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 3 - ADMINISTRATIVE ACTIONS AND SANCTIONS › Section 371.1705 - Mandatory Exclusion

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG must
					 exclude from participation in Titles V, XIX, XX, and CHIP programs, as
					 applicable, any person if it determines that the person:
(1) has been excluded from participation in
					 Medicare or any other federal health care programs;
(2) is a provider whose health care license,
					 certification, or other qualifying requirement to perform certain types of
					 service is revoked, suspended, voluntarily surrendered, or otherwise terminated
					 such that the provider is unable to legally perform their profession due to
					 loss of their license, certification, or other qualifying
					 requirement;
(3) has been convicted
					 of a criminal offense related to the delivery of an item or service under
					 Medicare or a state health care program, including the performance of
					 management or administrative services relating to the delivery of items or
					 services under any such program;
(4) has been convicted, under federal or
					 state law, of a felony relating to fraud, theft, embezzlement, breach of
					 fiduciary responsibility, or other financial misconduct:
(A) in connection with the delivery of a
					 health care item or service, including the performance of management or
					 administrative services relating to the delivery of such items or services;
					 or
(B) with respect to any act or
					 omission in a health care program (other than Medicare and a State health care
					 program) operated by, or financed in whole or in part, by any federal, state or
					 local government agency;
(5) has been convicted, under federal or
					 state law, of a felony relating to the unlawful manufacture, distribution,
					 prescription or dispensing of a controlled substance, as defined under federal
					 or state law. This applies to a person that:
(A) is, or has ever been, a health care
					 practitioner, person, or supplier;
(B) holds, or has held, a direct or indirect
					 ownership or control interest (as defined in §1124(a)(3) of the Social
					 Security Act) in an entity that is a health care person or supplier, or is, or
					 has ever been, an officer, director, agent or managing employee (as defined in
					 §1126(b) of the Social Security Act) of such an entity; or
(C) is or has ever been, employed in any
					 capacity in the health care industry;
(6) is an MCO or other entity furnishing
					 services under a waiver approved under §1915(b)(1) of the Social Security
					 Act that has an affiliate relationship with a person, and that person:
(A) has been convicted:
(i) of an offense that is a ground for
					 mandatory exclusion under this section;
(ii) of an offense under federal or state law
					 consisting of a misdemeanor relating to fraud, theft, embezzlement, breach of
					 fiduciary responsibility, or other financial misconduct:
(I) in connection with the delivery of a
					 health care item or service;
(II)
					 with respect to any act or omission in a health care program (other than those
					 specifically described in paragraph (1) of this subsection) operated by or
					 financed in whole or in part by any federal, state, or local government agency;
					 or
(III) relating to fraud, theft,
					 embezzlement, breach of fiduciary responsibility, or other financial misconduct
					 with respect to any act or omission in a program (other than a health care
					 program) operated by or financed in whole or in part by any federal, state, or
					 local government agency;
(iii) of an offense under federal or state
					 law in connection with the interference with or obstruction of any
					 investigation related to:
(I) an offense that
					 is a ground for mandatory exclusion under this section; or
(II) the use of funds received, directly or
					 indirectly, from any federal health care program;
(iv) of an offense under federal or state law
					 for acts that took place after January 1, 2010, in connection with the
					 interference with or obstruction of any audit related to:
(I) an offense that is a ground for mandatory
					 exclusion under this section; or
(II) the use of funds received, directly or
					 indirectly, from any federal health care program;
(v) has had civil money penalties or
					 assessments imposed under §1128A of the Social Security Act (federal false
					 claims); or
(vi) has been excluded
					 from participation in Medicare or any of the state health care programs or
					 CHIP; and
(B) that
					 person:
(i) has an ownership interest in the
					 entity;
(ii) is the owner of a
					 whole or part interest in any mortgage, deed of trust, note or other obligation
					 secured (in whole or in part) by the entity or any of the property assets
					 thereof, in which whole or part interest is equal to or exceeds five percent of
					 the total property and assets of the entity;
(iii) is an officer or director of the
					 entity, if the entity is organized as a corporation;
(iv) is a partner in the entity, if the
					 entity is organized as a partnership;
(v) is an agent of the entity;
(vi) is a managing employee, that is, a an
					 person (including a general manager, business manager, administrator, or
					 director) who exercises operational or managerial control over the entity or
					 part thereof, or directly or indirectly conducts the day-to-day operations of
					 the entity or part thereof; or
(vii) was formerly described in clauses (i) -
					 (vi) of this subparagraph, but is no longer so described because of a transfer
					 of ownership or control interest to an immediate family member or a member of
					 the person's household in anticipation of or following a conviction, assessment
					 of a civil monetary penalty, or imposition of an exclusion;
(7) is an individual
					 and has an ownership or control interest or a substantial contractual
					 relationship in or is an officer or managing employee of a sanctioned entity,
					 and who knew or should have known of an action that constituted the basis for a
					 conviction or mandatory exclusion of the sanctioned entity; or
(8) is convicted, pleads guilty or pleads
					 nolo contendere to an offense arising from a fraudulent act under the Medicaid
					 program, which results in injury to a person age 65 or older, a person with a
					 disability, or a person younger than 18 years of age.