As Introduced

128th General Assembly Regular Session 2009-2010

H. B. No. 240

Representative Sears 

Cosponsors: Representatives Adams, J., Adams, R., Balderson, Boose, Burke, Combs, Grossman, Huffman, Jones, Jordan, McGregor, Stebelton, Wachtmann 

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A BILL

To amend section 5111.083 and to enact sections

1

5111.035, 5111.092, 5111.093, 5111.141, 5111.142,

2

and 5111.165 of the Revised Code to modify the

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Medicaid program.

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

Section 1. That section 5111.083 be amended and sections	5
5111.035, 5111.092, 5111.093, 5111.141, 5111.142, and 5111.165 of	6
the Revised Code be enacted to read as follows:	7

Sec. 5111.035. (A) Each medicaid provider selected by the	8
department of job and family services shall give bond with surety	9
to the department, in the amount the department determines and to	10
the satisfaction of the department, for the faithful adherence by	11
the provider to the requirements of section 5111.03 of the Revised	12
Code.	13

(B) The department shall determine which providers are	14
subject to division (A) of this section, but at a minimum shall	15
apply the bond requirement to each provider who has been	16
investigated for any criminal offense of fraud, as defined in	17
Chapter 2913. of the Revised Code. The department shall set the	18
amount of the bond at a level that reflects, as determined by the	19
director of job and family services, the level of risk of fraud by	20
the provider.	21

Sec. 5111.083. (A) As used in this section, "licensed health	22
professional authorized to prescribe drugs" has the same meaning	23
as in section 4729.01 of the Revised Code.	24

(B) The director of job and family services mayshall	25
establish an e-prescribing system for the medicaid program under	26
which a medicaid provider who is a licensed health professional	27
authorized to prescribe drugs shall use an electronic system to	28
prescribe a drug for a medicaid recipient when required to do so	29
by division (C) of this section. The e-prescribing system shall	30
eliminate the need for such medicaid providers to make	31
prescriptions for medicaid recipients by handwriting or telephone.	32
The e-prescribing system also shall provide such medicaid	33
providers with an up-to-date, clinically relevant drug information	34
database and a system of electronically monitoring medicaid	35
recipients' medical history, drug regimen compliance, and fraud	36
and abuse.	37

(C) If the director establishesIn establishing an	38
e-prescribing system under division (B) of this section, the	39
director shall do all of the following:	40

(1) Require that a medicaid provider who is a licensed health	41
professional authorized to prescribe drugs use the e-prescribing	42
system during a fiscal year if the medicaid provider was one of	43
the ten medicaid providers who, during the calendar year that	44
precedes that fiscal year, issued the most prescriptions for	45
medicaid recipients receiving hospital services;	46

(2) Before the beginning of each fiscal year, determine the	47
ten medicaid providers that issued the most prescriptions for	48
medicaid recipients receiving hospital services during the	49
calendar year that precedes the upcoming fiscal year and notify	50
those medicaid providers that they must use the e-prescribing	51
system for the upcoming fiscal year;	52

(3) Seek the most federal financial participation available	53
for the development and implementation of the e-prescribing	54
system.	55

Sec. 5111.092. (A) Not later than January 1, 2010, and each	56
year thereafter, the department of job and family services shall	57
prepare a report on the department's efforts to minimize fraud,	58
waste, and abuse in the medicaid program. In preparing the report,	59
the department shall collaborate with other medicaid program	60
fraud, waste, and abuse personnel from all of the following:	61

(1) The medicaid fraud control unit of the office of the	62
attorney general;	63

(2) The fraud and investigative audit group of the auditor of	64
state;	65

(3) State agencies with which the department contracts under	66
section 5111.91 of the Revised Code to administer one or more	67
components of the medicaid program or one or more aspects of a	68
component;	69

(4) County departments of job and family services.

70

(B) Each report shall include at least both of the following	71
with regard to minimizing fraud, waste, and abuse in the medicaid	72
program:	73

(1) Goals and objectives that are mutually agreed upon by the	74
department and the entities with which it collaborates under	75
division (A) of this section;	76

(2) Performance measures for monitoring all state and local	77
activities.	78

(C) Each report shall be made available on the department's	79
web site. Copies of the report shall be made available to the	80
public on request.	81

Sec. 5111.093. (A) As used in this section, "local medicaid	82
administrative agency" means all of the following:	83

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

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(2) A county board of mental retardation and developmental	85
disabilities;	86

(3) A board of alcohol, drug addiction, and mental health	87
services;	88

(4) A PASSPORT administrative agency;

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(5) A board of education of a city, local, or exempted	90
village school district;	91

(6) The governing authority of a community school established	92
under Chapter 3314. of the Revised Code.	93

(B) Each local medicaid administrative agency shall report	94
annually to the department of job and family services and office	95
of budget and management all of the following information	96
regarding the previous calendar year:	97

(1) The total amount of local government funds the local	98
medicaid administrative agency expended for the medicaid program;	99

(2) The portion of the total reported under division (B)(1)	100
of this section that represents funds raised by local property tax	101
levies;	102

(3) The local medicaid administrative agency's total	103
administrative costs for the medicaid program;	104

(4) The local medicaid administrative agency's administrative	105
costs for the medicaid program for which the agency receives no	106
federal financial participation;	107

(5) The total amount of state funds provided to the local	108
medicaid administrative agency for the medicaid program.	109

Sec. 5111.141. (A) The department of job and family services	110
shall implement a disease management component of the medicaid	111
program. Medicaid recipients participating in the care management	112
system established under section 5111.16 of the Revised Code shall	113
be excluded from the disease management component. The department	114
may implement the disease management component as part of the	115
alternative care management program established under section	116
5111.165 of the Revised Code.	117

(B) The disease management component shall consist of a	118
system of coordinated health care interventions and patient	119
communications for groups of medicaid recipients who have medical	120
conditions for which the department determines patient self-care	121
efforts are significant. The disease management component shall	122
do all of the following:	123

(1) Support physicians, the professional relationship between	124
patients and their medical caregivers, and patients' plans of	125
care;	126

(2) Emphasize prevention of exacerbations and complications	127
of medical conditions using evidence-based practice guidelines and	128
patient empowerment strategies;	129

(3) Evaluate clinical, humanistic, and economic outcomes on	130
an ongoing basis with the goal of improving overall health.	131

(C) To the extent the department considers appropriate,	132
contracts that the department enters into with other state	133
agencies under section 5111.91 of the Revised Code shall provide	134
for the other state agencies to include the disease management	135
component in the component of the medicaid program that the other	136
state agency administers pursuant to the contract.	137

Sec. 5111.142.  (A) The department of job and family services	138
shall conduct a review of case management services provided under	139
the fee-for-service component of the medicaid program. In	140
conducting the review, the department shall identify which groups	141
of medicaid recipients not participating in the care management	142
system established under section 5111.16 of the Revised Code or	143
enrolled in a medicaid waiver component as defined in section	144
5111.85 of the Revised Code do not receive case management	145
services and which groups of such medicaid recipients receive case	146
management services as part of two or more components of the	147
medicaid program or from two or more providers.	148

After completing the review, the department shall implement a	149
case management component of the medicaid program. The department	150
shall model the case management component on the former enhanced	151
care management program that the department created as part of the	152
care management system established under section 5111.16 of the	153
Revised Code. The department shall make adjustments to the former	154
enhanced care management program as are necessary to accomodate	155
the groups the case management component is to serve.	156

(B) At a minimum, the case management component shall serve	157
medicaid recipients who are members of the groups identified in	158
the review conducted under this section and have been diagnosed by	159
a physician as having any of the following medical conditions:	160

(1) A high-risk pregnancy;

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(2) Diabetes;

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(3) Asthma;

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(4) Lung disease;

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(5) Congestive heart failure;

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(6) Coronary artery disease;

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(7) Hypertension;

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(8) Hyperlipidemia;

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(9) Infection with the human immunodeficiency virus;

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(10) Acquired immunodeficiency syndrome;

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(11) Chronic obstructive pulmonary disease.

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Sec. 5111.165.  (A) The department of job and family	172
services shall develop and implement an alternative care	173
management program for medicaid recipients that is separate from	174
the care management program established under section 5111.16 of	175
the Revised Code. The purpose of the program shall be to test and	176
evaluate multiple alternative care management models for providing	177
health care services to medicaid recipients designated under this	178
section as participants in the program.	179

(B) The program shall be implemented not later than October	180
1, 2009, or, if by that date the department has not received any	181
necessary federal approval to implement the program, as soon as	182
practicable after receiving the approval. From among the medicaid	183
recipients who are not participants in the care management system	184
established under section 5111.16 of the Revised Code, the	185
department shall designate the medicaid recipients who are	186
required to participate in the alternative care management program	187
established under this section.	188

(C) The department shall ensure that each alternative care	189
management model included in the program is operated in at least	190
three counties. The department shall select the counties in which	191
each model is to be operated. The department may extend the	192
operation of a model into other counties if the department	193
determines that such an expansion is necessary to evaluate the	194
effectiveness of the model.	195

The department may periodically alter the requirements,	196
design, or eligible participants in the program in order to test	197
and evaluate the effectiveness of varying care management models	198
for providing medicaid services, except that each model included	199
in the program shall be in effect for a period sufficient in	200
length to evaluate the effectiveness of the model.	201

(D) The department shall conduct an evaluation of each	202
alternative care management model included in the program. As part	203
of the evaluation, the department shall maintain statistics on	204
physician expenditures, hospital expenditures, preventable	205
hospitalizations, costs for each participant, effectiveness, and	206
health outcomes for participants.	207

(E) The department shall adopt rules in accordance with	208
Chapter 119. of the Revised Code as necessary to implement this	209
section. The rules shall specify standards and procedures to be	210
used in designating participants of the program.	211

Section 2. That existing section 5111.083 of the Revised	212
Code is hereby repealed.	213

Section 3.  THIRD PARTY LIABILITY - PILOT PROGRAM

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(A) As used in this section:

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(1) "Medicaid program" means the medical assistance program	216
established under Chapter 5111. of the Revised Code.	217

(2) "Third party" has the same meaning as in section 5101.571	218
of the Revised Code.	219

(B)(1) Except as provided in division (C) of this section and	220
using technology designed to identify all persons liable to pay a	221
claim for a medical item or service, the Director of Job and	222
Family Services shall establish and administer a pilot program for	223
the purpose of identifying third parties that are liable for	224
paying all or a portion of a claim for a medical item or service	225
provided to a Medicaid recipient before the claim is submitted to,	226
or paid by, the Medicaid program. The Director shall determine the	227
duration of the pilot program, except that the Director shall not	228
terminate the program less than eighteen months after it is	229
established.	230

(2) In administering the pilot program, the Director shall,	231
subject to division (B)(3) of this section, ensure that all	232
aspects of the program comply with Ohio and federal law, including	233
the "Health Insurance Portability and Accountability Act of 1996,"	234
Pub. L. No. 104-191, as amended, and regulations promulgated by	235
the United States Department of Health and Human Services to	236
implement the Act.	237

(3) The Director's duty to ensure compliance with the laws	238
described in division (B)(2) of this section does not prohibit	239
either of the following:	240

(a) A third party from providing information to the	241
Department of Job and Family Services or disclosing or making use	242
of information as permitted under section 5101.572 of the Revised	243
Code or when required by any other provision of Ohio or federal	244
law;	245

(b) The Department from using information provided by a third	246
party as permitted in section 5101.572 of the Revised Code or when	247
required by any other provision of Ohio or federal law.	248

(C)(1) The Director may enter into a contract with any person	249
under which the person serves as the administrator of the pilot	250
program. Before entering into a contract for a pilot program	251
administrator, the Department shall issue a request for proposals	252
from persons seeking to be considered. The Department shall	253
develop a process to be used in issuing the request for proposals,	254
receiving responses to the request, and evaluating the responses	255
on a competitive basis. In accordance with that process, the	256
Department shall select the person to be awarded the contract.	257

(2) The Director may delegate to the person awarded the	258
contract any of the Director's powers or duties specified in this	259
section. The terms of the contract shall specify the extent to	260
which the powers or duties are delegated to the pilot program	261
administrator.	262

(3) In exercising powers or performing duties delegated under	263
the contract, the pilot program administrator is subject to the	264
same provisions of this section that grant the powers or duties to	265
the Director, as well as any limitations or restrictions that are	266
applicable to or associated with those powers or duties.	267

(4) The terms of a contract for a pilot program administrator	268
shall include a provision that specifies that the Director or any	269
agent of the Director is not liable for the failure of the	270
administrator to comply with a term of the contract, including any	271
term that specifies the administrator's duty to ensure compliance	272
with the laws described in division (B)(1) of this section.	273

(D) Twelve months after the pilot program is established, the	274
Director shall evaluate the program's effectiveness. As part of	275
this evaluation, the Director shall determine both of the	276
following:	277

(1) For the twelve months immediately preceding the	278
establishment of the pilot program, all of the following:	279

(a) The amount of money paid for each Medicaid claim in which	280
no third party liability was indicated by the Medicaid recipient	281
but for which at least one third party was liable to pay all or a	282
portion of the claim, and the amount attributable to each liable	283
party;	284

(b) The portions of the amounts attributable to each liable	285
third party, described in division (D)(1)(a) of this section, that	286
were recovered by the Director or a person with which the Director	287
has contracted to manage the recovery of money due from liable	288
third parties;	289

(c) The portions of the amounts attributable to each liable	290
third party, described in division (D)(1)(a) of this section, that	291
would have been identified by the technology used by the pilot	292
program had the technology been used in those twelve months.	293

(2) For the first twelve months of the pilot program, both of	294
the following:	295

(a) The items described in divisions (D)(1)(a) and (b) of	296
this section;	297

(b) The portions of the amounts attributable to each liable	298
third party, described in division (D)(1)(a) of this section, that	299
were identified by the technology used by the pilot program.	300

(E) Not later than three months after the evaluation required	301
by division (D) of this section is initiated, the Director shall	302
prepare and submit to the Governor, the Speaker and Minority	303
Leader of the House of Representatives, and the President and	304
Minority Leader of the Senate a report that summarizes the results	305
of the Director's evaluation of the pilot program. At a minimum,	306
the report shall summarize and compare the determinations made	307
under division (D) of this section, conclude whether the program	308
achieved savings for the Medicaid program, and make a	309
recommendation as to whether the pilot program should be extended	310
or be made permanent.	311

(F) The Director may adopt rules in accordance with Chapter	312
119. of the Revised Code as necessary to implement this section.	313

Section 4.  (A) As used in this section, "community	314
behavioral health services" means both of the following:	315

(1) Community mental health services certified by the	316
Director of Mental Health under section 5119.611 of the Revised	317
Code;	318

(2) Services provided by an alcohol and drug addiction	319
program certified by the Department of Alcohol and Drug Addiction	320
Services under section 3793.06 of the Revised Code.	321

(B) There is hereby created the Medicaid Community Behavioral	322
Health Administration Examination Group. The Examination Group	323
shall consist of all of the following:	324

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

325

(2) The Director of Alcohol and Drug Addiction Services or	326
the Director's designee;	327

(3) The Director of Job and Family Services or the Director's	328
designee;	329

(4) Two members of the House of Representatives from	330
different political parties appointed by the Speaker of the House	331
of Representatives;	332

(5) Two members of the Senate from different political	333
parties appointed by the President of the Senate.	334

(C) The Directors of Mental Health and Alcohol and Drug	335
Addiction Services, or their designees, shall serve as	336
co-chairpersons of the Examination Group. The Departments of	337
Mental Health and Alcohol and Drug Addiction Services shall	338
provide administrative services to the Examination Group.	339

(D) Members of the Examination Group shall serve without	340
compensation, except to the extent that serving as members is	341
considered part of their regular employment duties.	342

(E) The Examination Group shall study the administration	343
and management of Medicaid-covered community behavioral health	344
services. Not later than one year after the effective date of this	345
act, the Examination Group shall submit a report regarding its	346
study to the Governor and, in accordance with section 101.68 of	347
the Revised Code, the General Assembly. The report shall	348
include all of the following:	349

(1) Recommendations for system changes needed for the	350
effective administration and management of Medicaid-covered	351
community behavioral health services. The recommendations shall	352
focus on increasing efficiencies, transparency, and	353
accountability in order to improve the delivery of community	354
behavioral health services.	355

(2) An evaluation of merging the Departments of Mental Health	356
and Alcohol and Drug Addiction Services or of other options to	357
improve the organizational structure used to provide	358
Medicaid-covered community behavioral health services;	359

(3) An examination of the best practices for providing	360
Medicaid-covered community behavioral health services, using as a	361
reference other state's best practices for providing such	362
services;	363

(4) An analysis of using a case management program for	364
Medicaid-covered community behavioral health services.	365

(F) The Examination Group shall cease to exist on	366
submission of its report.	367