SB 315

(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
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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
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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
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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
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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
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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
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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;
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        (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
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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
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  (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
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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.
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  (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
Sub. S. B. No. 315  136th G.A.
  13
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.
Sub. S. B. No. 315  136th G.A.
  14
  (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
Sub. S. B. No. 315  136th G.A.
  15
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.
Sub. S. B. No. 315  136th G.A.
  16
  (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
Sub. S. B. No. 315  136th G.A.
  17
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
Sub. S. B. No. 315  136th G.A.
  18
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
Sub. S. B. No. 315  136th G.A.
  19
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
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  20
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:
Sub. S. B. No. 315  136th G.A.
  21
  (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;
Sub. S. B. No. 315  136th G.A.
  22
  (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,
Sub. S. B. No. 315  136th G.A.
  23
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
Sub. S. B. No. 315  136th G.A.
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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.
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  (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
Sub. S. B. No. 315  136th G.A.
  26
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;
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  27
  (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.
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  (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
Sub. S. B. No. 315  136th G.A.
  29
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
Sub. S. B. No. 315  136th G.A.
  30
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
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  31
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.
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  (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
Sub. S. B. No. 315  136th G.A.
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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
Sub. S. B. No. 315  136th G.A.
  34
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
Sub. S. B. No. 315  136th G.A.
  35
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
Sub. S. B. No. 315  136th G.A.
  36
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.
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  37
  (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;
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  38
  (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).
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  39
        (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
Sub. S. B. No. 315  136th G.A.
  40
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.
Sub. S. B. No. 315  136th G.A.
  41
  (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,
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  42
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
Sub. S. B. No. 315  136th G.A.
  43
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
Sub. S. B. No. 315  136th G.A.
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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.
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        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.
Sub. S. B. No. 315  136th G.A.
      Speaker ___________________ of the House of Representatives.
  President ___________________ of the Senate.
Passed ________________________, 20____
Approved ________________________, 20____
  Governor.
Sub. S. B. No. 315  136th G.A.
  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 ___________________