(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.
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Terms Used In Alabama Code 22-6-8

  • Fraud: Intentional deception resulting in injury to another.
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
  • state: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Alabama Code 1-1-1
  • year: means a calendar year; but, whenever the word "year" is used in reference to any appropriations for the payment of money out of the treasury, it shall mean fiscal year. See Alabama Code 1-1-1
(b) Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a period of not less than one year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(c) When a Medicaid recipient, whose eligibility has been revoked due to abuse, fraud, or other deliberate misuse of the program, reapplies for coverage during the period of suspension due to pregnancy, the utilization review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.
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