Current through Register Vol. 54, No. 49, December 7, 2024
Section 1101.92 - Recipient prohibited acts, criminal penalties and civil penalties(a) It shall be unlawful for a person to commit any of the following acts: (1) Knowingly or intentionally make or cause to be made a false statement or representation of a material fact in an application for a benefit or payment.(2) Having knowledge of the occurrence of an event affecting his initial or continued right to a benefit or payment or the initial or continued right to a benefit or payment of another individual in whose behalf he has applied for or is receiving the benefit or payment, conceal or fail to disclose the event with an intent fraudulently to secure the benefit or payment either in a greater amount or quantity than is due or when no the benefit or payment is authorized.(3) Having made application to receive a benefit or payment for the use and benefit of himself or another and having received it, knowingly or intentionally convert the benefit or a part of it to a use other than for the use and benefit of himself or the other person.(4) Knowingly or intentionally visit more than three practitioners or providers, who specialize in the same field, in the course of 1 month for the purpose of obtaining excessive services or benefits beyond what is reasonably needed (as determined by medical professionals engaged by the Department) for the treatment of a diagnosed condition of the recipient.(5) Borrow or use a MA identification card for which he is not entitled or otherwise gain or attempt to gain medical services covered under the MA Program if he has not been determined eligible for the Program.(b) Criminal penalties shall consist of the following: (1) A person who commits a violation of subsection (a)(1), (2) or (3) is guilty of a felony of the third degree for each violation thereof with a maximum penalty $15,000 and 7 years imprisonment.(2) A person who commits a violation of subsection (a)(4) or (5) is guilty of a misdemeanor of the first degree for each violation thereof with a maximum penalty of $10,000 and 5 years imprisonment.(c) Noncriminal penalties shall consist of the following:(1) A person who is convicted of a violation of subsection (a)(1), (2), (3), (4) or (5) shall, upon notification by the Department, forfeit all rights to MA benefits for any period of incarceration.(2) If the Department determines that a recipient misuses or overutilizes MA benefits, the Department is authorized to restrict a recipient to a provider of his choice for each medical specialty or type of provider covered under the MA Program.(3) If the Department determines that a general assistance eligible person who is also a MA recipient has violated subsection (a)(3), (4) or (5), the Department will have the authority to terminate the recipient's rights to MA benefits for a period up to 1 year.(4) If the Department determines that a recipient has violated subsection (a)(3), (4) or (5), the Department will have the authority to institute a civil suit against the recipient in the court of common pleas for the amount of the benefits obtained by the recipient in violation of the paragraphs plus legal interest from the date the violations occurred.(5) If it is found that a recipient or a member of his family or household, who would have been ineligible for MA, possessed unreported real or personal property in excess of the amount permitted by law, the amount collectible shall be limited to an amount equal to the market value of such excess property or the amount of MA granted during the period the excess property was held, whichever is less. Reimbursement of the overpayment shall be sought from the recipient, the person acting on the recipient's behalf or survivors benefiting from receiving the property. Proof of date of acquisition of the property shall be provided by the recipient or person acting on his behalf. Where a person receives MA for which he would have been ineligible due to possession of the unreported property, and proof of date of acquisition of the property is not provided, it shall be deemed that the personal property was held by the recipient the entire time he was on Medical Assistance, and reimbursement shall be for MA paid for the recipient or the value of the excess property, whichever is less. Reimbursement shall be sought from the recipient, the person acting on the recipient's behalf, the person receiving or holding the property, the recipient's estate or survivors benefiting from receiving the property. The Department is authorized to institute a civil suit in the court of common pleas to enforce the rights established by this section.The provisions of this § 1101.92 amended November 18, 1983, effective 11/19/1983, 13 Pa.B. 3653.