SECTION 371.1657. Unallowable Fiscal Gain

A person is subject to administrative actions or sanctions if the person:

(1) requests payment from a recipient for services or items delivered within the Medicaid or other HHS program when payment for the services was recouped by Medicaid or another HHS program for any reason;

(2) requests payment from recipients for services or items furnished, directed, ordered, or prescribed by an excluded person without first:

(A) informing the recipient, before delivery of the item or service, that those services are not reimbursable by the Medicaid or other HHS program; and

(B) obtaining and retaining, before delivery of the item or service, a written signed consent from the recipient indicating that the recipient understands he or she is responsible for payment for the services and that the services or items are still desired;

(3) misapplies, misuses, embezzles, converts, steals, or fails to promptly release upon a valid request, or fails to keep detailed receipts of expenditures relating to any funds or other property in trust for a Medicaid or other HHS program recipient;

(4) causes or permits the embezzlement, misuse, misapplication, improper withholding, conversion, or misappropriation of Medicaid or Medicaid-related funds:

(A) while the Medicaid provider is bankrupt, in receivership, or insolvent;

(B) rendering the Medicaid provider insolvent by such act; or

(C) deepening or contributing to the insolvency of the Medicaid provider by such act;

(5) requests payment from a recipient for services or items delivered within the Medicaid or other HHS program for any amount that exceeds the amount Medicaid or other HHS program paid for such services or items, with the exception of any cost-sharing authorized by the program;

(6) markets, offers, supplies, or sells confidential information, including recipient names, Medicaid recipient identification numbers, and other recipient information, for a use that is not expressly authorized by a Medicaid or other HHS program;

(7) discloses a recipient's protected health information to any person in exchange for direct or indirect remuneration, except that a person may disclose a recipient's protected health information:

(A) to a covered entity as defined by §181.001 of the Texas Health and Safety Code or to a covered entity as that term is defined by §602.001 of the Texas Insurance Code for the purpose of:

(i) treatment;

(ii) payment;

(iii) health care operations; or

(iv) performing an insurance or health maintenance organization function as described by §602.053 of the Texas Insurance Code; or

(B) as otherwise authorized by state or federal law.

Source Note: The provisions of this §371.1657 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective May 1, 2016, 41 TexReg 2941