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.