2005 Texas Penal Code CHAPTER 35A. MEDICAID FRAUD

PENAL CODE

CHAPTER 35A. MEDICAID FRAUD


	§ 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, § 16, eff. Sept. 1, 2005.          


	§ 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, § 16, eff. Sept. 1, 2005.