Texas § GV.544.0153 - PROVIDER ELIGIBILITY FOR MEDICAID PARTICIPATION

§ GV.544.0153. PROVIDER ELIGIBILITY FOR MEDICAID PARTICIPATION

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 (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and in good standing; and (2) the licensing authority immediately notifies the office if: (A) a provider's license has been revoked or suspended; or (B) the licensing authority has taken disciplinary action against a provider.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) Except as required by federal law, to determine a health care professional's eligibility to participate as a Medicaid provider, the office of inspector general may not conduct a fingerprint-based 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. Amended by: Acts 2025, 89th Leg., R.S., Ch. 260 (H.B. 142 ), Sec. 3, eff. September 1, 2025.