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A BILL TO BE ENTITLED
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AN ACT
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relating to health care and insurance fraud; creating a criminal |
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offense; authorizing a civil penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 544.0103(e), Government Code, as |
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effective April 1, 2025, is amended to read as follows: |
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(e) The office of inspector general may: |
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(1) assess administrative penalties otherwise |
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authorized by law on behalf of the commission or a health and human |
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services agency; |
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(2) request that the attorney general obtain an |
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injunction to prevent a person from disposing of an asset the office |
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of inspector general identifies as potentially subject to recovery |
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by the office of inspector general due to the person's fraud or |
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abuse; |
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(3) provide for coordination between the office of |
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inspector general and special investigative units formed by managed |
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care organizations under Subchapter H or entities with which |
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managed care organizations contract under that subchapter; |
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(3-a) provide for coordination between the office of |
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inspector general and the Texas Department of Insurance, as |
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provided by Section 701.110, Insurance Code, to coordinate health |
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care fraud detection and prevention in the state; |
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(4) audit the use and effectiveness of state or |
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federal funds, including contract and grant funds, administered by |
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a person or state agency receiving the funds from a health and human |
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services agency; |
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(5) conduct investigations relating to the funds |
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described by Subdivision (4); and |
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(6) recommend policies to: |
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(A) promote the economical and efficient |
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administration of the funds described by Subdivision (4); and |
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(B) prevent and detect fraud and abuse in the |
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administration of those funds. |
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SECTION 2. The heading to Subchapter B, Chapter 701, |
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Insurance Code, is amended to read as follows: |
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SUBCHAPTER B. REPORTING FRAUDULENT INSURANCE ACTS; CIVIL REMEDIES |
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SECTION 3. Subchapter B, Chapter 701, Insurance Code, is |
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amended by adding Section 701.053 to read as follows: |
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Sec. 701.053. CIVIL REMEDIES. (a) Except as provided by |
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Subsection (c), a person who violates Section 35A.02(a-1), Penal |
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Code, is liable to the state for: |
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(1) the amount of a payment made by or the value of a |
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benefit provided by a health benefit plan issuer, directly or |
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indirectly, as a result of the violation, including any payment |
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made to a third party; |
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(2) interest on the amount of the payment or the value |
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of the benefit described by Subdivision (1) at the prejudgment |
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interest rate in effect on the day the payment or benefit was |
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received or paid, for the period from the date the benefit was |
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received or paid to the date that the state recovers the amount of |
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the payment or value of the benefit; |
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(3) a civil penalty of: |
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(A) not less than $5,500 and not more than |
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$15,000 for each violation committed by the person that results in |
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injury to an elderly person, as defined by Section 48.002(a)(1), |
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Human Resources Code, a person with a disability, as defined by |
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Section 48.002(a)(8)(A), Human Resources Code, or a person younger |
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than 18 years of age; or |
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(B) not less than $5,500 and not more than |
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$11,000 for each violation committed by the person that does not |
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result in injury to a person described by Paragraph (A); and |
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(4) two times the amount of the payment or the value of |
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the benefit described by Subdivision (1). |
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(b) In determining the amount of the civil penalty described |
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by Subsection (a)(3), the trier of fact shall consider: |
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(1) whether the person has previously violated Section |
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35A.02(a-1), Penal Code; |
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(2) the seriousness of the violation committed by the |
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person, including the nature, circumstances, extent, and gravity of |
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the violation; |
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(3) whether the health and safety of the public or an |
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individual was threatened by the violation; |
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(4) whether the person acted in bad faith when the |
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person engaged in the conduct that formed the basis of the |
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violation; and |
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(5) the amount necessary to deter future violations. |
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(c) The trier of fact may assess a total of not more than two |
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times the amount of a payment or the value of a benefit described by |
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Subsection (a)(1) if the trier of fact finds that: |
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(1) the person reported to the insurance fraud unit of |
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the department all information known to the person about the |
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violation not later than the 30th day after the date on which the |
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person first obtained the information; and |
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(2) at the time the person furnished all the |
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information to the insurance fraud unit of the department, the |
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insurance fraud unit of the department had not yet begun an |
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investigation under this chapter. |
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SECTION 4. Section 701.102, Insurance Code, is amended to |
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read as follows: |
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Sec. 701.102. INVESTIGATION OF CERTAIN ACTS OF FRAUD. (a) |
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If the commissioner has reason to believe a person has engaged in, |
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is engaging in, has committed, or is about to commit a fraudulent |
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insurance act, the commissioner may conduct any investigation |
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|
necessary inside or outside this state to: |
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(1) determine whether the act occurred; or |
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|
(2) aid in enforcing laws relating to fraudulent |
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insurance acts, including by providing technical or litigation |
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assistance to other governmental agencies. |
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(b) In exercising the commissioner's authority under |
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Subsection (a), the commissioner shall prioritize investigating |
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|
alleged violations of Section 35A.02(a-1), Penal Code. |
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(c) Except as provided by Section 701.214, the department |
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|
may retain up to 50 percent of any money recovered as a result of an |
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|
investigation conducted under Subsection (b). The department shall |
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|
remit the remaining amount of money to the person or persons harmed |
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by the offense. |
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SECTION 5. Subchapter C, Chapter 701, Insurance Code, is |
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|
amended by adding Section 701.110 to read as follows: |
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Sec. 701.110. FRAUD PREVENTION PARTNERSHIP. (a) The |
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department shall, in coordination with the Health and Human |
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|
Services Commission office of inspector general, establish the |
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fraud prevention partnership to detect and prevent health care |
|
|
fraud in this state across the private and public markets. |
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|
(b) The partnership shall include: |
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|
(1) a representative of one or more Medicaid managed |
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|
care organizations; |
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(2) a representative of one or more health benefit |
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|
plan issuers, as defined by Section 1222.0001; and |
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|
(3) any other appropriate person as determined by the |
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|
commissioner and inspector general. |
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|
SECTION 6. Chapter 701, Insurance Code, is amended by |
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|
adding Subchapter E to read as follows: |
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SUBCHAPTER E. ACTION BY PRIVATE PERSON |
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Sec. 701.201. ACTION BY PRIVATE PERSON AUTHORIZED. (a) A |
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person may bring a civil action for a violation of Section |
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|
35A.02(a-1), Penal Code, on behalf of the person and the state. The |
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|
action must be brought in the name of the person and of the state. |
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|
(b) In an action brought under this subchapter, a person who |
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|
violates Section 35A.02(a-1), Penal Code, is liable as provided by |
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Section 701.053. |
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Sec. 701.202. INITIATION OF ACTION. (a) A person bringing |
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|
an action under this subchapter shall serve a copy of the petition |
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|
and a written disclosure of substantially all material evidence and |
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|
information the person possesses on the attorney general in |
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|
compliance with the Texas Rules of Civil Procedure. |
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(b) A person shall file a petition for an action under this |
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|
subchapter in camera and, except as provided by Section 701.203(b) |
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|
or (c), the petition must remain under seal until the earlier of: |
|
|
(1) the 180th day after the date the petition is served |
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|
on the attorney general; or |
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|
(2) the date on which the state elects to intervene. |
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|
(c) A person bringing an action under this subchapter may |
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|
not serve process on a defendant until the court orders service of |
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process. |
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Sec. 701.203. STATE INTERVENTION. (a) The state may elect |
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|
to intervene and proceed with an action under this subchapter not |
|
|
later than the 180th day after the date the attorney general |
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|
receives the petition and the material evidence and information |
|
|
under Section 701.202(a). |
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|
(b) At the time the state intervenes in an action under this |
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|
subchapter, the attorney general may file a motion with the court |
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|
requesting that the petition remain under seal for an extended |
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|
period. |
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|
(c) In an action under this subchapter, the state may, for |
|
|
good cause shown, move the court to extend the 180-day periods |
|
|
prescribed by Subsection (a) or Section 701.202(b). A motion under |
|
|
this subsection may be supported by affidavits or other submissions |
|
|
in camera. |
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|
Sec. 701.204. CONSENT REQUIRED FOR DISMISSAL. An action |
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|
under this subchapter may be dismissed only if the court and the |
|
|
attorney general consent in writing to the dismissal and state |
|
|
their reasons for consenting. |
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|
Sec. 701.205. ANSWER BY DEFENDANT. A defendant is not |
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|
required to file in accordance with the Texas Rules of Civil |
|
|
Procedure an answer to a petition filed under this subchapter until |
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|
the petition is unsealed and served on the defendant. |
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|
Sec. 701.206. STATE DECISION; CONTINUATION OF ACTION. (a) |
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|
Not later than the last day of the period prescribed by Section |
|
|
701.203(a) or an extension of that period as provided by Section |
|
|
701.203(c), the state shall: |
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|
(1) proceed with the action; or |
|
|
(2) notify the court that the state declines to take |
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|
over the action. |
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|
(b) If the state declines to take over an action under this |
|
|
subchapter, the person bringing the action may proceed without the |
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|
state's participation. A person proceeding under this subsection |
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|
may recover for a violation for a period of up to six years before |
|
|
the date the action was filed, or for a period beginning when the |
|
|
violation occurred until up to three years from the date the state |
|
|
knows or reasonably should have known facts material to the |
|
|
violation, whichever of these two periods is longer, regardless of |
|
|
whether the violation occurred more than six years before the date |
|
|
the action was filed. Notwithstanding this subsection, a person |
|
|
proceeding under this subsection may not recover for a violation |
|
|
that occurred more than 10 years before the date the action was |
|
|
filed. |
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|
(c) On request by the state, the state is entitled to be |
|
|
served with copies of all pleadings filed in an action under this |
|
|
subchapter and be provided at the state's expense with copies of all |
|
|
deposition transcripts. If the person bringing the action proceeds |
|
|
without the state's participation, the court, without limiting the |
|
|
status and right of that person, may permit the state to intervene |
|
|
at a later date on a showing of good cause. |
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|
Sec. 701.207. REPRESENTATION OF STATE BY PRIVATE ATTORNEY. |
|
|
The attorney general may contract with a private attorney to |
|
|
represent the state in an action under this subchapter with which |
|
|
the state elects to proceed. |
|
|
Sec. 701.208. INTERVENTION BY OTHER PARTIES PROHIBITED. A |
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|
person other than the state may not intervene or bring a related |
|
|
action based on the facts underlying a pending action under this |
|
|
subchapter. |
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|
Sec. 701.209. RIGHTS OF PARTIES IF STATE CONTINUES ACTION. |
|
|
(a) If the state proceeds with an action under this subchapter, the |
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|
state has the primary responsibility for prosecuting the action and |
|
|
is not bound by an act of the person bringing the action. The person |
|
|
bringing the action has the right to continue as a party to the |
|
|
action, subject to the limitations set forth by this section. |
|
|
(b) The state may dismiss an action under this subchapter |
|
|
notwithstanding the objections of the person bringing the action |
|
|
if: |
|
|
(1) the attorney general notifies the person that the |
|
|
state has filed a motion to dismiss; and |
|
|
(2) the court provides the person with an opportunity |
|
|
for a hearing on the motion. |
|
|
(c) The state may settle an action under this subchapter |
|
|
with the defendant notwithstanding the objections of the person |
|
|
bringing the action if the court determines, after a hearing, that |
|
|
the proposed settlement is fair, adequate, and reasonable under all |
|
|
the circumstances. On a showing of good cause, the hearing may be |
|
|
held in camera. |
|
|
(d) On a showing by the state that unrestricted |
|
|
participation during the course of the litigation by the person |
|
|
bringing an action under this subchapter would interfere with or |
|
|
unduly delay the state's prosecution of the action, or would be |
|
|
repetitious, irrelevant, or for purposes of harassment, the court |
|
|
may impose limitations on the person's participation, including: |
|
|
(1) limiting the number of witnesses the person may |
|
|
call; |
|
|
(2) limiting the length of the testimony of witnesses |
|
|
called by the person; |
|
|
(3) limiting the person's cross-examination of |
|
|
witnesses; or |
|
|
(4) otherwise limiting the participation by the person |
|
|
in the litigation. |
|
|
(e) On a showing by a defendant in an action under this |
|
|
subchapter that unrestricted participation during the course of the |
|
|
litigation by the person bringing the action would be for purposes |
|
|
of harassment or would cause the defendant undue burden or |
|
|
unnecessary expense, the court may limit the participation by the |
|
|
person in the litigation. |
|
|
Sec. 701.210. STAY OF CERTAIN DISCOVERY. (a) On a showing |
|
|
by the state that certain actions of discovery by the person |
|
|
bringing an action under this subchapter would interfere with the |
|
|
state's investigation or prosecution of a criminal or civil matter |
|
|
arising out of the same facts, the court may stay the discovery for |
|
|
a period not to exceed 60 days. |
|
|
(b) The court shall hear a motion to stay discovery under |
|
|
this section in camera. |
|
|
(c) The court may extend the period prescribed by Subsection |
|
|
(a) on a further showing in camera that the state has pursued the |
|
|
criminal or civil investigation or proceedings with reasonable |
|
|
diligence and that any proposed discovery in the civil action will |
|
|
interfere with the ongoing criminal or civil investigation or |
|
|
proceedings. |
|
|
Sec. 701.211. PURSUIT OF ALTERNATE REMEDY BY STATE. (a) |
|
|
Notwithstanding Section 701.201, the state may elect to pursue the |
|
|
state's claim through any alternate remedy available to the state, |
|
|
including any administrative proceeding to determine an |
|
|
administrative penalty. If an alternate remedy is pursued in |
|
|
another proceeding, the person bringing an action under this |
|
|
subchapter has the same rights in the other proceeding as the person |
|
|
would have had if the action had continued under this subchapter. |
|
|
(b) A finding of fact or conclusion of law made in the other |
|
|
proceeding that has become final is conclusive on all parties to an |
|
|
action under this subchapter. For purposes of this subsection, a |
|
|
finding or conclusion is final if: |
|
|
(1) the finding or conclusion has been finally |
|
|
determined on appeal to the appropriate court; |
|
|
(2) no appeal has been filed with respect to the |
|
|
finding or conclusion and all time for filing an appeal has expired; |
|
|
or |
|
|
(3) the finding or conclusion is not subject to |
|
|
judicial review. |
|
|
Sec. 701.212. AWARD TO PRIVATE CLAIMANT. (a) If the state |
|
|
proceeds with an action under this subchapter, the person bringing |
|
|
the action is entitled, except as provided by Subsection (c), to |
|
|
receive at least 15 percent but not more than 25 percent of the |
|
|
proceeds of the action, depending on the extent to which the person |
|
|
substantially contributed to the prosecution of the action. |
|
|
(b) If the state does not proceed with an action under this |
|
|
subchapter, the person bringing the action is entitled, except as |
|
|
provided by Subsection (c), to receive at least 25 percent but not |
|
|
more than 30 percent of the proceeds of the action. The entitlement |
|
|
of a person under this subsection is not affected by any subsequent |
|
|
intervention in the action by the state in accordance with Section |
|
|
701.206(c). |
|
|
(c) If the court finds that an action under this subchapter |
|
|
is based primarily on disclosures of specific information, other |
|
|
than information provided by the person bringing the action, |
|
|
relating to allegations or transactions in a Texas or federal |
|
|
criminal or civil hearing, in a Texas or federal legislative or |
|
|
administrative report, hearing, audit, or investigation, or from |
|
|
the news media, the court may award the amount the court considers |
|
|
appropriate but not more than 10 percent of the proceeds of the |
|
|
action. The court shall consider the significance of the |
|
|
information and the role of the person bringing the action in |
|
|
advancing the case to litigation. |
|
|
(d) A payment to a person under this section shall be made |
|
|
from the proceeds of the action. A person receiving a payment under |
|
|
this section is also entitled to receive from the defendant an |
|
|
amount for reasonable expenses, reasonable attorney's fees, and |
|
|
costs that the court finds to have been necessarily incurred. The |
|
|
court's determination of expenses, fees, and costs to be awarded |
|
|
under this subsection shall be made only after the defendant has |
|
|
been found liable in the action or the claim is settled. |
|
|
(e) In this section, "proceeds of the action" includes |
|
|
proceeds of a settlement of the action. |
|
|
Sec. 701.213. REDUCTION OF AWARD. (a) If the court finds |
|
|
that an action under this subchapter was brought by a person who |
|
|
planned and initiated the violation on which the action was |
|
|
brought, the court may, to the extent the court considers |
|
|
appropriate, reduce the share of the proceeds of the action the |
|
|
person would otherwise receive under Section 701.212, taking into |
|
|
account the person's role in advancing the case to litigation and |
|
|
any relevant circumstances pertaining to the violation. |
|
|
(b) If the person bringing an action under this subchapter |
|
|
is convicted of criminal conduct arising from the person's role in |
|
|
the violation, the court shall dismiss the person from the civil |
|
|
action and the person may not receive any share of the proceeds of |
|
|
the action. A dismissal under this subsection does not prejudice |
|
|
the right of the state to continue the action. |
|
|
Sec. 701.214. AWARD TO DEPARTMENT. (a) If the state |
|
|
proceeds with an action under this subchapter, the department is |
|
|
entitled to receive at least 15 percent but not more than 25 percent |
|
|
of the proceeds of the action, depending on the extent to which the |
|
|
department substantially contributed to the prosecution of the |
|
|
action. |
|
|
(b) In this section, "proceeds of the action" includes |
|
|
proceeds of a settlement of the action. |
|
|
Sec. 701.215. AWARD TO INJURED INSURER. If the person |
|
|
bringing an action under this subchapter is not an insurer harmed by |
|
|
the violation that is the subject of the action, the insurer is |
|
|
entitled to any money remaining after all awards and costs are |
|
|
distributed as provided by this subchapter, including, in an action |
|
|
where the state proceeds, reasonable expenses, reasonable |
|
|
attorney's fees, and costs to the state that the court finds to have |
|
|
been necessarily incurred. |
|
|
Sec. 701.216. AWARD TO DEFENDANT FOR FRIVOLOUS ACTION. |
|
|
Chapter 105, Civil Practice and Remedies Code, applies to an action |
|
|
under this subchapter with which the state proceeds. |
|
|
Sec. 701.217. CERTAIN ACTIONS BARRED. (a) A person may not |
|
|
bring an action under this subchapter that is based on allegations |
|
|
or transactions that are the subject of a civil action or an |
|
|
administrative penalty proceeding in which the state is already a |
|
|
party. |
|
|
(b) The court shall dismiss an action or claim under this |
|
|
subchapter, unless opposed by the attorney general, if |
|
|
substantially the same allegations or transactions as alleged in |
|
|
the action or claim were publicly disclosed in a Texas or federal |
|
|
criminal or civil hearing in which the state or an agent of the |
|
|
state is a party, in a legislative or administrative report of this |
|
|
state, or other hearing, audit, or investigation in this state, or |
|
|
from the news media, unless the person bringing the action is an |
|
|
original source of the information. In this subsection, "original |
|
|
source" means an individual who: |
|
|
(1) before a public disclosure described by this |
|
|
subsection, has voluntarily disclosed to the state the information |
|
|
on which allegations or transactions in a claim are based; or |
|
|
(2) has knowledge that is independent of and |
|
|
materially adds to the publicly disclosed allegations or |
|
|
transactions and who has voluntarily provided the information to |
|
|
the state before filing an action under this subchapter. |
|
|
Sec. 701.218. STATE NOT LIABLE FOR CERTAIN EXPENSES. The |
|
|
state is not liable for expenses that a person incurs in bringing an |
|
|
action under this subchapter. |
|
|
Sec. 701.219. RETALIATION AGAINST PERSON PROHIBITED. (a) |
|
|
A person, including an employee, contractor, or agent, who is |
|
|
discharged, demoted, suspended, threatened, harassed, or in any |
|
|
other manner discriminated against in the terms or conditions of |
|
|
employment because of a lawful act taken by the person or associated |
|
|
others in furtherance of an action under this subchapter, including |
|
|
investigation for, initiation of, testimony for, or assistance in |
|
|
an action filed or to be filed under this subchapter, or other |
|
|
efforts taken by the person to stop one or more violations is |
|
|
entitled to: |
|
|
(1) reinstatement with the same seniority status the |
|
|
person would have had but for the discrimination; and |
|
|
(2) not less than two times the amount of back pay, |
|
|
interest on the back pay, and compensation for any special damages |
|
|
sustained as a result of the discrimination, including litigation |
|
|
costs and reasonable attorney's fees. |
|
|
(b) A person may bring an action under this section in the |
|
|
appropriate district court not later than the third anniversary of |
|
|
the date on which the cause of action accrues. For purposes of this |
|
|
subsection, the cause of action accrues on the date the retaliation |
|
|
occurs. |
|
|
Sec. 701.220. SOVEREIGN IMMUNITY NOT WAIVED. Except as |
|
|
provided by Section 701.216, this subchapter does not waive |
|
|
sovereign immunity. |
|
|
Sec. 701.221. ATTORNEY GENERAL COMPENSATION. The attorney |
|
|
general may retain a reasonable portion of the amount recovered |
|
|
under this subchapter, not to exceed amounts specified in the |
|
|
General Appropriations Act, for the administration of this |
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subchapter. |
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SECTION 7. Section 35A.01, Penal Code, is amended by adding |
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Subdivisions (2-a), (2-b), and (2-c) and amending Subdivision (9) |
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to read as follows: |
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(2-a) "Health benefit claim" means a written or |
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electronically submitted request or demand that: |
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(A) is submitted by a person who provides or |
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purports to provide a service or product to an individual covered |
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under a health benefit plan or by that person's agent and identifies |
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a service or product provided or purported to have been provided to |
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the covered individual as reimbursable under the health benefit |
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plan, without regard to whether the money that is requested or |
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demanded is paid and without regard to whether the individual was |
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eligible for benefits under the health benefit plan; or |
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(B) states the income earned or expense incurred |
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by a person in providing a service or product to an individual |
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covered by a health benefit plan and is used to determine a rate of |
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payment under the plan. |
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(2-b) "Health benefit plan" means a health insurance |
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policy, a health care plan, as defined by Section 843.002, |
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Insurance Code, or another agreement, contract, or evidence of |
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coverage under which a person undertakes to provide, arrange for, |
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pay for, or reimburse any part of the cost of health care services. |
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(2-c) "Health benefit plan issuer" means a person who |
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is authorized or otherwise permitted by law to issue a health |
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insurance policy, to arrange for or provide a health care plan, as |
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defined by Section 843.002, Insurance Code, or to otherwise provide |
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health benefit plan coverage. |
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(9) "Service" includes care or treatment of a health |
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care recipient or an individual covered under a health benefit |
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plan. |
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SECTION 8. Section 35A.02, Penal Code, is amended by adding |
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Subsection (a-1) and amending Subsections (b) and (d) to read as |
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follows: |
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(a-1) 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 from a health benefit plan issuer a benefit or |
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payment that is not authorized or that is greater than the benefit |
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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 from a health benefit |
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plan issuer a benefit or payment that is not authorized or that is |
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greater than the benefit or payment that is authorized; |
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(3) knowingly makes or causes to be made a health |
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benefit claim to a health benefit plan issuer 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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or mislabeled or that is otherwise inappropriate; or |
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(4) knowingly enters into an agreement, combination, |
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or conspiracy to defraud a health benefit plan issuer by obtaining |
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or aiding another person in obtaining an unauthorized payment or |
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benefit from a health benefit plan issuer. |
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(b) An offense under this section is: |
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(1) a Class C misdemeanor if the amount of any payment |
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or the value of any monetary or in-kind benefit provided or claim |
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for payment made under a health care program, or the amount of a |
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payment made by or the value of a benefit provided by or claim for |
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payment made to a health benefit plan issuer, directly or |
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indirectly, as a result of the conduct is less than $100; |
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(2) a Class B misdemeanor if the amount of any payment |
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or the value of any monetary or in-kind benefit provided or claim |
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for payment made under a health care program, or the amount of a |
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payment made by or the value of a benefit provided by or claim for |
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payment made to a health benefit plan issuer, directly or |
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indirectly, as a result of the conduct is $100 or more but less than |
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$750; |
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(3) a Class A misdemeanor if the amount of any payment |
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or the value of any monetary or in-kind benefit provided or claim |
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for payment made under a health care program, or the amount of a |
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payment made by or the value of a benefit provided by or claim for |
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payment made to a health benefit plan issuer, directly or |
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indirectly, as a result of the conduct is $750 or more but less than |
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$2,500; |
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(4) a state jail felony if: |
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(A) the amount of any payment or the value of any |
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monetary or in-kind benefit provided or claim for payment made |
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under a health care program, or the amount of a payment made by or |
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the value of a benefit provided by or claim for payment made to a |
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health benefit plan issuer, directly or indirectly, as a result of |
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the conduct is $2,500 or more but less than $30,000; |
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(B) the offense is committed under Subsection |
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(a)(11); or |
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(C) it is shown on the trial of the offense that |
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the amount of the payment or value of the benefit described by this |
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subsection cannot be reasonably ascertained; |
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(5) a felony of the third degree if: |
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(A) the amount of any payment or the value of any |
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monetary or in-kind benefit provided or claim for payment made |
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under a health care program, or the amount of a payment made by or |
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the value of a benefit provided by or claim for payment made to a |
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health benefit plan issuer, directly or indirectly, as a result of |
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the conduct is $30,000 or more but less than $150,000; or |
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(B) it is shown on the trial of the offense that |
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the defendant submitted more than 25 but fewer than 50 fraudulent |
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claims under a health care program or to a health benefit plan |
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issuer, as applicable, and the submission of each claim constitutes |
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conduct prohibited by Subsection (a) or (a-1), as applicable; |
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(6) a felony of the second degree if: |
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(A) the amount of any payment or the value of any |
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monetary or in-kind benefit provided or claim for payment made |
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under a health care program, or the amount of a payment made by or |
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the value of a benefit provided by or claim for payment made to a |
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health benefit plan issuer, directly or indirectly, as a result of |
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the conduct is $150,000 or more but less than $300,000; or |
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(B) it is shown on the trial of the offense that |
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the defendant submitted 50 or more fraudulent claims under a health |
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care program or to a health benefit plan issuer, as applicable, and |
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the submission of each claim constitutes conduct prohibited by |
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Subsection (a) or (a-1), as applicable; or |
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(7) a felony of the first degree if the amount of any |
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payment or the value of any monetary or in-kind benefit provided or |
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claim for payment made under a health care program, or the amount of |
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a payment made by or the value of a benefit provided by or claim for |
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payment made to a health benefit plan issuer, directly or |
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indirectly, as a result of the conduct is $300,000 or more. |
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(d) When multiple payments or monetary or in-kind benefits |
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are provided under one or more health care programs or by one or |
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more health benefit plan issuers as a result of one scheme or |
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continuing course of conduct, the conduct may be considered as one |
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offense and the amounts of the payments or monetary or in-kind |
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benefits aggregated in determining the grade of the offense. |
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SECTION 9. Section 3(a)(3), Article 37.07, Code of Criminal |
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Procedure, is amended to read as follows: |
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(3) Regardless of the plea and whether the punishment |
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is assessed by the judge or the jury, during the punishment phase of |
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the trial of an offense under Section 35A.02, Penal Code, subject to |
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the applicable rules of evidence, the state and the defendant may |
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offer evidence not offered during the guilt or innocence phase of |
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the trial concerning the total pecuniary loss to the affected |
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health care program or health benefit plan issuer, as applicable, |
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caused by the defendant's conduct or, if applicable, the scheme or |
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continuing course of conduct of which the defendant's conduct is |
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part. Evidence may be offered in summary form concerning the total |
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pecuniary loss to the affected health care program or health |
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benefit plan issuer, as applicable. Testimony regarding the total |
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pecuniary loss to the affected health care program or health |
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benefit plan issuer, as applicable, is subject to |
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cross-examination. Evidence offered under this subdivision may be |
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considered by the judge or jury in ordering or recommending the |
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amount of any restitution to be made to the affected health care |
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program or health benefit plan issuer, as applicable, or the |
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appropriate punishment for the defendant. |
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SECTION 10. The change in law made by this Act applies only |
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to an offense committed on or after the effective date of this Act. |
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An offense committed before the effective date of this Act is |
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governed by the law in effect at the time the offense was committed, |
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and the former law is continued in effect for that purpose. For |
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purposes of this section, an offense was committed 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 11. This Act takes effect September 1, 2025. |