<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".14" citation="COMAR 10.09.24.14" title_num="10" subtitle_num="09" chapter_num="24" heading="Fraud.">
  <paragraph num="A.">
    <text>“Medicaid fraud” means:</text>
    <paragraph num="(1)">
      <text>Knowingly and willfully making or causing to be made any false statement or representation of a material fact in any application for any benefit or payment under a State plan established by Title XIX of the Social Security Act of 1939;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Knowingly and willfully making or causing to be made any false statement or representation of a material fact for use in determining rights to those benefits or payments;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Having knowledge of the occurrence of any event affecting:</text>
      <paragraph num="(a)">
        <text>The initial or continued right to those benefits or payments, or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The initial or continued right to those benefits or payments to any other individual in whose behalf an application has been made or in whose behalf benefits or payments are being received, and concealing or failing to disclose that event with an intent to secure fraudulently those benefits or payments either in a greater amount or quantity than is due or when benefits or payments are not authorized;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Having made application to receive or having received any of those benefits or payments for the use and benefit of another, and knowingly and willfully converting any part of the benefit or payment to a use other than for the use and benefit of that other person;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Fraudulently obtaining, attempting to obtain, or aiding another person in obtaining or attempting to obtain any drug product or any medical care, the benefit or payment of any part of which is or may be made from federal or state funds under a state Medical Assistance program, by use of:</text>
      <paragraph num="(a)">
        <text>Fraud, deceit, misrepresentation, or subterfuge;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Forgery or alteration of a Medical Assistance prescription; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Concealment of any material fact or by the use of false names or addresses;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Possession of a blank Medical Assistance prescription, unless possession is authorized by:</text>
      <paragraph num="(a)">
        <text>A contract or other power, right, or permission to manufacture, store, transport, or distribute blank prescriptions;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A grant of a rendering privilege as evidenced by the issuance of a rendering number by a state Medical Assistance program by which one is authorized to prescribe pharmaceutical products for Medical Assistance recipients if the authorization:</text>
        <paragraph num="(i)">
          <text>To possess a blank Medical Assistance prescription terminates 30 days after notice of suspension or termination of provider status in a state Medical Assistance program or exhaustion of final appeal rights, whichever is later; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Does not extend to possession of blank Medical Assistance prescriptions which have been obtained from a source not authorized to distribute blank Medical Assistance prescriptions under §S(6)(a) of this regulation; or</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>Performance of one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(7)">
      <text>Possession of a Medical Assistance card without the authorization of the individual to whom the card is issued, unless:</text>
      <paragraph num="(a)">
        <text>Possession is obtained by a provider without knowledge that the presenting party lacked authorization; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Possession is pursuant to one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>Manufacture, distribution, or possession of a counterfeit Medical Assistance card, or prescription blank except when possession is obtained:</text>
      <paragraph num="(a)">
        <text>By a provider without knowledge that the card or prescription blank is counterfeit; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Pursuant to one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>Manufacture, distribution, or possession of a provider identification plate used or capable of use to imprint Medical Assistance prescriptions unless authorized by:</text>
      <paragraph num="(a)">
        <text>A contract or other power, right, or permission to manufacture, transport, distribute, handle, or possess the plates;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Issuance by a state Medical Assistance program to the party in possession; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Performance of one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Examples. The following are examples of circumstances that may be Medicaid fraud:</text>
    <paragraph num="(1)">
      <text>Failure to report income, resources, if applicable, and family composition at the time of application or reapplication;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Failure to report within 10 working days any changes in income, resources, if applicable, and circumstances during any period of eligibility;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Lending a Medical Assistance card to another person;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Using or attempting to use a Medical Assistance card with intent to secure fraudulently benefits which are not authorized.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>LDSS Reporting. All cases of suspected Medicaid fraud that are discovered by personnel of a local department of social services shall be reported to the Department or its designee.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Other Reporting. All cases of suspected Medicaid fraud that are discovered by agencies other than a local department of social services, that is, other state or federal agencies, providers, or concerned citizens, may be reported to the Department or its designee.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Review and Investigation. The Department or its designee shall review and, when appropriate, investigate all referrals when an allegation is made that a misrepresentation of a material fact has been made or is suspected to have been made.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Disposition of Referrals. Each referral shall be processed by the Department or its designee for appropriate resolution which includes, but is not limited to:</text>
    <paragraph num="(1)">
      <text>Referral for prosecution;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Filing of charges at District Court;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Recovery of incorrect benefit payments;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>A finding that the allegation has not been sustained;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Referral to the appropriate agency; and</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Other administrative action.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Penalties. A person convicted of the crime of Medicaid fraud is subject to penalties as described in Criminal Law Article, §§8-510—8-512, Annotated Code of Maryland.</text>
  </paragraph>
</regulation>