| (C) the date of the criminal judgment of conviction
or date of order the person received for deferred adjudication or
pre-trial diversion as described in subsection (a)(3) - (5) and (8)
of this section;
(D) the date of the criminal judgment of conviction,
or effective date of the assessment of civil monetary penalties or
exclusion as described in subsection (a)(6) of this section;
(E) the effective date of final determination of liability
pursuant to Texas Human Resources Code §32.039(c) as described
in subsection (a)(8) of this section;
(F) the date of the final notice of exclusion if the
exclusion is based on a health or safety risk as described in subsection
(b)(1) of this section;
(G) the date of the original request for records if
the exclusion is based on failure to provide access as described in
subsection (b)(2) of this section; or
(H) if the exclusion is upheld at an administrative
hearing, the effective date is made retroactive to the applicable
effective date described in this section.
(2) An exclusion remains in effect for the period indicated
in the final notice of exclusion. The person is not eligible to apply
for reinstatement or reenrollment as a provider until the exclusion
period has elapsed. The minimum length of exclusion is determined
as follows:
(A) The minimum length of exclusion is the federally
mandated exclusion period plus one additional year if the exclusion
is based upon a conviction as described in subsection (a)(3), (4),
or (5) of this section.
(B) An MCO is excluded for the same period as the related
person was excluded, as described in subsection (a)(6) of this section.
(C) An individual is excluded for the same period as
the sanctioned entity in which the individual held an ownership, control
interest, or substantial contractual relationship as described in
subsection (a)(7) of this section.
(D) The exclusion is effective for ten years if the
exclusion is based upon an assessment of civil monetary penalties
pursuant to Texas Human Resources Code §32.039(c) arising out
of injury to a person who is 65 years of age or older, a person with
a disability, or a person under 18 years of age as described in subsection
(a)(8) of this section.
(E) The exclusion is effective for three years if the
exclusion is based upon an assessment of civil monetary penalties
pursuant to Texas Human Resources Code §32.039(c).
(F) The exclusion is permanent if the exclusion is
based upon a criminal conviction for committing a fraudulent act under
the Medicaid program that results in injury to a person who is 65
years of age or older, a person with a disability, or a person under
18 years of age as described in subsection (a)(8) of this section.
(G) Unless otherwise provided, the length of exclusion
is determined by the OIG in its discretion. The OIG considers the
factors enumerated in §371.1305(c) of this chapter (relating
to Preliminary Investigation and Report) in determining the length
of exclusion.
(3) Unless a person is reinstated and re-enrolled as
a provider in the Texas Medicaid program, no payment is made by the
Medicaid program for any item or service furnished or requested by
an excluded person on or after the effective date of exclusion.
(4) An excluded person is prohibited from:
(A) personally or through a clinic, group, corporation,
or other association or entity, billing or otherwise requesting or
receiving payment for any Title V, XVIII, XIX, XX, or CHIP program
for items or services provided on or after the effective date of the
exclusion;
(B) providing any service under the Medicaid program,
whether or not the excluded person directly requests Medicaid program
payment for such services;
(C) assessing care or ordering or prescribing services,
directly or indirectly, to Title V, XIX, XX, or CHIP recipients after
the effective date of the person's exclusion; and
(D) accepting employment by any person whose revenue
stream includes funds from a Title V, XVIII, XIX, XX, or CHIP program.
(5) If, after the effective date of an exclusion, an
excluded person submits or causes to be submitted claims for services
or items furnished within the period of exclusion, the person may
be subject to civil monetary penalty liability under §1128A(a)(1)(D),
and criminal liability under §1128B(a)(3) of the Social Security
Act in addition to sanctions or penalties by the OIG.
(6) In accordance with federal and state requirements,
when the OIG excludes a person, the OIG may notify each state agency
administering or supervising the applicable state health care program,
as well as the appropriate state or local authority or agency responsible
for licensing or certifying the person excluded. If issued, notification
includes:
(A) the facts, circumstances, and period of exclusion;
(B) a request that appropriate investigations be made
and any necessary sanctions or disciplinary actions be imposed in
accordance with applicable law and policy; and
(C) a request that the state or local authority or
agency fully and timely inform the OIG with respect to any actions
taken in response to the OIG's request.
(7) The OIG notifies the public of all persons excluded.
(8) A person who has been excluded from the Texas Medicaid
or CHIP program is excluded from the Medicaid and/or CHIP program
in every other state and from the Medicare program pursuant to each
program's applicable state or federal authority. When exclusion from
the Texas Medicaid and/or CHIP program is based on the person's exclusion
from Medicare, or from another state's Medicaid or CHIP program, the
prohibitions enumerated in paragraph (4) of this subsection may apply.
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| Source Note: The provisions of this §371.1705 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941 |
