Bill Text: OH HB12 | 2011-2012 | 129th General Assembly | Introduced

---

Bill Title: To establish new requirements concerning services, providers, third-party liability, and reports for the Medicaid program.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2011-01-11 - To Health & Aging [HB12 Detail]

Download: Ohio-2011-HB12-Introduced.html

---

As Introduced

129th General Assembly Regular Session 2011-2012

H. B. No. 12

Representative Sears 

---

A BILL

To amend section 5111.083 and to enact sections

1

5111.035, 5111.093, 5111.141, 5111.142, and

2

5111.165 of the Revised Code to establish new

3

requirements concerning services, providers,

4

third-party liability, and reports for the

5

Medicaid program.

6

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

Section 1. That section 5111.083 be amended and sections	7
5111.035, 5111.093, 5111.141, 5111.142, and 5111.165 of the	8
Revised Code be enacted to read as follows:	9

Sec. 5111.035.  Each medicaid provider selected by the	10
department of job and family services shall give to the department	11
bond with surety, to the satisfaction of the department, for the	12
faithful adherence by the provider to the requirements of section	13
5111.03 of the Revised Code.	14

The department shall select the providers to which the bond	15
requirement is to be applied. In selecting the providers, the	16
department shall include, at a minimum, each provider who has been	17
investigated for any criminal offense of fraud, as defined in	18
Chapter 2913. of the Revised Code.	19

For each provider subject to the bond requirement, the	20
department shall set the amount of the bond at a level that	21
reflects, as determined by the director of job and family	22
services, the level of risk of fraud by the provider.	23

Sec. 5111.083. (A) As used in this section, "licensed health	24
professional authorized to prescribe drugs" has the same meaning	25
as in section 4729.01 of the Revised Code.	26

(B) The director of job and family services mayshall	27
establish an e-prescribing system for the medicaid program under	28
which a medicaid provider who is a licensed health professional	29
authorized to prescribe drugs shall use an electronic system to	30
prescribe a drug for a medicaid recipient when required to do so	31
by division (C) of this section. The e-prescribing system shall	32
eliminate the need for such medicaid providers to make	33
prescriptions for medicaid recipients by handwriting or telephone.	34
The e-prescribing system also shall provide such medicaid	35
providers with an up-to-date, clinically relevant drug information	36
database and a system of electronically monitoring medicaid	37
recipients' medical history, drug regimen compliance, and fraud	38
and abuse.	39

(C) If the director establishesIn establishing an	40
e-prescribing system under division (B) of this section, the	41
director shall do all of the following:	42

(1) Require that a medicaid provider who is a licensed health	43
professional authorized to prescribe drugs use the e-prescribing	44
system during a fiscal year if the medicaid provider was one of	45
the ten medicaid providers who, during the calendar year that	46
precedes that fiscal year, issued the most prescriptions for	47
medicaid recipients receiving hospital services;	48

(2) Before the beginning of each fiscal year, determine the	49
ten medicaid providers that issued the most prescriptions for	50
medicaid recipients receiving hospital services during the	51
calendar year that precedes the upcoming fiscal year and notify	52
those medicaid providers that they must use the e-prescribing	53
system for the upcoming fiscal year;	54

(3) Seek the most federal financial participation available	55
for the development and implementation of the e-prescribing	56
system.	57

Sec. 5111.093. (A) As used in this section, "local medicaid	58
administrative agency" means all of the following:	59

(1) A county department of job and family services;

60

(2) A county board of developmental disabilities;

61

(3) A board of alcohol, drug addiction, and mental health	62
services;	63

(4) A PASSPORT administrative agency;

64

(5) A board of education of a city, local, or exempted	65
village school district;	66

(6) The governing authority of a community school established	67
under Chapter 3314. of the Revised Code.	68

(B) Each local medicaid administrative agency shall report	69
annually to the department of job and family services and office	70
of budget and management all of the following information	71
regarding the previous calendar year:	72

(1) The total amount of local government funds the local	73
medicaid administrative agency expended for the medicaid program;	74

(2) The portion of the total reported under division (B)(1)	75
of this section that represents funds raised by local property tax	76
levies;	77

(3) The local medicaid administrative agency's total	78
administrative costs for the medicaid program;	79

(4) The local medicaid administrative agency's administrative	80
costs for the medicaid program for which the agency receives no	81
federal financial participation;	82

(5) The total amount of state funds provided to the local	83
medicaid administrative agency for the medicaid program.	84

Sec. 5111.141. (A) The department of job and family services	85
shall implement a disease management component of the medicaid	86
program. Medicaid recipients participating in the care management	87
system established under section 5111.16 of the Revised Code shall	88
be excluded from the disease management component. The department	89
may implement the disease management component as part of the	90
alternative care management program established under section	91
5111.165 of the Revised Code.	92

(B) The disease management component shall consist of a	93
system of coordinated health care interventions and patient	94
communications for groups of medicaid recipients who have medical	95
conditions for which the department determines patient self-care	96
efforts are significant. The disease management component shall do	97
all of the following:	98

(1) Support physicians, the professional relationship between	99
patients and their medical caregivers, and patients' plans of	100
care;	101

(2) Emphasize prevention of exacerbations and complications	102
of medical conditions using evidence-based practice guidelines and	103
patient empowerment strategies;	104

(3) Evaluate clinical, humanistic, and economic outcomes on	105
an ongoing basis with the goal of improving overall health.	106

(C) To the extent the department considers appropriate, each	107
contract that the department enters into with another state agency	108
under section 5111.91 of the Revised Code shall provide for the	109
other state agency to include the disease management component in	110
the component of the medicaid program that the other state agency	111
administers pursuant to the contract.	112

Sec. 5111.142.  (A) The department of job and family services	113
shall conduct a review of case management services provided under	114
the fee-for-service component of the medicaid program. In	115
conducting the review, the department shall identify which groups	116
of medicaid recipients not participating in the care management	117
system established under section 5111.16 of the Revised Code or	118
enrolled in a medicaid waiver component as defined in section	119
5111.85 of the Revised Code do not receive case management	120
services. In addition, the department shall identify which groups	121
of such medicaid recipients receive case management services as	122
part of two or more components of the medicaid program or from two	123
or more providers.	124

After completing the review, the department shall implement a	125
case management component of the medicaid program. The department	126
shall model the case management component on the former enhanced	127
care management program that the department created as part of the	128
care management system established under section 5111.16 of the	129
Revised Code. The department shall make adjustments to the former	130
enhanced care management program as are necessary to accomodate	131
the groups the case management component is to serve.	132

(B) At a minimum, the case management component shall serve	133
medicaid recipients who are members of the groups identified in	134
the review conducted under this section and have been diagnosed by	135
a physician as having any of the following medical conditions:	136

(1) A high-risk pregnancy;

137

(2) Diabetes;

138

(3) Asthma;

139

(4) Lung disease;

140

(5) Congestive heart failure;

141

(6) Coronary artery disease;

142

(7) Hypertension;

143

(8) Hyperlipidemia;

144

(9) Infection with the human immunodeficiency virus;

145

(10) Acquired immunodeficiency syndrome;

146

(11) Chronic obstructive pulmonary disease.

147

Sec. 5111.165.  (A) The department of job and family services	148
shall develop and implement an alternative care management program	149
for medicaid recipients that is separate from the care management	150
program established under section 5111.16 of the Revised Code. The	151
purpose of the program shall be to test and evaluate multiple	152
alternative care management models for providing health care	153
services to medicaid recipients designated under this section as	154
participants in the program.	155

(B) The program shall be implemented not later than October	156
1, 2011, or, if by that date the department has not received any	157
necessary federal approval to implement the program, as soon as	158
practicable after receiving the approval. From among the medicaid	159
recipients who are not participants in the care management system	160
established under section 5111.16 of the Revised Code, the	161
department shall designate the medicaid recipients who are	162
required to participate in the alternative care management program	163
established under this section.	164

(C) The department shall ensure that each alternative care	165
management model included in the program is operated in at least	166
three counties. The department shall select the counties in which	167
each model is to be operated. The department may extend the	168
operation of a model into other counties if the department	169
determines that such an expansion is necessary to evaluate the	170
effectiveness of the model.	171

The department may periodically alter the requirements or	172
design of the program, including the designation of the medicaid	173
recipients who are required to participate in the program, in	174
order to test and evaluate the effectiveness of varying care	175
management models for providing medical assistance under medicaid,	176
except that each model included in the program shall be in effect	177
for a period sufficient in length to evaluate the effectiveness of	178
the model.	179

(D) The department shall conduct an evaluation of each	180
alternative care management model included in the program. As part	181
of the evaluation, the department shall maintain statistics on	182
physician expenditures, hospital expenditures, preventable	183
hospitalizations, costs for each participant, effectiveness, and	184
health outcomes for participants.	185

(E) The department shall adopt rules in accordance with	186
Chapter 119. of the Revised Code as necessary to implement this	187
section. The rules shall specify standards and procedures to be	188
used in designating participants of the program.	189

Section 2. That existing section 5111.083 of the Revised Code	190
is hereby repealed.	191

Section 3.  THIRD PARTY LIABILITY - PILOT PROGRAM

192

(A) As used in this section:

193

(1) "Medicaid program" means the medical assistance program	194
established under Chapter 5111. of the Revised Code.	195

(2) "Third party" has the same meaning as in section 5101.571	196
of the Revised Code.	197

(B)(1) Except as provided in division (C) of this section and	198
using technology designed to identify all persons liable to pay a	199
claim for a medical item or service, the Director of Job and	200
Family Services shall establish and administer a pilot program for	201
the purpose of identifying third parties that are liable for	202
paying all or a portion of a claim for a medical item or service	203
provided to a Medicaid recipient before the claim is submitted to	204
or paid by the Medicaid program. The Director shall determine the	205
duration of the pilot program, except that the Director shall not	206
terminate the program less than eighteen months after it is	207
established.	208

(2) In administering the pilot program, the Director shall,	209
subject to division (B)(3) of this section, ensure that all	210
aspects of the program comply with Ohio and federal law, including	211
the "Health Insurance Portability and Accountability Act of 1996,"	212
Pub. L. No. 104-191, as amended, and regulations promulgated by	213
the United States Department of Health and Human Services to	214
implement the Act.	215

(3) The Director's duty to ensure compliance with the laws	216
described in division (B)(2) of this section does not prohibit	217
either of the following:	218

(a) A third party from providing information to the	219
Department of Job and Family Services or disclosing or making use	220
of information as permitted under section 5101.572 of the Revised	221
Code or when required by any other provision of Ohio or federal	222
law;	223

(b) The Department from using information provided by a third	224
party as permitted in section 5101.572 of the Revised Code or when	225
required by any other provision of Ohio or federal law.	226

(C)(1) The Director may enter into a contract with any person	227
under which the person serves as the administrator of the pilot	228
program. Before entering into a contract for a pilot program	229
administrator, the Department shall issue a request for proposals	230
from persons seeking to be considered. The Department shall	231
develop a process to be used in issuing the request for proposals,	232
receiving responses to the request, and evaluating the responses	233
on a competitive basis. In accordance with that process, the	234
Department shall select the person to be awarded the contract.	235

(2) The Director may delegate to the pilot program	236
administrator any of the Director's powers or duties specified in	237
this section. The terms of the contract shall specify the extent	238
to which the powers or duties are delegated to the administrator.	239

(3) In exercising powers or performing duties delegated under	240
the contract, the pilot program administrator is subject to the	241
same provisions of this section that grant the powers or duties to	242
the Director, as well as any limitations or restrictions that are	243
applicable to or associated with those powers or duties.	244

(4) The terms of a contract for a pilot program administrator	245
shall include a provision that specifies that the Director or any	246
agent of the Director is not liable for the failure of the	247
administrator to comply with a term of the contract, including any	248
term that specifies the administrator's duty to ensure compliance	249
with the laws described in division (B)(1) of this section.	250

(D) Twelve months after the pilot program is established, the	251
Director shall evaluate the program's effectiveness. As part of	252
this evaluation, the Director shall determine both of the	253
following:	254

(1) For the twelve months immediately preceding the	255
establishment of the pilot program, all of the following:	256

(a) The amount of money paid for each Medicaid claim in which	257
no third party liability was indicated by the Medicaid recipient	258
but for which at least one third party was liable to pay all or a	259
portion of the claim, and the amount attributable to each liable	260
party;	261

(b) The portions of the amounts attributable to each liable	262
third party, described in division (D)(1)(a) of this section, that	263
were recovered by the Director or a person with which the Director	264
has contracted to manage the recovery of money due from liable	265
third parties;	266

(c) The portions of the amounts attributable to each liable	267
third party, described in division (D)(1)(a) of this section, that	268
would have been identified by the technology used by the pilot	269
program had the technology been used in those twelve months.	270

(2) For the first twelve months of the pilot program, both of	271
the following:	272

(a) The items described in divisions (D)(1)(a) and (b) of	273
this section;	274

(b) The portions of the amounts attributable to each liable	275
third party, described in division (D)(1)(a) of this section, that	276
were identified by the technology used by the pilot program.	277

(E) Not later than three months after the evaluation required	278
by division (D) of this section is initiated, the Director shall	279
prepare and submit a report to the Governor and, in accordance	280
with section 101.68 of the Revised Code, the General Assembly. At	281
a minimum, the report shall summarize and compare the	282
determinations made under division (D) of this section, conclude	283
whether the program achieved savings for the Medicaid program, and	284
make a recommendation as to whether the pilot program should be	285
extended or be made permanent.	286

(F) The Director may adopt rules in accordance with Chapter	287
119. of the Revised Code as necessary to implement this section.	288

Section 4.  (A) As used in this section, "community	289
behavioral health services" means both of the following:	290

(1) Community mental health services certified by the	291
Director of Mental Health under section 5119.611 of the Revised	292
Code;	293

(2) Services provided by an alcohol and drug addiction	294
program certified by the Department of Alcohol and Drug Addiction	295
Services under section 3793.06 of the Revised Code.	296

(B) There is hereby created the Medicaid Community Behavioral	297
Health Administration Examination Group. The Examination Group	298
shall consist of all of the following:	299

(1) The Director of Mental Health or the Director's designee;

300

(2) The Director of Alcohol and Drug Addiction Services or	301
the Director's designee;	302

(3) The Director of Job and Family Services or the Director's	303
designee;	304

(4) Two members of the House of Representatives from	305
different political parties appointed by the Speaker of the House	306
of Representatives;	307

(5) Two members of the Senate from different political	308
parties appointed by the President of the Senate.	309

(C) The Directors of Mental Health and Alcohol and Drug	310
Addiction Services, or their designees, shall serve as	311
co-chairpersons of the Examination Group. The Departments of	312
Mental Health and Alcohol and Drug Addiction Services shall	313
provide administrative services to the Examination Group.	314

(D) Members of the Examination Group shall serve without	315
compensation, except to the extent that serving as members is	316
considered part of their regular employment duties.	317

(E) The Examination Group shall study the administration and	318
management of Medicaid-covered community behavioral health	319
services. Not later than one year after the effective date of this	320
act, the Examination Group shall submit a report regarding its	321
study to the Governor and, in accordance with section 101.68 of	322
the Revised Code, the General Assembly. The report shall include	323
all of the following:	324

(1) Recommendations for system changes needed for the	325
effective administration and management of Medicaid-covered	326
community behavioral health services. The recommendations shall	327
focus on increasing efficiencies, transparency, and accountability	328
in order to improve the delivery of community behavioral health	329
services.	330

(2) An evaluation of merging the Departments of Mental Health	331
and Alcohol and Drug Addiction Services or of other options to	332
improve the organizational structure used to provide	333
Medicaid-covered community behavioral health services;	334

(3) An examination of the best practices for providing	335
Medicaid-covered community behavioral health services, using as a	336
reference other state's best practices for providing such	337
services;	338

(4) An analysis of using a case management program for	339
Medicaid-covered community behavioral health services.	340

(F) The Examination Group shall cease to exist on submission	341
of its report.	342