As Introduced

136th General Assembly

Regular Session H. B. No. 795

2025-2026

To enact sections 5164.40, 5164.401, 5164.402, 5164.403, 5164.404, 5164.405, and 5164.406 of the Revised Code to require the Department of Medicaid to establish electronic verification systems that promote program integrity for certain components of the Medicaid program and to name this act the Safeguarding Healthcare Integrity through Electronic Location Data (SHIELD) Act.

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

Section 1. That sections 5164.40, 5164.401, 5164.402, 5164.403, 5164.404, 5164.405, and 5164.406 of the Revised Code be enacted to read as follows:

Sec. 5164.40. As used in sections 5164.40 to 5164.406 of the Revised Code:

(A) "Breadcrumb location data" means data that provides a geographical position during a designated time period allowing the movements of a user to be tracked.

(B) "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.

(C) "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.

(D) "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.

(E) "Personal care services" has the same meaning as in 42 C.F.R. 440.167.

Sec. 5164.401. (A) The department of medicaid shall develop, procure, certify, or approve one or more systems for the electronic verification of nonemergency medical transportation services and in-home personal care 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) For claims submitted by a nonemergency medical transportation service provider:

(a) Utilize a ride dispatch system that is similar to other private transportation services;

(b) 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;

(d) Record timestamps, route data, and total distance traveled during a transport;

(e) Be capable of transmitting data directly to the department as a condition of payment.

(2) For claims submitted by an in-home personal care services provider:

(a) Require personal care service providers to clock in and clock out when physically present at the location where services are being provided;

(b) Utilize GPS-based verification to track when a provider clocks in and clocks out;

(d) Record timestamps and the total duration of delivered services;

(e) Be capable of transmitting data directly to the department for integration with other claims submissions.

(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 department shall require all nonemergency medical transportation service providers to utilize an electronic verification system established under division (B)(1) of this section.

(4) Beginning not later than twenty-four months after the effective date of this section, the department shall require all in-home personal care service providers to utilize an electronic verification system established under division (B)(2) 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 or in-home personal care service provider shall be eligible to receive medicaid payment for transportation or personal care 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 or personal care services submitted through an electronic verification system if all of the following conditions are satisfied:

(1) All required GPS-based verification and timestamp data are present.

(2) The breadcrumb location data utilized by an electronic verification system is consistent with the billed services.

(3) 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 data received from a nonemergency medical transportation service provider through an electronic verification system developed, procured, certified, or approved under section 5164.401 of the Revised Code 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.

(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 and irregular route patterns taken 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 developed, procured, certified, or approved 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;

(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, breadcrumb location data parameters, 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 through 5164.406 of the Revised Code.

Section 2. 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 3. This act shall be known as the Safeguarding Healthcare Integrity through Electronic Location Data (SHIELD) Act.