Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 7,990
7533-7814 p. ; 28 cm.View a full description of this periodical.
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371.1687, and 371.1689, concerning administrative sanctions;
Division 5, 371.1701, 371.1703, 371.1705, 371.1707, and
371.1709, concerning recovery of overpayments; and Division
6, 371.1721, 371.1723, 371.1725, 371.1727, 371.1729,
371.1731, 371.1733, 371.1735, 371.1737, 371.1739, and
371.1741, concerning administrative damages and penalties.
The repeals are adopted without changes to the proposal
published in the August 10, 2012, issue of the Texas Register
(37 TexReg 5869).
HHSC also adopts new Subchapter G, Administrative Ac-
tions and Sanctions, consisting of Division 1, 371.1601,
371.1603, 371.1605, 371.1607, 371.1609, 371.1611, 371.1613,
371.1615, 371.1617, 371.1619, 371.1621, 371.1623, 371.1625,
and 371.1627, concerning general provisions; Division 2,
371.1651, 371.1653, 371.1655, 371.1657, 371.1659,
371.1661, 371.1663, 371.1665, 371.1667, and 371.1669, con-
cerning grounds for enforcement; and Division 3, 371.1701,
371.1703, 371.1705, 371.1707, 371.1709, 371.1711, 371.1713,
371.1715, 371.1717, and 371.1719, concerning administrative
actions and sanctions, in Chapter 371, Medicaid and Other
Health and Human Services Fraud and Abuse Program Integrity.
New 371.1607, 371.1659, 371.1705, 371.1707, 371.1709,
and 371.1715 are adopted with changes to the proposed text as
published in the August 10, 2012, issue of the Texas Register
(37 TexReg 5869) and will be republished with this preamble.
New 371.1601, 371.1603, 371.1605, 371.1609, 371.1611,
371.1613, 371.1615, 371.1617, 371.1619, 371.1621, 371.1623,
371.1625, 371.1627, 371.1651, 371.1653, 371.1655, 371.1657,
371.1661, 371.1663, 371.1665, 371.1667, 371.1669, 371.1701,
371.1703, 371.1711, 371.1713, 371.1717, and 371.1719 are
adopted without changes to the proposed text as published in
the August 10, 2012, issue of the Texas Register (37 TexReg
5869) and will not be republished.
The changes are non-substantive. Section 371.1607(64)(E)
and 371.1659(9)(A)(iii) add the word "or" for clarification and
grammatical completeness. Section 371.1705(a)(6)(B)(vi)
replaces the word "an" with "a." Sections 371.1705(e)(2)(F),
371.1707(a)(6), and 371.1715(e)(1)(B) replace the phrase,
"an elderly person, disabled person, or minor," with a more
definitive one, "a person who is 65 years of age or older, a
person with a disability, or a person under 18 years of age," and
371.1709(c)(3) corrects a grammatical inconsistency.
HHSC intends that a program violation committed before the ef-
fective date of the adopted rules be governed by the prior rules
and provisions of Subchapter G that were in effect when the pro-
gram violation was committed, and that the repealed provisions
of Subchapter G continue in effect for this purpose. HHSC does
not intend for the repeal of the rules in Subchapter G to affect
the prior operation of the rules, any prior actions taken under the
rules, any validation, cure, right, privilege, obligation, or liability
previously acquired, accrued, accorded, or incurred under the
rules, any violation of the rules or any penalty, forfeiture, or pun-
ishment incurred under the rules before their amendment or re-
peal, any investigation, proceeding, or remedy concerning any
privilege, obligation, liability, penalty, forfeiture, or punishment.
HHSC additionally intends that any investigation, proceeding,
or remedy may be instituted, continued, or enforced, and the
penalty, forfeiture, or punishment imposed, as if the rules had
not been repealed or amended.
HHSC intends that should any sentence, paragraph, subdivision,
clause, phrase, or section of the new rules in Subchapter G be
determined, adjudged, or held to be unconstitutional, illegal orinvalid, the same shall not affect the validity of the subchapter
as a whole, or any part or provision hereof other than the part so
declared to be unconstitutional, illegal, or invalid, and shall not
affect the validity of the subchapter as a whole.
Background and Justification
The existing rules in Subchapter G include various provisions to
ensure Medicaid and other health and human services (HHS)
agency program integrity by discovering, preventing, and cor-
recting fraud, waste, and abuse.
The new rules in Subchapter G are adopted in light of recent
state and federal legislation, specifically Senate Bill 223, House
Bill (H.B.) 300, and H.B. 1720, 82nd Legislature, Regular Ses-
sion, 2011; and the federal Patient Protection and Affordable
Care Act. Updated provisions in light of this state and federal
legislation include the following:
- New 371.1651, which reflects the requirement that providers
with certain affiliations that are terminated by another state's
Medicaid program or Children's Health Insurance Program
(CHIP), have been convicted of a criminal offense related to
involvement in Medicaid, Medicare, or a Title XXI program in the
last ten years, or do not pass new provider screening measures
be terminated from the Texas Medicaid Program.
- New 371.1653, which incorporates the requirement that the
national provider number of supervising and supervised practi-
tioners be included in claims for payment for services and the
requirement that durable medical equipment and home health
providers conduct in-person evaluations every 12 months.
- New 371.1655, which requires CHIP providers that fail to re-
pay overpayments or who are affiliated with and who control a
prohibited provider be terminated; requires providers to establish
a compliance program for detecting criminal, civil, and adminis-
trative violations and that promotes quality of care; and requires
providers who that are inactive for a period of 12 months be ter-
minated from enrollment.
- New 371.1657, which adds specific prohibitions against the
misuse and improper transmission of protected health informa-
tion.
- New 371.1663, which incorporates requirements related to
managed care organization's investigation, recovery, and report-
ing of fraud and abuse.
- New 371.1703, which incorporates grounds for mandatory ter-
mination from program participation.
- New 371.1709, which incorporates requirements for manda-
tory payment holds upon receipt of reliable evidence that the cir-
cumstances giving rise to the hold involve provider fraud or willful
misrepresentation.
- New 371.1715, which incorporates the authorization that al-
lows OIG to impose penalties for any program violation commit-
ted knowingly and for failure to maintain documentation to sup-
port a claim for payment in accordance with program require-
ments.
Further, the new rules are adopted to delete unnecessary lan-
guage, revise or eliminate obsolete terminology, and to provide
better and more helpful organization. Unless otherwise indi-
cated, the new rules do not substantially change current HHSC
Office of Inspector General (OIG) policy related to providers' sub-
stantive rights or the procedural due process afforded them.37 TexReg 7990 October 5, 2012 Texas Register
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Texas. Secretary of State. Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012, periodical, October 5, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth288982/m1/175/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.