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A BILL TO BE ENTITLED
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AN ACT
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relating to unlawful acts against and criminal offenses involving |
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the Medicaid program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 36.002, Human Resources Code, is amended |
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to read as follows: |
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Sec. 36.002. UNLAWFUL ACTS. A person commits an unlawful |
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act if the person: |
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(1) knowingly makes or causes to be made a false |
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statement or misrepresentation of a material fact to permit a |
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person to receive a benefit or payment under the Medicaid program |
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that is not authorized or that is greater than the benefit or |
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payment that is authorized; |
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(2) knowingly conceals or fails to disclose |
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information that permits a person to receive a benefit or payment |
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under the Medicaid program that is not authorized or that is greater |
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than the benefit or payment that is authorized; |
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(3) knowingly applies for and receives a benefit or |
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payment on behalf of another person under the Medicaid program and |
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converts any part of the benefit or payment to a use other than for |
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the benefit of the person on whose behalf it was received; |
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(4) knowingly makes, causes to be made, induces, or |
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seeks to induce the making of a false statement or |
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misrepresentation of material fact concerning: |
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(A) the conditions or operation of a facility in |
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order that the facility may qualify for certification or |
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recertification required by the Medicaid program, including |
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certification or recertification as: |
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(i) a hospital; |
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(ii) a nursing facility or skilled nursing |
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facility; |
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(iii) a hospice; |
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(iv) an intermediate care facility for the |
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mentally retarded; |
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(v) an assisted living facility; or |
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(vi) a home health agency; or |
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(B) information required to be provided by a |
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federal or state law, rule, regulation, or provider agreement |
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pertaining to the Medicaid program; |
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(5) except as authorized under the Medicaid program, |
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knowingly pays, charges, solicits, accepts, or receives, in |
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addition to an amount paid under the Medicaid program, a gift, |
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money, a donation, or other consideration as a condition to the |
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provision of a service or product or the continued provision of a |
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service or product if the cost of the service or product is paid |
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for, in whole or in part, under the Medicaid program; |
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(6) knowingly presents or causes to be presented a |
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claim for payment under the Medicaid program for a product provided |
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or a service rendered by a person who: |
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(A) is not licensed to provide the product or |
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render the service, if a license is required; or |
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(B) is not licensed in the manner claimed; |
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(7) knowingly makes or causes to be made a claim under |
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the Medicaid program for: |
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(A) a service or product that has not been |
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approved or acquiesced in by a treating physician or health care |
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practitioner; |
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(B) a service or product that is substantially |
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inadequate or inappropriate when compared to generally recognized |
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standards within the particular discipline or within the health |
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care industry; or |
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(C) a product that has been adulterated, debased, |
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mislabeled, or that is otherwise inappropriate; |
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(8) makes a claim under the Medicaid program and |
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knowingly fails to indicate the type of license and the |
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identification number of the licensed health care provider who |
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actually provided the service; |
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(9) knowingly enters into an agreement, combination, |
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or conspiracy to defraud the state by obtaining or aiding another |
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person in obtaining an unauthorized payment or benefit from the |
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Medicaid program or a fiscal agent; |
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(10) is a managed care organization that contracts |
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with the Health and Human Services Commission or other state agency |
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to provide or arrange to provide health care benefits or services to |
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individuals eligible under the Medicaid program and knowingly: |
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(A) fails to provide to an individual a health |
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care benefit or service that the organization is required to |
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provide under the contract; |
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(B) fails to provide to the commission or |
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appropriate state agency information required to be provided by |
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law, commission or agency rule, or contractual provision; or |
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(C) engages in a fraudulent activity in |
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connection with the enrollment of an individual eligible under the |
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Medicaid program in the organization's managed care plan or in |
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connection with marketing the organization's services to an |
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individual eligible under the Medicaid program; |
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(11) knowingly obstructs an investigation by the |
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attorney general of an alleged unlawful act under this section; |
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(12) knowingly makes, uses, or causes the making or |
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use of a false record or statement to conceal, avoid, or decrease an |
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obligation to pay or transmit money or property to this state under |
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the Medicaid program; or |
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(13) knowingly engages in conduct that constitutes a |
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violation under Section 32.039(b). |
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SECTION 2. Subsection (a), Section 35A.02, Penal Code, is |
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amended to read as follows: |
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(a) A person commits an offense if the person: |
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(1) knowingly makes or causes to be made a false |
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|
statement or misrepresentation of a material fact to permit a |
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|
person to receive a benefit or payment under the Medicaid program |
|
|
that is not authorized or that is greater than the benefit or |
|
|
payment that is authorized; |
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|
(2) knowingly conceals or fails to disclose |
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|
information that permits a person to receive a benefit or payment |
|
|
under the Medicaid program that is not authorized or that is greater |
|
|
than the benefit or payment that is authorized; |
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|
(3) knowingly applies for and receives a benefit or |
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|
payment on behalf of another person under the Medicaid program and |
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|
converts any part of the benefit or payment to a use other than for |
|
|
the benefit of the person on whose behalf it was received; |
|
|
(4) knowingly makes, causes to be made, induces, or |
|
|
seeks to induce the making of a false statement or |
|
|
misrepresentation of material fact concerning: |
|
|
(A) the conditions or operation of a facility in |
|
|
order that the facility may qualify for certification or |
|
|
recertification required by the Medicaid program, including |
|
|
certification or recertification as: |
|
|
(i) a hospital; |
|
|
(ii) a nursing facility or skilled nursing |
|
|
facility; |
|
|
(iii) a hospice; |
|
|
(iv) an intermediate care facility for the |
|
|
mentally retarded; |
|
|
(v) an assisted living facility; or |
|
|
(vi) a home health agency; or |
|
|
(B) information required to be provided by a |
|
|
federal or state law, rule, regulation, or provider agreement |
|
|
pertaining to the Medicaid program; |
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|
(5) except as authorized under the Medicaid program, |
|
|
knowingly pays, charges, solicits, accepts, or receives, in |
|
|
addition to an amount paid under the Medicaid program, a gift, |
|
|
money, a donation, or other consideration as a condition to the |
|
|
provision of a service or product or the continued provision of a |
|
|
service or product if the cost of the service or product is paid |
|
|
for, in whole or in part, under the Medicaid program; |
|
|
(6) knowingly presents or causes to be presented a |
|
|
claim for payment under the Medicaid program for a product provided |
|
|
or a service rendered by a person who: |
|
|
(A) is not licensed to provide the product or |
|
|
render the service, if a license is required; or |
|
|
(B) is not licensed in the manner claimed; |
|
|
(7) knowingly makes or causes to be made a claim under |
|
|
the Medicaid program for: |
|
|
(A) a service or product that has not been |
|
|
approved or acquiesced in by a treating physician or health care |
|
|
practitioner; |
|
|
(B) a service or product that is substantially |
|
|
inadequate or inappropriate when compared to generally recognized |
|
|
standards within the particular discipline or within the health |
|
|
care industry; or |
|
|
(C) a product that has been adulterated, debased, |
|
|
mislabeled, or that is otherwise inappropriate; |
|
|
(8) makes a claim under the Medicaid program and |
|
|
knowingly fails to indicate the type of license and the |
|
|
identification number of the licensed health care provider who |
|
|
actually provided the service; |
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|
(9) knowingly enters into an agreement, combination, |
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|
or conspiracy to defraud the state by obtaining or aiding another |
|
|
person in obtaining an unauthorized payment or benefit from the |
|
|
Medicaid program or a fiscal agent; |
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|
(10) is a managed care organization that contracts |
|
|
with the Health and Human Services Commission or other state agency |
|
|
to provide or arrange to provide health care benefits or services to |
|
|
individuals eligible under the Medicaid program and knowingly: |
|
|
(A) fails to provide to an individual a health |
|
|
care benefit or service that the organization is required to |
|
|
provide under the contract; |
|
|
(B) fails to provide to the commission or |
|
|
appropriate state agency information required to be provided by |
|
|
law, commission or agency rule, or contractual provision; or |
|
|
(C) engages in a fraudulent activity in |
|
|
connection with the enrollment of an individual eligible under the |
|
|
Medicaid program in the organization's managed care plan or in |
|
|
connection with marketing the organization's services to an |
|
|
individual eligible under the Medicaid program; |
|
|
(11) knowingly obstructs an investigation by the |
|
|
attorney general of an alleged unlawful act under this section or |
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|
under Section 32.039, 32.0391, or 36.002, Human Resources Code; or |
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|
(12) knowingly makes, uses, or causes the making or |
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|
use of a false record or statement to conceal, avoid, or decrease an |
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|
obligation to pay or transmit money or property to this state under |
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|
the Medicaid program. |
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SECTION 3. (a) The change in law made by this Act applies |
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only to conduct that occurs on or after the effective date of this |
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Act. Conduct that occurs before the effective date of this Act is |
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governed by the law in effect at the time the conduct occurred, and |
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that law is continued in effect for that purpose. |
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(b) For purposes of this section, conduct constituting an |
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offense under the penal law of this state occurred before the |
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effective date of this Act if any element of the offense occurred |
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before that date. |
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SECTION 4. This Act takes effect September 1, 2011. |
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* * * * * |