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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 371MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY
SUBCHAPTER GADMINISTRATIVE ACTIONS AND SANCTIONS
DIVISION 3ADMINISTRATIVE ACTIONS AND SANCTIONS
RULE §371.1705Mandatory Exclusion

    (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.


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

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