By: Seliger  S.B. No. 544
         (In the Senate - Filed February 7, 2011; February 17, 2011,
  read first time and referred to Committee on Health and Human
  Services; March 28, 2011, reported favorably by the following
  vote:  Yeas 9, Nays 0; March 28, 2011, sent to printer.)
 
 
A BILL TO BE ENTITLED
 
AN ACT
 
  relating to unlawful acts against and criminal offenses involving
  the Medicaid program.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 36.002, Human Resources Code, is amended
  to read as follows:
         Sec. 36.002.  UNLAWFUL ACTS. A person commits an unlawful
  act if the person:
               (1)  knowingly makes or causes to be made a false
  statement or misrepresentation of a material fact to permit 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;
               (2)  knowingly conceals or fails to disclose
  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;
               (3)  knowingly applies for and receives a benefit or
  payment on behalf of another person under the Medicaid program and
  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;
               (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;
               (9)  knowingly enters into an agreement, combination,
  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;
               (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;
               (12)  knowingly makes, uses, or causes the making or
  use of a false record or statement to conceal, avoid, or decrease an
  obligation to pay or transmit money or property to this state under
  the Medicaid program; or
               (13)  knowingly engages in conduct that constitutes a
  violation under Section 32.039(b).
         SECTION 2.  Subsection (a), Section 35A.02, Penal Code, is
  amended to read as follows:
         (a)  A person commits an offense if the person:
               (1)  knowingly makes or causes to be made a false
  statement or misrepresentation of a material fact to permit 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;
               (2)  knowingly conceals or fails to disclose
  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;
               (3)  knowingly applies for and receives a benefit or
  payment on behalf of another person under the Medicaid program and
  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;
               (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;
               (9)  knowingly enters into an agreement, combination,
  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;
               (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
  under Section 32.039, 32.0391, or 36.002, Human Resources Code; or
               (12)  knowingly makes, uses, or causes the making or
  use of a false record or statement to conceal, avoid, or decrease an
  obligation to pay or transmit money or property to this state under
  the Medicaid program.
         SECTION 3.  (a)  The change in law made by this Act applies
  only to conduct that occurs on or after the effective date of this
  Act.  Conduct that occurs before the effective date of this Act is
  governed by the law in effect at the time the conduct occurred, and
  that law is continued in effect for that purpose.
         (b)  For purposes of this section, conduct constituting an
  offense under the penal law of this state occurred before the
  effective date of this Act if any element of the offense occurred
  before that date.
         SECTION 4.  This Act takes effect September 1, 2011.
 
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