Relating to fraud prevention and verifying eligibility for benefits under Medicaid.

89(R) SB 961 - House Committee Report version - Bill Text

By: Kolkhorst, et al.

S.B. No. 961

(Noble)

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 amending Subsection (c) and adding

Subsection (c-1) to read as follows:

(c) On a monthly basis, the commission shall:

(1) conduct electronic data matches with the Texas

Lottery Commission to determine whether a recipient of supplemental

nutrition assistance benefits
or Medicaid benefits
or a recipient's

household member received reportable lottery winnings;

(2) use the database system developed under Section

532.0201 to:

(A) match vital statistics unit death records

with a list of individuals eligible for financial assistance

benefits,
[
or
] supplemental nutrition assistance benefits
, or

Medicaid benefits
; and

(B) ensure that any individual receiving

benefits
[
assistance
] under
a
[
either
] program
described by

Paragraph (A)
who is discovered to be deceased has the individual's

eligibility for
benefits
[
assistance
] promptly terminated; [
and
]

(3) review the out-of-state electronic benefit

transfer card transactions a recipient of supplemental nutrition

assistance benefits made to determine whether those transactions

indicate a possible change in the recipient's residence
; and

(4)

if a Medicaid recipient also receives supplemental

nutrition assistance 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-1)

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.

VERIFICATION OF CERTAIN SELF-ATTESTED

ELIGIBILITY CRITERIA.

Except as provided by Section

32.024715(b)(3)(B) and unless self-attestation is 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 obtained by or provided to the

commission before the commission may enroll or reenroll the person

in the medical assistance program.

The commission must attempt to

obtain the additional verification through electronic data

matching before requesting documentation from the person.

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.