Illinois General Assembly - Full Text of SB2840
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Full Text of SB2840  97th General Assembly




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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5, 11-13, 11-26, and 12-13.1 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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1procedures provided by or under the supervision of a dentist in
2the practice of his or her profession; (11) physical therapy
3and related services; (12) prescribed drugs, dentures, and
4prosthetic devices; and eyeglasses prescribed by a physician
5skilled in the diseases of the eye, or by an optometrist,
6whichever the person may select; (13) other diagnostic,
7screening, preventive, and rehabilitative services, for
8children and adults; (14) transportation and such other
9expenses as may be necessary; (15) medical treatment of sexual
10assault survivors, as defined in Section 1a of the Sexual
11Assault Survivors Emergency Treatment Act, for injuries
12sustained as a result of the sexual assault, including
13examinations and laboratory tests to discover evidence which
14may be used in criminal proceedings arising from the sexual
15assault; (16) the diagnosis and treatment of sickle cell
16anemia; and (17) any other medical care, and any other type of
17remedial care recognized under the laws of this State, but not
18including abortions, or induced miscarriages or premature
19births, unless, in the opinion of a physician, such procedures
20are necessary for the preservation of the life of the woman
21seeking such treatment, or except an induced premature birth
22intended to produce a live viable child and such procedure is
23necessary for the health of the mother or her unborn child. The
24Illinois Department, by rule, shall prohibit any physician from
25providing medical assistance to anyone eligible therefor under
26this Code where such physician has been found guilty of



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1performing an abortion procedure in a wilful and wanton manner
2upon a woman who was not pregnant at the time such abortion
3procedure was performed. The term "any other type of remedial
4care" shall include nursing care and nursing home service for
5persons who rely on treatment by spiritual means alone through
6prayer for healing.
7    Notwithstanding any other provision of this Section, a
8comprehensive tobacco use cessation program that includes
9purchasing prescription drugs or prescription medical devices
10approved by the Food and Drug Administration shall be covered
11under the medical assistance program under this Article for
12persons who are otherwise eligible for assistance under this
14    Notwithstanding any other provision of this Code, the
15Illinois Department may not require, as a condition of payment
16for any laboratory test authorized under this Article, that a
17physician's handwritten signature appear on the laboratory
18test order form. The Illinois Department may, however, impose
19other appropriate requirements regarding laboratory test order
21    The Department of Healthcare and Family Services shall
22provide the following services to persons eligible for
23assistance under this Article who are participating in
24education, training or employment programs operated by the
25Department of Human Services as successor to the Department of
26Public Aid:



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1        (1) dental services provided by or under the
2    supervision of a dentist; and
3        (2) eyeglasses prescribed by a physician skilled in the
4    diseases of the eye, or by an optometrist, whichever the
5    person may select.
6    Notwithstanding any other provision of this Code and
7subject to federal approval, the Department may adopt rules to
8allow a dentist who is volunteering his or her service at no
9cost to render dental services through an enrolled
10not-for-profit health clinic without the dentist personally
11enrolling as a participating provider in the medical assistance
12program. A not-for-profit health clinic shall include a public
13health clinic or Federally Qualified Health Center or other
14enrolled provider, as determined by the Department, through
15which dental services covered under this Section are performed.
16The Department shall establish a process for payment of claims
17for reimbursement for covered dental services rendered under
18this provision.
19    The Illinois Department, by rule, may distinguish and
20classify the medical services to be provided only in accordance
21with the classes of persons designated in Section 5-2.
22    The Department of Healthcare and Family Services must
23provide coverage and reimbursement for amino acid-based
24elemental formulas, regardless of delivery method, for the
25diagnosis and treatment of (i) eosinophilic disorders and (ii)
26short bowel syndrome when the prescribing physician has issued



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1a written order stating that the amino acid-based elemental
2formula is medically necessary.
3    The Illinois Department shall authorize the provision of,
4and shall authorize payment for, screening by low-dose
5mammography for the presence of occult breast cancer for women
635 years of age or older who are eligible for medical
7assistance under this Article, as follows:
8        (A) A baseline mammogram for women 35 to 39 years of
9    age.
10        (B) An annual mammogram for women 40 years of age or
11    older.
12        (C) A mammogram at the age and intervals considered
13    medically necessary by the woman's health care provider for
14    women under 40 years of age and having a family history of
15    breast cancer, prior personal history of breast cancer,
16    positive genetic testing, or other risk factors.
17        (D) A comprehensive ultrasound screening of an entire
18    breast or breasts if a mammogram demonstrates
19    heterogeneous or dense breast tissue, when medically
20    necessary as determined by a physician licensed to practice
21    medicine in all of its branches.
22    All screenings shall include a physical breast exam,
23instruction on self-examination and information regarding the
24frequency of self-examination and its value as a preventative
25tool. For purposes of this Section, "low-dose mammography"
26means the x-ray examination of the breast using equipment



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1dedicated specifically for mammography, including the x-ray
2tube, filter, compression device, and image receptor, with an
3average radiation exposure delivery of less than one rad per
4breast for 2 views of an average size breast. The term also
5includes digital mammography.
6    On and after January 1, 2012, providers participating in a
7quality improvement program approved by the Department shall be
8reimbursed for screening and diagnostic mammography at the same
9rate as the Medicare program's rates, including the increased
10reimbursement for digital mammography.
11    The Department shall convene an expert panel including
12representatives of hospitals, free-standing mammography
13facilities, and doctors, including radiologists, to establish
14quality standards.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities.
20    The Department shall establish a methodology to remind
21women who are age-appropriate for screening mammography, but
22who have not received a mammogram within the previous 18
23months, of the importance and benefit of screening mammography.
24    The Department shall establish a performance goal for
25primary care providers with respect to their female patients
26over age 40 receiving an annual mammogram. This performance



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1goal shall be used to provide additional reimbursement in the
2form of a quality performance bonus to primary care providers
3who meet that goal.
4    The Department shall devise a means of case-managing or
5patient navigation for beneficiaries diagnosed with breast
6cancer. This program shall initially operate as a pilot program
7in areas of the State with the highest incidence of mortality
8related to breast cancer. At least one pilot program site shall
9be in the metropolitan Chicago area and at least one site shall
10be outside the metropolitan Chicago area. An evaluation of the
11pilot program shall be carried out measuring health outcomes
12and cost of care for those served by the pilot program compared
13to similarly situated patients who are not served by the pilot
15    Any medical or health care provider shall immediately
16recommend, to any pregnant woman who is being provided prenatal
17services and is suspected of drug abuse or is addicted as
18defined in the Alcoholism and Other Drug Abuse and Dependency
19Act, referral to a local substance abuse treatment provider
20licensed by the Department of Human Services or to a licensed
21hospital which provides substance abuse treatment services.
22The Department of Healthcare and Family Services shall assure
23coverage for the cost of treatment of the drug abuse or
24addiction for pregnant recipients in accordance with the
25Illinois Medicaid Program in conjunction with the Department of
26Human Services.



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1    All medical providers providing medical assistance to
2pregnant women under this Code shall receive information from
3the Department on the availability of services under the Drug
4Free Families with a Future or any comparable program providing
5case management services for addicted women, including
6information on appropriate referrals for other social services
7that may be needed by addicted women in addition to treatment
8for addiction.
9    The Illinois Department, in cooperation with the
10Departments of Human Services (as successor to the Department
11of Alcoholism and Substance Abuse) and Public Health, through a
12public awareness campaign, may provide information concerning
13treatment for alcoholism and drug abuse and addiction, prenatal
14health care, and other pertinent programs directed at reducing
15the number of drug-affected infants born to recipients of
16medical assistance.
17    Neither the Department of Healthcare and Family Services
18nor the Department of Human Services shall sanction the
19recipient solely on the basis of her substance abuse.
20    The Illinois Department shall establish such regulations
21governing the dispensing of health services under this Article
22as it shall deem appropriate. The Department should seek the
23advice of formal professional advisory committees appointed by
24the Director of the Illinois Department for the purpose of
25providing regular advice on policy and administrative matters,
26information dissemination and educational activities for



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1medical and health care providers, and consistency in
2procedures to the Illinois Department.
3    Notwithstanding any other provision of law, a health care
4provider under the medical assistance program may elect, in
5lieu of receiving direct payment for services provided under
6that program, to participate in the State Employees Deferred
7Compensation Plan adopted under Article 24 of the Illinois
8Pension Code. A health care provider who elects to participate
9in the plan does not have a cause of action against the State
10for any damages allegedly suffered by the provider as a result
11of any delay by the State in crediting the amount of any
12contribution to the provider's plan account.
13    The Illinois Department may develop and contract with
14Partnerships of medical providers to arrange medical services
15for persons eligible under Section 5-2 of this Code.
16Implementation of this Section may be by demonstration projects
17in certain geographic areas. The Partnership shall be
18represented by a sponsor organization. The Department, by rule,
19shall develop qualifications for sponsors of Partnerships.
20Nothing in this Section shall be construed to require that the
21sponsor organization be a medical organization.
22    The sponsor must negotiate formal written contracts with
23medical providers for physician services, inpatient and
24outpatient hospital care, home health services, treatment for
25alcoholism and substance abuse, and other services determined
26necessary by the Illinois Department by rule for delivery by



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1Partnerships. Physician services must include prenatal and
2obstetrical care. The Illinois Department shall reimburse
3medical services delivered by Partnership providers to clients
4in target areas according to provisions of this Article and the
5Illinois Health Finance Reform Act, except that:
6        (1) Physicians participating in a Partnership and
7    providing certain services, which shall be determined by
8    the Illinois Department, to persons in areas covered by the
9    Partnership may receive an additional surcharge for such
10    services.
11        (2) The Department may elect to consider and negotiate
12    financial incentives to encourage the development of
13    Partnerships and the efficient delivery of medical care.
14        (3) Persons receiving medical services through
15    Partnerships may receive medical and case management
16    services above the level usually offered through the
17    medical assistance program.
18    Medical providers shall be required to meet certain
19qualifications to participate in Partnerships to ensure the
20delivery of high quality medical services. These
21qualifications shall be determined by rule of the Illinois
22Department and may be higher than qualifications for
23participation in the medical assistance program. Partnership
24sponsors may prescribe reasonable additional qualifications
25for participation by medical providers, only with the prior
26written approval of the Illinois Department.



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1    Nothing in this Section shall limit the free choice of
2practitioners, hospitals, and other providers of medical
3services by clients. In order to ensure patient freedom of
4choice, the Illinois Department shall immediately promulgate
5all rules and take all other necessary actions so that provided
6services may be accessed from therapeutically certified
7optometrists to the full extent of the Illinois Optometric
8Practice Act of 1987 without discriminating between service
10    The Department shall apply for a waiver from the United
11States Health Care Financing Administration to allow for the
12implementation of Partnerships under this Section.
13    The Illinois Department shall require health care
14providers to maintain records that document the medical care
15and services provided to recipients of Medical Assistance under
16this Article. Such records must be retained for a period of not
17less than 6 years from the date of service or as provided by
18applicable State law, whichever period is longer, except that
19if an audit is initiated within the required retention period
20then the records must be retained until the audit is completed
21and every exception is resolved. The Illinois Department shall
22require health care providers to make available, when
23authorized by the patient, in writing, the medical records in a
24timely fashion to other health care providers who are treating
25or serving persons eligible for Medical Assistance under this
26Article. All dispensers of medical services shall be required



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1to maintain and retain business and professional records
2sufficient to fully and accurately document the nature, scope,
3details and receipt of the health care provided to persons
4eligible for medical assistance under this Code, in accordance
5with regulations promulgated by the Illinois Department. The
6rules and regulations shall require that proof of the receipt
7of prescription drugs, dentures, prosthetic devices and
8eyeglasses by eligible persons under this Section accompany
9each claim for reimbursement submitted by the dispenser of such
10medical services. No such claims for reimbursement shall be
11approved for payment by the Illinois Department without such
12proof of receipt, unless the Illinois Department shall have put
13into effect and shall be operating a system of post-payment
14audit and review which shall, on a sampling basis, be deemed
15adequate by the Illinois Department to assure that such drugs,
16dentures, prosthetic devices and eyeglasses for which payment
17is being made are actually being received by eligible
18recipients. Within 90 days after the effective date of this
19amendatory Act of 1984, the Illinois Department shall establish
20a current list of acquisition costs for all prosthetic devices
21and any other items recognized as medical equipment and
22supplies reimbursable under this Article and shall update such
23list on a quarterly basis, except that the acquisition costs of
24all prescription drugs shall be updated no less frequently than
25every 30 days as required by Section 5-5.12.
26    The rules and regulations of the Illinois Department shall



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1require that a written statement including the required opinion
2of a physician shall accompany any claim for reimbursement for
3abortions, or induced miscarriages or premature births. This
4statement shall indicate what procedures were used in providing
5such medical services.
6    The Illinois Department shall require all dispensers of
7medical services, other than an individual practitioner or
8group of practitioners, desiring to participate in the Medical
9Assistance program established under this Article to disclose
10all financial, beneficial, ownership, equity, surety or other
11interests in any and all firms, corporations, partnerships,
12associations, business enterprises, joint ventures, agencies,
13institutions or other legal entities providing any form of
14health care services in this State under this Article.
15    The Illinois Department may require that all dispensers of
16medical services desiring to participate in the medical
17assistance program established under this Article disclose,
18under such terms and conditions as the Illinois Department may
19by rule establish, all inquiries from clients and attorneys
20regarding medical bills paid by the Illinois Department, which
21inquiries could indicate potential existence of claims or liens
22for the Illinois Department.
23    The Illinois Department shall have the authority to
24establish by rule the necessary procedures and policies to
25comply with the federal Patient Protection and Affordable Care
26Act as amended by the Health Care and Education Reconciliation



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1Act of 2010, and with subsequent federal statutes, rules, and
2regulations pertaining to Department functions.
3    Prior to enrollment in the medical assistance program, all
4vendors shall be subject to enhanced oversight, screening, and
5review based on categories of risk of fraud, waste, and abuse.
6The Illinois Department shall establish by rule the procedures
7for such screening and review.
8    Enrollment of a vendor that provides non-emergency medical
9transportation, defined by the Department by rule, shall be
10subject to a provisional period and shall be conditional for
11one year 180 days. During the period of conditional enrollment
12that time, the Department of Healthcare and Family Services may
13terminate the vendor's eligibility to participate in, or may
14disenroll the vendor from, the medical assistance program
15without cause. Such That termination of eligibility or
16disenrollment is not subject to the Department's hearing
18    Prior to enrollment and during the conditional enrollment
19period, a vendor shall be subject to enhanced oversight based
20on risk categories that may include, but are not limited to,
21criminal and financial background checks; fingerprinting;
22license, certification, and authorization verifications;
23unscheduled or unannounced site visits; database checks;
24pre-payment audit reviews; audits; payment caps; payment
25suspensions; and other screening as required by federal or
26State law.



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1    To be eligible for payment consideration, a provider's
2vendor-payment claim or bill, either as an initial or
3resubmitted claim following prior rejection, must be received
4by the Illinois Department, or its fiscal intermediary, no
5later than 90 days after the date on which medical goods or
6services were provided, with the following exception: the
7Illinois Department must receive a claim after disposition by
8Medicare or its fiscal intermediary no later than 24 months
9after the date on which medical goods or services were
11    For claims for services rendered during a period for which
12a recipient received retroactive eligibility, claims must be
13filed within 90 days after the recipient was made eligible. For
14claims for which the Illinois Department is not the primary
15payer, claims must be submitted to the Illinois Department
16within 90 days after the final adjudication by the primary
17payer, but in no event more than 1 year after the date of
19    Claims that are not submitted and received in compliance
20with the foregoing requirement shall not be eligible for
21payment under the medical assistance program, and the State
22shall have no liability for payment of those claims.
23    To the extent consistent with applicable information,
24privacy, security, and disclosure laws, State and federal
25agencies shall provide the Illinois Department access to
26confidential and other information and data necessary to



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1perform eligibility and payment verifications and other
2Illinois Department functions. This includes, but is not
3limited to, information pertaining to licensure;
4certification; earnings; immigration status; citizenship; wage
5reporting; unearned and earned income; pension income;
6employment; supplemental security income; social security
7numbers; National Provider Identifier (NPI) numbers; the
8National Practitioner Data Bank (NPDB); program and agency
9exclusions; taxpayer identification numbers; tax delinquency;
10corporate information; and death records.
11    The Illinois Department shall enter into agreements with
12State and federal agencies and Departments under which such
13agencies shall share data necessary for program integrity
14functions and oversight. The Illinois Department shall
15develop, in cooperation with other State departments and
16agencies, and in compliance with applicable federal laws and
17regulations, appropriate and effective methods to share such
18data. At a minimum, and to the extent necessary to provide data
19sharing, the Illinois Department shall enter into agreements
20with State and federal agencies, including but not limited to,
21the Secretary of State; the Department of Revenue; the
22Department of Public Health; the Department of Human Services;
23and the Department of Financial and Professional Regulation.
24    Beginning in fiscal year 2013, the Illinois Department
25shall set forth a request for information to identify the
26benefits of a pre-payment, post-adjudication, and post-edit



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



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1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the State
6where they are not currently available or are undeveloped.
7    The Illinois Department shall develop and operate, in
8cooperation with other State Departments and agencies and in
9compliance with applicable federal laws and regulations,
10appropriate and effective systems of health care evaluation and
11programs for monitoring of utilization of health care services
12and facilities, as it affects persons eligible for medical
13assistance under this Code.
14    The Illinois Department shall report annually to the
15General Assembly, no later than the second Friday in April of
161979 and each year thereafter, in regard to:
17        (a) actual statistics and trends in utilization of
18    medical services by public aid recipients;
19        (b) actual statistics and trends in the provision of
20    the various medical services by medical vendors;
21        (c) current rate structures and proposed changes in
22    those rate structures for the various medical vendors; and
23        (d) efforts at utilization review and control by the
24    Illinois Department.
25    The period covered by each report shall be the 3 years
26ending on the June 30 prior to the report. The report shall



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



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1thereby. Acceptance of the payment by or in behalf of the
2vendor shall bar him from obtaining, or attempting to obtain,
3additional payment therefor from the recipient or any other
4person. A vendor payment shall not, however, bar recovery of
5the value of goods and services the obligation for which, under
6the rules and regulations of the Illinois Department, is to be
7met from the income and resources available to the recipient,
8and in respect to which the vendor payment of the Illinois
9Department or the local governmental unit represents
10supplementation of such available income and resources.
11    Vendors seeking to enforce obligations of a governmental
12unit or the Illinois Department for goods or services (1)
13furnished to or in behalf of recipients and (2) subject to a
14vendor payment as defined in Section 2-5, shall commence their
15actions in the appropriate Circuit Court or the Court of
16Claims, as the case may require, within one year next after the
17cause of action accrued.
18    A cause of action accrues within the meaning of this
19Section upon the following date:
20    (1) If the vendor can prove that he submitted a bill for
21the service rendered to the Illinois Department or a
22governmental unit within 90 days after 12 months of the date
23the service was rendered, then (a) upon the date the Illinois
24Department or a governmental unit mails to the vendor
25information that it is paying a bill in part or is refusing to
26pay a bill in whole or in part, or (b) upon the date one year



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1following the date the vendor submitted such bill if the
2Illinois Department or a governmental unit fails to mail to the
3vendor such payment information within one year following the
4date the vendor submitted the bill; or
5    (2) If the vendor cannot prove that he submitted a bill for
6the service rendered within 90 days after 12 months of the date
7the service was rendered, then upon the date 12 months
8following the date the vendor rendered the service to the
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



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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 provider type
10as determined by the Department primary care provider, primary
11care pharmacy, primary dentist, primary podiatrist, or primary
12durable medical equipment provider. Instead of requiring a
13recipient to make a designation as provided in this subsection,
14the Department, pursuant to rules adopted by the Department and
15without regard to any choice of an entity that the recipient
16might otherwise make, may initially designate a primary
17provider type provided that the primary provider type is
18willing 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



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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:



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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



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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



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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 5/12-13.1)
21    Sec. 12-13.1. Inspector General.
22    (a) The Governor shall appoint, and the Senate shall
23confirm, an Inspector General who shall function within the
24Illinois Department of Public Aid (now Healthcare and Family
25Services) and report to the Governor. The term of the Inspector



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1General shall expire on the third Monday of January, 1997 and
2every 4 years thereafter.
3    (b) In order to prevent, detect, and eliminate fraud,
4waste, abuse, mismanagement, and misconduct, the Inspector
5General shall oversee the Department of Healthcare and Family
6Services' integrity functions, which include, but are not
7limited to, the following:
8        (1) Investigation of misconduct by employees, vendors,
9    contractors and medical providers, except for allegations
10    of violations of the State Officials and Employees Ethics
11    Act which shall be referred to the Office of the Governor's
12    Executive Inspector General for investigation.
13        (2) Pre-payment and post-payment audits Audits of
14    medical providers related to ensuring that appropriate
15    payments are made for services rendered and to the
16    prevention and recovery of overpayments.
17        (3) Monitoring of quality assurance programs
18    administered by the Department of Healthcare and Family
19    Services generally related to the medical assistance
20    program and specifically related to any managed care
21    program.
22        (4) Quality control measurements of the programs
23    administered by the Department of Healthcare and Family
24    Services.
25        (5) Investigations of fraud or intentional program
26    violations committed by clients of the Department of



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1    Healthcare and Family Services.
2        (6) Actions initiated against contractors, vendors, or
3    medical providers for any of the following reasons:
4            (A) Violations of the medical assistance program.
5            (B) Sanctions against providers brought in
6        conjunction with the Department of Public Health or the
7        Department of Human Services (as successor to the
8        Department of Mental Health and Developmental
9        Disabilities).
10            (C) Recoveries of assessments against hospitals
11        and long-term care facilities.
12            (D) Sanctions mandated by the United States
13        Department of Health and Human Services against
14        medical providers.
15            (E) Violations of contracts related to any
16        programs administered by the Department of Healthcare
17        and Family Services managed care programs.
18        (7) Representation of the Department of Healthcare and
19    Family Services at hearings with the Illinois Department of
20    Financial and Professional Regulation in actions taken
21    against professional licenses held by persons who are in
22    violation of orders for child support payments.
23    (b-5) At the request of the Secretary of Human Services,
24the Inspector General shall, in relation to any function
25performed by the Department of Human Services as successor to
26the Department of Public Aid, exercise one or more of the



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1powers provided under this Section as if those powers related
2to the Department of Human Services; in such matters, the
3Inspector General shall report his or her findings to the
4Secretary of Human Services.
5    (c) Notwithstanding, and in addition to, any other
6provision of law, the The Inspector General shall have access
7to all information, personnel and facilities of the Department
8of Healthcare and Family Services and the Department of Human
9Services (as successor to the Department of Public Aid), their
10employees, vendors, contractors and medical providers and any
11federal, State or local governmental agency that are necessary
12to perform the duties of the Office as directly related to
13public assistance programs administered by those departments.
14No medical provider shall be compelled, however, to provide
15individual medical records of patients who are not clients of
16the programs administered by the Department of Healthcare and
17Family Services Medical Assistance Program. State and local
18governmental agencies are authorized and directed to provide
19the requested information, assistance or cooperation.
20    For purposes of enhanced program integrity functions and
21oversight, and to the extent consistent with applicable
22information, privacy, security, and disclosure laws, State and
23federal agencies shall provide the Inspector General access to
24confidential and other information and data. This includes, but
25is not limited to, information pertaining to licensure;
26certification; earnings; immigration status; citizenship; wage



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1reporting; unearned and earned income; pension income;
2employment; supplemental security income; social security
3numbers; National Provider Identifier (NPI) numbers; the
4National Practitioner Data Bank (NPDB); program and agency
5exclusions; taxpayer identification numbers; tax delinquency;
6corporate information; and death records.
7    The Department of Healthcare and Family Services shall
8enter into agreements with State and federal agencies under
9which such agencies share data necessary for vendor screening,
10vendor review, and payment verification. The Department shall
11develop, in cooperation with other State and federal
12departments and agencies, and in compliance with applicable
13federal laws and regulations, appropriate and effective
14methods to share such data necessary for vendor screening,
15vendor review, and payment verification. The Department shall
16enter into agreements with State and federal agencies,
17including but not limited to, the Secretary of State; the
18Department of Revenue; the Department of Public Health; the
19Department of Human Services; and the Department of Financial
20and Professional Regulation.
21    The Inspector General shall have the authority to deny
22payment, prevent overpayments, and recover overpayments.
23    The Inspector General shall have the authority to deny or
24suspend payment to, and deny, terminate, or suspend the
25eligibility of, any vendor who fails to grant the Inspector
26General timely access to full and complete records in



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1accordance with Section 140.28 of Title 89 of the Illinois
2Administrative Code, and other information for the purpose of
3audits, investigations, or other program integrity functions,
4after reasonable written request by the Inspector General.
5    The Inspector General shall have the authority to establish
6by rule the necessary procedures and policies to comply with
7the federal Patient Protection and Affordable Care Act as
8amended by the Health Care and Education Reconciliation Act of
92010, and with subsequent federal statutes and rules pertaining
10to state program integrity requirements.
11    (d) The Inspector General shall serve as the Department of
12Healthcare and Family Services' primary liaison with law
13enforcement, investigatory and prosecutorial agencies,
14including but not limited to the following:
15        (1) The Department of State Police.
16        (2) The Federal Bureau of Investigation and other
17    federal law enforcement agencies.
18        (3) The various Inspectors General of federal agencies
19    overseeing the programs administered by the Department of
20    Healthcare and Family Services.
21        (4) The various Inspectors General of any other State
22    agencies with responsibilities for portions of programs
23    primarily administered by the Department of Healthcare and
24    Family Services.
25        (5) The Offices of the several United States Attorneys
26    in Illinois.



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1        (6) The several State's Attorneys.
2        (7) The offices of the Centers for Medicare and
3    Medicaid Services that administer the Medicare and
4    Medicaid integrity programs.
5    The Inspector General shall meet on a regular basis with
6these entities to share information regarding possible
7misconduct by any persons or entities involved with the public
8aid programs administered by the Department of Healthcare and
9Family Services.
10    (e) All investigations conducted by the Inspector General
11shall be conducted in a manner that ensures the preservation of
12evidence for use in criminal prosecutions. If the Inspector
13General determines that a possible criminal act relating to
14fraud in the provision or administration of the medical
15assistance program has been committed, the Inspector General
16shall immediately notify the Medicaid Fraud Control Unit. If
17the Inspector General determines that a possible criminal act
18has been committed within the jurisdiction of the Office, the
19Inspector General may request the special expertise of the
20Department of State Police. The Inspector General may present
21for prosecution the findings of any criminal investigation to
22the Office of the Attorney General, the Offices of the several
23United States Attorneys in Illinois or the several State's
25    (f) To carry out his or her duties as described in this
26Section, the Inspector General and his or her designees shall



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1have the power to compel by subpoena the attendance and
2testimony of witnesses and the production of books, electronic
3records and papers as directly related to public assistance
4programs administered by the Department of Healthcare and
5Family Services or the Department of Human Services (as
6successor to the Department of Public Aid). No medical provider
7shall be compelled, however, to provide individual medical
8records of patients who are not clients of the Medical
9Assistance Program.
10    (g) The Inspector General shall report all convictions,
11terminations, and suspensions taken against vendors,
12contractors and medical providers to the Department of
13Healthcare and Family Services and to any agency responsible
14for licensing or regulating those persons or entities.
15    (h) The Inspector General shall make annual reports,
16findings, and recommendations regarding the Office's
17investigations into reports of fraud, waste, abuse,
18mismanagement, or misconduct relating to any public aid
19programs administered by the Department of Healthcare and
20Family Services or the Department of Human Services (as
21successor to the Department of Public Aid) to the General
22Assembly and the Governor. These reports shall include, but not
23be limited to, the following information:
24        (1) Aggregate provider billing and payment
25    information, including the number of providers at various
26    Medicaid earning levels.



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1        (2) The number of audits of the medical assistance
2    program and the dollar savings resulting from those audits.
3        (3) The number of prescriptions rejected annually
4    under the Department of Healthcare and Family Services'
5    Refill Too Soon program and the dollar savings resulting
6    from that program.
7        (4) Provider sanctions, in the aggregate, including
8    terminations and suspensions.
9        (5) A detailed summary of the investigations
10    undertaken in the previous fiscal year. These summaries
11    shall comply with all laws and rules regarding maintaining
12    confidentiality in the public aid programs.
13    (i) Nothing in this Section shall limit investigations by
14the Department of Healthcare and Family Services or the
15Department of Human Services that may otherwise be required by
16law or that may be necessary in their capacity as the central
17administrative authorities responsible for administration of
18their agency's public aid programs in this State.
19    (j) The Inspector General may issue shields or other
20distinctive identification to his or her employees not
21exercising the powers of a peace officer if the Inspector
22General determines that a shield or distinctive identification
23is needed by an employee to carry out his or her
25(Source: P.A. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09;
2696-1316, eff. 1-1-11.)



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1    Section 99. Effective date. This Act takes effect upon
2becoming law.