CHAPTER 35A. MEDICAID FRAUD
PENAL CODE
TITLE 7. OFFENSES AGAINST PROPERTY
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. September 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 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.
(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 or claim for
payment made 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 or claim for
payment made 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 or claim for
payment made 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:
(A) the amount of any payment or the value of any monetary or
in-kind benefit provided or claim for payment made under the
Medicaid program, directly or indirectly, as a result of the
conduct is $1,500 or more but less than $20,000;
(B) the offense is committed under Subsection (a)(11); or
(C) it is shown on the trial of the offense that the amount of
the payment or value of the benefit described by this subsection
cannot be reasonably ascertained;
(5) a felony of the third degree if the amount of any payment or
the value of any monetary or in-kind benefit provided or claim
for payment made 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 or claim
for payment made 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 or claim
for payment made 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. September 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
127, Sec. 5, eff. September 1, 2007.