Ohio Senate Bill 315 Brings Sweeping Changes to Medicaid Program Integrity
Senate Bill 315 —with an effective date of October 6, 2026—significantly expands oversight, enforcement authority, and program integrity requirements across Ohio Medicaid. This alert summarizes a few of the many changes within SB 315. Health care providers should closely monitor upcoming Medicaid administrative rules to understand how the requirements of SB 315 will be implemented and carried out in practice. The health care team at Vorys is prepared to answer questions and help guide providers through the implementation of the bill. Below is a brief summary of a few of the key provisions of SB 315, the complete text of which can be found here.
Expanded Authority for the Attorney General to Investigate the Medicaid Program
SB 315 grants subpoena and other powers to the attorney general to pursue investigations of violations of the law related to the Medicaid program. Various office holders can request investigations of potential criminal or civil violations of the law or “improper activity.” During an investigation, the attorney general may issue subpoenas for witness testimony or the production of documents. Any provider served with a subpoena should immediately seek legal counsel.
Prior Authorization for Therapeutic Behavioral Services (TBS)
The legislation requires a prior authorization requirement for all TBS provided under the Medicaid program. TBS are interventions designed to help individuals manage behavioral challenges, emotional regulation, and daily life activities. Providers of TBS should begin preparing for the additional administrative work associated with submitting prior authorization requests.
Suspension of Infrequent Billers
Medicaid can suspend the provider agreement of any provider that has not submitted a claim for a period of one year. This provision may create a significant burden for out-of-state providers in neighboring states that infrequently provide services to Ohio Medicaid members. These providers may need to consider single-case agreements or otherwise be prepared to seek reconsideration of any suspension given that this provision was likely not intended to target infrequent out-of-state billers.
Additional Scrutiny of New Providers and Increases in Claim Submissions
Medicaid is required to increase provider scrutiny. Namely, it must:
- Suspend new providers when there is a “suspicious increase” in the number of claims submitted by the provider in the first 60 days of the provider having a provider agreement.
- Flag and investigate large increases in the number of claims when there is not a corresponding increase in the number of Medicaid enrollees receiving services from the providers.
- Establish additional oversight mechanisms for services provided by family caregivers.
- Conduct an in-person review of an individual or site inspection of an entity seeking initial enrollment as a provider of home and community-based services.
Providers should seek legal counsel if suspended or investigated. Indeed, some of the new provisions—such as new claims by new providers—may very well have a reasonable explanation, such as a successful start-up in an underserved area.
Expansion of Electronic Visit Verification
SB 315 extends electronic visit verification to nonemergency medical transportation and in-home care services. Transportation providers should begin to take training and test EVV systems well in advance of this provision taking effect.
More Frequent Credentialing Submissions
SB 315 requires numerous provider types to submit credentialing, licensing, certification, and insurance information to the department more frequently. Providers should track the revised submission deadlines and update administrative procedures.
Alternative Insurance Checks
Before paying any claim, SB 315 requires Medicaid to use automated algorithmic analysis and insurance discovery engines to determine whether a different primary insurance source is responsible for payment.
Limitations on the Number of Home and Community-Based Providers using the Same Business Location
SB 315 places limits on the number of home and community-based providers having the same business address, and in some instances requires Medicaid to make a referral to the auditor of state. The SB 315 provisions related to business addresses are most likely to impact home and community providers that provide services in non-office settings but share office space for administrative purposes. Providers should consult with legal counsel anytime they share office space to ensure that they are not only complying with SB 315 but also have appropriate procedures and protections in place to comply with patient privacy laws, anti-kickback laws, and other regulations.
Vorys attorneys are monitoring the impacts of Senate Bill 315 and counseling clients who will be impacted by the changes in the law.
