(a) Upon determination by a utilization review committee of the designated State Medicaid Agency that a Medicaid recipient has abused, defrauded, or misused the benefits of the program said recipient shall immediately become ineligible for Medicaid benefits.
(b) Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a period of not less than one year and until full restitution has been made to the designated State Medicaid Agency.
(c) When a Medicaid recipient, whose eligibility has been revoked due to abuse, fraud, or other deliberate misuse of the program, reapplies for coverage during the period of suspension due to pregnancy, the utilization review committee for the State Medicaid Agency may change the suspended status of the recipient to restricted status where it has been determined that it would be in the best interest of the unborn child for the mother to receive coverage for pregnancy related services. Where such a change in status is granted, the case will be reconsidered by the utilization review committee within sixty days after the birth of the child for further action.
(d) The provisions of this section shall not be effective if they are found by a court of competent jurisdiction to contravene federal laws or federal regulations applicable to the Medicaid Program.
Last modified: May 3, 2021