Text of subsection effective until April 01, 2025

(a) The commission or the office of inspector general established under Chapter 531, Government Code, may obtain from any law enforcement or criminal justice agency the criminal history record information that relates to a provider under the medical assistance program or a person applying to enroll as a provider under the medical assistance program.

Text of subsection effective on April 01, 2025

Terms Used In Texas Human Resources Code 32.0322

  • Conviction: A judgement of guilt against a criminal defendant.
  • Embezzlement: In most states, embezzlement is defined as theft/larceny of assets (money or property) by a person in a position of trust or responsibility over those assets. Embezzlement typically occurs in the employment and corporate settings. Source: OCC
  • Fraud: Intentional deception resulting in injury to another.
  • Justice: when applied to a magistrate, means justice of the peace. See Texas Government Code 312.011
  • Person: includes corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity. See Texas Government Code 311.005
  • Rule: includes regulation. See Texas Government Code 311.005
  • Written: includes any representation of words, letters, symbols, or figures. See Texas Government Code 311.005

(a) The commission or the office of inspector general established under Subchapter C, Chapter 544, Government Code, may obtain from any law enforcement or criminal justice agency the criminal history record information that relates to a provider under the medical assistance program or a person applying to enroll as a provider under the medical assistance program.
(a-1) The criminal history record information the commission and the office of inspector general are authorized to obtain under Subsection (a) includes criminal history record information relating to:
(1) a person with a direct or indirect ownership or control interest, as defined by 42 C.F.R. § 455.101, in a provider of five percent or more; and
(2) a person whose information is required to be disclosed in accordance with 42 C.F.R. part 1001.
(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. § 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. § 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.

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