Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 2 - GROUNDS FOR ENFORCEMENT › Section 371.1663 - Managed Care

Current through Reg. 49, No. 28; July 12, 2024
A person is subject to administrative action or sanctions
						if the person:
(1) is an MCO or an MCO
					 provider and fails to provide a health care benefit, service, or item that the
					 MCO or MCO provider is required to provide according to the terms of its
					 contract with an operating agency, its fiscal agent, or other contractor to
					 provide health care services to Medicaid or HHS program recipients;
(2) is an MCO or MCO provider and fails to
					 provide to an individual a health care benefit, service, or item that the MCO
					 or MCO provider is required to provide by state or federal law, regulation, or
					 program rule;
(3) is an MCO and
					 engages in actions that indicate a pattern of wrongful denial, excessive delay,
					 barriers to treatment, authorization requirements that exceed professionally
					 recognized standards of health care, or other wrongful avoidance of payment for
					 a health care benefit, service or item that the organization is required to
					 provide under its contract with an operating agency;
(4) is an MCO and engages in actions that
					 cause a delay in making payment for a health care benefit, service or item that
					 the organization is required to provide under its contract with an operating
					 agency, and the delay results in processing or paying the claim on a date later
					 than that allowed by the MCO's contract;
(5) is an MCO or MCO provider and engages in
					 fraudulent activity or misrepresents or omits material facts in connection with
					 the enrollment in the MCO's managed care plan of an individual eligible for
					 medical assistance or in connection with marketing the organization's services
					 to an individual eligible for medical assistance;
(6) is an MCO or MCO provider and receives a
					 capitation payment, premium, or other remuneration after enrolling a member in
					 the MCO's managed care plan whom the MCO knows or should have known is not
					 eligible for medical assistance;
(7) is an MCO or MCO provider and
					 discriminates against MCO-enrollees or prospective MCO-enrollees in any manner,
					 including marketing and disenrollment, and on any basis, including, without
					 limitation, age, gender, ethnic origin, or health status;
(8) is an MCO or MCO provider and fails to
					 comply with any term of a contract with a Medicaid or other HHS program or
					 operating agency or other contract to provide health care services to Medicaid
					 or HHS program recipients and the failure leads to patient harm, creates a risk
					 of fiscal harm to the state, or results in fiscal harm to the state;
(9) is an MCO or an MCO provider and fails to
					 provide, in the form requested, to the relevant operating agency or its
					 authorized agent upon written request, accurate encounter data, accurate claims
					 data, or other information contractually or otherwise required to document the
					 services and items delivered by or through the MCO to recipients;
(10) is an MCO or an MCO provider and files a
					 cost report or other report with the Medicaid or other HHS program that
					 violates any of the cost report violations in §371.1665 of this division
					 (relating to Cost Report Violations);
(11) is an MCO or MCO provider and
					 misrepresents, falsifies, makes a material omission, or otherwise
					 mischaracterizes any facts on a request for proposal, contract, report, or
					 other document with respect to the MCO's ownership, provider network,
					 credentials of the provider network, affiliated persons, solvency, special
					 investigative unit, plan for detecting and preventing fraud, waste, or abuse,
					 or any other material fact;
(12) is
					 an MCO or MCO provider and fails to maintain the criteria and conditions
					 supporting an application and grant of a waiver to HHSC, or fails to
					 demonstrate the results that were contemplated, based upon representations by
					 the MCO or provider in its proposal submissions or contract negotiations when
					 the waiver was granted, if the failure is related to representations made by
					 the MCO in its proposal, readiness review, contract, marketing materials, audit
					 management responses, or other written representation submitted to the state,
					 and the failure leads to patient harm, creates a risk of fiscal harm to the
					 state, or results in fiscal harm to the state;
(13) is an MCO or MCO provider and
					 misrepresents, falsifies, makes a material omission, or otherwise
					 mischaracterizes any facts on a patient assessment or any other document that
					 would have the effect of increasing the MCO's capitation or reimbursement rate,
					 would increase incentive payments or premiums, would decrease the amount of
					 capitation at risk, or would decrease the experience rebate owed to the
					 Medicaid program;
(14) is an MCO or
					 MCO provider and fails to simultaneously notify the OIG and the OAG in writing
					 of the discovery of fraud, waste, or abuse in the Medicaid or CHIP
					 program;
(15) is an MCO and fails
					 to ensure that any payment recovery efforts in which the MCO engages are in
					 accordance with applicable law, contract requirements, or other applicable
					 procedures established by the Executive Commissioner or the OIG;
(16) is an MCO and engages in payment
					 recovery of an amount sought that exceeds $100,000 and that is related to
					 fraud, waste, or abuse in the Medicaid or CHIP program:
(A) without first notifying the OIG and the
					 OAG in writing of the discovery of fraud, waste, or abuse in the Medicaid or
					 CHIP program;
(B) within ten
					 business days after notifying the OIG or the OAG of the discovery or fraud,
					 waste, or abuse in the Medicaid or CHIP program; or
(C) after receipt of a notice from the OIG or
					 the OAG indicating that the MCO is not authorized to proceed with recovery
					 efforts;