CHAPTER 35A. MEDICAID FRAUD

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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

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

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

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.

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.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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