
(D)(1)

After suspending a provider agreement under division
(B)
(B)(1)

of this section, the department shall send notice of the suspension
to the affected medicaid provider or, if the provider is a
noninstitutional provider, the owner in accordance with the following
time frames:

(1)
(a)

Not later than five days after the suspension, unless a law
enforcement agency makes a written request to temporarily delay the
notice;

(2)
(b)

If a law enforcement agency makes a written request to temporarily
delay the notice, not later than thirty days after the suspension
occurs subject to the conditions specified in division (E) of this
section.

(2)
If medicaid payments are suspended in accordance with division (B)(3)
of this section, the medicaid provider or, if the provider is a
noninstitutional provider, the owner shall be entitled to a hearing
and independent administrative review of the suspension.

(E)
A written request for a temporary delay described in division

(D)(2)
(D)(1)(b)

of this section may be renewed in writing by a law enforcement agency
not more than two times except that under no circumstances shall the
notice be issued more than ninety days after the suspension occurs.

(F)
The notice required by division (D) of this section shall do all of
the following:

(1)
State that payments are being suspended in accordance with this
section and 42 C.F.R. 455.23;

(2)
Set forth the general allegations related to the nature of the
conduct leading to the suspension, except that it is not necessary to
disclose any specific information concerning an ongoing
investigation;

(3)
State that the suspension continues to be in effect until the latest
of the circumstances specified in division
(B)(3)
(B)(4)

of this section occur;

(4)
Specify, if applicable, the type or types of medicaid claims or
business units of the medicaid provider that are affected by the
suspension;

(5)
Inform the medicaid provider or owner of the opportunity to submit to
the department, not later than thirty days after receiving the
notice, a request for reconsideration of the suspension in accordance
with division (G) of this section.

(G)(1)
Pursuant to the procedure specified in division (G)(2) of this
section, a medicaid provider subject to a suspension under this
section or, if the provider is a noninstitutional provider, the owner
may request a reconsideration of the suspension. The request shall be
made not later than thirty days after receipt of a notice required by
division
(D)
(D)(1)

of this section. The reconsideration is not subject to an
adjudication hearing pursuant to Chapter 119. of the Revised Code.

(2)
In requesting a reconsideration, the medicaid provider or owner shall
submit written information and documents to the department. The
information and documents may pertain to either of the following
issues:

(a)
Whether the determination to suspend the provider agreement was based
on a mistake of fact, other than the validity of an indictment in a
related criminal case.

(b)
If there has been an indictment in a related criminal case, whether
the indictment is a disqualifying indictment.

(H)
The department shall review the information and documents submitted
in a request made under division (G) of this section for
reconsideration of a suspension. After the review, the suspension may
be affirmed, reversed, or modified, in whole or in part. The
department shall notify the affected provider or owner of the results
of the review.

(I)
Rules adopted under section 5164.02 of the Revised Code may specify
circumstances under which the department would not suspend a provider
agreement pursuant to this section.

The department shall adopt rules establishing expedited appeal
procedures for purposes of an administrative review conducted under
division (D)(2) of this section.

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

(A)
"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.

(B)
"GPS-based verification"has the same meaning as in section
5164.42 of the Revised Code.

(C)
"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. "Nonemergency medical
transportation" does not include transportation conducted by an
emergency medical service organization or nonemergency medical
service organization as defined in section 4766.01 of the Revised
Code that is licensed by the state board of emergency medical, fire,
and transportation services.

Sec.
5164.401.
(A)
The department of medicaid shall develop, procure, certify, or
approve a process or system to obtain global positioning system
coordinates to verify nonemergency medical transportation 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)
Utilize a ride dispatch system that is similar to other private
transportation services;

(2)
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;

(3)
Record timestamps, route data, and total distance traveled during a
transport;

(4)
Be capable of transmitting data directly to the department as a
condition of payment.

(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) 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 shall be eligible to receive medicaid
payment for transportation 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 services submitted through an electronic verification
system if both of the following conditions are satisfied:

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

(2)
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 global positioning system coordinates data received from a
nonemergency medical transportation service provider 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 or irregular patterns 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 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, 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 to 5164.406 of the Revised Code.

Sec.
5164.41.
(A)
As used in this section, "home and community-based services
medicaid waiver component" has the same meaning as in section
5166.01 of the Revised Code.

(B)
The department of medicaid shall establish oversight mechanisms
concerning services provided by a family caregiver under a home and
community-based services medicaid waiver component. Oversight may
include any of the following:

(1)
Quarterly audits;

(2)
Enhanced check-in review;

(3)
Annual recertification as a medicaid provider;

(4)
Independent case manager verification;

(5)
Caps on hours of compensated care absent documented medical
necessity;

(6)
Forensic review triggers;

(7)
Background check monitoring pursuant to section 5164.341 of the
Revised Code through the retained applicant fingerprint database
established under section 109.5721 of the Revised Code.

(C)
The department may require a family caregiver who the department
considers to be high risk or who has repeatedly violated the
department's requirements concerning family caregivers to provide
services through a waiver agency as defined in section 5164.342 of
the Revised Code, rather than as an independent provider.

Sec.
5164.42.
(A)
As used in this section and section 5164.421 of the Revised Code:

(1)
"Electronic visit verification" has the same meaning as in
section 1903(l) of the "Social Security Act," 42 U.S.C.
1396b(l).

(2)
"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.

(3)(a)
"In-home care services" include all of the following:

(i)
Personal care services as defined in 42 C.F.R. 440.167;

(ii)
Home health services covered by the medicaid program as part of the
home health services benefit pursuant to 42 C.F.R. 440.70;

(iii)
Services provided under a medicaid home and community-based services
medicaid waiver component as defined in section 5166.01 of the
Revised Code;

(iv)
Any other medicaid services that are provided to a medicaid recipient
in either a residential or community setting.

(b)
To the extent permitted under federal law, "in-home care
services" does not include waiver services that are not personal
care in nature or services that satisfy any of the following:

(i)
The services are residential services billed on a daily rate,
habilitation services, or transportation services.

(ii)
The services are provided under a home and community-based services
medicaid waiver component to an individual with developmental
disabilities or to an individual who has a severe, chronic disability
that is characterized by all of the following:

(I)
It is attributable to a mental or physical impairment or a
combination of mental and physical impairments, other than a mental
or physical impairment solely caused by mental illness, as defined in
division (A) of section 5122.01 of the Revised Code.

(II)
It is likely to continue indefinitely.

(III)
It results in one of the following: in the case of a person under
three years of age, at least one developmental delay, as defined in
rules adopted under section 5123.011 of the Revised Code, or a
diagnosed physical or mental condition that has a high probability of
resulting in a developmental delay, as defined in those rules; in the
case of a person at least three years of age but under six years of
age, at least two developmental delays, as defined in rules adopted
under section 5123.011 of the Revised Code; in the case of a person
six years of age or older, a substantial functional limitation in at
least three of the following areas of major life activity, as
appropriate for the person's age: self-care, receptive and expressive
language, learning, mobility, self-direction, capacity for
independent living, and, if the person is at least sixteen years of
age, capacity for economic self-sufficiency.

(IV)
It causes the person to need a combination and sequence of special,
interdisciplinary, or other type of care, treatment, or provision of
services for an extended period of time that is individually planned
and coordinated for the person.

(iii)
The services are provided in an ICF/IID or provided under the
assisted living program as defined in section 173.51 of the Revised
Code.

(B)(1)
The department of medicaid shall require each claim for a service
that is subject to electronic visit verification requirements under
state or federal law, including claims submitted by in-home care
service providers, to be supported by a validated electronic visit
verification record as a condition of payment.

(2)
The department shall establish standards and procedures for matching
claims for medicaid payment to electronic visit verification records.
The standards and procedures shall identify the data elements
necessary to validate that the service billed was delivered to a
medicaid recipient, including the type of service performed, the
individual receiving the service, the date of service, the location
of service delivery, the individual providing the service, and the
time the service began and ended.

(3)
The standards described in division (B)(2) of this section shall do
all of the following:

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

(b)
Except for in-home care services provided by a family caregiver that
resides at the same residence as the individual receiving services,
utilize GPS-based verification to track when a provider clocks in and
clocks out;

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

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

(4)
In addition to the standards described in divisions (B)(2) and (3) of
this section, all services provided under the self-direction service
model shall require a provider to clock in and clock out when
physically present at the location where services are being provided.

(C)(1)
The department may deny, suspend, defer, or recoup payment for a
claim that is not supported by a validated electronic visit
verification record.

(2)
Prior to taking an action described in division (C)(1) of this
section, the department shall provide affected providers with notice,
training, technical assistance, and compliance education regarding
claim validation requirements established under this section.

(D)
The department may establish performance benchmarks or minimum
compliance thresholds related to electronic visit verification
utilization, matching accuracy, manual entry rates, modified visit
rates, late visit entry rates, and unmatched claim rates.

(E)
The medicaid director shall adopt rules under section 5164.02 of the
Revised Code to implement this section. The rules shall establish all
of the following:

(1)
Claim validation procedures;

(2)
Standards for verified electronic visit verification records;

(3)
Good-cause exemptions;

(4)
Corrective action processes;

(5)
Procedures for technical assistance and provider remediation;

(6)
Phased implementation schedules by provider type or service category;

(7)
Standards for denying, suspending, deferring, or recouping payment
for claims not supported by validated electronic visit verification
records.

(F)
Nothing in this section prohibits the department, the auditor of
state, the attorney general, or any other authorized state or federal
entity from conducting a post-payment review, audit, investigation,
enforcement action, or recovery action related to a claim subject to
electronic visit verification requirements.

Sec.
5164.421.
(A)
In addition to the electronic visit verification system described in
section 5165.42 of the Revised Code, the department of medicaid shall
establish requirements under which high risk in-home care service
providers are required to verify data regarding the services provided
to a medicaid recipient.

(B)
The department shall establish criteria under which an in-home care
service provider is considered to be a high-risk provider. The
criteria shall at a minimum include all of the following:

(1)
Repeated mismatches in check-in data;

(2)
Data that indicates impossible travel times;

(3)
Claims data that overlaps with a medicaid recipient's stay in a
hospital for services that were not provided in accordance with an
authorized individual service plan;

(4)
Unusual outliers in billing data;

(5)
Other data indicators that demonstrate a high risk of fraud.

(C)
Each in-home care service provider classified by the department as a
high risk provider shall satisfy the requirements established under
this section, including that the high-risk provider utilize
fingerprint scanning, facial recognition, vocal recognition, a secure
personal identification number, or other approved verification method
as a condition of receiving payment for services provided under the
medicaid program.

(D)
The department shall not sell or otherwise distribute any data
transmitted or stored as part of a provider's use of electronic visit
verification under this section. No such data shall be used for any
purpose other than to verify medicaid payment claims submitted by a
provider and reduce fraud within the medicaid program.

Sec.
5164.43.
(A)
As used in this section:

(1)
"Employee" means any person who performs a service for
wages or other remuneration for an employer.

(2)
"Employer" means any person who has one or more employees
and includes an agent of an employer, the state or any agency or
instrumentality of the state, and any political subdivision or any
agency or instrumentality thereof.

(B)
No employer shall discharge, demote, reassign, or take any punitive
action against an employee because the employee, based on a
reasonable belief, submitted a good faith report that an instance of
fraud occurred in the medicaid program.

(C)
An employee alleging an employer has violated division (B) of this
section may commence an action in any court of competent jurisdiction
for reinstatement with back pay, if the action is based on discharge,
or for equitable relief, together with reasonable attorney's fees.

Sec.
5164.57.
(A)(1)
Except as provided in division (A)(2)
and
division (E)
of
this section, the department of medicaid may recover a medicaid
payment or portion of a payment made to a medicaid provider to which
the provider is not entitled if the department notifies the provider
of the overpayment during the five-year period immediately following
the end of the state fiscal year in which the overpayment was made.

(2)
In the case of a hospital medicaid provider, if the department
determines as a result of a medicare or medicaid cost report
settlement that the provider received an amount under the medicaid
program to which the provider is not entitled, the department may
recover the overpayment if the department notifies the provider of
the overpayment during the later of the following:

(a)
The five-year period immediately following the end of the state
fiscal year in which the overpayment was made;

(b)
The one-year period immediately following the date the department
receives from the United States centers for medicare and medicaid
services a completed, audited, medicare cost report for the provider
that applies to the state fiscal year in which the overpayment was
made.

(B)
Among the overpayments that may be recovered under this section are
the following:

(1)
Payment for a medicaid service, or a day of service, not rendered;

(2)
Payment for a day of service at a full per diem rate that should have
been paid at a percentage of the full per diem rate;

(3)
Payment for a medicaid service, or day of service, that was paid by,
or partially paid by, a third party, as defined in section 5160.35 of
the Revised Code, and the third party's payment or partial payment
was not offset against the amount paid by the medicaid program to
reduce or eliminate the amount that was paid by the medicaid program;

(4)
Payment when a medicaid recipient's responsibility for payment was
understated and resulted in an overpayment to the provider.

(C)
The department may recover an overpayment under this section prior to
or after any of the following:

(1)
Adjudication of a final fiscal audit that section 5164.38 of the
Revised Code requires to be conducted in accordance with Chapter 119.
of the Revised Code;

(2)
Adjudication of a finding under any other provision of state statutes
governing the medicaid program or the rules adopted under those
statutes;

(3)
Expiration of the time to issue a final fiscal audit that section
5164.38 of the Revised Code requires to be conducted in accordance
with Chapter 119. of the Revised Code;

(4)
Expiration of the time to issue a finding under any other provision
of state statutes governing the medicaid program or the rules adopted
under those statutes.

(D)(1)
Subject to division (D)(2) of this section, the recovery of an
overpayment under this section does not preclude the department from
subsequently doing the following:

(a)
Issuing a final fiscal audit in accordance with Chapter 119. of the
Revised Code, as required under section 5164.38 of the Revised Code;

(b)
Issuing a finding under any other provision of state statutes
governing the medicaid program or the rules adopted under those
statutes.

(2)
A final fiscal audit or finding issued subsequent to the recovery of
an overpayment under this section shall be reduced by the amount of
the prior recovery, as appropriate.

(E)

The
department shall recover all overpayments to a provider when an audit
determines and verifies an impossible claim submitted by the
provider, such as when a provider has submitted a claim for providing
in-home care services, as defined in section 5164.40 of the Revised
Code, on a date when the recipient was in the hospital or when a
provider has submitted claims for providing in-home services to
recipients located at different addresses at the same time.

(F)

Nothing
in this section limits the department's authority to recover
overpayments pursuant to any other provision of the Revised Code.

Sec.
5167.03.
(A)
As part of the medicaid program, the department of medicaid shall
establish a care management system. The department shall implement
the system in some or all counties.

(B)
The department shall designate the medicaid recipients who are
required or permitted to participate in the care management system.
Those who shall be required to participate in the system include
medicaid recipients who receive cognitive behavioral therapy as
described in division (A)(2) of section 5167.16 of the Revised Code.
Except as provided in section 5166.406 of the Revised Code, no
medicaid recipient participating in the healthy Ohio program
established under section 5166.40 of the Revised Code shall
participate in the system.

(C)
Except as otherwise provided in this section, the general assembly's
authorization through the enactment of legislation is needed before
home and community-based services available under a medicaid waiver
component or nursing facility services are included in the care
management system. ICDS participants, or participants in the ICDS
successor program, may be required or permitted to obtain such
services under the system. Medicaid recipients who receive such
services may be designated for voluntary or mandatory participation
in the system in order to receive other health care services included
in the system.

(D)

the

Subject
to division (E) of this section, the
department
may require or permit participants in the care management system to
do either or both of the following:

(1)
Obtain health care services from providers designated by the
department;

(2)
Enroll in a medicaid MCO plan.

(E)
Concerning medicaid recipients permitted or required to participate
in the care management system, for a period of eighteen months
beginning on the effective date of this amendment, the department of
medicaid shall ensure that each medicaid MCO plan participating in
the care management system enrolls at least ten per cent of the total
number of participants participating in the care management system.

Sec.
5167.18.
Each
medicaid managed care organization shall comply with federal and
state efforts to identify fraud, waste, and abuse in the medicaid
program.

Upon the identification of credible evidence of fraud, waste, or
abuse, or materially inconsistent billing, each medicaid managed care
organization shall make a report to the department of medicaid. The
department shall refer potential fraud in a timely manner to the
attorney general for investigation.

Sec.
5167.23.
(A)
As used in this section, "deconfliction" means the
systematic coordination between medicaid managed care organizations
and multiple state and federal oversight agencies to share
investigative data, eliminate overlapping inquiries, and streamline
the prosecution of fraudulent medicaid providers.

(B)
Upon the identification of credible indicators of fraud, waste, or
abuse, a medicaid managed care organization may implement reasonable
and timely payment integrity actions, including payment suspension
and prepayment review and denial.

(C)(1)
A medicaid managed care organization shall not initiate prepayment
review for a medicaid provider without first obtaining approval from
the department of medicaid. Notwithstanding any provision of law to
the contrary, a prepayment review initiated under this section may
remain in effect for longer than six months without renewal.

(2)
A medicaid managed care organization may place suspected high-risk
providers, as determined by the medicaid managed care organization,
on claims payment suspension during any open investigation or
stand-down period. A medicaid managed care organization shall notify
and obtain approval from the department or the attorney general prior
to implementing claims payment suspension under this section.

(3)
A medicaid managed care organization shall provide a provider placed
on prepayment review under division (C)(1) of this section or claims
payment suspension under division (C)(2) of this section with written
notice of the decision and an opportunity for the provider to
participate in the organization's grievance process established in
accordance with section 5167.11 of the Revised Code. Upon completion
of any grievance process, an affected provider may seek an appeal of
a medicaid managed care organization's decision with the department
of medicaid.

(D)
Following the initiation of payment integrity actions, a medicaid
managed care organization shall complete all applicable deconfliction
procedures in accordance with procedures established by the
department. A medicaid managed care organization may take an action
described in this section prior to the completion of deconfliction
procedures when necessary to prevent continued improper payments and
to mitigate a program integrity risk.

(E)
A medicaid managed care organization shall maintain documented
evidence of credible indicators of fraud, waste, and abuse that are
the basis for an action taken under this section. The department
shall ensure that all actions taken under this section are consistent
with state and federal law.

Section
2.
That
existing sections 109.85, 117.10, 2903.216, 2913.40, 2923.31,
4113.52
,
5101.542
,
5164.32, 5164.33, 5164.36, 5164.57
,
5167.03
,
and 5167.18 of the Revised Code are hereby repealed.

Section
3.
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
4.
Not
later than March 31, 2027, the Department of Medicaid shall prepare
and submit a report to the General Assembly in accordance with
section 101.68 of the Revised Code regarding the creation of a
Medicaid encounter data system and the creation of a risk matrix that
may be used to connect individuals with national provider identifier
records associated with providers. The report and study shall examine
the operation of a potential Medicaid encounter data system and risk
matrix, including the scope of work required by the Department to
operationalize them.

Section
5.
Section
5101.542 of the Revised Code as amended in this act and section
5101.5411 of the Revised Code as enacted in this act shall be known
as the Enhanced Cybersecurity for SNAP Act and the remainder of this
act shall be known as the Ohio Medicaid Program Integrity and Fraud
Prevention Act.

Section
6.
The
General Assembly, applying the principle stated in division (B) of
section 1.52 of the Revised Code that amendments are to be harmonized
if reasonably capable of simultaneous operation, finds that the
following sections, presented in this act as composites of the
sections as amended by the acts indicated, are the resulting versions
of the sections in effect prior to the effective date of the sections
as presented in this act:

Section
117.10 of the Revised Code as amended by both H.B. 59 and S.B. 67 of
the 130th General Assembly.

Section
2923.31 of the Revised Code as amended by both H.B. 199 and H.B. 405
of the 132nd General Assembly.

Speaker
___________________ of the House of Representatives.

President
___________________ of the Senate.

Passed
________________________, 20____

Approved
________________________, 20____

Governor.

The section numbering of law
of a general and permanent nature is complete and in conformity with
the Revised Code.

Director, Legislative
Service Commission.

Filed
in the office of the Secretary of State at Columbus, Ohio, on the
____ day of ___________, A. D. 20____.

Secretary of State.

File
No. _________ Effective Date ___________________