SECTION 371.1703. Termination of Enrollment or Cancellation of Contract

(a) The OIG may terminate the enrollment or cancel the contract of a person by debarment, suspension, revocation, or other deactivation of participation, as appropriate. The OIG may terminate or cancel a person's enrollment or contract if it determines that the person committed an act for which a person is subject to administrative actions or sanctions.

(b) When the OIG establishes the following by prima facie evidence, the OIG must terminate or cancel the enrollment or contract from the Medicaid program or any other HHS program of:

(1) a provider or any person with an ownership interest in the provider has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or CHIP program in the last ten years;

(2) a provider that is terminated or revoked for cause, excluded, or debarred under Title XVIII of the Social Security Act or under the Medicaid program or CHIP program of any other state;

(3) a provider that fails to permit access to any and all provider locations for unannounced or announced on-site inspections required during the provider screening process as provided by rule;

(4) a provider when any person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely and accurate information, including fingerprints if required by CMS or state rule, and cooperate with any and all screening methods required during the provider screening process as provided by rule, statute, rule, or regulation;

(5) a provider that fails to submit sets of fingerprints in a form and manner to be provided by rule;

(6) a person that fails to repay overpayments under the Medicaid program or CHIP;

(7) a person that owns, controls, manages, or is otherwise affiliated with and has financial, managerial, or administrative influence over a provider who has been suspended or prohibited from participating in Medicare, Medicaid, or CHIP;

(8) a provider that fails to identify or disclose in the provider screening process for any HHS program:

(A) all persons with a direct or indirect ownership or control interest, as defined by 42 C.F.R. §455.101;

(B) all information required to be disclosed in accordance with 42 C.F.R. §1001.1101, 42 C.F.R. chapter 455, or other by statute, rule, or regulation; or

(C) all agents or subcontractors of the provider:

(i) if the provider or a person with an ownership interest in the provider has an ownership interest in the agent or subcontractor; or

(ii) if the provider engages in a business transaction with the agent or subcontractor that meets the criteria specified by 42 C.F.R. §455.105; or

(9) a provider that has been excluded or debarred from participation in a state or federally funded health care program as a result of:

(A) 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

(B) a criminal conviction for committing an act under a state or federally funded health care program that caused bodily injury to:

(i) a person who is 65 years of age or older;

(ii) a person with a disability; or

(iii) a person under 18 years of age.

(c) When the OIG establishes the following by prima facie evidence, the OIG may terminate or cancel the enrollment or contract from Medicaid, CHIP, or any other HHS program of:

(1) a provider if a criminal history check reveals a prior criminal conviction;

(2) a provider that has failed to bill for medical assistance or refer clients for medical assistance within a 12-month period;

(3) a provider that has been excluded or debarred from participation in any federally funded health care program not described in subsection (b)(2) of this section;

(4) a provider that has falsified any information on its application for enrollment as determined by the OIG;

(5) a provider whose identity on an application for enrollment cannot be verified by the OIG;

(6) a person that commits a program violation;

(7) a person that is affiliated with a person who commits a program violation;

(8) a person that commits an act for which sanctions, damages, penalties, or liability could be or are assessed by the OIG; or

(9) a person whose contract may be cancelled for any other reason specified by statute or regulation.

(d) Exceptions.

(1) The OIG need not terminate participation if the person or provider voluntarily resigned from participation under Title XVIII of the Social Security Act or under the Medicaid program or CHIP program of any other state, and the resignation was not in lieu of or to avoid exclusion, termination, or any other sanction.

(2) The OIG need not terminate participation based on a conviction described in subsection (b)(1) of this section, a termination described in subsection (b)(2) of this section, or a failure to allow access described in subsection (b)(3) of this section if the OIG:

(A) determines that termination is not in the best interests of the Medicaid program; and

(B) documents that determination and the rationale in writing.

(e) Notice. Notice of termination includes:

(1) a description of the termination;

(2) the basis for the termination;

(3) the effect of the termination;

(4) the duration of the termination;

(5) whether re-enrollment will be required after the period of termination; and

(6) a statement of the person's right to request an informal resolution meeting or an administrative hearing regarding the imposition of the termination unless the termination is required under 42 C.F.R. §455.416.

(f) Due process.

(1) After receiving a notice of termination, a person has a right to the informal resolution process in accordance with §371.1613 of this subchapter (relating to Informal Resolution Process) unless the termination is required under 42 C.F.R. §455.416.

(2) A person may request an administrative hearing after receipt of a final notice of termination in accordance with §371.1615 of this subchapter (relating to Appeals) unless the termination is required under 42 C.F.R. §455.416. The OIG must receive the written request for a hearing no later than the 15 days after the date the person receives the notice.

(g) Scope and effect of termination.

(1) A person's enrollment agreement or contract is nullified on the effective date of the termination.

(2) Once a person's enrollment agreement or contract is terminated or cancelled, no items or services furnished are reimbursed by the Medicaid or other HHS program during the period of termination or cancellation.

(3) Following termination, the person must re-enroll in order to participate as a provider in the Medicaid or other HHS program, if the person was terminated for any grounds in subsection (b) or (c)(1) - (3) of this section. Re-enrollment requires the provider to meet all applicable screening requirements, including the payment of any application fees.

(4) A person may be terminated from participation in the Medicare program and in the Medicaid program of every other state as a result of the termination.

(5) If, after the effective date of the termination or cancellation, a person submits or causes to be submitted claims for services or items furnished within the period of termination or cancellation, the person may be liable to repay any submitted claims or subject to civil monetary penalty liability under §1128A(a)(1)(D), and criminal liability under §1128B(a)(3) of the Social Security Act in addition to sanctions or penalties by the OIG.

(6) The termination or cancellation may, as determined by the OIG, become immediately effective and final on the date reflected on the notice of cancellation in the following circumstances:

(A) the person subject to termination or cancellation may be placing at risk the health or safety of persons receiving services under Medicaid;

(B) the person who is subject to termination or cancellation fails:

(i) to grant immediate access to the OIG or to a requesting agency upon reasonable request;

(ii) to allow the OIG or a requesting agency to conduct any duties that are necessary to the performance of their official functions; or

(iii) to provide to the OIG or a requesting agency as requested copies or originals of any records, documents, or other items, as determined necessary by the OIG or the requesting agency.

(7) If the person timely filed a written request for an administrative hearing, the effective date of termination is the date the hearing officer's or administrative law judge's decision to uphold the termination becomes final; however, if the administrative law judge upholds a termination for grounds described in paragraph (6) of this subsection, the effective date is made retroactive to the date of the notice of termination.

(8) Unless otherwise provided in this section, the termination becomes final as provided in §371.1617(a) of this subchapter (relating to Finality and Collections).

(h) Reinstatement.

(1) The OIG may reinstate a provider's enrollment if the OIG finds:

(A) good cause to determine that it is in the best interest of the medical assistance program; and

(B) 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.

(2) The OIG must support a determination made under this section with written findings of good cause for the determination.

Source Note: The provisions of this §371.1703 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941