Rep. Kelly M. Cassidy

Filed: 4/30/2012

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 2840

2    AMENDMENT NO. ______. Amend Senate Bill 2840 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5, 11-13, 11-26, 12-4.25, and 12-13.1 as
6follows:
 
7    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
8    Sec. 5-5. Medical services. The Illinois Department, by
9rule, shall determine the quantity and quality of and the rate
10of reimbursement for the medical assistance for which payment
11will be authorized, and the medical services to be provided,
12which may include all or part of the following: (1) inpatient
13hospital services; (2) outpatient hospital services; (3) other
14laboratory and X-ray services; (4) skilled nursing home
15services; (5) physicians' services whether furnished in the
16office, the patient's home, a hospital, a skilled nursing home,

 

 

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1or elsewhere; (6) medical care, or any other type of remedial
2care furnished by licensed practitioners; (7) home health care
3services; (8) private duty nursing service; (9) clinic
4services; (10) dental services, including prevention and
5treatment of periodontal disease and dental caries disease for
6pregnant women, provided by an individual licensed to practice
7dentistry or dental surgery; for purposes of this item (10),
8"dental services" means diagnostic, preventive, or corrective
9procedures provided by or under the supervision of a dentist in
10the practice of his or her profession; (11) physical therapy
11and related services; (12) prescribed drugs, dentures, and
12prosthetic devices; and eyeglasses prescribed by a physician
13skilled in the diseases of the eye, or by an optometrist,
14whichever the person may select; (13) other diagnostic,
15screening, preventive, and rehabilitative services, for
16children and adults; (14) transportation and such other
17expenses as may be necessary; (15) medical treatment of sexual
18assault survivors, as defined in Section 1a of the Sexual
19Assault Survivors Emergency Treatment Act, for injuries
20sustained as a result of the sexual assault, including
21examinations and laboratory tests to discover evidence which
22may be used in criminal proceedings arising from the sexual
23assault; (16) the diagnosis and treatment of sickle cell
24anemia; and (17) any other medical care, and any other type of
25remedial care recognized under the laws of this State, but not
26including abortions, or induced miscarriages or premature

 

 

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1births, unless, in the opinion of a physician, such procedures
2are necessary for the preservation of the life of the woman
3seeking such treatment, or except an induced premature birth
4intended to produce a live viable child and such procedure is
5necessary for the health of the mother or her unborn child. The
6Illinois Department, by rule, shall prohibit any physician from
7providing medical assistance to anyone eligible therefor under
8this Code where such physician has been found guilty of
9performing an abortion procedure in a wilful and wanton manner
10upon a woman who was not pregnant at the time such abortion
11procedure was performed. The term "any other type of remedial
12care" shall include nursing care and nursing home service for
13persons who rely on treatment by spiritual means alone through
14prayer for healing.
15    Notwithstanding any other provision of this Section, a
16comprehensive tobacco use cessation program that includes
17purchasing prescription drugs or prescription medical devices
18approved by the Food and Drug Administration shall be covered
19under the medical assistance program under this Article for
20persons who are otherwise eligible for assistance under this
21Article.
22    Notwithstanding any other provision of this Code, the
23Illinois Department may not require, as a condition of payment
24for any laboratory test authorized under this Article, that a
25physician's handwritten signature appear on the laboratory
26test order form. The Illinois Department may, however, impose

 

 

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1other appropriate requirements regarding laboratory test order
2documentation.
3    The Department of Healthcare and Family Services shall
4provide the following services to persons eligible for
5assistance under this Article who are participating in
6education, training or employment programs operated by the
7Department of Human Services as successor to the Department of
8Public Aid:
9        (1) dental services provided by or under the
10    supervision of a dentist; and
11        (2) eyeglasses prescribed by a physician skilled in the
12    diseases of the eye, or by an optometrist, whichever the
13    person may select.
14    Notwithstanding any other provision of this Code and
15subject to federal approval, the Department may adopt rules to
16allow a dentist who is volunteering his or her service at no
17cost to render dental services through an enrolled
18not-for-profit health clinic without the dentist personally
19enrolling as a participating provider in the medical assistance
20program. A not-for-profit health clinic shall include a public
21health clinic or Federally Qualified Health Center or other
22enrolled provider, as determined by the Department, through
23which dental services covered under this Section are performed.
24The Department shall establish a process for payment of claims
25for reimbursement for covered dental services rendered under
26this provision.

 

 

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1    The Illinois Department, by rule, may distinguish and
2classify the medical services to be provided only in accordance
3with the classes of persons designated in Section 5-2.
4    The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11    The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for women
1435 years of age or older who are eligible for medical
15assistance under this Article, as follows:
16        (A) A baseline mammogram for women 35 to 39 years of
17    age.
18        (B) An annual mammogram for women 40 years of age or
19    older.
20        (C) A mammogram at the age and intervals considered
21    medically necessary by the woman's health care provider for
22    women under 40 years of age and having a family history of
23    breast cancer, prior personal history of breast cancer,
24    positive genetic testing, or other risk factors.
25        (D) A comprehensive ultrasound screening of an entire
26    breast or breasts if a mammogram demonstrates

 

 

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1    heterogeneous or dense breast tissue, when medically
2    necessary as determined by a physician licensed to practice
3    medicine in all of its branches.
4    All screenings shall include a physical breast exam,
5instruction on self-examination and information regarding the
6frequency of self-examination and its value as a preventative
7tool. For purposes of this Section, "low-dose mammography"
8means the x-ray examination of the breast using equipment
9dedicated specifically for mammography, including the x-ray
10tube, filter, compression device, and image receptor, with an
11average radiation exposure delivery of less than one rad per
12breast for 2 views of an average size breast. The term also
13includes digital mammography.
14    On and after January 1, 2012, providers participating in a
15quality improvement program approved by the Department shall be
16reimbursed for screening and diagnostic mammography at the same
17rate as the Medicare program's rates, including the increased
18reimbursement for digital mammography.
19    The Department shall convene an expert panel including
20representatives of hospitals, free-standing mammography
21facilities, and doctors, including radiologists, to establish
22quality standards.
23    Subject to federal approval, the Department shall
24establish a rate methodology for mammography at federally
25qualified health centers and other encounter-rate clinics.
26These clinics or centers may also collaborate with other

 

 

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1hospital-based mammography facilities.
2    The Department shall establish a methodology to remind
3women who are age-appropriate for screening mammography, but
4who have not received a mammogram within the previous 18
5months, of the importance and benefit of screening mammography.
6    The Department shall establish a performance goal for
7primary care providers with respect to their female patients
8over age 40 receiving an annual mammogram. This performance
9goal shall be used to provide additional reimbursement in the
10form of a quality performance bonus to primary care providers
11who meet that goal.
12    The Department shall devise a means of case-managing or
13patient navigation for beneficiaries diagnosed with breast
14cancer. This program shall initially operate as a pilot program
15in areas of the State with the highest incidence of mortality
16related to breast cancer. At least one pilot program site shall
17be in the metropolitan Chicago area and at least one site shall
18be outside the metropolitan Chicago area. An evaluation of the
19pilot program shall be carried out measuring health outcomes
20and cost of care for those served by the pilot program compared
21to similarly situated patients who are not served by the pilot
22program.
23    Any medical or health care provider shall immediately
24recommend, to any pregnant woman who is being provided prenatal
25services and is suspected of drug abuse or is addicted as
26defined in the Alcoholism and Other Drug Abuse and Dependency

 

 

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1Act, referral to a local substance abuse treatment provider
2licensed by the Department of Human Services or to a licensed
3hospital which provides substance abuse treatment services.
4The Department of Healthcare and Family Services shall assure
5coverage for the cost of treatment of the drug abuse or
6addiction for pregnant recipients in accordance with the
7Illinois Medicaid Program in conjunction with the Department of
8Human Services.
9    All medical providers providing medical assistance to
10pregnant women under this Code shall receive information from
11the Department on the availability of services under the Drug
12Free Families with a Future or any comparable program providing
13case management services for addicted women, including
14information on appropriate referrals for other social services
15that may be needed by addicted women in addition to treatment
16for addiction.
17    The Illinois Department, in cooperation with the
18Departments of Human Services (as successor to the Department
19of Alcoholism and Substance Abuse) and Public Health, through a
20public awareness campaign, may provide information concerning
21treatment for alcoholism and drug abuse and addiction, prenatal
22health care, and other pertinent programs directed at reducing
23the number of drug-affected infants born to recipients of
24medical assistance.
25    Neither the Department of Healthcare and Family Services
26nor the Department of Human Services shall sanction the

 

 

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1recipient solely on the basis of her substance abuse.
2    The Illinois Department shall establish such regulations
3governing the dispensing of health services under this Article
4as it shall deem appropriate. The Department should seek the
5advice of formal professional advisory committees appointed by
6the Director of the Illinois Department for the purpose of
7providing regular advice on policy and administrative matters,
8information dissemination and educational activities for
9medical and health care providers, and consistency in
10procedures to the Illinois Department.
11    Notwithstanding any other provision of law, a health care
12provider under the medical assistance program may elect, in
13lieu of receiving direct payment for services provided under
14that program, to participate in the State Employees Deferred
15Compensation Plan adopted under Article 24 of the Illinois
16Pension Code. A health care provider who elects to participate
17in the plan does not have a cause of action against the State
18for any damages allegedly suffered by the provider as a result
19of any delay by the State in crediting the amount of any
20contribution to the provider's plan account.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration projects
25in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by rule,

 

 

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1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by the
17    Partnership may receive an additional surcharge for such
18    services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

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1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that provided
14services may be accessed from therapeutically certified
15optometrists to the full extent of the Illinois Optometric
16Practice Act of 1987 without discriminating between service
17providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance under
24this Article. Such records must be retained for a period of not
25less than 6 years from the date of service or as provided by
26applicable State law, whichever period is longer, except that

 

 

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1if an audit is initiated within the required retention period
2then the records must be retained until the audit is completed
3and every exception is resolved. The Illinois Department shall
4require health care providers to make available, when
5authorized by the patient, in writing, the medical records in a
6timely fashion to other health care providers who are treating
7or serving persons eligible for Medical Assistance under this
8Article. All dispensers of medical services shall be required
9to maintain and retain business and professional records
10sufficient to fully and accurately document the nature, scope,
11details and receipt of the health care provided to persons
12eligible for medical assistance under this Code, in accordance
13with regulations promulgated by the Illinois Department. The
14rules and regulations shall require that proof of the receipt
15of prescription drugs, dentures, prosthetic devices and
16eyeglasses by eligible persons under this Section accompany
17each claim for reimbursement submitted by the dispenser of such
18medical services. No such claims for reimbursement shall be
19approved for payment by the Illinois Department without such
20proof of receipt, unless the Illinois Department shall have put
21into effect and shall be operating a system of post-payment
22audit and review which shall, on a sampling basis, be deemed
23adequate by the Illinois Department to assure that such drugs,
24dentures, prosthetic devices and eyeglasses for which payment
25is being made are actually being received by eligible
26recipients. Within 90 days after the effective date of this

 

 

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1amendatory Act of 1984, the Illinois Department shall establish
2a current list of acquisition costs for all prosthetic devices
3and any other items recognized as medical equipment and
4supplies reimbursable under this Article and shall update such
5list on a quarterly basis, except that the acquisition costs of
6all prescription drugs shall be updated no less frequently than
7every 30 days as required by Section 5-5.12.
8    The rules and regulations of the Illinois Department shall
9require that a written statement including the required opinion
10of a physician shall accompany any claim for reimbursement for
11abortions, or induced miscarriages or premature births. This
12statement shall indicate what procedures were used in providing
13such medical services.
14    The Illinois Department shall require all dispensers of
15medical services, other than an individual practitioner or
16group of practitioners, desiring to participate in the Medical
17Assistance program established under this Article to disclose
18all financial, beneficial, ownership, equity, surety or other
19interests in any and all firms, corporations, partnerships,
20associations, business enterprises, joint ventures, agencies,
21institutions or other legal entities providing any form of
22health care services in this State under this Article.
23    The Illinois Department may require that all dispensers of
24medical services desiring to participate in the medical
25assistance program established under this Article disclose,
26under such terms and conditions as the Illinois Department may

 

 

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1by rule establish, all inquiries from clients and attorneys
2regarding medical bills paid by the Illinois Department, which
3inquiries could indicate potential existence of claims or liens
4for the Illinois Department.
5    Enrollment of a vendor that provides non-emergency medical
6transportation, defined by the Department by rule, shall be
7subject to a provisional period and shall be conditional for
8one year 180 days. During the period of conditional enrollment
9that time, the Department of Healthcare and Family Services may
10terminate the vendor's eligibility to participate in, or may
11disenroll the vendor from, the medical assistance program
12without cause. Such That termination of eligibility or
13disenrollment is not subject to the Department's hearing
14process. However, a disenrolled provider may reapply without
15penalty.
16    The Department has the discretion to limit the conditional
17enrollment period for providers.
18    Prior to enrollment and during the conditional enrollment
19period in the medical assistance program, all vendors shall be
20subject to enhanced oversight, screening, and review based on
21risk of fraud, waste, and abuse. The Illinois Department shall
22establish the procedures for oversight, screening, and review,
23which may include, but need not be limited to: criminal and
24financial background checks; fingerprinting; license,
25certification, and authorization verifications; unscheduled or
26unannounced site visits; database checks; prepayment audit

 

 

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1reviews; audits; payment caps; payment suspensions; and other
2screening as required by federal or State law.
3    To be eligible for payment consideration, a vendor's
4payment claim or bill, either as an initial claim or as a
5resubmitted claim following prior rejection, must be received
6by the Illinois Department, or its fiscal intermediary, no
7later than 180 days after the latest date on the claim on which
8medical goods or services were provided, with the following
9exceptions:
10        (1) In the case of a provider whose enrollment is in
11    process by the Illinois Department, the 180-day period
12    shall not begin until the date on the written notice from
13    the Illinois Department that the provider enrollment is
14    complete.
15        (2) In the case of errors attributable to the Illinois
16    Department or any of its claims processing intermediaries
17    which result in an inability to receive, process, or
18    adjudicate a claim, the 180-day period shall not begin
19    until the provider has been notified of the error.
20        (3) In the case of a provider for whom the Illinois
21    Department initiates the billing process.
22    For claims for services rendered during a period for which
23a recipient received retroactive eligibility, claims must be
24filed within 180 days after the recipient was made eligible.
25For claims for which the Illinois Department is not the primary
26payer, claims must be submitted to the Illinois Department

 

 

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1within 180 days after the final adjudication by the primary
2payer.
3    In the case of long term care facilities, admission
4documents shall be submitted through the Medical Electronic
5Data Interchange (MEDI) or the Recipient Eligibility
6Verification (REV) System within 5 days of an admission to the
7facility. Confirmation numbers assigned to an accepted
8transaction shall be retained by a facility to verify timely
9submittal. Once an admission transaction has been completed,
10all resubmitted claims following prior rejection are subject to
11receipt no later than 180 days after the rejection date.
12    Claims that are not submitted and received in compliance
13with the foregoing requirements shall not be eligible for
14payment under the medical assistance program, and the State
15shall have no liability for payment of those claims.
16    To the extent consistent with applicable information,
17privacy, security and disclosure laws, State and federal
18agencies and departments shall provide the Illinois Department
19access to confidential and other information and data necessary
20to perform eligibility and payment verifications and other
21Illinois Department functions. This includes, but is not
22limited to: information pertaining to licensure;
23certification; earnings; immigration status; citizenship; wage
24reporting; unearned and earned income; pension income;
25employment; supplemental security income; social security
26numbers; National Provider Identifier (NPI) numbers; the

 

 

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1National Practitioner Data Bank (NPDB); program and agency
2exclusions; taxpayer identification numbers; tax delinquency;
3corporate information; and death records.
4    The Illinois Department shall enter into agreements with
5State agencies and departments, and is authorized to enter into
6agreements with federal agencies and departments, under which
7such agencies and departments shall share data necessary for
8medical assistance program integrity functions and oversight.
9The Illinois Department shall develop, in cooperation with
10other State departments and agencies, and in compliance with
11applicable federal laws and regulations, appropriate and
12effective methods to share such data. At a minimum, and to the
13extent necessary to provide data sharing, the Illinois
14Department shall enter into agreements with State agencies and
15departments, and is authorized to enter into agreements with
16federal agencies and departments, including but not limited to:
17the Secretary of State; the Department of Revenue; the
18Department of Public Health; the Department of Human Services;
19and the Department of Financial and Professional Regulation.
20    Beginning in fiscal year 2013, the Illinois Department
21shall set forth a request for information to identify the
22benefits of a pre-payment, post-adjudication, and post-edit
23claims system with the goals of streamlining claims processing
24and provider reimbursement, reducing the number of pending or
25rejected claims, and helping to ensure a more transparent
26adjudication process through the utilization of: (i) provider

 

 

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1data verification and provider screening technology; and (ii)
2clinical code editing. Such a request for information shall not
3be considered as a request for proposal, or as an obligation on
4the part of the Illinois Department to take any action or
5acquire any products or services.
6    The Illinois Department shall establish policies,
7procedures, standards and criteria by rule for the acquisition,
8repair and replacement of orthotic and prosthetic devices and
9durable medical equipment. Such rules shall provide, but not be
10limited to, the following services: (1) immediate repair or
11replacement of such devices by recipients without medical
12authorization; and (2) rental, lease, purchase or
13lease-purchase of durable medical equipment in a
14cost-effective manner, taking into consideration the
15recipient's medical prognosis, the extent of the recipient's
16needs, and the requirements and costs for maintaining such
17equipment. Such rules shall enable a recipient to temporarily
18acquire and use alternative or substitute devices or equipment
19pending repairs or replacements of any device or equipment
20previously authorized for such recipient by the Department.
21    The Department shall execute, relative to the nursing home
22prescreening project, written inter-agency agreements with the
23Department of Human Services and the Department on Aging, to
24effect the following: (i) intake procedures and common
25eligibility criteria for those persons who are receiving
26non-institutional services; and (ii) the establishment and

 

 

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1development of non-institutional services in areas of the State
2where they are not currently available or are undeveloped.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation and
7programs for monitoring of utilization of health care services
8and facilities, as it affects persons eligible for medical
9assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The filing of one copy of the report with the
25Speaker, one copy with the Minority Leader and one copy with
26the Clerk of the House of Representatives, one copy with the

 

 

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1President, one copy with the Minority Leader and one copy with
2the Secretary of the Senate, one copy with the Legislative
3Research Unit, and such additional copies with the State
4Government Report Distribution Center for the General Assembly
5as is required under paragraph (t) of Section 7 of the State
6Library Act shall be deemed sufficient to comply with this
7Section.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
15eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
16eff. 1-1-12.)
 
17    (305 ILCS 5/11-13)  (from Ch. 23, par. 11-13)
18    Sec. 11-13. Conditions For Receipt of Vendor Payments -
19Limitation Period For Vendor Action - Penalty For Violation. A
20vendor payment, as defined in Section 2-5 of Article II, shall
21constitute payment in full for the goods or services covered
22thereby. Acceptance of the payment by or in behalf of the
23vendor shall bar him from obtaining, or attempting to obtain,
24additional payment therefor from the recipient or any other
25person. A vendor payment shall not, however, bar recovery of

 

 

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1the value of goods and services the obligation for which, under
2the rules and regulations of the Illinois Department, is to be
3met from the income and resources available to the recipient,
4and in respect to which the vendor payment of the Illinois
5Department or the local governmental unit represents
6supplementation of such available income and resources.
7    Vendors seeking to enforce obligations of a governmental
8unit or the Illinois Department for goods or services (1)
9furnished to or in behalf of recipients and (2) subject to a
10vendor payment as defined in Section 2-5, shall commence their
11actions in the appropriate Circuit Court or the Court of
12Claims, as the case may require, within one year next after the
13cause of action accrued.
14    A cause of action accrues within the meaning of this
15Section upon the following date:
16    (1) If the vendor can prove that he submitted a bill for
17the service rendered to the Illinois Department or a
18governmental unit within 180 days after 12 months of the date
19the service was rendered, then (a) upon the date the Illinois
20Department or a governmental unit mails to the vendor
21information that it is paying a bill in part or is refusing to
22pay a bill in whole or in part, or (b) upon the date one year
23following the date the vendor submitted such bill if the
24Illinois Department or a governmental unit fails to mail to the
25vendor such payment information within one year following the
26date the vendor submitted the bill; or

 

 

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1    (2) If the vendor cannot prove that he submitted a bill for
2the service rendered within 180 days after 12 months of the
3date the service was rendered, then upon the date 12 months
4following the date the vendor rendered the service to the
5recipient.
6    In the case of long term care facilities, where the
7Illinois Department initiates the billing process for the
8vendor, the cause of action shall accrue 12 months after the
9last day of the month the service was rendered.
10    This paragraph governs only vendor payments as defined in
11this Code and as limited by regulations of the Illinois
12Department; it does not apply to goods or services purchased or
13contracted for by a recipient under circumstances in which the
14payment is to be made directly by the recipient.
15    Any vendor who accepts a vendor payment and who knowingly
16obtains or attempts to obtain additional payment for the goods
17or services covered by the vendor payment from the recipient or
18any other person shall be guilty of a Class B misdemeanor.
19(Source: P.A. 86-430.)
 
20    (305 ILCS 5/11-26)  (from Ch. 23, par. 11-26)
21    Sec. 11-26. Recipient's abuse of medical care;
22restrictions on access to medical care.
23        (a) When the Department determines, on the basis of
24statistical norms and medical judgment, that a medical care
25recipient has received medical services in excess of need and

 

 

09700SB2840ham001- 23 -LRB097 15631 KTG 68774 a

1with such frequency or in such a manner as to constitute an
2abuse of the recipient's medical care privileges, the
3recipient's access to medical care may be restricted.
4    (b) When the Department has determined that a recipient is
5abusing his or her medical care privileges as described in this
6Section, it may require that the recipient designate a primary
7provider type of the recipient's own choosing to assume
8responsibility for the recipient's care. For the purposes of
9this subsection, "primary provider type" means a a provider
10type as determined by the Department primary care provider,
11primary care pharmacy, primary dentist, primary podiatrist, or
12primary durable medical equipment provider. Instead of
13requiring a recipient to make a designation as provided in this
14subsection, the Department, pursuant to rules adopted by the
15Department and without regard to any choice of an entity that
16the recipient might otherwise make, may initially designate a
17primary provider type provided that the primary provider type
18is willing to provide that care.
19    (c) When the Department has requested that a recipient
20designate a primary provider type and the recipient fails or
21refuses to do so, the Department may, after a reasonable period
22of time, assign the recipient to a primary provider type of its
23own choice and determination, provided such primary provider
24type is willing to provide such care.
25    (d) When a recipient has been restricted to a designated
26primary provider type, the recipient may change the primary

 

 

09700SB2840ham001- 24 -LRB097 15631 KTG 68774 a

1provider type:
2        (1) when the designated source becomes unavailable, as
3    the Department shall determine by rule; or
4        (2) when the designated primary provider type notifies
5    the Department that it wishes to withdraw from any
6    obligation as primary provider type; or
7        (3) in other situations, as the Department shall
8    provide by rule.
9    The Department shall, by rule, establish procedures for
10providing medical or pharmaceutical services when the
11designated source becomes unavailable or wishes to withdraw
12from any obligation as primary provider type, shall, by rule,
13take into consideration the need for emergency or temporary
14medical assistance and shall ensure that the recipient has
15continuous and unrestricted access to medical care from the
16date on which such unavailability or withdrawal becomes
17effective until such time as the recipient designates a primary
18provider type or a primary provider type willing to provide
19such care is designated by the Department consistent with
20subsections (b) and (c) and such restriction becomes effective.
21    (e) Prior to initiating any action to restrict a
22recipient's access to medical or pharmaceutical care, the
23Department shall notify the recipient of its intended action.
24Such notification shall be in writing and shall set forth the
25reasons for and nature of the proposed action. In addition, the
26notification shall:

 

 

09700SB2840ham001- 25 -LRB097 15631 KTG 68774 a

1        (1) inform the recipient that (i) the recipient has a
2    right to designate a primary provider type of the
3    recipient's own choosing willing to accept such
4    designation and that the recipient's failure to do so
5    within a reasonable time may result in such designation
6    being made by the Department or (ii) the Department has
7    designated a primary provider type to assume
8    responsibility for the recipient's care; and
9        (2) inform the recipient that the recipient has a right
10    to appeal the Department's determination to restrict the
11    recipient's access to medical care and provide the
12    recipient with an explanation of how such appeal is to be
13    made. The notification shall also inform the recipient of
14    the circumstances under which unrestricted medical
15    eligibility shall continue until a decision is made on
16    appeal and that if the recipient chooses to appeal, the
17    recipient will be able to review the medical payment data
18    that was utilized by the Department to decide that the
19    recipient's access to medical care should be restricted.
20    (f) The Department shall, by rule or regulation, establish
21procedures for appealing a determination to restrict a
22recipient's access to medical care, which procedures shall, at
23a minimum, provide for a reasonable opportunity to be heard
24and, where the appeal is denied, for a written statement of the
25reason or reasons for such denial.
26    (g) Except as otherwise provided in this subsection, when a

 

 

09700SB2840ham001- 26 -LRB097 15631 KTG 68774 a

1recipient has had his or her medical card restricted for 4 full
2quarters (without regard to any period of ineligibility for
3medical assistance under this Code, or any period for which the
4recipient voluntarily terminates his or her receipt of medical
5assistance, that may occur before the expiration of those 4
6full quarters), the Department shall reevaluate the
7recipient's medical usage to determine whether it is still in
8excess of need and with such frequency or in such a manner as
9to constitute an abuse of the receipt of medical assistance. If
10it is still in excess of need, the restriction shall be
11continued for another 4 full quarters. If it is no longer in
12excess of need, the restriction shall be discontinued. If a
13recipient's access to medical care has been restricted under
14this Section and the Department then determines, either at
15reevaluation or after the restriction has been discontinued, to
16restrict the recipient's access to medical care a second or
17subsequent time, the second or subsequent restriction may be
18imposed for a period of more than 4 full quarters. If the
19Department restricts a recipient's access to medical care for a
20period of more than 4 full quarters, as determined by rule, the
21Department shall reevaluate the recipient's medical usage
22after the end of the restriction period rather than after the
23end of 4 full quarters. The Department shall notify the
24recipient, in writing, of any decision to continue the
25restriction and the reason or reasons therefor. A "quarter",
26for purposes of this Section, shall be defined as one of the

 

 

09700SB2840ham001- 27 -LRB097 15631 KTG 68774 a

1following 3-month periods of time: January-March, April-June,
2July-September or October-December.
3    (h) In addition to any other recipient whose acquisition of
4medical care is determined to be in excess of need, the
5Department may restrict the medical care privileges of the
6following persons:
7        (1) recipients found to have loaned or altered their
8    cards or misused or falsely represented medical coverage;
9        (2) recipients found in possession of blank or forged
10    prescription pads;
11        (3) recipients who knowingly assist providers in
12    rendering excessive services or defrauding the medical
13    assistance program.
14    The procedural safeguards in this Section shall apply to
15the above individuals.
16    (i) Restrictions under this Section shall be in addition to
17and shall not in any way be limited by or limit any actions
18taken under Article VIII-A of this Code.
19(Source: P.A. 96-1501, eff. 1-25-11.)
 
20    (305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
21    Sec. 12-4.25. Medical assistance program; vendor
22participation.
23    (A) The Illinois Department may deny, suspend, exclude, or
24terminate the eligibility of any person, firm, corporation,
25association, agency, institution or other legal entity to

 

 

09700SB2840ham001- 28 -LRB097 15631 KTG 68774 a

1participate as a vendor of goods or services to recipients
2under the medical assistance program under Article V, and may
3deny, suspend, or recover payments if after reasonable notice
4and opportunity for a hearing the Illinois Department finds:
5        (a) Such vendor is not complying with the Department's
6    policy or rules and regulations, or with the terms and
7    conditions prescribed by the Illinois Department in its
8    vendor agreement, which document shall be developed by the
9    Department as a result of negotiations with each vendor
10    category, including physicians, hospitals, long term care
11    facilities, pharmacists, optometrists, podiatrists and
12    dentists setting forth the terms and conditions applicable
13    to the participation of each vendor group in the program;
14    or
15        (b) Such vendor has failed to keep or make available
16    for inspection, audit or copying, after receiving a written
17    request from the Illinois Department, such records
18    regarding payments claimed for providing services. This
19    section does not require vendors to make available patient
20    records of patients for whom services are not reimbursed
21    under this Code; or
22        (c) Such vendor has failed to furnish any information
23    requested by the Department regarding payments for
24    providing goods or services; or
25        (d) Such vendor has knowingly made, or caused to be
26    made, any false statement or representation of a material

 

 

09700SB2840ham001- 29 -LRB097 15631 KTG 68774 a

1    fact in connection with the administration of the medical
2    assistance program; or
3        (e) Such vendor has furnished goods or services to a
4    recipient which are (1) in excess of need his or her needs,
5    (2) harmful to the recipient, or (3) of grossly inferior
6    quality, all of such determinations to be based upon
7    competent medical judgment and evaluations; or
8        (f) The vendor; a person with management
9    responsibility for a vendor; an officer or person owning,
10    either directly or indirectly, 5% or more of the shares of
11    stock or other evidences of ownership in a corporate
12    vendor; an owner of a sole proprietorship which is a
13    vendor; or a partner in a partnership which is a vendor,
14    either:
15            (1) was previously terminated, suspended, or
16        excluded from participation in the Illinois medical
17        assistance program, or was terminated, suspended, or
18        excluded from participation in another state or
19        federal medical assistance or health care program a
20        medical assistance program in another state that is of
21        the same kind as the program of medical assistance
22        provided under Article V of this Code; or
23            (2) was a person with management responsibility
24        for a vendor previously terminated, suspended, or
25        excluded from participation in the Illinois medical
26        assistance program, or terminated, suspended, or

 

 

09700SB2840ham001- 30 -LRB097 15631 KTG 68774 a

1        excluded from participation in another state or
2        federal a medical assistance or health care program in
3        another state that is of the same kind as the program
4        of medical assistance provided under Article V of this
5        Code, during the time of conduct which was the basis
6        for that vendor's termination, suspension, or
7        exclusion; or
8            (3) was an officer, or person owning, either
9        directly or indirectly, 5% or more of the shares of
10        stock or other evidences of ownership in a corporate
11        vendor previously terminated, suspended, or excluded
12        from participation in the Illinois medical assistance
13        program, or terminated, suspended, or excluded from
14        participation in a state or federal medical assistance
15        or health care program in another state that is of the
16        same kind as the program of medical assistance provided
17        under Article V of this Code, during the time of
18        conduct which was the basis for that vendor's
19        termination, suspension, or exclusion; or
20            (4) was an owner of a sole proprietorship or
21        partner of a partnership previously terminated,
22        suspended, or excluded from participation in the
23        Illinois medical assistance program, or terminated,
24        suspended, or excluded from participation in a state or
25        federal medical assistance or health care program in
26        another state that is of the same kind as the program

 

 

09700SB2840ham001- 31 -LRB097 15631 KTG 68774 a

1        of medical assistance provided under Article V of this
2        Code, during the time of conduct which was the basis
3        for that vendor's termination, suspension, or
4        exclusion; or
5        (f-1) Such vendor has a delinquent debt owed to the
6    Illinois Department; or
7        (g) The vendor; a person with management
8    responsibility for a vendor; an officer or person owning,
9    either directly or indirectly, 5% or more of the shares of
10    stock or other evidences of ownership in a corporate
11    vendor; an owner of a sole proprietorship which is a
12    vendor; or a partner in a partnership which is a vendor,
13    either:
14            (1) has engaged in practices prohibited by
15        applicable federal or State law or regulation relating
16        to the medical assistance program; or
17            (2) was a person with management responsibility
18        for a vendor at the time that such vendor engaged in
19        practices prohibited by applicable federal or State
20        law or regulation relating to the medical assistance
21        program; or
22            (3) was an officer, or person owning, either
23        directly or indirectly, 5% or more of the shares of
24        stock or other evidences of ownership in a vendor at
25        the time such vendor engaged in practices prohibited by
26        applicable federal or State law or regulation relating

 

 

09700SB2840ham001- 32 -LRB097 15631 KTG 68774 a

1        to the medical assistance program; or
2            (4) was an owner of a sole proprietorship or
3        partner of a partnership which was a vendor at the time
4        such vendor engaged in practices prohibited by
5        applicable federal or State law or regulation relating
6        to the medical assistance program; or
7        (h) The direct or indirect ownership of the vendor
8    (including the ownership of a vendor that is a sole
9    proprietorship, a partner's interest in a vendor that is a
10    partnership, or ownership of 5% or more of the shares of
11    stock or other evidences of ownership in a corporate
12    vendor) has been transferred by an individual who is
13    terminated, suspended, or excluded or barred from
14    participating as a vendor to the individual's spouse,
15    child, brother, sister, parent, grandparent, grandchild,
16    uncle, aunt, niece, nephew, cousin, or relative by
17    marriage.
18    (A-5) The Illinois Department may deny, suspend, or
19terminate, or exclude the eligibility of any person, firm,
20corporation, association, agency, institution, or other legal
21entity to participate as a vendor of goods or services to
22recipients under the medical assistance program under Article V
23if, after reasonable notice and opportunity for a hearing, the
24Illinois Department finds that the vendor; a person with
25management responsibility for a vendor; an officer or person
26owning, either directly or indirectly, 5% or more of the shares

 

 

09700SB2840ham001- 33 -LRB097 15631 KTG 68774 a

1of stock or other evidences of ownership in a corporate vendor;
2an owner of a sole proprietorship that is a vendor; or a
3partner in a partnership that is a vendor has been convicted of
4an a felony offense based on fraud or willful misrepresentation
5related to any of the following:
6        (1) The medical assistance program under Article V of
7    this Code.
8        (2) A medical assistance or health care program in
9    another state that is of the same kind as the program of
10    medical assistance provided under Article V of this Code.
11        (3) The Medicare program under Title XVIII of the
12    Social Security Act.
13        (4) The provision of health care services.
14        (5) A violation of this Code, as provided in Article
15    VIIIA, or another state or federal medical assistance
16    program or health care program.
17    (A-10) The Illinois Department may deny, suspend, or
18terminate, or exclude the eligibility of any person, firm,
19corporation, association, agency, institution, or other legal
20entity to participate as a vendor of goods or services to
21recipients under the medical assistance program under Article V
22if, after reasonable notice and opportunity for a hearing, the
23Illinois Department finds that (i) the vendor, (ii) a person
24with management responsibility for a vendor, (iii) an officer
25or person owning, either directly or indirectly, 5% or more of
26the shares of stock or other evidences of ownership in a

 

 

09700SB2840ham001- 34 -LRB097 15631 KTG 68774 a

1corporate vendor, (iv) an owner of a sole proprietorship that
2is a vendor, or (v) a partner in a partnership that is a vendor
3has been convicted of an a felony offense related to any of the
4following:
5        (1) Murder.
6        (2) A Class X felony under the Criminal Code of 1961.
7        (3) Sexual misconduct that may subject recipients to an
8    undue risk of harm.
9        (4) A criminal offense that may subject recipients to
10    an undue risk of harm.
11        (5) A crime of fraud or dishonesty.
12        (6) A crime involving a controlled substance.
13        (7) A misdemeanor relating to fraud, theft,
14    embezzlement, breach of fiduciary responsibility, or other
15    financial misconduct related to a health care program.
16    (A-15) The Illinois Department may deny the eligibility of
17any person, firm, corporation, association, agency,
18institution, or other legal entity to participate as a vendor
19of goods or services to recipients under the medical assistance
20program under Article V if, after reasonable notice and
21opportunity for a hearing, the Illinois Department finds:
22        (1) The applicant or any person with management
23    responsibility for the applicant; an officer or member of
24    the board of directors of an applicant; an entity owning
25    (directly or indirectly) 5% or more of the shares of stock
26    or other evidences of ownership in a corporate vendor

 

 

09700SB2840ham001- 35 -LRB097 15631 KTG 68774 a

1    applicant; an owner of a sole proprietorship applicant; a
2    partner in a partnership applicant; or a technical or other
3    advisor to an applicant has a debt owed to the Illinois
4    Department, and no payment arrangements acceptable to the
5    Illinois Department have been made by the applicant.
6        (2) The applicant or any person with management
7    responsibility for the applicant; an officer or member of
8    the board of directors of an applicant; an entity owning
9    (directly or indirectly) 5% or more of the shares of stock
10    or other evidences of ownership in a corporate vendor
11    applicant; an owner of a sole proprietorship applicant; a
12    partner in a partnership vendor applicant; or a technical
13    or other advisor to an applicant was (i) a person with
14    management responsibility, (ii) an officer or member of the
15    board of directors of an applicant, (iii) an entity owning
16    (directly or indirectly) 5% or more of the shares of stock
17    or other evidences of ownership in a corporate vendor, (iv)
18    an owner of a sole proprietorship, (v) a partner in a
19    partnership vendor, (vi) a technical or other advisor to a
20    vendor, during a period of time where the conduct of that
21    vendor resulted in a debt owed to the Illinois Department,
22    and no payment arrangements acceptable to the Illinois
23    Department have been made by that vendor.
24        (3) There is a credible allegation of the use,
25    transfer, or lease of assets of any kind to an applicant
26    from a current or prior vendor who has a debt owed to the

 

 

09700SB2840ham001- 36 -LRB097 15631 KTG 68774 a

1    Illinois Department, no payment arrangements acceptable to
2    the Illinois Department have been made by that vendor or
3    the vendor's alternate payee, and the applicant knows or
4    should have known of such debt.
5        (4) There is a credible allegation of a transfer of
6    management responsibilities, or direct or indirect
7    ownership, to an applicant from a current or prior vendor
8    who has a debt owed to the Illinois Department, and no
9    payment arrangements acceptable to the Illinois Department
10    have been made by that vendor or the vendor's alternate
11    payee, and the applicant knows or should have known of such
12    debt.
13        (5) There is a credible allegation of the use,
14    transfer, or lease of assets of any kind to an applicant
15    who is a spouse, child, brother, sister, parent,
16    grandparent, grandchild, uncle, aunt, niece, relative by
17    marriage, nephew, cousin, or relative of a current or prior
18    vendor who has a debt owed to the Illinois Department and
19    no payment arrangements acceptable to the Illinois
20    Department have been made.
21        (6) There is a credible allegation that the applicant's
22    previous affiliations with a provider of medical services
23    that has an uncollected debt, a provider that has been or
24    is subject to a payment suspension under a federal health
25    care program, or a provider that has been previously
26    excluded from participation in the medical assistance

 

 

09700SB2840ham001- 37 -LRB097 15631 KTG 68774 a

1    program, poses a risk of fraud, waste, or abuse to the
2    Illinois Department.
3    As used in this subsection, "credible allegation" is
4defined to include an allegation from any source, including,
5but not limited to, fraud hotline complaints, claims data
6mining, patterns identified through provider audits, civil
7actions filed under the False Claims Act, and law enforcement
8investigations. An allegation is considered to be credible when
9it has indicia of reliability.
10    (B) The Illinois Department shall deny, suspend, or
11terminate, or exclude the eligibility of any person, firm,
12corporation, association, agency, institution or other legal
13entity to participate as a vendor of goods or services to
14recipients under the medical assistance program under Article
15V:
16        (1) if such vendor is not properly licensed, certified,
17    or authorized;
18        (2) within 30 days of the date when such vendor's
19    professional license, certification or other authorization
20    has been refused renewal, restricted, or has been revoked,
21    suspended, or otherwise terminated; or
22        (3) if such vendor has been convicted of a violation of
23    this Code, as provided in Article VIIIA.
24    (C) Upon termination, suspension, or exclusion of a vendor
25of goods or services from participation in the medical
26assistance program authorized by this Article, a person with

 

 

09700SB2840ham001- 38 -LRB097 15631 KTG 68774 a

1management responsibility for such vendor during the time of
2any conduct which served as the basis for that vendor's
3termination, suspension, or exclusion is barred from
4participation in the medical assistance program.
5    Upon termination, suspension, or exclusion of a corporate
6vendor, the officers and persons owning, directly or
7indirectly, 5% or more of the shares of stock or other
8evidences of ownership in the vendor during the time of any
9conduct which served as the basis for that vendor's
10termination, suspension, or exclusion are barred from
11participation in the medical assistance program. A person who
12owns, directly or indirectly, 5% or more of the shares of stock
13or other evidences of ownership in a terminated, suspended, or
14excluded corporate vendor may not transfer his or her ownership
15interest in that vendor to his or her spouse, child, brother,
16sister, parent, grandparent, grandchild, uncle, aunt, niece,
17nephew, cousin, or relative by marriage.
18    Upon termination, suspension, or exclusion of a sole
19proprietorship or partnership, the owner or partners during the
20time of any conduct which served as the basis for that vendor's
21termination, suspension, or exclusion are barred from
22participation in the medical assistance program. The owner of a
23terminated, suspended, or excluded vendor that is a sole
24proprietorship, and a partner in a terminated, suspended, or
25excluded vendor that is a partnership, may not transfer his or
26her ownership or partnership interest in that vendor to his or

 

 

09700SB2840ham001- 39 -LRB097 15631 KTG 68774 a

1her spouse, child, brother, sister, parent, grandparent,
2grandchild, uncle, aunt, niece, nephew, cousin, or relative by
3marriage.
4    A person who owns, directly or indirectly, 5% or more of
5the shares of stock or other evidences of ownership in a vendor
6who owes a debt to the Illinois Department, if that vendor has
7not made payment arrangements acceptable to the Illinois
8Department, shall not transfer his or her ownership interest in
9that vendor, or vendor assets of any kind, to his or her
10spouse, child, brother, sister, parent, grandparent,
11grandchild, uncle, aunt, niece, nephew, cousin, or relative by
12marriage.
13    Rules adopted by the Illinois Department to implement these
14provisions shall specifically include a definition of the term
15"management responsibility" as used in this Section. Such
16definition shall include, but not be limited to, typical job
17titles, and duties and descriptions which will be considered as
18within the definition of individuals with management
19responsibility for a provider.
20    A vendor or a prior vendor who has been terminated,
21excluded, or suspended from the medical assistance program, or
22from another state or federal medical assistance or health care
23program, and any individual currently or previously barred from
24the medical assistance program, or from another state or
25federal medical assistance or health care program, as a result
26of being an officer or a person owning, directly, or

 

 

09700SB2840ham001- 40 -LRB097 15631 KTG 68774 a

1indirectly, 5% or more of the shares of stock or other
2evidences of ownership in a vendor during the time of any
3conduct which served as the basis for that vendor's
4termination, suspension, or exclusion, may be required to post
5a surety bond as part of a condition of enrollment or
6participation in the medical assistance program. The Illinois
7Department shall establish, by rule, the criteria and
8requirements for determining when a surety bond must be posted
9and the value of the bond.
10    A vendor or a prior vendor who has a debt owed to the
11Illinois Department and any individual currently or previously
12barred from the medical assistance program, or from another
13state or federal medical assistance or health care program, as
14a result of being an officer or a person owning, directly or
15indirectly, 5% or more of the shares of stock or other
16evidences of ownership in that vendor during the time of any
17conduct which served as the basis for the debt, may be required
18to post a surety bond as part of a condition of enrollment or
19participation in the medical assistance program. The Illinois
20Department shall establish, by rule, the criteria and
21requirements for determining when a surety bond must be posted
22and the value of the bond.
23    (D) If a vendor has been suspended from the medical
24assistance program under Article V of the Code, the Director
25may require that such vendor correct any deficiencies which
26served as the basis for the suspension. The Director shall

 

 

09700SB2840ham001- 41 -LRB097 15631 KTG 68774 a

1specify in the suspension order a specific period of time,
2which shall not exceed one year from the date of the order,
3during which a suspended vendor shall not be eligible to
4participate. At the conclusion of the period of suspension the
5Director shall reinstate such vendor, unless he finds that such
6vendor has not corrected deficiencies upon which the suspension
7was based.
8    If a vendor has been terminated, suspended, or excluded
9from the medical assistance program under Article V, such
10vendor shall be barred from participation for at least one
11year, except that if a vendor has been terminated, suspended,
12or excluded based on a conviction of a violation of Article
13VIIIA or a conviction of a felony based on fraud or a willful
14misrepresentation related to (i) the medical assistance
15program under Article V, (ii) a federal or another state's
16medical assistance or health care program in another state that
17is of the kind provided under Article V, (iii) the Medicare
18program under Title XVIII of the Social Security Act, or (iii)
19(iv) the provision of health care services, then the vendor
20shall be barred from participation for 5 years or for the
21length of the vendor's sentence for that conviction, whichever
22is longer. At the end of one year a vendor who has been
23terminated, suspended, or excluded may apply for reinstatement
24to the program. Upon proper application to be reinstated such
25vendor may be deemed eligible by the Director providing that
26such vendor meets the requirements for eligibility under this

 

 

09700SB2840ham001- 42 -LRB097 15631 KTG 68774 a

1Code. If such vendor is deemed not eligible for reinstatement,
2he shall be barred from again applying for reinstatement for
3one year from the date his application for reinstatement is
4denied.
5    A vendor whose termination, suspension, or exclusion from
6participation in the Illinois medical assistance program under
7Article V was based solely on an action by a governmental
8entity other than the Illinois Department may, upon
9reinstatement by that governmental entity or upon reversal of
10the termination, suspension, or exclusion, apply for
11rescission of the termination, suspension, or exclusion from
12participation in the Illinois medical assistance program. Upon
13proper application for rescission, the vendor may be deemed
14eligible by the Director if the vendor meets the requirements
15for eligibility under this Code.
16    If a vendor has been terminated, suspended, or excluded and
17reinstated to the medical assistance program under Article V
18and the vendor is terminated, suspended, or excluded a second
19or subsequent time from the medical assistance program, the
20vendor shall be barred from participation for at least 2 years,
21except that if a vendor has been terminated, suspended, or
22excluded a second time based on a conviction of a violation of
23Article VIIIA or a conviction of a felony based on fraud or a
24willful misrepresentation related to (i) the medical
25assistance program under Article V, (ii) a federal or another
26state's medical assistance or health care program in another

 

 

09700SB2840ham001- 43 -LRB097 15631 KTG 68774 a

1state that is of the kind provided under Article V, (iii) the
2Medicare program under Title XVIII of the Social Security Act,
3or (iii) (iv) the provision of health care services, then the
4vendor shall be barred from participation for life. At the end
5of 2 years, a vendor who has been terminated, suspended, or
6excluded may apply for reinstatement to the program. Upon
7application to be reinstated, the vendor may be deemed eligible
8if the vendor meets the requirements for eligibility under this
9Code. If the vendor is deemed not eligible for reinstatement,
10the vendor shall be barred from again applying for
11reinstatement for 2 years from the date the vendor's
12application for reinstatement is denied.
13    (E) The Illinois Department may recover money improperly or
14erroneously paid, or overpayments, either by setoff, crediting
15against future billings or by requiring direct repayment to the
16Illinois Department. The Illinois Department may suspend or
17deny payment, in whole or in part, if such payment would be
18improper or erroneous or would otherwise result in overpayment.
19        (1) Payments may be suspended, denied, or recovered
20    from a vendor or alternate payee: (i) for services rendered
21    in violation of the Illinois Department's provider notice,
22    statutes, rules, and regulations; (ii) for services
23    rendered in violation of the terms and conditions
24    prescribed by the Illinois Department in its vendor
25    agreement; (iii) for any vendor who fails to grant the
26    Office of Inspector General timely access to full and

 

 

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1    complete records, including, but not limited to, records
2    relating to recipients under the medical assistance
3    program for the most recent 6 years, in accordance with
4    Section 140.28 of Title 89 of the Illinois Administrative
5    Code, and other information for the purpose of audits,
6    investigations, or other program integrity functions,
7    after reasonable written request by the Inspector General;
8    this subsection (E) does not require vendors to make
9    available the medical records of patients for whom services
10    are not reimbursed under this Code, or to provide access to
11    medical records more than 6 years old; (iv) when the vendor
12    has knowingly made, or caused to be made, any false
13    statement or representation of a material fact in
14    connection with the administration of the medical
15    assistance program; or (v) when the vendor previously
16    rendered services while terminated, suspended, or excluded
17    from participation in the medical assistance program, or
18    while terminated or excluded from participation in another
19    state or federal medical assistance or health care program.
20        (2) Notwithstanding any other provision of law, if a
21    vendor has the same taxpayer identification number
22    (assigned under Section 6109 of the Internal Revenue Code
23    of 1986) as is assigned to a vendor with past-due financial
24    obligations to the Illinois Department, the Illinois
25    Department may make any necessary adjustments to payments
26    to that vendor in order to satisfy any past-due

 

 

09700SB2840ham001- 45 -LRB097 15631 KTG 68774 a

1    obligations, regardless of whether the vendor is assigned a
2    different billing number under the medical assistance
3    program.
4    If the Illinois Department establishes through an
5administrative hearing that the overpayments resulted from the
6vendor or alternate payee knowingly willfully making, using, or
7causing to be made or used, a false record or statement to
8obtain payment or other benefit from or misrepresentation of a
9material fact in connection with billings and payments under
10the medical assistance program under Article V, the Department
11may recover interest on the amount of the payment or other
12benefit overpayments at the rate of 5% per annum. In addition
13to any other penalties that may be prescribed by law, such a
14vendor or alternate payee shall be subject to civil penalties
15consisting of an amount not to exceed 3 times the amount of
16payment or other benefit resulting from each such false record
17or statement, and the sum of $2,000 for each such false record
18or statement for payment or other benefit. For purposes of this
19paragraph, "knowingly" "willfully" means that a vendor or
20alternate payee with respect to information: (i) has person
21makes a statement or representation with actual knowledge of
22the information, (ii) acts in deliberate ignorance of the truth
23or falsity of the information, or (iii) acts in reckless
24disregard of the truth or falsity of the information. No proof
25of specific intent to defraud is required. that it was false,
26or makes a statement or representation with knowledge of facts

 

 

09700SB2840ham001- 46 -LRB097 15631 KTG 68774 a

1or information that would cause one to be aware that the
2statement or representation was false when made.
3    (F) The Illinois Department may withhold payments to any
4vendor or alternate payee prior to or during the pendency of
5any audit or proceeding under this Section, and through the
6pendency of any administrative appeal or administrative review
7by any court proceeding. The Illinois Department shall state by
8rule with as much specificity as practicable the conditions
9under which payments will not be withheld during the pendency
10of any proceeding under this Section. Payments may be denied
11for bills submitted with service dates occurring during the
12pendency of a proceeding, after a final decision has been
13rendered, or after the conclusion of any administrative appeal,
14where the final administrative decision is to terminate,
15exclude, or suspend eligibility to participate in the medical
16assistance program. The Illinois Department shall state by rule
17with as much specificity as practicable the conditions under
18which payments will not be denied for such bills. The Illinois
19Department shall state by rule a process and criteria by which
20a vendor or alternate payee may request full or partial release
21of payments withheld under this subsection. The Department must
22complete a proceeding under this Section in a timely manner.
23    Notwithstanding recovery allowed under subsection (E) or
24this subsection (F) of this Section, the Illinois Department
25may withhold payments to any vendor or alternate payee who is
26not properly licensed, certified, or in compliance with State

 

 

09700SB2840ham001- 47 -LRB097 15631 KTG 68774 a

1or federal agency regulations. Payments may be denied for bills
2submitted with service dates occurring during the period of
3time wherein a vendor is not properly licensed, certified, or
4in compliance with State or federal regulations. Facilities
5licensed under the Nursing Home Care Act shall be exempt from
6this paragraph.
7    (F-5) The Illinois Department may temporarily withhold
8payments to a vendor or alternate payee if any of the following
9individuals have been indicted or otherwise charged under a law
10of the United States or this or any other state with an a
11felony offense that is based on alleged fraud or willful
12misrepresentation on the part of the individual related to (i)
13the medical assistance program under Article V of this Code,
14(ii) a federal or another state's medical assistance or health
15care program provided in another state which is of the kind
16provided under Article V of this Code, (iii) the Medicare
17program under Title XVIII of the Social Security Act, or (iii)
18(iv) the provision of health care services:
19        (1) If the vendor or alternate payee is a corporation:
20    an officer of the corporation or an individual who owns,
21    either directly or indirectly, 5% or more of the shares of
22    stock or other evidence of ownership of the corporation.
23        (2) If the vendor is a sole proprietorship: the owner
24    of the sole proprietorship.
25        (3) If the vendor or alternate payee is a partnership:
26    a partner in the partnership.

 

 

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1        (4) If the vendor or alternate payee is any other
2    business entity authorized by law to transact business in
3    this State: an officer of the entity or an individual who
4    owns, either directly or indirectly, 5% or more of the
5    evidences of ownership of the entity.
6    If the Illinois Department withholds payments to a vendor
7or alternate payee under this subsection, the Department shall
8not release those payments to the vendor or alternate payee
9while any criminal proceeding related to the indictment or
10charge is pending unless the Department determines that there
11is good cause to release the payments before completion of the
12proceeding. If the indictment or charge results in the
13individual's conviction, the Illinois Department shall retain
14all withheld payments, which shall be considered forfeited to
15the Department. If the indictment or charge does not result in
16the individual's conviction, the Illinois Department shall
17release to the vendor or alternate payee all withheld payments.
18    (F-10) If the Illinois Department establishes that the
19vendor or alternate payee owes a debt to the Illinois
20Department, and the vendor or alternate payee subsequently
21fails to pay or make satisfactory payment arrangements with the
22Illinois Department for the debt owed, the Illinois Department
23may seek all remedies available under the law of this State to
24recover the debt, including, but not limited to, wage
25garnishment or the filing of claims or liens against the vendor
26or alternate payee.

 

 

09700SB2840ham001- 49 -LRB097 15631 KTG 68774 a

1    (F-15) Enforcement of judgment.
2        (1) Any fine, recovery amount, other sanction, or costs
3    imposed, or part of any fine, recovery amount, other
4    sanction, or cost imposed, remaining unpaid after the
5    exhaustion of or the failure to exhaust judicial review
6    procedures under the Illinois Administrative Review Law is
7    a debt due and owing the State and may be collected using
8    all remedies available under the law.
9        (2) After expiration of the period in which judicial
10    review under the Illinois Administrative Review Law may be
11    sought for a final administrative decision, unless stayed
12    by a court of competent jurisdiction, the findings,
13    decision, and order of the Director may be enforced in the
14    same manner as a judgment entered by a court of competent
15    jurisdiction.
16        (3) In any case in which any person or entity has
17    failed to comply with a judgment ordering or imposing any
18    fine or other sanction, any expenses incurred by the State
19    agency to enforce the judgment, including, but not limited
20    to, attorney's fees, court costs, and costs related to
21    property demolition or foreclosure, after they are fixed by
22    a court of competent jurisdiction or the Director, shall be
23    a debt due and owing the State and may be collected in
24    accordance with applicable law. Prior to any expenses being
25    fixed by a final administrative decision pursuant to this
26    subsection (F-15), the Illinois Department or appropriate

 

 

09700SB2840ham001- 50 -LRB097 15631 KTG 68774 a

1    body shall provide notice to the individual or entity that
2    states that the individual shall appear at a hearing before
3    the administrative hearing officer to determine whether
4    the defendant has failed to comply with the judgment. The
5    notice shall set the date for such a hearing, which shall
6    not be less than 7 days from the date that notice is
7    served. If notice is served by mail, the 7-day period shall
8    begin to run on the date that the notice was deposited in
9    the mail.
10        (4) Upon being recorded in the manner required by
11    Article XII of the Code of Civil Procedure or by the
12    Uniform Commercial Code, a lien shall be imposed on the
13    real estate or personal estate, or both, of the individual
14    or entity in the amount of any debt due and owing the State
15    under this Section. The lien may be enforced in the same
16    manner as a judgment of a court of competent jurisdiction.
17    A lien shall attach to all property and assets of such
18    person, firm, corporation, association, agency,
19    institution, or other legal entity until the judgment is
20    satisfied.
21        (5) The Director may set aside any judgment entered by
22    default and set a new hearing date upon a petition filed
23    within 21 days after the issuance of the order of default,
24    if the hearing officer determines that the petitioner's
25    failure to appear at the hearing was for good cause or at
26    any time if the petitioner's failure to appear at the

 

 

09700SB2840ham001- 51 -LRB097 15631 KTG 68774 a

1    hearing was for good cause or at any time if the petitioner
2    established that the Department did not provide proper
3    service of process. If any judgment is set aside pursuant
4    to this paragraph (5), the hearing officer shall have
5    authority to enter an order extinguishing any lien which
6    has been recorded for any debt due and owing the Illinois
7    Department as a result of the vacated default judgment.
8    (G) The provisions of the Administrative Review Law, as now
9or hereafter amended, and the rules adopted pursuant thereto,
10shall apply to and govern all proceedings for the judicial
11review of final administrative decisions of the Illinois
12Department under this Section. The term "administrative
13decision" is defined as in Section 3-101 of the Code of Civil
14Procedure.
15    (G-5) Vendors who pose a risk of fraud, waste, abuse, or
16harm Non-emergency transportation.
17        (1) Notwithstanding any other provision in this
18    Section, for non-emergency transportation vendors, the
19    Department may terminate, suspend, or exclude vendors who
20    pose a risk of fraud, waste, abuse, or harm the vendor from
21    participation in the medical assistance program prior to an
22    evidentiary hearing but after reasonable notice and
23    opportunity to respond as established by the Department by
24    rule.
25        (2) Vendors who pose a risk of fraud, waste, abuse, or
26    harm of non-emergency medical transportation services, as

 

 

09700SB2840ham001- 52 -LRB097 15631 KTG 68774 a

1    defined by the Department by rule, shall submit to a
2    fingerprint-based criminal background check on current and
3    future information available in the State system and
4    current information available through the Federal Bureau
5    of Investigation's system by submitting all necessary fees
6    and information in the form and manner prescribed by the
7    Department of State Police. The following individuals
8    shall be subject to the check:
9            (A) In the case of a vendor that is a corporation,
10        every shareholder who owns, directly or indirectly, 5%
11        or more of the outstanding shares of the corporation.
12            (B) In the case of a vendor that is a partnership,
13        every partner.
14            (C) In the case of a vendor that is a sole
15        proprietorship, the sole proprietor.
16            (D) Each officer or manager of the vendor.
17        Each such vendor shall be responsible for payment of
18    the cost of the criminal background check.
19        (3) Vendors who pose a risk of fraud, waste, abuse, or
20    harm of non-emergency medical transportation services may
21    be required to post a surety bond. The Department shall
22    establish, by rule, the criteria and requirements for
23    determining when a surety bond must be posted and the value
24    of the bond.
25        (4) The Department, or its agents, may refuse to accept
26    requests for authorization from specific vendors who pose a

 

 

09700SB2840ham001- 53 -LRB097 15631 KTG 68774 a

1    risk of fraud, waste, abuse or harm non-emergency
2    transportation authorizations, including prior-approval
3    and post-approval requests, for a specific non-emergency
4    transportation vendor if:
5            (A) the Department has initiated a notice of
6        termination, suspension, or exclusion of the vendor
7        from participation in the medical assistance program;
8        or
9            (B) the Department has issued notification of its
10        withholding of payments pursuant to subsection (F-5)
11        of this Section; or
12            (C) the Department has issued a notification of its
13        withholding of payments due to reliable evidence of
14        fraud or willful misrepresentation pending
15        investigation.
16        (5) As used in this subsection, the following terms are
17    defined as follows:
18            (A) "Fraud" means an intentional deception or
19        misrepresentation made by a person with the knowledge
20        that the deception could result in some unauthorized
21        benefit to himself or herself or some other person. It
22        includes any act that constitutes fraud under
23        applicable federal or State law.
24            (B) "Abuse" means provider practices that are
25        inconsistent with sound fiscal, business, or medical
26        practices and that result in an unnecessary cost to the

 

 

09700SB2840ham001- 54 -LRB097 15631 KTG 68774 a

1        medical assistance program or in reimbursement for
2        services that are not medically necessary or that fail
3        to meet professionally recognized standards for health
4        care. It also includes recipient practices that result
5        in unnecessary cost to the medical assistance program.
6            (C) "Waste" means the unintentional misuse of
7        medical assistance resources, resulting in unnecessary
8        cost to the medical assistance program.
9            (D) "Harm" means physical, mental, or monetary
10        damage to recipients or to the medical assistance
11        program.
12    (G-6) The Illinois Department, upon making a determination
13based upon information in the possession of the Illinois
14Department, that commencement or continuation of participation
15in the medical assistance program by a vendor would constitute
16an immediate danger to the public, may immediately suspend such
17vendor's participation in the medical assistance program
18without a hearing. In instances in which the Illinois
19Department immediately suspends the medical assistance program
20participation of a vendor under this Section, a hearing upon
21the vendor's participation must be convened by the Illinois
22Department within 15 days after such suspension and completed
23without appreciable delay. Such hearing shall be held to
24determine whether to recommend to the Director that the
25vendor's medical assistance program participation be denied,
26terminated, suspended, placed on provisional status, or

 

 

09700SB2840ham001- 55 -LRB097 15631 KTG 68774 a

1reinstated. In the hearing, any evidence relevant to the vendor
2constituting an immediate danger to the public may be
3introduced against such vendor; provided, however, that the
4vendor, or his or her counsel, shall have the opportunity to
5discredit, impeach, and submit evidence rebutting such
6evidence.
7    (H) Nothing contained in this Code shall in any way limit
8or otherwise impair the authority or power of any State agency
9responsible for licensing of vendors.
10    (I) Based on a finding of noncompliance on the part of a
11nursing home with any requirement for certification under Title
12XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
13seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
14may impose one or more of the following remedies after notice
15to the facility:
16        (1) Termination of the provider agreement.
17        (2) Temporary management.
18        (3) Denial of payment for new admissions.
19        (4) Civil money penalties.
20        (5) Closure of the facility in emergency situations or
21    transfer of residents, or both.
22        (6) State monitoring.
23        (7) Denial of all payments when the U.S. Department of
24    Health and Human Services Health Care Finance
25    Administration has imposed this sanction.
26    The Illinois Department shall by rule establish criteria

 

 

09700SB2840ham001- 56 -LRB097 15631 KTG 68774 a

1governing continued payments to a nursing facility subsequent
2to termination of the facility's provider agreement if, in the
3sole discretion of the Illinois Department, circumstances
4affecting the health, safety, and welfare of the facility's
5residents require those continued payments. The Illinois
6Department may condition those continued payments on the
7appointment of temporary management, sale of the facility to
8new owners or operators, or other arrangements that the
9Illinois Department determines best serve the needs of the
10facility's residents.
11    Except in the case of a facility that has a right to a
12hearing on the finding of noncompliance before an agency of the
13federal government, a facility may request a hearing before a
14State agency on any finding of noncompliance within 60 days
15after the notice of the intent to impose a remedy. Except in
16the case of civil money penalties, a request for a hearing
17shall not delay imposition of the penalty. The choice of
18remedies is not appealable at a hearing. The level of
19noncompliance may be challenged only in the case of a civil
20money penalty. The Illinois Department shall provide by rule
21for the State agency that will conduct the evidentiary
22hearings.
23    The Illinois Department may collect interest on unpaid
24civil money penalties.
25    The Illinois Department may adopt all rules necessary to
26implement this subsection (I).

 

 

09700SB2840ham001- 57 -LRB097 15631 KTG 68774 a

1    (J) The Illinois Department, by rule, may permit individual
2practitioners to designate that Department payments that may be
3due the practitioner be made to an alternate payee or alternate
4payees.
5        (a) Such alternate payee or alternate payees shall be
6    required to register as an alternate payee in the Medical
7    Assistance Program with the Illinois Department.
8        (b) If a practitioner designates an alternate payee,
9    the alternate payee and practitioner shall be jointly and
10    severally liable to the Department for payments made to the
11    alternate payee. Pursuant to subsection (E) of this
12    Section, any Department action to suspend or deny payment
13    or recover money or overpayments from an alternate payee
14    shall be subject to an administrative hearing.
15        (c) Registration as an alternate payee or alternate
16    payees in the Illinois Medical Assistance Program shall be
17    conditional. At any time, the Illinois Department may deny
18    or cancel any alternate payee's registration in the
19    Illinois Medical Assistance Program without cause. Any
20    such denial or cancellation is not subject to an
21    administrative hearing.
22        (d) The Illinois Department may seek a revocation of
23    any alternate payee, and all owners, officers, and
24    individuals with management responsibility for such
25    alternate payee shall be permanently prohibited from
26    participating as an owner, an officer, or an individual

 

 

09700SB2840ham001- 58 -LRB097 15631 KTG 68774 a

1    with management responsibility with an alternate payee in
2    the Illinois Medical Assistance Program, if after
3    reasonable notice and opportunity for a hearing the
4    Illinois Department finds that:
5            (1) the alternate payee is not complying with the
6        Department's policy or rules and regulations, or with
7        the terms and conditions prescribed by the Illinois
8        Department in its alternate payee registration
9        agreement; or
10            (2) the alternate payee has failed to keep or make
11        available for inspection, audit, or copying, after
12        receiving a written request from the Illinois
13        Department, such records regarding payments claimed as
14        an alternate payee; or
15            (3) the alternate payee has failed to furnish any
16        information requested by the Illinois Department
17        regarding payments claimed as an alternate payee; or
18            (4) the alternate payee has knowingly made, or
19        caused to be made, any false statement or
20        representation of a material fact in connection with
21        the administration of the Illinois Medical Assistance
22        Program; or
23            (5) the alternate payee, a person with management
24        responsibility for an alternate payee, an officer or
25        person owning, either directly or indirectly, 5% or
26        more of the shares of stock or other evidences of

 

 

09700SB2840ham001- 59 -LRB097 15631 KTG 68774 a

1        ownership in a corporate alternate payee, or a partner
2        in a partnership which is an alternate payee:
3                (a) was previously terminated, suspended, or
4            excluded from participation as a vendor in the
5            Illinois Medical Assistance Program, or was
6            previously revoked as an alternate payee in the
7            Illinois Medical Assistance Program, or was
8            terminated, suspended, or excluded from
9            participation as a vendor in a medical assistance
10            program in another state that is of the same kind
11            as the program of medical assistance provided
12            under Article V of this Code; or
13                (b) was a person with management
14            responsibility for a vendor previously terminated,
15            suspended, or excluded from participation as a
16            vendor in the Illinois Medical Assistance Program,
17            or was previously revoked as an alternate payee in
18            the Illinois Medical Assistance Program, or was
19            terminated, suspended, or excluded from
20            participation as a vendor in a medical assistance
21            program in another state that is of the same kind
22            as the program of medical assistance provided
23            under Article V of this Code, during the time of
24            conduct which was the basis for that vendor's
25            termination, suspension, or exclusion or alternate
26            payee's revocation; or

 

 

09700SB2840ham001- 60 -LRB097 15631 KTG 68774 a

1                (c) was an officer, or person owning, either
2            directly or indirectly, 5% or more of the shares of
3            stock or other evidences of ownership in a
4            corporate vendor previously terminated, suspended,
5            or excluded from participation as a vendor in the
6            Illinois Medical Assistance Program, or was
7            previously revoked as an alternate payee in the
8            Illinois Medical Assistance Program, or was
9            terminated, suspended, or excluded from
10            participation as a vendor in a medical assistance
11            program in another state that is of the same kind
12            as the program of medical assistance provided
13            under Article V of this Code, during the time of
14            conduct which was the basis for that vendor's
15            termination, suspension, or exclusion; or
16                (d) was an owner of a sole proprietorship or
17            partner in a partnership previously terminated,
18            suspended, or excluded from participation as a
19            vendor in the Illinois Medical Assistance Program,
20            or was previously revoked as an alternate payee in
21            the Illinois Medical Assistance Program, or was
22            terminated, suspended, or excluded from
23            participation as a vendor in a medical assistance
24            program in another state that is of the same kind
25            as the program of medical assistance provided
26            under Article V of this Code, during the time of

 

 

09700SB2840ham001- 61 -LRB097 15631 KTG 68774 a

1            conduct which was the basis for that vendor's
2            termination, suspension, or exclusion or alternate
3            payee's revocation; or
4            (6) the alternate payee, a person with management
5        responsibility for an alternate payee, an officer or
6        person owning, either directly or indirectly, 5% or
7        more of the shares of stock or other evidences of
8        ownership in a corporate alternate payee, or a partner
9        in a partnership which is an alternate payee:
10                (a) has engaged in conduct prohibited by
11            applicable federal or State law or regulation
12            relating to the Illinois Medical Assistance
13            Program; or
14                (b) was a person with management
15            responsibility for a vendor or alternate payee at
16            the time that the vendor or alternate payee engaged
17            in practices prohibited by applicable federal or
18            State law or regulation relating to the Illinois
19            Medical Assistance Program; or
20                (c) was an officer, or person owning, either
21            directly or indirectly, 5% or more of the shares of
22            stock or other evidences of ownership in a vendor
23            or alternate payee at the time such vendor or
24            alternate payee engaged in practices prohibited by
25            applicable federal or State law or regulation
26            relating to the Illinois Medical Assistance

 

 

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1            Program; or
2                (d) was an owner of a sole proprietorship or
3            partner in a partnership which was a vendor or
4            alternate payee at the time such vendor or
5            alternate payee engaged in practices prohibited by
6            applicable federal or State law or regulation
7            relating to the Illinois Medical Assistance
8            Program; or
9            (7) the direct or indirect ownership of the vendor
10        or alternate payee (including the ownership of a vendor
11        or alternate payee that is a partner's interest in a
12        vendor or alternate payee, or ownership of 5% or more
13        of the shares of stock or other evidences of ownership
14        in a corporate vendor or alternate payee) has been
15        transferred by an individual who is terminated,
16        suspended, or excluded or barred from participating as
17        a vendor or is prohibited or revoked as an alternate
18        payee to the individual's spouse, child, brother,
19        sister, parent, grandparent, grandchild, uncle, aunt,
20        niece, nephew, cousin, or relative by marriage.
21    (K) The Illinois Department of Healthcare and Family
22Services may withhold payments, in whole or in part, to a
23provider or alternate payee where there is credible upon
24receipt of evidence, received from State or federal law
25enforcement or federal oversight agencies or from the results
26of a preliminary Department audit and determined by the

 

 

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1Department to be credible, that the circumstances giving rise
2to the need for a withholding of payments may involve fraud or
3willful misrepresentation under the Illinois Medical
4Assistance program. The Department shall by rule define what
5constitutes "credible" evidence for purposes of this
6subsection. The Department may withhold payments without first
7notifying the provider or alternate payee of its intention to
8withhold such payments. A provider or alternate payee may
9request a reconsideration of payment withholding, and the
10Department must grant such a request. The Department shall
11state by rule a process and criteria by which a provider or
12alternate payee may request full or partial release of payments
13withheld under this subsection. This request may be made at any
14time after the Department first withholds such payments.
15        (a) The Illinois Department must send notice of its
16    withholding of program payments within 5 days of taking
17    such action. The notice must set forth the general
18    allegations as to the nature of the withholding action, but
19    need not disclose any specific information concerning its
20    ongoing investigation. The notice must do all of the
21    following:
22            (1) State that payments are being withheld in
23        accordance with this subsection.
24            (2) State that the withholding is for a temporary
25        period, as stated in paragraph (b) of this subsection,
26        and cite the circumstances under which withholding

 

 

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1        will be terminated.
2            (3) Specify, when appropriate, which type or types
3        of Medicaid claims withholding is effective.
4            (4) Inform the provider or alternate payee of the
5        right to submit written evidence for reconsideration
6        of the withholding by the Illinois Department.
7            (5) Inform the provider or alternate payee that a
8        written request may be made to the Illinois Department
9        for full or partial release of withheld payments and
10        that such requests may be made at any time after the
11        Department first withholds such payments.
12        (b) All withholding-of-payment actions under this
13    subsection shall be temporary and shall not continue after
14    any of the following:
15            (1) The Illinois Department or the prosecuting
16        authorities determine that there is insufficient
17        evidence of fraud or willful misrepresentation by the
18        provider or alternate payee.
19            (2) Legal proceedings related to the provider's or
20        alternate payee's alleged fraud, willful
21        misrepresentation, violations of this Act, or
22        violations of the Illinois Department's administrative
23        rules are completed.
24            (3) The withholding of payments for a period of 3
25        years.
26        (c) The Illinois Department may adopt all rules

 

 

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1    necessary to implement this subsection (K).
2    (K-5) The Illinois Department may withhold payments, in
3whole or in part, to a provider or alternate payee upon
4initiation of an audit, quality of care review, or
5investigation when there is a credible allegation of fraud, or
6the provider or alternate payee demonstrates a clear failure to
7cooperate with the Illinois Department such that the
8circumstances give rise to the need for a withholding of
9payments. As used in this subsection, "credible allegation" is
10defined to include an allegation from any source, including,
11but not limited to, fraud hotline complaints, claims data
12mining, patterns identified through provider audits, civil
13actions filed under the False Claims Act, and law enforcement
14investigations. An allegation is considered to be credible when
15it has indicia of reliability. The Illinois Department may
16withhold payments without first notifying the provider or
17alternate payee of its intention to withhold such payments. A
18provider or alternate payee may request a reconsideration of
19payment withholding, and the Illinois Department must grant
20such a request. The Illinois Department shall state by rule a
21process and criteria by which a provider or alternate payee may
22request full or partial release of payments withheld under this
23subsection. This request may be made at any time after the
24Illinois Department first withholds such payments.
25        (a) The Illinois Department must send notice of its
26    withholding of program payments within 5 days of taking

 

 

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1    such action. The notice must set forth the general
2    allegations as to the nature of the withholding action but
3    need not disclose any specific information concerning its
4    ongoing investigation. The notice must do all of the
5    following:
6            (1) State that payments are being withheld in
7        accordance with this subsection.
8            (2) State that the withholding is for a temporary
9        period, as stated in paragraph (b) of this subsection,
10        and cite the circumstances under which withholding
11        will be terminated.
12            (3) Specify, when appropriate, which type or types
13        of claims are withheld.
14            (4) Inform the provider or alternate payee of the
15        right to submit written evidence for reconsideration
16        of the withholding by the Illinois Department.
17            (5) Inform the provider or alternate payee that a
18        written request may be made to the Illinois Department
19        for full or partial release of withheld payments and
20        that such requests may be made at any time after the
21        Illinois Department first withholds such payments.
22        (b) All withholding of payment actions under this
23    subsection shall be temporary and shall not continue after
24    any of the following:
25            (1) The Illinois Department determines that there
26        is insufficient evidence of fraud, or the provider or

 

 

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1        alternate payee demonstrates clear cooperation with
2        the Illinois Department, as determined by the Illinois
3        Department, such that the circumstances do not give
4        rise to the need for withholding of payments; or
5            (2) The withholding of payments has lasted for a
6        period in excess of 3 years.
7        (c) The Illinois Department may adopt all rules
8    necessary to implement this subsection (K-5).
9    (L) The Illinois Department shall establish a protocol to
10enable health care providers to disclose an actual or potential
11violation of this Section pursuant to a self-referral
12disclosure protocol, referred to in this Section as "the
13protocol". The protocol shall include direction for health care
14providers on a specific person, official, or office to whom
15such disclosures shall be made. The Illinois Department shall
16post information on the protocol on the Illinois Department's
17public website. The Illinois Department may adopt rules
18necessary to implement this subsection (L). In addition to
19other factors that the Illinois Department finds appropriate,
20the Illinois Department may consider a health care provider's
21timely use or failure to use the protocol in considering the
22provider's failure to comply with this Code.
23    (M) Notwithstanding any other provision of this Code, the
24Illinois Department, at its discretion, may exempt entities
25licensed under the Nursing Home Care Act and the ID/DD
26Community Care Act from the provisions of subsections (A-15),

 

 

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1(B), and (C) of this Section if the licensed entity is in
2receivership.
3(Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
 
4    (305 ILCS 5/12-13.1)
5    Sec. 12-13.1. Inspector General.
6    (a) The Governor shall appoint, and the Senate shall
7confirm, an Inspector General who shall function within the
8Illinois Department of Public Aid (now Healthcare and Family
9Services) and report to the Governor. The term of the Inspector
10General shall expire on the third Monday of January, 1997 and
11every 4 years thereafter.
12    (b) In order to prevent, detect, and eliminate fraud,
13waste, abuse, mismanagement, and misconduct, the Inspector
14General shall oversee the Department of Healthcare and Family
15Services' integrity functions, which include, but are not
16limited to, the following:
17        (1) Investigation of misconduct by employees, vendors,
18    contractors and medical providers, except for allegations
19    of violations of the State Officials and Employees Ethics
20    Act which shall be referred to the Office of the Governor's
21    Executive Inspector General for investigation.
22        (2) Prepayment and post-payment audits Audits of
23    medical providers related to ensuring that appropriate
24    payments are made for services rendered and to the
25    prevention and recovery of overpayments.

 

 

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1        (3) Monitoring of quality assurance programs
2    administered by the Department of Healthcare and Family
3    Services generally related to the medical assistance
4    program and specifically related to any managed care
5    program.
6        (4) Quality control measurements of the programs
7    administered by the Department of Healthcare and Family
8    Services.
9        (5) Investigations of fraud or intentional program
10    violations committed by clients of the Department of
11    Healthcare and Family Services.
12        (6) Actions initiated against contractors, vendors or
13    medical providers for any of the following reasons:
14            (A) Violations of the medical assistance program.
15            (B) Sanctions against providers brought in
16        conjunction with the Department of Public Health or the
17        Department of Human Services (as successor to the
18        Department of Mental Health and Developmental
19        Disabilities).
20            (C) Recoveries of assessments against hospitals
21        and long-term care facilities.
22            (D) Sanctions mandated by the United States
23        Department of Health and Human Services against
24        medical providers.
25            (E) Violations of contracts related to any
26        programs administered by the Department of Healthcare

 

 

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1        and Family Services managed care programs.
2        (7) Representation of the Department of Healthcare and
3    Family Services at hearings with the Illinois Department of
4    Financial and Professional Regulation in actions taken
5    against professional licenses held by persons who are in
6    violation of orders for child support payments.
7    (b-5) At the request of the Secretary of Human Services,
8the Inspector General shall, in relation to any function
9performed by the Department of Human Services as successor to
10the Department of Public Aid, exercise one or more of the
11powers provided under this Section as if those powers related
12to the Department of Human Services; in such matters, the
13Inspector General shall report his or her findings to the
14Secretary of Human Services.
15    (c) Notwithstanding, and in addition to, any other
16provision of law, the The Inspector General shall have access
17to all information, personnel and facilities of the Department
18of Healthcare and Family Services and the Department of Human
19Services (as successor to the Department of Public Aid), their
20employees, vendors, contractors and medical providers and any
21federal, State or local governmental agency that are necessary
22to perform the duties of the Office as directly related to
23public assistance programs administered by those departments.
24No medical provider shall be compelled, however, to provide
25individual medical records of patients who are not clients of
26the programs administered by the Department of Healthcare and

 

 

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1Family Services Medical Assistance Program. State and local
2governmental agencies are authorized and directed to provide
3the requested information, assistance or cooperation.
4    For purposes of enhanced program integrity functions and
5oversight, and to the extent consistent with applicable
6information, privacy, security, and disclosure laws, State
7agencies and departments shall provide the Office of Inspector
8General access to confidential and other information and data,
9and the Inspector General is authorized to enter into
10agreements with appropriate federal agencies and departments
11to secure similar data. This includes, but is not limited to,
12information pertaining to: licensure; certification; earnings;
13immigration status; citizenship; wage reporting; unearned and
14earned income; pension income; employment; supplemental
15security income; social security numbers; National Provider
16Identifier (NPI) numbers; the National Practitioner Data Bank
17(NPDB); program and agency exclusions; taxpayer identification
18numbers; tax delinquency; corporate information; and death
19records.
20    The Illinois Department shall enter into agreements with
21State agencies and departments, and is authorized to enter into
22agreements with federal agencies and departments, under which
23such agencies and departments shall share data necessary for
24medical assistance program integrity functions and oversight.
25The Illinois Department shall enter into agreements with State
26agencies and departments, and is authorized to enter into

 

 

09700SB2840ham001- 72 -LRB097 15631 KTG 68774 a

1agreements with federal agencies and departments, under which
2such agencies shall share data necessary for recipient or
3vendor screening, review, investigation, and payment and
4eligibility verification. The Illinois Department shall
5develop, in cooperation with other State and federal agencies
6and departments, and in compliance with applicable federal laws
7and regulations, appropriate and effective methods to share
8such data. The Illinois Department shall enter into agreements
9with State agencies and departments, and is authorized to enter
10into agreements with federal agencies and departments,
11including but not limited to: the Secretary of State; the
12Department of Revenue; the Department of Public Health; the
13Department of Human Services; and the Department of Financial
14and Professional Regulation.
15    The Inspector General shall have the authority to deny
16payment, prevent overpayments, and recover overpayments.
17    The Inspector General shall have the authority to deny or
18suspend payment to, and deny, terminate, or suspend the
19eligibility of, any vendor who fails to grant the Inspector
20General timely access to full and complete records, including
21records of recipients under the medical assistance program for
22the most recent 6 years, in accordance with Section 140.28 of
23Title 89 of the Illinois Administrative Code, and other
24information for the purpose of audits, investigations, or other
25program integrity functions, after reasonable written request
26by the Inspector General.

 

 

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1    (d) The Inspector General shall serve as the Department of
2Healthcare and Family Services' primary liaison with law
3enforcement, investigatory and prosecutorial agencies,
4including but not limited to the following:
5        (1) The Department of State Police.
6        (2) The Federal Bureau of Investigation and other
7    federal law enforcement agencies.
8        (3) The various Inspectors General of federal agencies
9    overseeing the programs administered by the Department of
10    Healthcare and Family Services.
11        (4) The various Inspectors General of any other State
12    agencies with responsibilities for portions of programs
13    primarily administered by the Department of Healthcare and
14    Family Services.
15        (5) The Offices of the several United States Attorneys
16    in Illinois.
17        (6) The several State's Attorneys.
18        (7) The offices of the Centers for Medicare and
19    Medicaid Services that administer the Medicare and
20    Medicaid integrity programs.
21    The Inspector General shall meet on a regular basis with
22these entities to share information regarding possible
23misconduct by any persons or entities involved with the public
24aid programs administered by the Department of Healthcare and
25Family Services.
26    (e) All investigations conducted by the Inspector General

 

 

09700SB2840ham001- 74 -LRB097 15631 KTG 68774 a

1shall be conducted in a manner that ensures the preservation of
2evidence for use in criminal prosecutions. If the Inspector
3General determines that a possible criminal act relating to
4fraud in the provision or administration of the medical
5assistance program has been committed, the Inspector General
6shall immediately notify the Medicaid Fraud Control Unit. If
7the Inspector General determines that a possible criminal act
8has been committed within the jurisdiction of the Office, the
9Inspector General may request the special expertise of the
10Department of State Police. The Inspector General may present
11for prosecution the findings of any criminal investigation to
12the Office of the Attorney General, the Offices of the several
13United States Attorneys in Illinois or the several State's
14Attorneys.
15    (f) To carry out his or her duties as described in this
16Section, the Inspector General and his or her designees shall
17have the power to compel by subpoena the attendance and
18testimony of witnesses and the production of books, electronic
19records and papers as directly related to public assistance
20programs administered by the Department of Healthcare and
21Family Services or the Department of Human Services (as
22successor to the Department of Public Aid). No medical provider
23shall be compelled, however, to provide individual medical
24records of patients who are not clients of the Medical
25Assistance Program.
26    (g) The Inspector General shall report all convictions,

 

 

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1terminations, and suspensions taken against vendors,
2contractors and medical providers to the Department of
3Healthcare and Family Services and to any agency responsible
4for licensing or regulating those persons or entities.
5    (h) The Inspector General shall make annual reports,
6findings, and recommendations regarding the Office's
7investigations into reports of fraud, waste, abuse,
8mismanagement, or misconduct relating to any public aid
9programs administered by the Department of Healthcare and
10Family Services or the Department of Human Services (as
11successor to the Department of Public Aid) to the General
12Assembly and the Governor. These reports shall include, but not
13be limited to, the following information:
14        (1) Aggregate provider billing and payment
15    information, including the number of providers at various
16    Medicaid earning levels.
17        (2) The number of audits of the medical assistance
18    program and the dollar savings resulting from those audits.
19        (3) The number of prescriptions rejected annually
20    under the Department of Healthcare and Family Services'
21    Refill Too Soon program and the dollar savings resulting
22    from that program.
23        (4) Provider sanctions, in the aggregate, including
24    terminations and suspensions.
25        (5) A detailed summary of the investigations
26    undertaken in the previous fiscal year. These summaries

 

 

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1    shall comply with all laws and rules regarding maintaining
2    confidentiality in the public aid programs.
3    (i) Nothing in this Section shall limit investigations by
4the Department of Healthcare and Family Services or the
5Department of Human Services that may otherwise be required by
6law or that may be necessary in their capacity as the central
7administrative authorities responsible for administration of
8their agency's public aid programs in this State.
9    (j) The Inspector General may issue shields or other
10distinctive identification to his or her employees not
11exercising the powers of a peace officer if the Inspector
12General determines that a shield or distinctive identification
13is needed by an employee to carry out his or her
14responsibilities.
15(Source: P.A. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09;
1696-1316, eff. 1-1-11.)
 
17    Section 99. Effective date. This Act takes effect upon
18becoming law.".