Bill Text: OH SB100 | 2013-2014 | 130th General Assembly | Introduced

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Bill Title: To specify that the Ohio prompt payment law applies to payment of claims by Medicaid managed care organizations.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Introduced - Dead) 2013-04-09 - To Insurance & Financial Institutions [SB100 Detail]

Download: Ohio-2013-SB100-Introduced.html

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As Introduced

130th General Assembly Regular Session 2013-2014

S. B. No. 100

Senator Tavares 

Cosponsors: Senators Cafaro, Brown 

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A BILL

To amend sections 3901.38, 3901.383, and 3901.3814

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and to repeal section 5111.178 of the Revised Code

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to specify that the Ohio prompt payment law

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applies to payment of claims by Medicaid managed

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care organizations.

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

Section 1. That sections 3901.38, 3901.383, and 3901.3814 of	6
the Revised Code be amended to read as follows:	7

Sec. 3901.38.  As used in this section and sections 3901.381	8
to 3901.3814 of the Revised Code:	9

(A) "Beneficiary" means any policyholder, subscriber, member,	10
employee, or other person who is eligible for benefits under a	11
benefits contract.	12

(B) "Benefits contract" means a sickness and accident	13
insurance policy providing hospital, surgical, or medical expense	14
coverage, or a health insuring corporation contract or other	15
policy or agreement under which a third-party payer agrees to	16
reimburse for covered health care or dental services rendered to	17
beneficiaries, up to the limits and exclusions contained in the	18
benefits contract.	19

(C) "Hospital" has the same meaning as in section 3727.01 of	20
the Revised Code.	21

(D) "Medicaid managed care organization" means a managed care	22
organization that has a contract with the department of job and	23
family services pursuant to section 5111.17 of the Revised Code.	24

(E) "Provider" means a hospital, nursing home, physician,	25
podiatrist, dentist, pharmacist, chiropractor, or other health	26
care provider entitled to reimbursement by a third-party payer for	27
services rendered to a beneficiary under a benefits contract.	28

(E)(F) "Reimburse" means indemnify, make payment, or	29
otherwise accept responsibility for payment for health care	30
services rendered to a beneficiary, or arrange for the provision	31
of health care services to a beneficiary.	32

(F)(G) "Third-party payer" means any of the following:

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(1) An insurance company;

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(2) A health insuring corporation;

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(3) A labor organization;

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(4) An employer;

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(5) An intermediary organization, as defined in section	38
1751.01 of the Revised Code, that is not a health delivery network	39
contracting solely with self-insured employers;	40

(6) An administrator subject to sections 3959.01 to 3959.16	41
of the Revised Code;	42

(7) A health delivery network, as defined in section 1751.01	43
of the Revised Code;	44

(8) A medicaid managed care organization;

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(9) Any other person that is obligated pursuant to a benefits	46
contract to reimburse for covered health care services rendered to	47
beneficiaries under such contract.	48

Sec. 3901.383. (A) A provider and a third-party payer may do	49
either of the following:	50

(1) Enter into a contractual agreement under which time	51
periods shorter than those set forth in section 3901.381 of the	52
Revised Code are applicable to the third-party payer in paying a	53
claim for any amount due for health care services rendered by the	54
provider;	55

(2) Enter into a contractual agreement under which the timing	56
of payments by the third-party payer is not directly related to	57
the receipt of a claim form. The contractual arrangement may	58
include periodic interim payment arrangements, capitation payment	59
arrangements, or other periodic payment arrangements acceptable to	60
the provider and the third-party payer. Under a capitation payment	61
arrangement, the third-party payer shall begin paying the	62
capitated amounts to the beneficiary's primary care provider not	63
later than sixty days after the date the beneficiary selects or is	64
assigned to the provider. Under any other contractual periodic	65
payment arrangement, the contractual agreement shall state, with	66
specificity, the timing of payments by the third-party payer.	67

(B) Regardless of whether a third-party payer is exempted	68
under division (D) of section 3901.3814 from sections 3901.38 and	69
3901.381 to 3901.3813 of the Revised Code, aA provider and thea	70
third-party payer, including a third-party payer that provides	71
coverage under the medicaid program, shall not enter into a	72
contractual arrangement under which time periods longer than those	73
provided for in paragraph (c)(1) of 42 C.F.R. 447.46 are	74
applicable to the third-party payer in paying a claim for any	75
amount due for health care services rendered by the provider.	76

Sec. 3901.3814. (A) Sections 3901.38 and 3901.381 to	77
3901.3813 of the Revised Code do not apply to the following:	78

(A)(1) Policies offering coverage that is regulated under	79
Chapters 3935. and 3937. of the Revised Code;	80

(B)(2) An employer's self-insurance plan and any of its	81
administrators, as defined in section 3959.01 of the Revised Code,	82
to the extent that federal law supersedes, preempts, prohibits, or	83
otherwise precludes the application of any provisions of those	84
sections to the plan and its administrators;	85

(C)(3) A third-party payer for coverage provided under the	86
medicare advantage program operated under Title XVIII of the	87
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as	88
amended;	89

(D) A third-party payer for coverage provided under the	90
medicaid program operated under Title XIX of the "Social Security	91
Act," except that if a federal waiver applied for under section	92
5111.178 of the Revised Code is granted or the director of job and	93
family services determines that this provision can be implemented	94
without a waiver, sections 3901.38 and 3901.381 to 3901.3813 of	95
the Revised Code apply to claims submitted electronically or	96
non-electronically that are made with respect to coverage of	97
medicaid recipients by health insuring corporations licensed under	98
Chapter 1751. of the Revised Code, instead of the prompt payment	99
requirements of 42 C.F.R. 447.46;	100

(E)(4) A third-party payer for coverage provided under the	101
tricare program offered by the United States department of	102
defense.	103

(B) The application of sections 3901.38 to 3901.3814 of the	104
Revised Code to medicaid managed care organizations does not	105
affect the authority of the department of job and family services	106
to do either of the following:	107

(1) Act as the single state agency to supervise	108
administration of the medicaid program, as specified in section	109
5111.01 of the Revised Code;	110

(2) Enter into contracts with managed care organizations	111
under section 5111.17 of the Revised Code.	112

Section 2. That existing sections 3901.38, 3901.383, and	113
3901.3814 and section 5111.178 of the Revised Code are hereby	114
repealed.	115