TITLE 1. ADMINISTRATION

PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 371. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY

SUBCHAPTER G. ADMINISTRATIVE ACTIONS AND SANCTIONS

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §371.1603, concerning Legal Basis and Scope; and §371.1715, concerning Damages and Penalties.

The amendments to §371.1603 and §371.1715 are adopted without changes to the proposed text as published in the December 13, 2019, issue of the Texas Register (44 TexReg 7576). These rules will not be republished.

BACKGROUND AND PURPOSE

The purpose of the amendments is to clarify the factors that the agency considers when imposing and scaling enforcement actions as required by Texas Government Code §531.102(x), including appropriate mitigating factors, as well as to clarify that the agency assesses penalties in accordance with relevant law, particularly Texas Human Resource Code §32.039.

During its last review of the HHSC-Office of Inspector General (OIG), the Sunset Advisory Commission recommended that the agency revise its rules to provide direction for determining which sanction to apply to each violation committed by a person subject to agency regulation. After consulting with stakeholders, the Executive Commissioner proposed amendments to §371.1603 to provide that direction while also affirming that each matter is evaluated on a case-by-case basis. The amended rule clarifies those factors that the agency applies when determining the seriousness, prevalence of error, harm, or potential harm of a violation, as required by statute. The amendments add examples of mitigating factors that the agency may consider when evaluating a violation and scaling resulting enforcement actions. The amendments also clarify that a person potentially subject to an enforcement action may introduce such mitigating factors in any contested case, as well as during the agency's informal resolution process.

The amendments to §371.1715 clarify that OIG has the authority to impose administrative penalties on behalf of HHSC or other health and human service agencies, if such penalties are authorized by law, and that penalties for violations concerning Medicaid and other medical assistance programs will be imposed in accordance with §32.039, Texas Human Resources Code, which provides ranges of penalties for specific violations. The amendments also clarify that OIG will, when imposing penalties, apply the factors in accordance with §371.1603.

COMMENTS

The 31-day comment period ended January 13, 2020. During this period, HHSC received comments regarding the proposed rules from the Texas Medical Association, the Texas Dental Association, the Texas Health Care Association, Superior HealthPlan, BakerHostetler, LLP, and In-Home Attendant Services. A summary of comments relating to the rules, and HHSC responses, follows.

Comment: One commenter agrees that the amended rule language in §371.1603 protects the due process of a person subject to agency regulation. The commenter also agrees with OIG that each case must be evaluated individually, allowing the person potentially subject to an enforcement action to submit mitigating factors for the agency's consideration during a contested case and during the agency's informal resolution process, as the agency evaluates violations, and scales resulting enforcement actions.

Response: OIG appreciates the supportive comment. No change was made in response to the comment.

Comment: Two commenters suggest changing the phrase "sole discretion" in §371.1603(c) to "reasonable discretion." One commenter believes this change is necessary to ensure that recipient and community needs are considered in connection with the determination of whether to grant an installment agreement. Further, one commenter suggests this change should occur to ensure that similarly situated providers are treated in a reasonably consistent manner.

Response: OIG regularly offers installment agreements when warranted by the facts. However, OIG considers this comment to be beyond the scope of the amendment. The language "[a]t OIG's sole discretion, overpayments may be collected in a lump sum or through installments" is an existing provision in the rule. OIG added the sentence to which the commenter referred as an accommodation to an informal commenter seeking to ensure that providers are aware of their opportunity to request installment agreements. The phrase "sole discretion" in the added sentence reiterates the existing provision in the first sentence of §371.1603(c). No change was made in response to this comment.

Comment: Two commenters recommend that the phrase "administrative penalties or both" in §371.1603(c) should be deleted. One commenter states that it is incongruous to subject a person to an administrative penalty for paying under the terms of an installment agreement when an installment agreement is not a basis for the imposition of an administrative penalty under the Texas Administrative Code (TAC) rules that provide grounds for enforcement. The commenter further states that the imposition of administrative penalties for utilization of an installment agreement would result in the stacking of administrative penalties.

Response: The administrative penalties referenced in the rule are default penalties for failing to comply with the terms of an installment agreement. OIG reserves the right to use installment agreements and reserves the right to include default penalty provisions in the installment agreements in case a person fails to comply with the agreement. Default penalties only come into effect if the provider fails to comply with the terms of the installment agreement. Additionally, a provider is not required to accept an installment agreement that includes a provision for the assessment of penalties. OIG has authority, under Texas Human Resources Code §32.039(b)(3) and 1 TAC §371.1655(3) and (9), to assess a penalty for failing to repay overpayments after receiving notice of a delinquency or failing to comply with a settlement agreement. A provider's delinquency in making a payment required by a settlement agreement is a new ground for enforcement that exposes the provider to the risk of additional penalties. This is not stacking of penalties, but penalties assessed as a result of contract non-compliance. No change was made in response to this comment.

Comment: One commenter suggests establishing a specified rate of interest in connection with installment agreements, including using a provision similar to that set forth in 1 TAC §357.643, updated to refer to Texas Finance Code §304.102.

Response: OIG uses, in its current settlement agreement forms, the judgment rate referenced in Texas Finance Code §304.003 to calculate interest in connection with installment agreements. No change was made in response to this comment.

Comment: One commenter requests that OIG provide a citation for the underlying statutory authority that serves as the basis for the proposed amendment language regarding authorization of interest and/or penalties in §371.1603(c).

Response: OIG has authority under Texas Human Resources Code §32.039(b)(3) and 1 TAC §371.1655(3) and (9) to assess a penalty for failing to repay overpayments after receiving notice of a delinquency or failing to comply with a settlement agreement. Furthermore, a provider is not required to accept an installment agreement that includes a provision for the assessment of interest and/or administrative penalties. Unless prohibited by law, parties to a contract may mutually agree on remedies for default. A provider's delinquency in making a payment required by a settlement agreement is a new ground for enforcement that exposes the provider to the risk of additional penalties. No change was made in response to this comment.

Comment: One commenter requests that if the proposed amendment language in §371.1603(c) is adopted, the language should be amended to state that (1) the interest and/or penalties referenced are only for late or missed payments and (2) a good cause exception must be included in the settlement agreement.

Response: OIG routinely considers evidence of good cause submitted by a provider who is delinquent in making payments required by a settlement agreement. Every settlement agreement contains an amendment clause allowing amendment by mutual agreement. When warranted by the facts, OIG considers amendment of the settlement agreement to adjust the payment schedule. No change was made in response to this comment.

Comment: One commenter suggests that OIG adopt an approach similar to that used in federal regulation 42 CFR §405.371(b)(3), which addresses suspension of Medicare payments to providers and suppliers of services. Specifically, HHSC would establish an outside period of time at which point a case would be deemed to be closed under §371.1603(e), unless OIG took affirmative action to keep the case open.

Response: OIG did not propose any amendments to §371.1603(e), the subsection this comment concerns. The purpose of the amendments is to clarify the factors the agency considers when imposing and scaling enforcement actions as required under Texas Government Code §531.102(x), including appropriate mitigating factors, as well as to clarify that the agency assesses penalties in accordance with relevant law, particularly Texas Human Resources Code §32.039. HHSC did not propose to amend how long an OIG case remains open. Therefore, the commenter's suggested amendment is outside the scope of the proposed amendments. No change was made in response to this comment.

Comment: One commenter recommends that other factors be included in §371.1603(f) for determining the severity of a sanction, including (1) the presence or absence of a direct benefit to the person, (2) whether complicity in the violation is widespread throughout the provider organization, (3) the level of intent or culpability of the parties, (4) the degree of difficulty in detecting the particular type of offense, and (5) the lack of remedial steps taken by the person.

Response: The factors listed in §371.1603(f)(1) - (3) and (g) already allow OIG to consider factors such as those proposed by the commenter. No change was made in response to this comment.

Comment: One commenter asserts that the phrase "except as provided in other statute, rule, or regulation" in §371.1603(f) is vague and fails to give physicians and providers fair notice of when the listed factors will be considered versus when they will not. The commenter further recommends that the proposed rules specifically describe whether and when OIG will consider the factors listed in the proposed rules and that OIG clearly specify any exceptions in the rule proposal (preferably with applicable statutory/regulatory citations).

Response: The introductory phrase --"[e]xcept as provided in other statute, rule, or regulation"-- is included in the rule because other law exists that does not allow OIG to use discretion in determining the appropriate administrative action or sanction. For example, federal law (42 USC §1396a(a)(39)) and 1 TAC §371.1705 require OIG to exclude from Medicaid persons convicted of certain crimes. Federal regulation (42 CFR §455.416) requires the State Medicaid agency to terminate the enrollment of a provider under certain circumstances, such as being terminated from Medicare or Medicaid in another state. Further, because federal and state law is so expansive, it would be impracticable to list all laws that may restrict OIG's discretion in determining the appropriate sanction. No change was made in response to this comment.

Comment: One commenter requests that OIG clarify the meaning of the phrase "prevalence of errors" in §371.1603(f)(2) to make clear the context, what type of errors are being considered (clerical or medical), and whether the errors must be related to the alleged violation.

Response: The rule language was taken directly from Texas Government Code §531.102(x), which requires the adoption of rules establishing criteria that include consideration of "the prevalence of errors by the provider." The statute does not limit the type of error that may be considered; therefore, OIG reserves the right to consider the prevalence of all types of errors committed by the provider in determining an appropriate administrative action or sanction. No change was made in response to this comment.

Comment: One commenter states that, with respect to harm "potentially resulting from [the] errors" as used in §371.1603(f)(3), OIG should establish a noncompliance matrix, based on the Severity Matrix used by CMS, to help assure that the potential errors are evaluated consistently. The commenter suggests that the matrix should focus on whether the harm potentially resulting from the noncompliance is isolated, part of a pattern, or a widespread occurrence, and on the severity of the harm.

Response: Texas Government Code §531.102(x) requires the adoption of rules establishing criteria that include consideration of "the financial or other harm to the state or recipients resulting or potentially resulting from those errors." A case-by-case approach in which OIG may consider all of the factors listed in §371.1603(f)(1) - (6), (g)(1) - (10), and (h)(1) - (7) allows for the most flexibility to consider all available facts. Additionally, the factors listed in §371.1603(f)(1) - (3) and (g) already allow OIG to consider factors such as those proposed by the commenter. The Severity Matrix used by CMS is a graphical representation of the assessment factors used to determine the severity and scope of the violations. Both of those concepts are factored into this rule along with many other factors prescribed by statute, recommended by stakeholders, and required to ensure appropriate actions under the circumstances. No change was made in response to this comment.

Comment: One commenter states that "potential harm" referenced in §371.1603(f)(3) is an unmeasurable standard, there is insufficient notice in the amended rule as to what type of actions would create potential harm, and that the inclusion of "potential harm" could have significant financial consequences to health plans and providers. The commenter urges HHSC to remove "potential" from the rule.

Response: Texas Government Code §531.102(x) requires the adoption of rules establishing criteria that include consideration of "the financial or other harm to the state or recipients resulting or potentially resulting from those errors" (emphasis added). No change was made in response to this comment.

Comment: One commenter states that the language "whether the person had previously committed a violation" in §371.1603(f)(4) could be interpreted as any violation within any given time, known or unknown and, therefore, should be changed to "whether the HHSC has made a prior finding of this violation."

Response: The language in §371.1603(f)(4) is identical to the language in Texas Human Resource Code §32.039(e)(2) that requires OIG to consider "whether the person had previously committed a violation" when OIG is determining the amount of penalty to be assessed for a violation of §32.039(b). No change was made in response to this comment.

Comment: One commenter states that the language in §371.1603(f)(4) and (6) is based on Texas Human Resource Code §32.039(e) and is specific to determining an amount of an administrative penalty for certain types of violations, but the proposed rule language would permit consideration of these factors in a broader context. The commenter further states that it is unaware of specific statutory authority that broadens the scope of the application of §32.039(e). Finally, the commenter recommends replacing §371.1603(f)(4) and (6) with the following language:

(f)(_) in determining the amount of a penalty to be assessed, if any, for a violation falling under Tex. Hum. Res. Code, Section 32.039(c)(2) and (e), the OIG shall consider:

(i) the seriousness of the violation;

(ii) whether the person had previously committed a violation; and

(iii) the amount necessary to deter the person from future violations.

Response: A state agency has authority expressly provided by statute or necessarily implied to carry out the express powers. Texas Government Code §531.102(x) requires the HHSC Executive Commissioner to "adopt rules establishing criteria for determining enforcement and punitive actions with regard to a provider who has violated state law, program rules, or the provider's Medicaid agreement," and the statute does not limit the factors HHSC may consider. Additionally, proposed §371.1603(f)(6) is limited to the application of administrative penalties. Finally, OIG increases transparency by including in rule the factors OIG considers in determining the appropriate administrative action or sanction. No change was made in response to this comment.

Comment: One commenter recommends that proposed §371.1603(f)(6) should include appropriate objective factors guiding OIG on how to calculate this form of administrative penalty, and that penalties should conform to actual harm and other factors and not solely OIG's view of a deterrent amount. The commenter is also concerned about the application of an administrative penalty for an action that causes no harm but is subject to a fine under the sole guidance that OIG believes that a penalty of that size would be required to deter the person from committing a future violation.

Response: OIG does not calculate an administrative penalty solely on OIG's view of a deterrent amount. When making a preliminary determination regarding the appropriate amount of administrative penalties, OIG, as set out in §371.1603(f), must consider the six factors listed in §371.1603(f) and may consider any other relevant factors, including the twenty-one factors in §371.1603(g) and (h). Texas Human Resource Code §32.039(e)(2) requires, in determining the amount of penalty to pursue under subsection (c)(2), that OIG consider "the amount necessary to deter the person from committing future violations." Because the Legislature has required consideration of this factor, no change was made in response to this comment.

Comment: One commenter states that Texas Government Code §531.102(x) only mentions mitigating factors, not "aggravating" ones and so there is no authorization for the list of aggravating factors in §371.1603(g). The commenter recommends that the proposed §371.1603(g) (and the current aggravating factor list) be removed from the rule and that OIG should only rely on consideration of those factors listed under §371.1603(f). The commenter further states that many of the additional factors listed in §371.1603(g) are redundant with the considerations listed in §371.1603(f). The commenter states that the first five aggravating factors listed in §371.1603(g) relate to harm to patients and the public; but "financial or other harm to the state or recipients" is already listed as a main consideration under §371.1603(f). The commenter recommends that if OIG continues to list consideration of additional factors in §371.1603(g), OIG should (i) remove criteria (g)(1) through (5) (since criteria (1) - (5) mention the type of harm caused by providers, which is already captured in the general consideration of "financial or other harm to the state or recipients" under §371.1603(f)(3)); and (ii) limit the consideration of previous disciplinary actions or violations to those related to the present violation (as reflected by OIG's proposed amendment language in proposed §371.1603(g)(9) and (g)(10)).

Response: The fact that Texas Government Code §531.102(x) does not contain the word "aggravating" does not mean that there is no authorization for consideration of a list of factors that are aggravating. Section 531.102(x) requires HHSC to adopt rules establishing criteria that include taking into consideration the three factors listed in (x)(1)(A) - (C). Those factors (seriousness of the violation, prevalence of errors, and harm resulting or potentially resulting), by their very nature, represent aggravating factors when present, or mitigating factors when absent. Additionally, the primary mandate in §531.102(x) is to adopt rules "establishing criteria for determining enforcement and punitive actions with regard to a provider who has violated state law, program rules, or the provider's Medicaid provider agreement." Because the statute requires the adoption of rules establishing criteria that "include" consideration of certain factors, the criteria listed in the rule is not limited to the specific factors listed in §531.102(x)(1)(A) - (C) and not limited to mitigating factors. Several of the factors listed in §371.1603(g) are not amended by the proposed rule changes (e.g. (g)(2), (5) - (7)). Other factors listed in §371.1603(g) are more specific than those listed in (f) (e.g. (g)(1), (8), (9)). OIG has, in response to informal stakeholder comments, limited - as described in amended (g)(8) and (9) - consideration of previous disciplinary action or violations of board orders to those relevant to the violation(s) under consideration by OIG. No change was made in response to this comment.

Comment: One commenter states that the potential for harm is a standard that covers all conduct, whether appropriate or otherwise, that such a standard cannot be uniformly applied, and that an unknown amount of potential harm does not provide appropriate notice for persons to identify what level or type of potential harm would be a factor in assessing the amount of administrative damage or penalty.

Response: Texas Government Code §531.102(x) requires the adoption of rules establishing criteria that include consideration of "[t]he financial or other harm to the state or recipients resulting or potentially resulting from those errors" (emphasis added). No change was made in response to this comment.

Comment: One commenter states that striking severity of economic harm done to a patient essentially leaves an ambiguous measurement of economic harm and leaves an abundance of discretion on behalf of OIG to assess harm to a patient. The commenter suggests that the word severity remain in the rule.

Response: Pursuant to §371.1603(g), when determining the seriousness, harm or potential harm of the violation, OIG may consider the physical, emotional, or economic harm to one or more patients/individuals. In OIG's view, considering the degree of the harm includes considering the severity of the harm. No change was made in response to this comment.

Comment: One commenter states that the use of the term "relevant" in §371.1603(g)(8) and (9) is confusing and should be replaced with "substantially the same as." The commenter states further that the previous licensure action should be final action of any board review.

Response: In response to informal stakeholder comments, OIG added language to §371.1603(g)(8) and (9) to narrow OIG's consideration of previous disciplinary action and violation of previous orders. OIG disagrees that the term "relevant" is confusing. The language "previous disciplinary action by a licensing board" is an existing provision in the current rule and is outside the scope of the proposed amendments. Additionally, licensing board disciplinary actions are often resolved through informal processes such as warning letters or settlement agreements. OIG reserves the right to consider a licensing board's previous disciplinary action in whatever form the various licensing boards utilize and agrees that mere allegations filed with a licensing board would not be sufficient. If a person disagrees with the finality of the licensing board's action or the weight OIG should give the action, a party may address these matters in discussions with OIG or in a contested case, if necessary. No change was made in response to this comment.

Comment: One commenter states that §371.1603(g)(8) and (9) are redundant in that licensing board disciplinary actions in (g)(8) are imposed for licensing board violations in (g)(9). The commenter states that these two sections should be combined to avoid unreasonable stacking or amplification of penalties.

Response: A disciplinary action taken by a licensing board may result in a board order imposing certain affirmative conditions or restrictions. As such, a violation of the board's order may constitute a new act or omission-- that may or may not result in board disciplinary action-- worthy of consideration when determining the appropriate sanction or penalty. No change was made in response to this comment.

Comment: One commenter states that the phrase "may consider" in §371.1603(h) should be changed to "shall consider." The commenter states that if OIG is aware of a mitigating factor, it should be considered. Another commenter requests that OIG clarify that it will consider all applicable mitigating evidence, regardless of its source, and will notify physicians and providers of the opportunity to present mitigating evidence.

Response: As provided in §371.1603(f), OIG must take into consideration any mitigating factors --regardless of source-- when making a preliminary determination of the appropriate administrative action or sanction. Section 371.1603(h) lists items that may be considered as mitigating factors. If the facts of a particular case support any of the items listed in (h), and OIG determines that such facts are mitigating, OIG must take such facts into consideration as required in (f). OIG notes that if a person disagrees with or wishes to dispute the proposed administrative action or sanction, the person may decline to sign a settlement agreement offered by OIG and has a right to request and have a hearing. OIG considers the rule language to be the vehicle by which OIG provides notice that providers have the burden to present mitigating evidence to OIG. No change was made in response to this comment.

Comment: One commenter recommends that OIG add two mitigating factors to §371.1603(h): (1) whether the physician or provider had implemented procedures or safeguards to prevent the violation; and (2) the provider's lack of prior record.

Response: OIG believes the factors listed in §371.1603(h), as amended, particularly (h)(2), (6), and (7), and (f)(4), provide sufficient opportunity for OIG to consider the mitigating factors proposed by the commenter. No change was made in response to this comment.

Comment: One commenter agrees that the amended rule language protects the due process of a person subject to agency regulation and agrees with OIG that each case must be evaluated individually.

Response: OIG appreciates the supportive comment. No change was made in response to the comment.

Comment: One commenter states that Texas Human Resource Code §32.039 is limited in its application to certain violations specifically listed in that statutory provision (e.g., certain anti-kickback violations, false claims violations, and managed care organization violations). The commenter further states that OIG's proposed amendment language in §371.1715 appears to extend the application of Texas Human Resource Code §32.039 to other types of violations. The commenter requested more information on the statutory language authorizing the amendments proposed in §371.1715.

Response: The language added to §371.1715(a) is taken directly from Texas Government Code §531.102(h)(1). No change was made in response to the comment.

Comment: One commenter states that the proposed change in §371.1715(a) greatly expands the scope clearly identified by the Legislature as it relates to OIG and would permit OIG to take any administrative penalty that has been granted to any health and human services agency, rather than the prescribed penalties authorized by Texas Human Resource Code §32.039.

Response: The language added to subsection (a) is taken directly from Texas Government Code §531.102(h)(1). No change was made in response to the comment.

Comment: One commenter submits questions, comments, concerns and suggested solutions related to Financial Management Services Agencies.

Response: This comment does not specifically address any particular proposed amendment to §371.1603 or §371.1715, therefore, OIG considers this comment to be beyond the scope of the proposed amendments. No change was made in response to this comment.

DIVISION 1. GENERAL PROVISIONS

1 TAC §371.1603

STATUTORY AUTHORITY

The amendments are authorized under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Government Code §531.102(a), which provides OIG with the authority to obtain any information or technology necessary to enable it to meet its responsibilities; Texas Government Code §531.102(a-2), which requires the Executive Commissioner of HHSC to work in consultation with OIG to adopt rules necessary to implement a power or duty of the office; Texas Government Code §531.102(x), which requires the HHSC Executive Commissioner, in consultation with OIG, to adopt rules establishing criteria for determining enforcement and punitive actions with regard to a provider who has violated state law, program rules, or the provider's Medicaid provider agreement; Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas, to administer Medicaid funds, and to adopt rules necessary for the proper and efficient regulations of the Medicaid program; Texas Government Code §531.1131(e), which provides HHSC with the authority to adopt rules necessary to implement that section; and Texas Human Resources Code §32.039, which provides HHSC with the authority to assess administrative penalties and damages and provides due process for persons potentially subject to more damages and penalties.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 30, 020.

TRD-202001720

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Effective date: May 20, 2020

Proposal publication date: December 13, 2019

For further information, please call: (512) 491-4058


DIVISION 3. ADMINISTRATIVE ACTIONS AND SANCTIONS

1 TAC §371.1715

STATUTORY AUTHORITY

The amendments are authorized under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Government Code §531.102(a), which provides OIG with the authority to obtain any information or technology necessary to enable it to meet its responsibilities; Texas Government Code §531.102(a-2), which requires the Executive Commissioner of HHSC to work in consultation with OIG to adopt rules necessary to implement a power or duty of the office; Texas Government Code §531.102(x), which requires the HHSC Executive Commissioner, in consultation with OIG, to adopt rules establishing criteria for determining enforcement and punitive actions with regard to a provider who has violated state law, program rules, or the provider's Medicaid provider agreement; Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas, to administer Medicaid funds, and to adopt rules necessary for the proper and efficient regulations of the Medicaid program; Texas Government Code §531.1131(e), which provides HHSC with the authority to adopt rules necessary to implement that section; and Texas Human Resources Code §32.039, which provides HHSC with the authority to assess administrative penalties and damages and provides due process for persons potentially subject to more damages and penalties.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 30, 2020.

TRD-202001721

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Effective date: May 20, 2020

Proposal publication date: December 13, 2019

For further information, please call: (512) 491-4058