CRIMINAL HISTORY RECORD INFORMATION; ENROLLMENT OF PROVIDERS

(b) Subject to Subsections (b-1) and (e), the executive commissioner by rule shall establish criteria for the commission or the commission's office of inspector general to suspend a provider's billing privileges under the medical assistance program, revoke a provider's enrollment under the program, or deny a person's application to enroll as a provider under the program based on:

(1) the results of a criminal history check;

(2) any exclusion or debarment of the provider from participation in a state or federally funded health care program;

(3) the provider's failure to bill for medical assistance or refer clients for medical assistance within a 12-month period; or

(4) any of the provider screening or enrollment provisions contained in 42 C.F.R. Part 455, Subpart E.

(b-1) In adopting rules under this section, the executive commissioner shall require revocation of a provider's enrollment or denial of a person's application for enrollment as a provider under the medical assistance program if the person has been excluded or debarred from participation in a state or federally funded health care program as a result of:

(1) a criminal conviction or finding of civil or administrative liability for committing a fraudulent act, theft, embezzlement, or other financial misconduct under a state or federally funded health care program; or

(2) a criminal conviction for committing an act under a state or federally funded health care program that caused bodily injury to:

(A) a person who is 65 years of age or older;

(B) a person with a disability; or

(C) a person under 18 years of age.

(c) As a condition of eligibility to participate as a provider in the medical assistance program, the executive commissioner by rule shall:

(1) require a provider or a person applying to enroll as a provider to disclose:

(A) all persons described by Subsection (a-1)(1);

(B) any managing employees of the provider; and

(C) an agent or subcontractor of the provider if:

(i) the provider or a person described by Subsection (a-1)(1) has a direct or indirect ownership interest of at least five percent in the agent or subcontractor; or

(ii) the provider engages in a business transaction with the agent or subcontractor that meets the criteria specified by 42 C.F.R. Section 455.105; and

(2) require disclosure by persons applying for enrollment as providers and provide for screening of applicants for enrollment in conformity and compliance with the requirements of 42 C.F.R. Part 455, Subparts B and E.

(d) In adopting rules under this section, the executive commissioner shall adopt rules as authorized by and in conformity with 42 C.F.R. Section 455.470 for the imposition of a temporary moratorium on enrollment of new providers, or to impose numerical caps or other limits on the enrollment of providers, that the commission or the commission's office of inspector general determines have a significant potential for fraud, waste, or abuse.

(e) The commission may reinstate a provider's enrollment under the medical assistance program or grant a person's previously denied application to enroll as a provider, including a person described by Subsection (b-1), if the commission finds:

(1) good cause to determine that it is in the best interest of the medical assistance program; and

(2) the person has not committed an act that would require revocation of a provider's enrollment or denial of a person's application to enroll since the person's enrollment was revoked or application was denied, as appropriate.

(f) The commission must support a determination made under Subsection (e) with written findings of good cause for the determination. Added by Acts 1997, 75th Leg., ch. 1153, Sec. 2.04(a), eff. Sept. 1, 1997. Amended by: Acts 2011, 82nd Leg., R.S., Ch. 879 (S.B. 223 ), Sec. 3.15, eff. September 1, 2011. Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720 ), Sec. 28, eff. September 1, 2011. Acts 2013, 83rd Leg., R.S., Ch. 1311 (S.B. 8 ), Sec. 10, eff. September 1, 2013. Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219 ), Sec. 4.108, eff. April 2, 2015. Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 2.83, eff. April 1, 2025.