Texas Register August 7, 2026 Volume: 51 Number: 32

Governor

Appointments Re:

Appointed to the Texas Medical Board District One Review Committee for a term to expire January 15, 2030, Manish Rungta, M.D. of Bellaire, Texas (replacing Rajesh G. Shenava, M.D. of Houston who resigned).

Appointed to the Texas Medical Board District One Review Committee for a term to expire January 15, 2032, Adrian Caraves of Galveston, Texas (replacing Kimberly R. Phillips of Houston whose term expired).

Appointed to the Texas Medical Board District One Review Committee for a term to expire January 15, 2032, Elizabeth A. Cloninger, M.D. of League City, Texas (replacing Imran A. Dar, M.D. of Houston whose term expired).

Appointed to the Texas Medical Board District Two Review Committee for a term to expire January 15, 2032, Ivan D. Rovner, M.D. of Plano, Texas (Dr. Rovner is being reappointed).

Appointed to the Texas Medical Board District Two Review Committee for a term to expire January 15, 2032, Steven B. “Steve” Westbrook, Ed.D. of Nacogdoches, Texas (replacing Angela A. Downes of Irving whose term expired).

Appointed to the Texas Medical Board District Four Review Committee for a term to expire January 15, 2032, Ruth Villarreal of Mission, Texas (Ms. Villarreal is being reappointed).

Appointed to the Texas Medical Board District Four Review Committee for a term to expire January 15, 2032, Matthew T. “Matt” Wallace, M.D. of Austin, Texas (replacing Andrew J. “Jimmy” Widmer, M.D. of Celina whose term expired).

Appointed to the Early Childhood Intervention Advisory Committee for a term to expire February 1, 2029, Sheri L. O’Daniel of Amarillo, Texas (replacing Audrey K. Jackson of San Marcos who resigned).

Appointed to the Early Childhood Intervention Advisory Committee for a term to expire February 1, 2031, Dana L. Dodgen of Dallas, Texas (replacing Cynthia D. “Cindy” Lee, Ed.D. of McKinney who resigned).

Appointed to the Early Childhood Intervention Advisory Committee for a term to expire February 1, 2031, Celina C. Perez of San Benito, Texas (replacing Chasey M. Sanchez, Ed.D. of Orange Grove whose term expired).

Executive Order GA-57 Re:

Directing the Texas Health and Human Services Commission, the Department of State Health Services, the HHSC Office of Inspector General, the Texas Medical Board, the Texas Board of Nursing, and the Texas Department of Licensing and Regulation to investigate and take enforcement action against birth tourism schemes involving Texas hospitals, birthing centers, and other licensed healthcare facilities and providers.

Relating to coordinated efforts to eliminate unlawful birth tourism schemes in Texas.

WHEREAS, for four years, the Biden-Harris Administration adopted open-border policies that invited mass illegal entry into Texas and other states, including by ignoring laws that require the federal government to secure the border, construct barrier infrastructure, detain illegal aliens, vet would-be entrants, and swiftly remove aliens pressing frivolous asylum claims; and

WHEREAS, the surge of individuals crossing the southern border resulted in roughly 12 million people-a number larger than the population of 43 different states-entering this country illegally in less than four years; and

WHEREAS, this unprecedented entry into the country forced the state to shoulder numerous costs associated with illegal immigration, including costs associated with strengthening law enforcement and defense measures and providing medical care, public education, and other public resources to individuals not lawfully present in the United States, predictably straining resources and increasing costs for all Texans; and

WHEREAS, this unprecedented entry also facilitated the movement of hostile non-state actors like violent criminals, gang members, and known terrorists, as predicted by former Federal Bureau of Investigation (FBI) officials who warned that “the surge in numbers of single, military-aged males” from hostile nations and regions “appears to be an accelerated and strategic penetration, a soft invasion, designed to gain internal access to” the United States and “inflict catastrophic damage” on this country, Letter from Former FBI Officials to Members of U.S. Congress (Jan. 17, 2024); and

WHEREAS, I, Greg Abbott, Governor of Texas, launched Operation Lone Star, consistent with Article I, Section 10, Clause 3 of the U.S. Constitution, to defend the people of Texas against a hostile invasion by employing strategies to deter efforts to violate Texas’ territorial sovereignty, deny efforts to enter illegally, and detain illegal immigrants; and

WHEREAS, I, Greg Abbott, Governor of Texas, issued a disaster proclamation on May 31, 2021, certifying under Section 418.014 of the Texas Government Code that the surge of individuals unlawfully crossing the Texas-Mexico border posed an ongoing and imminent threat of disaster for a number of Texas counties and for all state agencies affected by this disaster; and

WHEREAS, entities doing business in the State of Texas, including hospitals, have sought to profit from the ongoing effects of this disaster by incentivizing “birth tourism” schemes-the practice of non-citizen aliens exploiting our laws by traveling to the United States illegally or under false pretenses solely to give birth and secure citizenship for their child; and

WHEREAS, a narrow majority of the Supreme Court of the United States recently held that the U.S. Constitution automatically entitles children of illegal aliens and temporary birth tourists to U.S. citizenship if they are born in the United States, Trump v. Barbara, No. 25-365, slip op. at 12 (U.S. June 30, 2026); and

WHEREAS, that decision is not only inconsistent with centuries of practice excluding the children of non-citizen aliens who are temporarily present or who owe loyalty to a different sovereign from acquiring citizenship, Trump, slip op. at 9 (Kavanaugh, J., concurring in judgment and dissenting in part); Trump, slip op. at 2 (Gorsuch, J., dissenting), but also would bestow citizenship on the child “of a foreign spy” or “a strategic adversary or enemy of the United States,” Trump, slip op. at 56 (Thomas, J., dissenting); Trump, slip op. at 38 (Alito, J., dissenting); and

WHEREAS, the same day the Supreme Court issued this decision, the U.S. Department of Justice (DOJ) issued a memorandum “directing all United States Attorneys and the Criminal Division to work with the Department of Homeland Security to prioritize the investigation and prosecution of birth tourism schemes,” Memorandum from Colin M. McDonald, Assistant Attorney General, U.S. Department of Justice, National Fraud Enforcement Division (June 30, 2026); and

WHEREAS, the DOJ memorandum detailed how such schemes frequently involve “lies about the purpose or duration of one’s travel to the United States” and could run afoul of numerous federal criminal laws, including laws prohibiting visa fraud, wire fraud, money laundering, misuse of identification, identity theft, and health care fraud, see Memorandum from Colin M. McDonald (citing 18 U.S.C.§§ 1028, 1028A, 1343, 1347, 1349, 1546, 1956); and

WHEREAS, the Texas Attorney General has likewise taken steps to combat illegal birth tourism schemes, including suing a Houston-area facility that claims to have facilitated birth tourism for “1,000+” foreign nationals and allegedly coached customers to mislead or deceive federal immigration officials about the purpose of their visits to the United States, in violation of state laws, see TEX. PENAL CODE §§ 20.05(a)(2), 37.10, 71.02; TEX. CIV. PRAC. & REM. CODE § 125.062; TEX. BUS. & COMM. CODE § 17.46(a), (b)(2), (3), (5), (9), (12); and

WHEREAS, I, Greg Abbott, Governor of Texas, directed the Texas Health and Human Services Commission (HHSC) on July 7, 2026, to launch an immediate investigation into reports that Texas hospitals were advertising birth tourism packages to individuals in foreign countries and to refer any violations of state law to the Office of the Attorney General for civil enforcement and to the appropriate District or County Attorney for criminal prosecution; and

WHEREAS, HHSC acted swiftly in referring to the Texas Attorney General two Texas hospitals that allegedly placed billboards in a foreign country advertising “birth packages” in South Texas for fixed prices starting as low as $3,950, and directed viewers to a website soliciting patients to engage in medical birthing services; and

WHEREAS, no person may establish or operate a hospital, birthing center, freestanding emergency medical care facility, or any other facility authorized to conduct births in Texas without a license issued by the State of Texas, see TEX. HEALTH & SAFETY CODE §§ 241.021, 244.003, 254.051; and

WHEREAS, HHSC is responsible for promulgating the rules and minimum standards for hospitals and other health care providers and ensuring the efficient use of state and local health-related resources and monitoring Medicaid and other federal funding programs supporting health care services, see TEX. GOV’T CODE §§ 523.0001, 523.0002, 524.0001, 524.0151; TEX. HEALTH & SAFETY CODE §§ 62.051, 241.026; TEX. HUM. RES. CODE § 32.021; and

WHEREAS, the Texas Department of State Health Services (DSHS) administers the registration of vital statistics and licensing and regulates birthing facilities in Texas, see TEX. HEALTH & SAFETY CODE §§ 191.002, 192.002, 244.003, 311.032, 311.033; and

WHEREAS, the Office of Inspector General (OIG) of HHSC is tasked with preventing, detecting, auditing, inspecting, and investigating fraud, waste, and abuse in the provision and delivery of all health and human services in this State, see TEX. GOV’T CODE § 544.0103; and

WHEREAS, the Texas Medical Board (TMB) is tasked with regulating the practice of medicine, issuing, suspending, or revoking medical licenses, and promulgating rules concerning false or misleading advertising or other deceptive practices by a person licensed to practice medicine, see TEX. OCC. CODE §§ 152.001, 153.001, 153.002, 155.002, 155.212; and

WHEREAS, the Texas Board of Nursing (BON) is tasked with regulating the practice of professional nursing and vocational nursing, including by promulgating rules regarding specialized training, prescribing standards of professional conduct, and prohibiting false or misleading advertising or other deceptive practices, see TEX. OCC. CODE §§ 301.151, 301.152, 301.153; and

WHEREAS, the Texas Department of Licensing and Regulation (TDLR) is tasked with regulating the practice of midwifery, including by issuing, suspending, or revoking midwifery licenses, and promulgating rules prescribing the standards for the practice of midwifery, see TEX. OCC. CODE §§ 203.151, 203.251, 203.404;

NOW, THEREFORE, I, GREG ABBOTT, Governor of Texas, by virtue of the power and authority vested in me by the Constitution and Statutes of the State of Texas, do hereby direct the following actions:

(1) DSHS, HHSC, OIG, TMB, BON, and TDLR must investigate claims of birth tourism schemes in Texas’ healthcare industry and take action against licensed or regulated individuals and entities advertising, soliciting, engaging in, assisting with, providing, or otherwise participating in such activities, including by revoking or suspending licensure, prohibiting participation in state contracts, denying state benefits, or taking other enforcement action; and

(2) DSHS, HHSC, OIG, TMB, BON, and TDLR may, subject to approval by the Governor consistent with Article IV, Section 10 of the Texas Constitution, partner with federal prosecutors to identify and combat birth tourism schemes in Texas’ healthcare industry, including by sharing information or resources and referring potential violations of federal law.

This executive order supersedes all previous orders in conflict or inconsistent with its terms and shall remain in effect and in full force until modified, amended, rescinded, or superseded by the Governor.

Given under my hand this the 21st day of July, 2026.

Texas Health and Human Services Commission

Proposed Rules Re:

Amending 1 TAC §355.8070, to establish a calculation to allow unused Hospital Augmented Reimbursement Program (HARP) payment room to be distributed to other eligible hospitals within the same class.

CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
DIVISION 4. MEDICAID HOSPITAL SERVICES
1 TAC §355.8070

OVERVIEW

The executive commissioner of the Texas Health and Human Services Commission (HHSC) proposes an amendment to §355.8070, concerning Hospital Augmented Reimbursement Program (HARP).

BACKGROUND AND JUSTIFICATION

The purpose of the proposal is to establish a calculation to allow for any unused HARP payment room to be distributed to other eligible hospitals within the same class based on an allocation proportionate to the remaining Medicaid charges in excess of all Medicaid payments, including supplemental payments and the portion of HARP payments for the inpatient fee-for-service (FFS) Medicare payment gap.

An amendment to §355.8070 was adopted and effective on April 2, 2025. That amendment added the Centers for Medicare & Medicaid Services (CMS) definition of a nominal charge provider and clarified that the payment methodology for HARP payments would limit inpatient Medicaid payments so they would not exceed inpatient Medicaid charges for all providers, except those that meet the Medicare definition of a nominal charge provider. This proposal will establish a mechanism to distribute any unused payment room after the limitation is applied to other eligible hospitals within the same class.

Additional edits are made to the rule to correct grammar and punctuation, spell out acronyms for clarity, and reorganize parts where necessary.

SECTION-BY-SECTION SUMMARY

The proposed amendment to §355.8070(a) spells out acronyms and adds punctuation for clarity.

The proposed amendment to §355.8070(b) aligns the rule language with standard HHSC drafting conventions and includes a grammatical correction.

The proposed amendment to §355.8070(d) adds subparagraph (B) to paragraph (3) to explain the allocation of unused payment room as it applies to non-state government-owned and operated hospitals for program periods beginning on or after October 1, 2026. Edits are also made to add punctuation, correct grammar for clarity, and reorganize paragraph (3) to account for the addition of a subparagraph.

The proposed amendment to §355.8070(e) adds subparagraph (B) to paragraph (3) to explain the allocation of unused payment room as it applies to private hospitals for program periods beginning on or after October 1, 2026. Edits are also made to add an acronym, add punctuation, correct grammar for clarity, and reorganize paragraph (3) to account for the addition of a subparagraph.

The proposed amendment to §355.8070(f), (g), and (h) corrects grammar and punctuation for clarity.

Amending 26 TAC §550.1301, to limit survey frequency from annually to every three years and to update obsolete references.

CHAPTER 550. LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS
SUBCHAPTER F. INSPECTIONS AND VISITS
26 TAC §550.1301

OVERVIEW

The executive commissioner of the Texas Health and Human Services Commission (HHSC) proposes an amendment to §550.1301, concerning Inspections and Visits.

BACKGROUND AND JUSTIFICATION

The purpose of the proposal is to update the rule to limit survey frequency from annually to every three years in alignment with current licensure renewal and inspection timeframe requirements in Texas Health and Safety Code §248A.053 and §248A.102. The changes reduce administrative and operational burdens for providers associated with annual inspections.

This proposal also deletes or updates obsolete references and clarifies existing language to improve overall readability.

SECTION-BY-SECTION SUMMARY

The proposed amendment to §550.1301(a) and (b) clarifies language and improves readability. The edits to subsection (c) clarify that, except for visits outlined in subsection (e), HHSC does not announce inspections as well as investigations and visits described in subsection (a). The update to subsection (d) removes language referencing at least one licensing inspection annually because an inspection will now be conducted at least once every three years. The update to subsection (e) reorganizes the subsection for clarity and improved readability and includes restructuring paragraph (2) to new subsection (f).

Adopted Rules Re:

Adopting amendments to 1 TAC §354.4003, §354.4005, §354.4006, and §354.4013, to reflect the wind-down of the STAR+PLUS Medicare-Medicaid Plan Dual Demonstration Program, phase out the use of alternative devices for electronic visit verification, and update related compliance review and enforcement provisions.

CHAPTER 354. MEDICAID HEALTH SERVICES
SUBCHAPTER O. ELECTRONIC VISIT VERIFICATION
1 TAC §§354.4003, 354.4005, 354.4006, 354.4013

OVERVIEW

The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §354.4003, concerning Definitions; §354.4005, concerning Personal Care Services that Require the Use of EVV; §354.4006, concerning Home Health Care Services that Require the Use of EVV; and §354.4013, concerning HHSC and MCO Compliance Reviews and Enforcement Actions.

Sections 354.4003, 354.4005, 354.4006 and 354.4013 are adopted without changes to the proposed text as published in the April 3, 2026, issue of the Texas Register (51 TexReg 2166). These rules will not be republished.

BACKGROUND AND JUSTIFICATION

The amendments, in part, are necessary to comply with the Centers for Medicare & Medicaid Services (CMS) Contract Year 2023 Medicare Advantage and Part D Final Rule that required states to phase-out their Medicare-Medicaid Plan (MMP) Dual Demonstration Program. The amendments reflect that the STAR+PLUS MMP ended December 31, 2025.

The amendments also reflect that electronic visit verification (EVV) was required for STAR+PLUS MMP personal care and home health services, if delivered before January 1, 2026. This clarification is necessary because though the MMP Dual Demonstration Program ended on December 31, 2025, program providers and financial management services agencies (FMSAs) may need to submit EVV claims for MMP services that were delivered before the MMP Dual Demonstration Program end date.

The amendments remove Free Text Reviews from the list of compliance reviews because HHSC and managed care organizations (MCOs) stopped conducting these reviews in 2023.

The amendments add an EVV Alternative Device Compliance Review, and the actions HHSC and the MCO may take, if a program provider’s or consumer directed services (CDS) employer’s EVV Alternative Device Compliance score exceeds the allowable percentage score described in the EVV Policy Handbook. The alternative device reduction schedule is in the EVV Policy Handbook, limiting the use of an alternative device as an approved method to clock in and clock out of an EVV system over a four-year period beginning September 1, 2025 (fiscal year 2026). Gradually reducing reliance on alternative devices allows program providers and CDS employers time to migrate their service providers and CDS employees to one of the other approved clock in and clock out methods. The purpose for limiting the use of an alternative device is to enhance program integrity.

The amendments require a program provider or CDS employer to use EVV if Medicaid pays for any part of the personal care or home health care services that require EVV. These amendments clarify that EVV must be used if these services are paid for by both Medicaid and a third party, such as private insurance.

The amendment to §354.4003 defines “dual eligible member” to make sure the public understands the meaning of this term when used in the rules and revises the definitions of EVV proprietary system, EVV state vendor system, and program provider to make their meanings clearer.

The amendment to §354.4013 clarifies that the action HHSC or the MCO may propose the third time a CDS employer does not meet the EVV Usage Score may end the member’s participation in the CDS option, not terminate the member from the Medicaid program.

Adopting new 26 TAC Chapter 749, Subchapter F, Training Requirements (Divisions 1-3: Caregiver Training Requirements, Employee Training Requirements, Employee and Caregiver Training Documentation Requirements), §§749.801, 749.803, 749.805, 749.807, 749.821, 749.823, 749.825, and 749.831, as part of a comprehensive repeal and restructuring of Chapter 749, Minimum Standards for Child-Placing Agencies.

CHAPTER 749. MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES
SUBCHAPTER F. TRAINING REQUIREMENTS
26 TAC §§749.801, 749.803, 749.805, 749.807, 749.821, 749.823, 749.825, 749.831

OVERVIEW

The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts the repeal of the current Chapter 749 sections governing training and experience requirements, children’s rights, foster care admissions and placement, service planning and discharge, medical and dental care, emergency behavior intervention, foster home screenings and verifications, foster home management and evaluation, and foster home health, safety, space, and equipment requirements, and adopts new sections restructuring these same subject areas, as detailed in the Register.

New §§749.801, 749.803, 749.805, 749.807, 749.821, 749.831, 749.901, 749.923, 749.925, 749.929, 749.931, 749.935, 749.937, 749.951, 749.953, 749.955, 749.957, 749.973, 749.1001, 749.1003, 749.1005, 749.1007, 749.1009, 749.1013, 749.1017, 749.1035, 749.1051, 749.1101, 749.1103, 749.1109, 749.1201, 749.1211, 749.1213, 749.1215, 749.1231, 749.1235, 749.1251, 749.1303, 749.1419, 749.1501, 749.1505, 749.1601, and 749.1603 are adopted with changes to the proposed text as published in the February 13, 2026, issue of the Texas Register (51 TexReg 815) and will be republished.

New §§749.823, 749.825, 749.903, 749.905, 749.921, 749.927, 749.933, 749.959, 749.975, 749.977, 749.1011, 749.1015, 749.1019, 749.1031, 749.1033, 749.1037, 749.1053, 749.1061, 749.1063, 749.1065, 749.1105, 749.1107, 749.1203, 749.1205, 749.1207, 749.1209, 749.1217, 749.1233, 749.1237, 749.1253, 749.1301, 749.1305, 749.1307, 749.1401, 749.1403, 749.1405, 749.1407, 749.1409, 749.1411, 749.1413, 749.1415, 749.1417, 749.1421, 749.1423, 749.1503, 749.1605, 749.1607, 749.1621, 749.1623, 749.1625, 749.1631, 749.1633, and 749.1635 are adopted without changes and will not be republished.

BACKGROUND AND JUSTIFICATION

The repeals and new sections are necessary to (1) comply with Texas Human Resources Code (HRC) §42.042(b); (2) implement an HHSC regulatory reform initiative created by Senate Bill (SB) 593, 88th Legislature, Regular Session, 2023; (3) implement House Bill (HB) 1403, 89th Legislature, Regular Session, 2025; and (4) implement HB 2789, 89th Legislature, Regular Session, 2025.

HRC §42.042(b) requires HHSC Child Care Regulation (CCR) to conduct a comprehensive review of minimum standards at least once every six years. SB 593 required HHSC to contract with an independent entity to assess HHSC rules, minimum standards, Texas Department of Family and Protective Services (DFPS) contract requirements, and standards or oversight requirements prescribed by law. The independent contractor completed an assessment and found that existing minimum standards were overly detailed, repetitive, or administrative in nature and could be streamlined while maintaining protections for the health and safety of children in care.

HB 1403 amended HRC §42.042 to ensure the confidentiality of foster homes related to firearms. HRC §42.042 prohibits HHSC or a child-placing agency (CPA) from requiring a foster home to (1) disclose the specific types of firearms that are present in the home; or (2) notify the CPA if there is any change in the types of firearms present in the home.

Section 2 of HB 2789 amended HRC §42.043 to remove the requirement for a child in care to have a tuberculosis test.