The text as introduced · 1,233 words
89R4786 AND-F
By: Kolkhorst
S.B. No. 961
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 adding Subsections (c-1) and (c-2) to
read as follows:
(c-1) On at least a monthly basis, the commission shall:
(1) conduct electronic data matches with the Texas
Lottery Commission to determine whether a Medicaid recipient
received reportable lottery winnings in an amount equal to or
greater than $3,000;
(2) conduct electronic data matches with the Internal
Revenue Service to determine whether a Medicaid recipient received
reportable gambling winnings in an amount equal to or greater than
$3,000; and
(3) if a Medicaid recipient also receives supplemental
nutrition 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-2) 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. PRE-ENROLLMENT VERIFICATION OF CERTAIN
SELF-ATTESTED ELIGIBILITY CRITERIA. Except as provided by Section
32.024715(b)(3)(B) and to the extent 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 provided to or obtained by the commission
before the commission may enroll the person in the medical
assistance program.
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.
Monitoring 
