BILL ANALYSIS Senate Research Center C.S.S.B. 961 89R20409 AND-F By: Kolkhorst Health & Human Services 3/19/2025 Committee Report (Substituted) AUTHOR'S / SPONSOR'S STATEMENT OF INTENT Texas Medicaid provides coverage to over 4.3 million low-income children, pregnant women, elderly individuals, and people with disabilities. The Texas Health and Human Services Commission (HHSC) is responsible for determining the eligibility of all applicants to the state Medicaid program, which had an operating cost of $59.6 billion (AF) in fiscal year 2023. The Centers for Medicare & Medicaid Services (CMS) oversees the eligibility process, with each state verifying that applicants meet requirements such as income and citizenship. Currently, applicants are responsible for providing accurate income information. Ensuring the accuracy of eligibility decisions is essential, as errors can impact both state and federal budgets, potentially leading to the recoupment of federal funds for ineligible expenses. Consistency and accuracy in this process are critical to ensure that services are reserved for those who truly need assistance. Additionally, the rise of sports betting presents new risks for the Medicaid system. Many participants fail to report gambling income, which can lead to miscalculations in eligibility and allow ineligible individuals to qualify for Medicaid. On top of this, there have also been cases where Medicaid providers have submitted false claims, such as billing for services that were actually performed by another provider. S.B. 961 addresses the growing concerns of Medicaid fraud by strengthening the eligibility verification process. This bill directs HHSC to expand the key eligibility criteria and ensures that any claim submitted for Medicaid reimbursement identifies the provider who truly performed the procedure, helping to prevent improper payments and Medicaid fraud. Key Provisions Requires HHSC to verify all key eligibility before enrolling people in Medicaid. Directs HHSC to regularly crosscheck databases to identify any changes in circumstances that might impact ongoing eligibility. Prohibits providers from knowingly submitting claims for services performed by another licensed professional. Committee Substitute Changes Clarifies that unless it is permitted by federal law to accept self-attestation, all key eligibility factors must be verified. (SECTION 3 of the substitute). C.S.S.B. 961 amends current law relating to fraud prevention and verifying eligibility for benefits under Medicaid. RULEMAKING AUTHORITY This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 544.0455, Government Code, as effective April 1, 2025, by adding Subsection (g), to prohibit the Health and Human Services Commission (HHSC) from waiving or seeking authorization to waive a requirement that HHSC conduct periodic electronic data matches to verify a Medicaid recipient's income eligibility under this section or other law. SECTION 2. Amends Section 544.0456, Government Code, as effective April 1, 2025, by amending Subsection (c) and adding Subsection (c-1), as follows: (c) Requires HHSC, on a monthly basis, to: (1) conduct electronic data matches with the Texas Lottery Commission to determine whether a recipient of supplemental nutrition assistance benefits or Medicaid benefits or a recipient's household member received reportable lottery winnings; (2) use the database system developed under Section 532.0201 (Data Collection System) to: (A) match vital statistics unit death records with a list of individuals eligible for financial assistance benefits, supplemental nutrition assistance benefits, or Medicaid benefits; and (B) ensure that any individual receiving benefits under a program described by Paragraph (A), rather than assistance under either program, who is discovered to be deceased has the individual's eligibility for benefits, rather than assistance, promptly terminated; (3) makes a nonsubstantive change to this subdivision; and (4) if a Medicaid recipient also receives supplemental nutrition assistance benefits, review electronic benefit transfer card transactions made exclusively out of state by the recipient to determine whether the transactions indicate a possible change in the recipient's residence for purposes of Medicaid eligibility. Makes nonsubstantive changes to this subsection. (c-1) Requires HHSC, on at least a quarterly basis, to determine whether a Medicaid recipient's voter registration has been canceled under Subchapter B (Cancellation), Chapter 16 (Cancellation of Registration), Election Code, or for any other reason during the preceding 36-month period, to determine whether the cancellation indicates a possible change in the recipient's eligibility for Medicaid benefits. SECTION 3. Amends Subchapter B, Chapter 32, Human Resources Code, by adding Section 32.0267, as follows: Sec. 32.0267. VERIFICATION OF CERTAIN SELF-ATTESTED ELIGIBILITY CRITERIA. Prohibits HHSC, except as provided by Section 32.024715(b)(3)(B) (relating to requiring that the streamlined process for determining a former foster care youth's eligibility for Medicaid, if recertification is required under federal law, use a simple process that, if required that a youth verify state residency, allows them to attest to that fact without providing additional evidence) and unless self-attestation is permitted by federal law, when determining and certifying a person's eligibility for medical assistance, from accepting self-attestation of the person's income, residency, citizenship, age, household composition, caretaker relative status, or access to other health coverage without additional verification. Requires that the additional verification be obtained by or provided to HHSC before HHSC is authorized to enroll or reenroll the person in the medical assistance program. Requires HHSC to attempt to obtain the additional verification through electronic data matching before requesting documentation from the person. SECTION 4. Amends Section 36.002, Human Resources Code, as follows: Sec. 36.002. UNLAWFUL ACTS. Provides that a person commits an unlawful act if the person commits certain actions, including making a claim under a health care program and knowingly failing to indicate the type of license held by the licensed health care provider who actually provided the service or the identification number of the licensed health care provider who actually provided the service. Makes nonsubstantive changes. SECTION 5. Makes application of Section 36.002, Human Resources Code, as amended by this Act, prospective. SECTION 6. Requires a state agency, if necessary for implementation of a provision of this Act, to request a waiver or authorization from a federal agency, and authorizes delay of implementation until such a waiver or authorization is granted. SECTION 7. Effective date: September 1, 2025.
BILL ANALYSIS
Senate Research Center C.S.S.B. 961
89R20409 AND-F By: Kolkhorst
Health & Human Services
3/19/2025
Committee Report (Substituted)
Senate Research Center
C.S.S.B. 961
89R20409 AND-F
By: Kolkhorst
Health & Human Services
3/19/2025
Committee Report (Substituted)
AUTHOR'S / SPONSOR'S STATEMENT OF INTENT
Texas Medicaid provides coverage to over 4.3 million low-income children, pregnant women, elderly individuals, and people with disabilities. The Texas Health and Human Services Commission (HHSC) is responsible for determining the eligibility of all applicants to the state Medicaid program, which had an operating cost of $59.6 billion (AF) in fiscal year 2023.
The Centers for Medicare & Medicaid Services (CMS) oversees the eligibility process, with each state verifying that applicants meet requirements such as income and citizenship. Currently, applicants are responsible for providing accurate income information. Ensuring the accuracy of eligibility decisions is essential, as errors can impact both state and federal budgets, potentially leading to the recoupment of federal funds for ineligible expenses. Consistency and accuracy in this process are critical to ensure that services are reserved for those who truly need assistance.
Additionally, the rise of sports betting presents new risks for the Medicaid system. Many participants fail to report gambling income, which can lead to miscalculations in eligibility and allow ineligible individuals to qualify for Medicaid. On top of this, there have also been cases where Medicaid providers have submitted false claims, such as billing for services that were actually performed by another provider.
S.B. 961 addresses the growing concerns of Medicaid fraud by strengthening the eligibility verification process. This bill directs HHSC to expand the key eligibility criteria and ensures that any claim submitted for Medicaid reimbursement identifies the provider who truly performed the procedure, helping to prevent improper payments and Medicaid fraud.
Key Provisions
Committee Substitute Changes
C.S.S.B. 961 amends current law relating to fraud prevention and verifying eligibility for benefits under Medicaid.
RULEMAKING AUTHORITY
This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency.
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Section 544.0455, Government Code, as effective April 1, 2025, by adding Subsection (g), to prohibit the Health and Human Services Commission (HHSC) from waiving or seeking authorization to waive a requirement that HHSC conduct periodic electronic data matches to verify a Medicaid recipient's income eligibility under this section or other law.
SECTION 2. Amends Section 544.0456, Government Code, as effective April 1, 2025, by amending Subsection (c) and adding Subsection (c-1), as follows:
(c) Requires HHSC, on a monthly basis, to:
(1) conduct electronic data matches with the Texas Lottery Commission to determine whether a recipient of supplemental nutrition assistance benefits or Medicaid benefits or a recipient's household member received reportable lottery winnings;
(2) use the database system developed under Section 532.0201 (Data Collection System) to:
(A) match vital statistics unit death records with a list of individuals eligible for financial assistance benefits, supplemental nutrition assistance benefits, or Medicaid benefits; and
(B) ensure that any individual receiving benefits under a program described by Paragraph (A), rather than assistance under either program, who is discovered to be deceased has the individual's eligibility for benefits, rather than assistance, promptly terminated;
(3) makes a nonsubstantive change to this subdivision; and
(4) if a Medicaid recipient also receives supplemental nutrition assistance benefits, review electronic benefit transfer card transactions made exclusively out of state by the recipient to determine whether the transactions indicate a possible change in the recipient's residence for purposes of Medicaid eligibility.
Makes nonsubstantive changes to this subsection.
(c-1) Requires HHSC, on at least a quarterly basis, to determine whether a Medicaid recipient's voter registration has been canceled under Subchapter B (Cancellation), Chapter 16 (Cancellation of Registration), Election Code, or for any other reason during the preceding 36-month period, to determine whether the cancellation indicates a possible change in the recipient's eligibility for Medicaid benefits.
SECTION 3. Amends Subchapter B, Chapter 32, Human Resources Code, by adding Section 32.0267, as follows:
Sec. 32.0267. VERIFICATION OF CERTAIN SELF-ATTESTED ELIGIBILITY CRITERIA. Prohibits HHSC, except as provided by Section 32.024715(b)(3)(B) (relating to requiring that the streamlined process for determining a former foster care youth's eligibility for Medicaid, if recertification is required under federal law, use a simple process that, if required that a youth verify state residency, allows them to attest to that fact without providing additional evidence) and unless self-attestation is permitted by federal law, when determining and certifying a person's eligibility for medical assistance, from accepting self-attestation of the person's income, residency, citizenship, age, household composition, caretaker relative status, or access to other health coverage without additional verification. Requires that the additional verification be obtained by or provided to HHSC before HHSC is authorized to enroll or reenroll the person in the medical assistance program. Requires HHSC to attempt to obtain the additional verification through electronic data matching before requesting documentation from the person.
SECTION 4. Amends Section 36.002, Human Resources Code, as follows:
Sec. 36.002. UNLAWFUL ACTS. Provides that a person commits an unlawful act if the person commits certain actions, including making a claim under a health care program and knowingly failing to indicate the type of license held by the licensed health care provider who actually provided the service or the identification number of the licensed health care provider who actually provided the service. Makes nonsubstantive changes.
SECTION 5. Makes application of Section 36.002, Human Resources Code, as amended by this Act, prospective.
SECTION 6. Requires a state agency, if necessary for implementation of a provision of this Act, to request a waiver or authorization from a federal agency, and authorizes delay of implementation until such a waiver or authorization is granted.
SECTION 7. Effective date: September 1, 2025.