As Introduced

128th General Assembly Regular Session 2009-2010

S. B. No. 137

Senator Miller, R. 

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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 for health care services

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provided to Medicaid managed care participants.

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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	7
the Revised Code be amended to read as follows:	8

Sec. 3901.38.  As used in this section and sections 3901.381	9
to 3901.3814 of the Revised Code:	10

(A) "Beneficiary" means any policyholder, subscriber, member,	11
employee, or other person who is eligible for benefits under a	12
benefits contract.	13

(B) "Benefits contract" means a sickness and accident	14
insurance policy providing hospital, surgical, or medical expense	15
coverage, or a health insuring corporation contract or other	16
policy or agreement under which a third-party payer agrees to	17
reimburse for covered health care or dental services rendered to	18
beneficiaries, up to the limits and exclusions contained in the	19
benefits contract.	20

(C) "Hospital" has the same meaning as in section 3727.01 of	21
the Revised Code.	22

(D) "Medicaid managed care organization" means a managed care	23
organization that has a contract with the department of job and	24
family services pursuant to section 5111.17 of the Revised Code.	25

(E) "Provider" means a hospital, nursing home, physician,	26
podiatrist, dentist, pharmacist, chiropractor, or other health	27
care provider entitled to reimbursement by a third-party payer for	28
services rendered to a beneficiary under a benefits contract.	29

(E)(F) "Reimburse" means indemnify, make payment, or	30
otherwise accept responsibility for payment for health care	31
services rendered to a beneficiary, or arrange for the provision	32
of health care services to a beneficiary.	33

(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	39
1751.01 of the Revised Code, that is not a health delivery network	40
contracting solely with self-insured employers;	41

(6) An administrator subject to sections 3959.01 to 3959.16	42
of the Revised Code;	43

(7) A health delivery network, as defined in section 1751.01	44
of the Revised Code;	45

(8) A medicaid managed care organization;

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(9) Any other person that is obligated pursuant to a benefits	47
contract to reimburse for covered health care services rendered to	48
beneficiaries under such contract.	49

Sec. 3901.383. (A) A provider and a third-party payer may do	50
either of the following:	51

(1) Enter into a contractual agreement under which time	52
periods shorter than those set forth in section 3901.381 of the	53
Revised Code are applicable to the third-party payer in paying a	54
claim for any amount due for health care services rendered by the	55
provider;	56

(2) Enter into a contractual agreement under which the timing	57
of payments by the third-party payer is not directly related to	58
the receipt of a claim form. The contractual arrangement may	59
include periodic interim payment arrangements, capitation payment	60
arrangements, or other periodic payment arrangements acceptable to	61
the provider and the third-party payer. Under a capitation payment	62
arrangement, the third-party payer shall begin paying the	63
capitated amounts to the beneficiary's primary care provider not	64
later than sixty days after the date the beneficiary selects or is	65
assigned to the provider. Under any other contractual periodic	66
payment arrangement, the contractual agreement shall state, with	67
specificity, the timing of payments by the third-party payer.	68

(B) Regardless of whether a third-party payer is exempted	69
under division (D) of section 3901.3814 from sections 3901.38 and	70
3901.381 to 3901.3813 of the Revised Code, aA provider and thea	71
third-party payer, including a third-party payer that provides	72
coverage under the medicaid program, shall not enter into a	73
contractual arrangement under which time periods longer than those	74
provided for in paragraph (c)(1) of 42 C.F.R. 447.46 are	75
applicable to the third-party payer in paying a claim for any	76
amount due for health care services rendered by the provider.	77

Sec. 3901.3814. (A) Sections 3901.38 and 3901.381 to	78
3901.3813 of the Revised Code do not apply to the following:	79

(A)(1) Policies offering coverage that is regulated under	80
Chapters 3935. and 3937. of the Revised Code;	81

(B)(2) An employer's self-insurance plan and any of its	82
administrators, as defined in section 3959.01 of the Revised Code,	83
to the extent that federal law supersedes, preempts, prohibits, or	84
otherwise precludes the application of any provisions of those	85
sections to the plan and its administrators;	86

(C)(3) A third-party payer for coverage provided under the	87
medicare advantage program operated under Title XVIII of the	88
"Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as	89
amended;	90

(D) A third-party payer for coverage provided under the	91
medicaid program operated under Title XIX of the "Social Security	92
Act," except that if a federal waiver applied for under section	93
5111.178 of the Revised Code is granted or the director of job and	94
family services determines that this provision can be implemented	95
without a waiver, sections 3901.38 and 3901.381 to 3901.3813 of	96
the Revised Code apply to claims submitted electronically or	97
non-electronically that are made with respect to coverage of	98
medicaid recipients by health insuring corporations licensed under	99
Chapter 1751. of the Revised Code, instead of the prompt payment	100
requirements of 42 C.F.R. 447.46;	101

(E)(4) A third-party payer for coverage provided under the	102
tricare program offered by the United States department of	103
defense.;	104

(F)(5) A third-party payer for coverage provided under the	105
children's buy-in program established under sections 5101.5211 to	106
5101.5216 of the Revised Code.	107

(B) The application of sections 3901.38 to 3901.3814 of the	108
Revised Code to medicaid managed care organizations neither	109
affects the department of job and family services' authority	110
under section 5111.01 of the Revised Code to act as the single	111
state medicaid agency nor affects the department's authority to	112
enter into contracts with managed care organizations under section	113
5111.17 of the Revised Code.	114

Section 2. That existing sections 3901.38, 3901.383, and	115
3901.3814 and section 5111.178 of the Revised Code are hereby	116
repealed.	117