Title HR, Human Resources Code

Sec. 32.0312. REIMBURSEMENT FOR SERVICES ASSOCIATED WITH PREVENTABLE ADVERSE EVENTS. The executive commissioner shall adopt rules regarding the denial or reduction of reimbursement under the medical assistance program for preventable adverse events that occur in a hospital settin…

Sec. 32.03126. REIMBURSEMENT FOR CHILDHOOD CRANIAL REMOLDING ORTHOSIS. (a) In this section, "cranial remolding orthosis" means a custom-fitted or custom-fabricated medical device that is applied to the head to correct a deformity, improve function, or relieve symptoms of a struct…

Sec. 32.0313. INDUCED DELIVERIES OR CESAREAN SECTIONS BEFORE 39TH WEEK. (a) The commission shall achieve cost savings with improved outcomes by adopting and implementing quality initiatives that are evidence-based, tested, and fully consistent with established standards of clinic…

Sec. 32.0314. REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT AND SUPPLIES. The executive commissioner shall adopt rules requiring the electronic submission of any claim for reimbursement for durable medical equipment and supplies under the medical assistance program. Added by Acts 2…

Sec. 32.03141. AUTHORITY OF ADVANCED PRACTICE REGISTERED NURSES AND PHYSICIAN ASSISTANTS REGARDING DURABLE MEDICAL EQUIPMENT AND SUPPLIES. To the extent allowed by federal law, an advanced practice registered nurse or physician assistant acting under adequate physician supervisio…

Sec. 32.0315. FUNDS FOR GRADUATE MEDICAL EDUCATION. (a) Subject to appropriated state funds, the executive commissioner shall establish procedures and formulas for the allocation of federal medical assistance funds that are directed to be used to support graduate medical educatio…

Sec. 32.0316. ELECTRONIC TRANSACTIONS; MEDICAID. The executive commissioner shall adopt and the commission shall implement policies that encourage the use of electronic transactions in Medicaid. The policies shall require payment to Medicaid providers by electronic funds transfer…

Sec. 32.0317. REIMBURSEMENT FOR SERVICES PROVIDED UNDER SCHOOL HEALTH AND RELATED SERVICES PROGRAM. The executive commissioner shall adopt rules requiring parental consent for services provided under the school health and related services program in order for a school district to…

Sec. 32.032. PREVENTION AND DETECTION OF FRAUD AND ABUSE. The executive commissioner shall adopt reasonable rules for minimizing the opportunity for fraud and abuse, for establishing and maintaining methods for detecting and identifying situations in which a question of fraud or …

Sec. 32.0321. SURETY BOND. (a) The executive commissioner by rule may require each provider of medical assistance in a provider type that has demonstrated significant potential for fraud or abuse to file with the commission a surety bond in a reasonable amount. The executive comm…

Sec. 32.0322. CRIMINAL HISTORY RECORD INFORMATION; ENROLLMENT OF PROVIDERS. (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 reco…

Sec. 32.033. SUBROGATION. (a) The filing of an application for or receipt of medical assistance constitutes an assignment of the applicant's or recipient's right of recovery from: (1) personal insurance; (2) other sources; or (3) another person for personal injury caused by the o…

Sec. 32.034. CONTRACT CANCELLATION; NOTICE AND HEARING. (a) The commission has authority to adjudicate claims of contested cases in accordance with Chapter 2001, Government Code. When the commission intends to cancel its contract or impose monetary penalties under a contract with…

Sec. 32.035. APPEALS. The provisions of Section 31.034 governing the right of appeal of an applicant for or recipient of financial assistance authorized under Chapter 31 also apply to applicants for medical assistance authorized in this chapter. Acts 1979, 66th Leg., p. 2353, ch.…

Sec. 32.036. PROGRAM PAYMENTS NONASSIGNABLE AND EXEMPT FROM LEGAL PROCESS. (a) Neither medical assistance nor payments to providers of medical assistance under this chapter are transferable or assignable at law or in equity. (b) No money paid or payable under the provisions of th…

Sec. 32.038. COLLECTION OF INSURANCE PAYMENTS. (a) The commission may receive directly from an insurance company any payments to which the commission is entitled under Section 1204.153, Insurance Code. (b) The executive commissioner shall adopt rules to implement this section, in…

Sec. 32.0381. ICF-IID PAYMENT RATES. (a) The executive commissioner shall set the payment rates for ICF-IID facilities at least annually. (b) The executive commissioner shall adopt by rule the methodology used by the executive commissioner in setting payment rates for ICF-IID fac…

Sec. 32.039. ADMINISTRATIVE REMEDIES. (a) In this section: (1) "Claim" means an application, request, or demand for a benefit or payment under Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.). (1-a) "Inducement" includes a service, cash in any amount, enterta…

Sec. 32.0391. CRIMINAL OFFENSE. (a) A person commits an offense if the person intentionally or knowingly commits a violation under Section 32.039(b)(3), (4), (5), (6), or (7). (b) An offense under this section is a state jail felony. (c) If conduct constituting an offense under t…

Sec. 32.040. IDENTIFICATION OF HUSBAND OR ALLEGED FATHER. (a) A woman receiving medical assistance in the form of prenatal care, child delivery care, and obstetrical care related to prenatal care and child delivery care shall identify her husband, or, if unmarried, shall provide …

Sec. 32.0421. ADMINISTRATIVE PENALTY FOR FAILURE TO PROVIDE INFORMATION. (a) The commission may impose an administrative penalty on a person who does not comply with a request for information made under Section 32.0424(a). (b) The amount of the penalty may not exceed $10,000 for …

Sec. 32.0422. HEALTH INSURANCE PREMIUM PAYMENT REIMBURSEMENT PROGRAM FOR MEDICAL ASSISTANCE RECIPIENTS. (a) In this section, "group health benefit plan" means a plan described by Section 1207.001, Insurance Code. (b) The commission shall identify individuals, otherwise entitled t…

Sec. 32.0423. RECOVERY OF REIMBURSEMENTS FROM HEALTH COVERAGE PROVIDERS. To the extent allowed by federal law, a health care service provider must seek reimbursement from available third-party health coverage or insurance that the provider knows about or should know about before …

Sec. 32.0424. REQUIREMENTS OF THIRD-PARTY HEALTH INSURERS. (a) A third-party health insurer shall provide to the commission or the commission's designee, on the commission's or the commission's designee's request, information in a form prescribed by the executive commissioner nec…

Sec. 32.04242. PAYOR OF LAST RESORT. The executive commissioner shall adopt rules to ensure, to the extent allowed by federal law, that the Medicaid program: (1) is the payor of last resort; and (2) provides reimbursement for services, including long-term care services, only if, …

Sec. 32.0425. REIMBURSEMENT FOR WHEELED MOBILITY SYSTEMS. (a) In this section: (1) "Qualified rehabilitation professional" means a person who: (A) holds a certification as an assistive technology professional or a rehabilitation engineering technologist issued by, and is in good …

Sec. 32.043. PROCUREMENT RULES FOR PUBLIC DISPROPORTIONATE SHARE HOSPITALS. (a) A public hospital that is designated as a disproportionate share hospital during a fiscal year may acquire goods and services in accordance with this section during the succeeding fiscal year. A procu…

Sec. 32.044. GROUP PURCHASING FOR DISPROPORTIONATE SHARE HOSPITALS. (a) A public or private hospital that is designated as a disproportionate share hospital during a fiscal year may purchase goods and services in accordance with this section during the succeeding fiscal year. A p…

Sec. 32.045. ENHANCED REIMBURSEMENT. The commission shall develop a procedure for: (1) identifying each service provided under the medical assistance program for which the state is eligible to receive enhanced reimbursement of costs from the federal government; and (2) ensuring t…

Sec. 32.046. SANCTIONS AND PENALTIES RELATED TO THE PROVISION OF PHARMACY PRODUCTS. (a) The executive commissioner shall adopt rules governing sanctions and penalties that apply to a provider who participates in the vendor drug program or is enrolled as a network pharmacy provide…

Sec. 32.0461. VENDOR DRUG PROGRAM; COMPETITIVE BIDDING. (a) The commission shall seek competitive bids for the claims processing function of the vendor drug program. (b) The commission shall require any person seeking to contract for services under this section to comply with com…

Sec. 32.0462. VENDOR DRUG PROGRAM; PRICING STANDARD. (a) Notwithstanding any other provision of state law, the commission shall: (1) consider a nationally recognized, unbiased pricing standard for prescription drugs in determining reimbursement amounts under the vendor drug progr…

Sec. 32.0463. MEDICATIONS AND MEDICAL SUPPLIES. The executive commissioner may adopt rules establishing procedures for the purchase and distribution of medically necessary, over-the-counter medications and medical supplies under the medical assistance program that were previously…

Sec. 32.047. PROHIBITION OF CERTAIN HEALTH CARE SERVICE PROVIDERS. (a) A person is permanently prohibited from providing or arranging to provide health care services under the medical assistance program if: (1) the person is convicted of an offense arising from a fraudulent act u…

Sec. 32.048. MANAGED CARE INFORMATION AND TRAINING PLAN. (a) Subject to the availability of funds, the commission shall develop a comprehensive plan to provide information and training about the requirements of a managed care plan to recipients of medical assistance, providers of…

Sec. 32.049. MANAGED CARE CONTRACT COMPLIANCE. (a) The commission shall review each managed care organization that has contracted with the commission to provide medical assistance to medical assistance recipients through a managed care plan issued by the organization to determine…

Sec. 32.050. DUAL MEDICAID AND MEDICARE COVERAGE. (a) At least annually the commission shall identify each individual receiving medical assistance under the medical assistance program who is eligible to receive similar assistance under the Medicare program. (b) The commission sha…

Sec. 32.051. MISDIRECTED BILLING. To the extent authorized by federal law, the commission shall develop a procedure for the state to: (1) match claims for payment for medical assistance provided under the medical assistance program against data available from other entities, incl…

Sec. 32.052. WAIVER PROGRAMS FOR CHILDREN WITH DISABILITIES OR SPECIAL HEALTH CARE NEEDS. (a) This section applies to services under the medical assistance program provided to children younger than 23 years of age with disabilities or special health care needs under a waiver gran…

Sec. 32.053. PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE). (a) The commission, as an integral part of the medical assistance program, shall develop and implement a program of all-inclusive care for the elderly (PACE) in accordance with Section 4802 of the Balanced Budget …

Sec. 32.0531. PACE PROGRAM TEAM. (a) The Department of Aging and Disability Services shall establish a PACE program team composed of experienced personnel. The team is responsible for: (1) increasing public attention and awareness of the availability of PACE program sites; (2) in…

Sec. 32.0532. PACE PROGRAM REIMBURSEMENT METHODOLOGY. (a) In this section and Sections 32.0533 and 32.0534, "PACE program" means the program of all-inclusive care for the elderly (PACE) established under Section 32.053. (b) In setting the reimbursement rates under the PACE progra…

Sec. 32.0533. DATA COLLECTION: PACE AND STAR + PLUS MEDICAID MANAGED CARE PROGRAMS. The commission, in collaboration with the Department of Aging and Disability Services and appropriate stakeholder groups, shall modify the methods by which the commission and the department collec…

Sec. 32.054. DENTAL SERVICES. (a) For purposes of this section, the "dental necessity" for a dental service or product is based on whether a prudent dentist, acting in accordance with generally accepted practices of the professional dental community and within the American Dental…

Sec. 32.055. CATASTROPHIC CASE MANAGEMENT. (a) The commission shall develop and implement a catastrophic case management system to be used in providing medical assistance to persons with catastrophic health problems. (b) The system must provide for the assignment of a case manage…

Sec. 32.0551. OPTIMIZATION OF CASE MANAGEMENT SYSTEMS. The commission shall: (1) create and coordinate staffing and other administrative efficiencies for case management initiatives across the commission and health and human services agencies; and (2) optimize federal funding rev…