Tex. Gov't Code Section 544.0153
Provider Eligibility for Medicaid Participation: Criminal History Record Information


(a)

The office of inspector general and each licensing authority that requires the submission of fingerprints to conduct a criminal history record information check of a health care professional shall enter into a memorandum of understanding to ensure that only individuals who are licensed and in good standing as health care professionals participate as Medicaid providers. The memorandum under this section may be combined with a memorandum authorized under Section 544.0152 (Exchange of Criminal History Record Information Between Participating Agencies)(c) and must include a process by which:

(1)

to determine a health care professional’s eligibility to participate in Medicaid, the office may confirm with a licensing authority that the professional is licensed and in good standing; and

(2)

the licensing authority immediately notifies the office if:

(A)

a provider’s license has been revoked or suspended; or

(B)

the licensing authority has taken disciplinary action against a provider.

(b)

To determine a health care professional’s eligibility to participate as a Medicaid provider, the office of inspector general may not conduct a criminal history record information check of a health care professional who the office has confirmed under Subsection (a) is licensed and in good standing. This subsection does not prohibit the office from conducting a criminal history record information check of a provider that is required or appropriate for other reasons, including for conducting an investigation of fraud, waste, or abuse.

(c)

To determine a provider’s eligibility to participate in Medicaid and subject to Subsection (d), the office of inspector general, after seeking public input, shall establish and the executive commissioner by rule shall adopt guidelines for evaluating criminal history record information of providers and potential providers. The guidelines must outline conduct, by provider type, that may be contained in criminal history record information that will result in excluding a person as a Medicaid provider, taking into consideration:

(1)

the extent to which the underlying conduct relates to the services provided through Medicaid;

(2)

the degree to which the person would interact with Medicaid recipients as a provider; and

(3)

any previous evidence that the person engaged in Medicaid fraud, waste, or abuse.

(d)

The guidelines adopted under Subsection (c) may not impose stricter standards for an individual’s eligibility to participate in Medicaid than a licensing authority described by Subsection (a) requires for the individual to engage in a health care profession without restriction in this state.

(e)

The office of inspector general and the commission shall use the guidelines the executive commissioner adopts under Subsection (c) to determine whether a Medicaid provider continues to be eligible to participate as a Medicaid provider.

(f)

The provider enrollment contractor, if applicable, and a Medicaid managed care organization shall defer to the office of inspector general on whether an individual’s criminal history record information precludes the individual from participating as a Medicaid provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.

Source: Section 544.0153 — Provider Eligibility for Medicaid Participation: Criminal History Record Information, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­544.­htm#544.­0153 (accessed Jun. 5, 2024).

544.0001
Definitions
544.0002
Reference to Office of Investigations and Enforcement
544.0003
Authority of State Agency or Governmental Entity Not Limited
544.0051
Coordination with Office of Attorney General
544.0052
Rules Regarding Enforcement and Punitive Actions
544.0053
Provision of Information to Pharmacy Subject to Audit
544.0054
Records of Allegations of Fraud or Abuse
544.0055
Record and Confidentiality of Informal Resolution Meetings
544.0056
Expunction of Child’s Chemical Dependency Diagnosis in Certain Records
544.0101
Appointment of Inspector General
544.0102
Commission Powers and Duties Related to Office of Inspector General
544.0103
Office of Inspector General: General Powers and Duties
544.0104
Employment of Medical Director
544.0105
Employment of Dental Director
544.0106
Contract for Review of Investigative Findings by Qualified Expert
544.0107
Employment of Peace Officers
544.0108
Investigative Process Review
544.0109
Performance Audits and Coordination of Audit Activities
544.0110
Reports on Audits, Inspections, and Investigations
544.0111
Compliance with Federal Coding Guidelines
544.0112
Hospital Utilization Reviews and Audits: Provider Education Process
544.0113
Program Exclusions
544.0114
Report
544.0151
Definitions
544.0152
Exchange of Criminal History Record Information Between Participating Agencies
544.0153
Provider Eligibility for Medicaid Participation: Criminal History Record Information
544.0154
Monitoring of Certain Federal Databases
544.0155
Period for Determining Provider Eligibility for Medicaid
544.0201
Selection and Review of Medicaid Claims to Determine Resource Allocation
544.0202
Duties Related to Fraud Prevention
544.0203
Fraud, Waste, and Abuse Detection Training
544.0204
Health and Human Services Agency Medicaid Fraud, Waste, and Abuse Detection Goal
544.0205
Award for Reporting Medicaid Fraud, Abuse, or Overcharges
544.0251
Claims Criteria Requiring Commencement of Investigation
544.0252
Circumstances Requiring Commencement of Preliminary Investigation of Alleged Fraud or Abuse
544.0253
Conduct of Preliminary Investigation of Alleged Fraud or Abuse
544.0254
Finding of Certain Medicaid Fraud or Abuse Following Preliminary Investigation: Criminal Referral or Full Investigation
544.0255
Immediate Criminal Referral Under Certain Circumstances
544.0256
Continuation of Payment Hold Following Referral to Law Enforcement Agency
544.0257
Completion of Full Investigation of Alleged Medicaid Fraud or Abuse
544.0258
Memorandum of Understanding for Assisting Attorney General Investigations Related to Medicaid
544.0259
Subpoenas
544.0301
Imposition of Payment Hold
544.0302
Notice
544.0303
Expedited Administrative Hearing
544.0304
Informal Resolution
544.0305
Website Posting
544.0351
Applicability of Subchapter
544.0352
Special Investigative Unit or Contracted Entity to Investigate Fraud and Abuse
544.0353
Fraud and Abuse Prevention Plan
544.0354
Assistance and Oversight by Office of Inspector General
544.0355
Rules
544.0401
Definition
544.0402
False or Misleading Information Related to Financial Assistance Eligibility
544.0403
Commission Action Following Determination of Violation
544.0404
Ineligibility for Financial Assistance Following Violation
544.0405
Household Eligibility for Financial Assistance Not Affected
544.0406
Rules
544.0451
Learning, Neural Network, or Other Technology Relating to Medicaid
544.0452
Medicaid Fraud Investigation Tracking System
544.0453
Medicaid Fraud Detection Technology
544.0454
Data Matching Against Federal Felon List
544.0455
Electronic Data Matching
544.0456
Methods to Reduce Fraud, Waste, and Abuse in Certain Public Assistance Programs
544.0501
Recovery Monitoring System
544.0502
Payment Recovery Efforts by Certain Persons
544.0503
Process for Managed Care Organizations to Recoup Overpayments Related to Electronic Visit Verification Transactions
544.0504
Recovery Audit Contractors
544.0505
Annual Report on Certain Fraud and Abuse Recoveries
544.0506
Notice and Informal Resolution of Proposed Recoupment of Overpayment or Debt
544.0507
Appeal of Determination to Recoup Overpayment or Debt

Accessed:
Jun. 5, 2024

§ 544.0153’s source at texas​.gov