| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
| |
|
|
relating to fraud prevention and verifying eligibility for benefits |
|
|
under Medicaid. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Section 544.0455, Government Code, as effective |
|
|
April 1, 2025, is amended by adding Subsection (g) to read as |
|
|
follows: |
|
|
(g) The commission may not waive or seek authorization to |
|
|
waive a requirement that the commission conduct periodic electronic |
|
|
data matches to verify a Medicaid recipient's income eligibility |
|
|
under this section or other law. |
|
|
SECTION 2. Section 544.0456, Government Code, as effective |
|
|
April 1, 2025, is amended by amending Subsection (c) and adding |
|
|
Subsection (c-1) to read as follows: |
|
|
(c) On a monthly basis, the commission shall: |
|
|
(1) conduct electronic data matches with the Texas |
|
|
Lottery Commission to determine whether a recipient of supplemental |
|
|
nutrition assistance benefits or Medicaid benefits or a recipient's |
|
|
household member received reportable lottery winnings; |
|
|
(2) use the database system developed under Section |
|
|
532.0201 to: |
|
|
(A) match vital statistics unit death records |
|
|
with a list of individuals eligible for financial assistance |
|
|
benefits, [or] supplemental nutrition assistance benefits, or |
|
|
Medicaid benefits; and |
|
|
(B) ensure that any individual receiving |
|
|
benefits [assistance] under a [either] program described by |
|
|
Paragraph (A) who is discovered to be deceased has the individual's |
|
|
eligibility for benefits [assistance] promptly terminated; [and] |
|
|
(3) review the out-of-state electronic benefit |
|
|
transfer card transactions a recipient of supplemental nutrition |
|
|
assistance benefits made to determine whether those transactions |
|
|
indicate a possible change in the recipient's residence; and |
|
|
(4) if a Medicaid recipient also receives supplemental |
|
|
nutrition assistance benefits, review electronic benefit transfer |
|
|
card transactions made exclusively out of state by the recipient to |
|
|
determine whether the transactions indicate a possible change in |
|
|
the recipient's residence for purposes of Medicaid eligibility. |
|
|
(c-1) On at least a quarterly basis, the commission shall |
|
|
determine whether a Medicaid recipient's voter registration has |
|
|
been canceled under Subchapter B, Chapter 16, Election Code, or for |
|
|
any other reason during the preceding 36-month period, to determine |
|
|
whether the cancellation indicates a possible change in the |
|
|
recipient's eligibility for Medicaid benefits. |
|
|
SECTION 3. Subchapter B, Chapter 32, Human Resources Code, |
|
|
is amended by adding Section 32.0267 to read as follows: |
|
|
Sec. 32.0267. VERIFICATION OF CERTAIN SELF-ATTESTED |
|
|
ELIGIBILITY CRITERIA. Except as provided by Section |
|
|
32.024715(b)(3)(B) and unless self-attestation is permitted by |
|
|
federal law, when determining and certifying a person's eligibility |
|
|
for medical assistance, the commission may not accept |
|
|
self-attestation of the person's income, residency, citizenship, |
|
|
age, household composition, caretaker relative status, or access to |
|
|
other health coverage without additional verification. The |
|
|
additional verification must be obtained by or provided to the |
|
|
commission before the commission may enroll or reenroll the person |
|
|
in the medical assistance program. The commission must attempt to |
|
|
obtain the additional verification through electronic data |
|
|
matching before requesting documentation from the person. |
|
|
SECTION 4. 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 a health care 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 a health care 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 a health care 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 a health care program, including |
|
|
certification or recertification as: |
|
|
(i) a hospital; |
|
|
(ii) a nursing facility or skilled nursing |
|
|
facility; |
|
|
(iii) a hospice; |
|
|
(iv) an ICF-IID; |
|
|
(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 a health care program; |
|
|
(5) except as authorized under a health care program, |
|
|
knowingly pays, charges, solicits, accepts, or receives, in |
|
|
addition to an amount paid under the 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 program; |
|
|
(6) knowingly presents or causes to be presented a |
|
|
claim for payment under a health care 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 |
|
|
a health care 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 a health care program and |
|
|
knowingly fails to indicate: |
|
|
(A) the type of license held by the licensed |
|
|
health care provider who actually provided the service; or |
|
|
(B) [and] the identification number of the |
|
|
licensed health care provider who actually provided the service; |
|
|
(9) conspires to commit a violation of Subdivision |
|
|
(1), (2), (3), (4), (5), (6), (7), (8), (10), (11), (12), or (13); |
|
|
(10) is a managed care organization that contracts |
|
|
with the commission or other state agency to provide or arrange to |
|
|
provide health care benefits or services to individuals eligible |
|
|
under a health care 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 |
|
|
program in the organization's managed care plan or in connection |
|
|
with marketing the organization's services to an individual |
|
|
eligible under the 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 material to an obligation to pay |
|
|
or transmit money or property to this state under a health care |
|
|
program, or knowingly conceals or knowingly and improperly avoids |
|
|
or decreases an obligation to pay or transmit money or property to |
|
|
this state under a health care program; or |
|
|
(13) knowingly engages in conduct that constitutes a |
|
|
violation under Section 32.039(b). |
|
|
SECTION 5. Section 36.002, Human Resources Code, as amended |
|
|
by this Act, applies only to an unlawful act committed on or after |
|
|
the effective date of this Act. |
|
|
SECTION 6. If before implementing any provision of this Act |
|
|
a state agency determines that a waiver or authorization from a |
|
|
federal agency is necessary for the implementation of that |
|
|
provision, the agency affected by the provision shall request the |
|
|
waiver or authorization and may delay implementing that provision |
|
|
until the waiver or authorization is granted. |
|
|
SECTION 7. This Act takes effect September 1, 2025. |
|
|
|
|
|
* * * * * |