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PENAL CODE
CHAPTER 35A. MEDICAID FRAUD
Sec. 35A.01. DEFINITIONS. In this chapter:
(1) "Claim" has the meaning assigned by Section 36.001, Human Resources
Code.
(2) "Fiscal agent" has the meaning assigned by Section 36.001, Human
Resources Code.
(3) "Health care practitioner" has the meaning assigned by Section 36.001,
Human Resources Code.
(4) "Managed care organization" has the meaning assigned by Section
36.001, Human Resources Code.
(5) "Medicaid program" has the meaning assigned by Section 36.001, Human
Resources Code.
(6) "Medicaid recipient" has the meaning assigned by Section 36.001, Human
Resources Code.
(7) "Physician" has the meaning assigned by Section 36.001, Human
Resources Code.
(8) "Provider" has the meaning assigned by Section 36.001, Human
Resources Code.
(9) "Service" has the meaning assigned by Section 36.001, Human Resources
Code.
Added by Acts 2005, 79th Leg., ch. 806, Sec. 16, eff. Sept. 1, 2005.
Sec. 35A.02. MEDICAID FRAUD. (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 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 Section 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.
(b) An offense under this section is:
(1) a Class C misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is less than $50;
(2) a Class B misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $50 or more but less than $500;
(3) a Class A misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $500 or more but less than $1,500;
(4) a state jail felony if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $1,500 or more but less than $20,000;
(5) a felony of the third degree if the amount of any payment or the value of
any monetary or in-kind benefit provided under the Medicaid program, directly
or indirectly, as a result of the conduct is $20,000 or more but less than
$100,000;
(6) a felony of the second degree if the amount of any payment or the value
of any monetary or in-kind benefit provided under the Medicaid program,
directly or indirectly, as a result of the conduct is $100,000 or more but less
than $200,000; or
(7) a felony of the first degree if the amount of any payment or the value of
any monetary or in-kind benefit provided under the Medicaid program, directly
or indirectly, as a result of the conduct is $200,000 or more.
(c) If conduct constituting an offense under this section also constitutes an
offense under another section of this code or another provision of law, the
actor may be prosecuted under either this section or the other section or
provision.
(d) When multiple payments or monetary or in-kind benefits are provided
under the Medicaid program as a result of one scheme or continuing course of
conduct, the conduct may be considered as one offense and the amounts of
the payments or monetary or in-kind benefits aggregated in determining the
grade of the offense.
Added by Acts 2005, 79th Leg., ch. 806, Sec. 16, eff. Sept. 1, 2005.
CHAPTER 35A. MEDICAID FRAUD
Sec. 35A.01. DEFINITIONS. In this chapter:
(1) "Claim" has the meaning assigned by Section 36.001, Human Resources
Code.
(2) "Fiscal agent" has the meaning assigned by Section 36.001, Human
Resources Code.
(3) "Health care practitioner" has the meaning assigned by Section 36.001,
Human Resources Code.
(4) "Managed care organization" has the meaning assigned by Section
36.001, Human Resources Code.
(5) "Medicaid program" has the meaning assigned by Section 36.001, Human
Resources Code.
(6) "Medicaid recipient" has the meaning assigned by Section 36.001, Human
Resources Code.
(7) "Physician" has the meaning assigned by Section 36.001, Human
Resources Code.
(8) "Provider" has the meaning assigned by Section 36.001, Human
Resources Code.
(9) "Service" has the meaning assigned by Section 36.001, Human Resources
Code.
Added by Acts 2005, 79th Leg., ch. 806, Sec. 16, eff. Sept. 1, 2005.
Sec. 35A.02. MEDICAID FRAUD. (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 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 Section 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.
(b) An offense under this section is:
(1) a Class C misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is less than $50;
(2) a Class B misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $50 or more but less than $500;
(3) a Class A misdemeanor if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $500 or more but less than $1,500;
(4) a state jail felony if the amount of any payment or the value of any
monetary or in-kind benefit provided under the Medicaid program, directly or
indirectly, as a result of the conduct is $1,500 or more but less than $20,000;
(5) a felony of the third degree if the amount of any payment or the value of
any monetary or in-kind benefit provided under the Medicaid program, directly
or indirectly, as a result of the conduct is $20,000 or more but less than
$100,000;
(6) a felony of the second degree if the amount of any payment or the value
of any monetary or in-kind benefit provided under the Medicaid program,
directly or indirectly, as a result of the conduct is $100,000 or more but less
than $200,000; or
(7) a felony of the first degree if the amount of any payment or the value of
any monetary or in-kind benefit provided under the Medicaid program, directly
or indirectly, as a result of the conduct is $200,000 or more.
(c) If conduct constituting an offense under this section also constitutes an
offense under another section of this code or another provision of law, the
actor may be prosecuted under either this section or the other section or
provision.
(d) When multiple payments or monetary or in-kind benefits are provided
under the Medicaid program as a result of one scheme or continuing course of
conduct, the conduct may be considered as one offense and the amounts of
the payments or monetary or in-kind benefits aggregated in determining the
grade of the offense.
Added by Acts 2005, 79th Leg., ch. 806, Sec. 16, eff. Sept. 1, 2005.