(305 ILCS 5/5F-15) Sec. 5F-15. Definitions. As used in this Article: "Appeal" means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 CFR 422.566(b). These procedures include reconsiderations by the managed care organization and, if necessary, an independent review entity as provided by the Health Carrier External Review Act, hearings before administrative law judges, review by the Medicare Appeals Council, and judicial review. "Demonstration Project" means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project. "Department" means the Department of Healthcare and Family Services. "Enrollee" means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. "Health care services" means the diagnosis, treatment, and prevention of disease and includes medication, primary care, nursing or medical care, mental health treatment, psychiatric rehabilitation, memory loss services, physical, occupational, and speech rehabilitation, enhanced care, medical supplies and equipment and the repair of such equipment, and assistance with activities of daily living. "Managed care organization" or "MCO" means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. "Medical professional" means a physician, physician assistant, or nurse practitioner. "Medically necessary" means health care services that a medical professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms, and that are: (i) in accordance with the generally accepted standards of medical practice; (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, a medical professional, other health care provider, caregiver, family member, or other interested party. "Nursing home" means a facility licensed under the Nursing Home Care Act. "Nurse practitioner" means an individual properly licensed as a nurse practitioner under the Nurse Practice Act. "Physician" means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987. "Physician assistant" means an individual properly licensed under the Physician Assistant Practice Act of 1987. "Resident" means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. "RAI Manual" means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services. "Resident's representative" means a person designated in writing by a resident to be the resident's representative or the resident's guardian, as described by the Nursing Home Care Act. "SNFist" means a medical professional specializing in the care of individuals residing in nursing homes employed by or under contract with a MCO. "Transition period" means a period of time immediately following enrollment into the Demonstration Project or an enrollee's movement from one managed care organization to another managed care organization or one care setting to another care setting.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-20) Sec. 5F-20. Network adequacy. (a) Every managed care organization shall allow every nursing home in its service area an opportunity to be a network contracted facility at the plan's standard terms, conditions, and rates. Either party may opt to limit the contract to existing residents only. (b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met: (1) the quality standards are made known to the |
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(2) the quality standards can be objectively
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(3) the nursing home is measured on at least a
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| year's worth of performance;
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(4) a nursing home that the MCO has determined did
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| not meet a quality standard has the opportunity to contest that determination by challenging the accuracy or the measurement of the data through an arbitration process agreed to by contract; and
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(5) the Department may attempt to mediate a dispute
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(c) A managed care organization may terminate or refuse to renew a contract with a nursing home for a material breach of the contract, including, but not limited to, failure to grant reasonable and timely access to the MCO's care coordinators, SNFists and other providers, termination from the Medicare or Medicaid program, or revocation of license.
(Source: P.A. 98-651, eff. 6-16-14.)
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(305 ILCS 5/5F-32) Sec. 5F-32. Non-emergency prior approval and appeal. (a) MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year from nursing home residents, physicians, or providers. If a response is not provided within 24 hours of the request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO's contract in the Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO. In a non-emergency situation, notwithstanding any provisions in State law to the contrary, in the event a resident's physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO. If an enrollee, physician, or provider requests an expedited appeal pursuant to 42 CFR 438.410, the MCO shall notify the individual filing the appeal, whether it is the enrollee, physician, or provider, within 24 hours after the submission of the appeal of all information from the enrollee, physician, or provider that the MCO requires to evaluate the appeal. The MCO shall notify the individual filing the appeal of the MCO's decision on an expedited appeal within 24 hours after receipt of the required information. (b) While the appeal is pending or if the ordered service, treatment, or test is denied after appeal, the Department of Public Health may not cite the nursing home for failure to provide the ordered service, treatment, or test. The nursing home shall not be liable or responsible for an injury in any regulatory proceeding for the following: (1) failure to follow the appealed or denied order; |
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(2) injury to the extent it was caused by the delay
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| or failure to perform the appealed or denied service, treatment, or test.
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Provided however, a nursing home shall continue to monitor, document, and ensure the patient's safety. Nothing in this subsection (b) is intended to otherwise change the nursing home's existing obligations under State and federal law to appropriately care for its residents.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17 .)
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(305 ILCS 5/5G-30) Sec. 5G-30. Administration; enforcement provisions. (a) The Department shall administer and enforce this Article and collect the assessments and penalty assessments imposed under this Article using procedures employed in its administration of this Code generally and as follows: (1) The Department may initiate either administrative |
| or judicial proceedings, or both, to enforce provisions of this Article. Administrative enforcement proceedings initiated hereunder shall be governed by the Department's administrative rules. Judicial enforcement proceedings initiated hereunder shall be governed by the rules of procedure applicable in the courts of this State.
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(2) No proceedings for collection, refund, credit, or
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| other adjustment of an assessment amount shall be issued more than 3 years after the due date of the assessment, except in the case of an extended period agreed to in writing by the Department and the supportive living facility before the expiration of this limitation period.
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(3) Any unpaid assessment under this Article shall
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| become a lien upon the assets of the supportive living facility upon which it was assessed. If any supportive living facility, outside the usual course of its business, sells or transfers the major part of any one or more of (A) the real property and improvements, (B) the machinery and equipment, or (C) the furniture or fixtures, of any supportive living facility that is subject to the provisions of this Article, the seller or transferor shall pay the Department the amount of any assessment, assessment penalty, and interest (if any) due from it under this Article up to the date of the sale or transfer. If the seller or transferor fails to pay any assessment, assessment penalty, and interest (if any) due, the purchaser or transferee of such asset shall be liable for the amount of the assessment, penalty, and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee. The purchaser or transferee shall continue to be liable until the purchaser or transferee pays the full amount of the assessment, penalty, and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee or until the purchaser or transferee receives from the Department a certificate showing that such assessment, penalty, and interest have been paid or a certificate from the Department showing that no assessment, penalty, or interest is due from the seller or transferor under this Article.
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(b) In addition to any other remedy provided for and without sending a notice of assessment liability, the Department may collect an unpaid assessment by withholding, as payment of the assessment, reimbursements or other amounts otherwise payable by the Department to the supportive living facility.
(Source: P.A. 98-651, eff. 6-16-14.)
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(305 ILCS 5/5G-35) Sec. 5G-35. Supportive Living Facility Fund. (a) There is created in the State treasury the Supportive Living Facility Fund. Interest earned by the Fund shall be credited to the Fund. The Fund shall not be used to replace any moneys appropriated to the Medicaid program by the General Assembly. (b) The Fund is created for the purpose of receiving and disbursing moneys in accordance with this Article. Disbursements from the Fund, other than transfers authorized under paragraphs (5) and (6) of this subsection, shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Department. Disbursements from the Fund shall be made only as follows: (1) For making payments to supportive living |
| facilities as required under this Code, under the Children's Health Insurance Program Act, under the Covering ALL KIDS Health Insurance Act, and under the Long Term Acute Care Hospital Quality Improvement Transfer Program Act.
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(2) For the reimbursement of moneys collected by the
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| Department from supportive living facilities through error or mistake in performing the activities authorized under this Code.
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(3) For payment of administrative expenses incurred
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| by the Department or its agent in performing administrative oversight activities for the supportive living program or review of new supportive living facility applications.
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(4) For payments of any amounts which are
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| reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant.
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(5) For making transfers, as those transfers are
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| authorized in the proceedings authorizing debt under the Short Term Borrowing Act, but transfers made under this paragraph (5) shall not exceed the principal amount of debt issued in anticipation of the receipt by the State of moneys to be deposited into the Fund.
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(6) For making transfers to any other fund in the
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| State treasury, but transfers made under this paragraph (6) shall not exceed the amount transferred previously from that other fund into the Supportive Living Facility Fund plus any interest that would have been earned by that fund on the money that had been transferred.
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(c) The Fund shall consist of the following:
(1) All moneys collected or received by the
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| Department from the supportive living facility assessment imposed by this Article.
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(2) All moneys collected or received by the
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| Department from the supportive living facility certification fee imposed by this Article.
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(3) All federal matching funds received by the
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| Department as a result of expenditures made by the Department that are attributable to moneys deposited in the Fund.
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(4) Any interest or penalty levied in conjunction
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| with the administration of this Article.
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(5) Moneys transferred from another fund in the State
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(6) All other moneys received for the Fund from any
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| other source, including interest earned thereon.
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(Source: P.A. 98-651, eff. 6-16-14.)
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(305 ILCS 5/6-1.2) (from Ch. 23, par. 6-1.2)
Sec. 6-1.2. Need. Income available to the person, when added to
contributions in money, substance, or services from other sources,
including contributions from legally responsible relatives, must be
insufficient to equal the grant amount established by Department regulation
(or by local governmental unit in units which do not receive State funds)
for such a person.
In determining income to be taken into account:
(1) The first $75 of earned income in income |
| assistance units comprised exclusively of one adult person shall be disregarded, and for not more than 3 months in any 12 consecutive months that portion of earned income beyond the first $75 that is the difference between the standard of assistance and the grant amount, shall be disregarded.
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(2) For income assistance units not comprised
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| exclusively of one adult person, when authorized by rules and regulations of the Illinois Department, a portion of earned income, not to exceed the first $25 a month plus 50% of the next $75, may be disregarded for the purpose of stimulating and aiding rehabilitative effort and self-support activity.
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"Earned income" means money earned in self-employment or wages, salary,
or commission for personal services performed as an employee. The eligibility
of any applicant for or recipient of public aid under this Article is not
affected by the payment of any grant under the "Senior Citizens and Persons with Disabilities Property Tax Relief Act", any
refund
or payment of the federal Earned Income Tax Credit, any rebate authorized under Section 2201(a) of the Coronavirus Aid, Relief, and Economic Security Act (Public Law 116-136) or under any other federal economic stimulus program created in response to the COVID-19 emergency, or any distributions or
items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
(Source: P.A. 101-632, eff. 6-5-20.)
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(305 ILCS 5/6-2.1) (from Ch. 23, par. 6-2.1)
Sec. 6-2.1.
Assets of homeless persons.
(a) For the purpose of assisting homeless persons in securing housing,
all assistance units that include a homeless person shall have an asset
disregard no less than that applicable to recipients of benefits under
Article 4 of this Code. For purposes of this Section, "homeless" or
"homeless person" means either of the following:
(1) An individual who lacks a fixed, regular, and |
| adequate nighttime residence; or
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(2) An individual who has a primary nighttime
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| residence that is any of the following:
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(A) A supervised publicly or privately operated
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| shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill).
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(B) An institution that provides a temporary
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| residence for individuals intended to be institutionalized.
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(C) A public or private place not designed for,
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| or ordinarily used as, a regular sleeping accommodation for human beings.
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(b) While the Illinois Department shall consider other indicia of
homelessness in determining whether a person is homeless, a letter from a
shelter provider stating that a person is homeless or residing in its
shelter shall create a rebuttable presumption that the person is homeless.
(Source: P.A. 87-1185.)
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(305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
Sec. 6-11. General Assistance.
(a) Effective July 1, 1992, all State funded General Assistance and related
medical benefits shall be governed by this Section, provided that, notwithstanding any other provisions of this Code to the contrary, on and after July 1, 2012, the State shall not fund the programs outlined in this Section. Other parts of this Code
or other laws related to General Assistance shall remain in effect to the
extent they do not conflict with the provisions of this Section. If any other
part of this Code or other laws of this State conflict with the provisions of
this Section, the provisions of this Section shall control.
(b) General Assistance may consist of 2 separate
programs. One program shall be for adults with no children and shall be
known as Transitional Assistance. The other program may be for
families with children and for pregnant women and shall be known as
Family and Children Assistance.
(c) (1) To be eligible for Transitional Assistance on or after July
1, 1992, an individual must be ineligible for assistance under any other
Article of this Code, must be determined chronically needy, and must be one of
the following:
(A) age 18 or over or
(B) married and living with a spouse, regardless of |
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(2) The local governmental unit shall determine
whether individuals are chronically needy as follows:
(A) Individuals who have applied for Supplemental
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| Security Income (SSI) and are awaiting a decision on eligibility for SSI who are determined to be a person with a disability by the Illinois Department using the SSI standard shall be considered chronically needy, except that individuals whose disability is based solely on substance use disorders and whose disability would cease were their addictions to end shall be eligible only for medical assistance and shall not be eligible for cash assistance under the Transitional Assistance program.
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(B) (Blank).
(C) The unit of local government may specify other
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| categories of individuals as chronically needy; nothing in this Section, however, shall be deemed to require the inclusion of any specific category other than as specified in paragraph (A).
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(3) For individuals in Transitional Assistance, medical assistance may
be provided by the unit of local government in an amount and nature determined by the unit of local government. Nothing in this paragraph (3) shall be construed to require the coverage of
any particular medical service. In addition, the amount and nature of medical
assistance provided may be different for different categories of individuals
determined chronically needy.
(4) (Blank).
(5) (Blank).
(d) (1) To be eligible for Family and Children Assistance, a
family unit must be ineligible for assistance under any other Article of
this Code and must contain a child who is:
(A) under age 18 or
(B) age 18 and a full-time student in a secondary
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| school or the equivalent level of vocational or technical training, and who may reasonably be expected to complete the program before reaching age 19.
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Those children shall be eligible for Family and Children Assistance.
(2) The natural or adoptive parents of the child living in the same
household may be eligible for Family and Children Assistance.
(3) A pregnant woman whose pregnancy has been verified shall be
eligible for income maintenance assistance under the Family and
Children Assistance program.
(4) The amount and nature of medical assistance provided under the
Family and Children Assistance program shall be determined by the unit of local government. The amount and nature of medical
assistance provided
need not be the same as that provided under paragraph (3) of
subsection (c) of this Section, and nothing in this paragraph (4) shall be
construed to require the coverage of any particular medical service.
(5) (Blank).
(e) A local governmental unit that chooses to participate in a
General Assistance program under this Section shall provide
funding in accordance with Section 12-21.13 of this Act.
Local governmental funds used to qualify for State funding may only be
expended for clients eligible for assistance under this Section 6-11 and
related administrative expenses.
(f) (Blank).
(g) (Blank).
(Source: P.A. 99-143, eff. 7-27-15; 100-759, eff. 1-1-19 .)
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(305 ILCS 5/8A-2.5)
Sec. 8A-2.5. Unauthorized use of medical assistance.
(a) Any person who knowingly uses, acquires, possesses, or transfers a
medical card in any manner not authorized by law or by rules and regulations of
the Illinois Department, or who knowingly alters a medical card, or who
knowingly uses, acquires, possesses, or transfers an altered medical card, is
guilty of a violation of this Article and shall be punished as provided in
Section 8A-6.
(b) Any person who knowingly obtains unauthorized medical benefits or causes to be obtained unauthorized medical benefits with or
without use of a medical card is guilty of a violation of this Article and
shall be punished as provided in Section 8A-6.
(b-5) Any vendor that knowingly assists a person in committing a violation under subsection (a) or (b) of this Section is guilty of a violation of this Article and shall be punished as provided in Section 8A-6. (b-6) Any person (including a vendor, organization, agency, or other entity) that, in any matter related to the medical assistance program, knowingly or willfully falsifies, conceals, or omits by any trick, scheme, artifice, or device a material fact, or makes any false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with the provision of health care or related services, is guilty of a violation of this Article and shall be punished as provided in Section 8A-6. (c) The Department may seek to recover any and all State and federal monies for which it has improperly and erroneously paid benefits as a result of a fraudulent action and any civil penalties authorized in this Section. Pursuant to Section 11-14.5 of this Code, the Department may determine the monetary value of benefits improperly and erroneously received. The Department may recover the monies paid for such benefits and interest on that amount at the rate of 5% per annum for the period from which payment was made to the date upon which repayment is made to the State. Prior to the recovery of any amount paid for benefits allegedly obtained by fraudulent means, the recipient or payee of such benefits shall be afforded an opportunity for a hearing after reasonable notice. The notice shall be served personally or by certified or registered mail or as otherwise provided by law upon the parties or their agents appointed to receive service of process and shall include the following: (1) A statement of the time, place and nature of the |
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(2) A statement of the legal authority and
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| jurisdiction under which the hearing is to be held.
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(3) A reference to the particular Sections of the
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| substantive and procedural statutes and rules involved.
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(4) Except where a more detailed statement is
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| otherwise provided for by law, a short and plain statement of the matters asserted, the consequences of a failure to respond, and the official file or other reference number.
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(5) A statement of the monetary value of the benefits
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| fraudulently received by the person accused.
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(6) A statement that, in addition to any other
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| penalties provided by law, a civil penalty in an amount not to exceed $2,000 may be imposed for each fraudulent claim for benefits or payments.
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(7) A statement providing that the determination of
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| the monetary value may be contested by petitioning the Department for an administrative hearing within 30 days from the date of mailing the notice.
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(8) The names and mailing addresses of the
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| administrative law judge, all parties, and all other persons to whom the agency gives notice of the hearing unless otherwise confidential by law.
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An opportunity shall be afforded all parties to be represented by legal counsel and to respond and present evidence and argument.
Unless precluded by law, disposition may be made of any contested case by stipulation, agreed settlement, consent order, or default.
Any final order, decision, or other determination made, issued or executed by the Director under the provisions of this Article whereby any person is aggrieved shall be subject to review in accordance with the provisions of the Administrative Review Law, and the rules adopted pursuant thereto, which shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Director.
Upon entry of a final administrative decision for repayment of any benefits obtained by fraudulent means, or for any civil penalties assessed, a lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution, vendor, or other legal entity until the judgment is satisfied.
Within 18 months of the effective date of this amendatory Act of the 96th General Assembly, the Department of Healthcare and Family Services will report to the General Assembly on the number of fraud cases identified and pursued, and the fines assessed and collected. The report will also include the Department's analysis as to the use of private sector resources to bring action, investigate, and collect monies owed.
(d) In subsections (a), (b), (b-5) and (b-6), "knowledge" has the meaning ascribed to that term in Section 4-5 of the Criminal Code of 2012. For any administrative action brought under subsection (c) pursuant to a violation of this Section, the Department shall define "knowing" by rule.
(Source: P.A. 97-23, eff. 1-1-12; 98-354, eff. 8-16-13.)
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(305 ILCS 5/8A-3) (from Ch. 23, par. 8A-3)
Sec. 8A-3.
Vendor Fraud and Kickbacks.
(a) Any person, firm, corporation,
association, agency, institution or other legal entity that willfully, by
means of a false statement or representation, or by concealment of any material
fact or by other fraudulent scheme or device on behalf of himself or others,
obtains or attempts to obtain benefits or payments under this Code to which
he or it is not entitled, or in a greater amount than that to which he or
it is entitled, is guilty of a violation of this Article and shall be punished
as provided in Section 8A-6.
(b) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he solicits or receives any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind:
(1) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or service for which
payment may be made in whole or in part under this Code; or
(2) in return for purchasing, leasing, ordering, or arranging for or
recommending purchasing, leasing, or ordering any good, facility, service
or item for which payment may be made in whole or in part under this Code.
(c) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he offers or pays any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or
in kind to any person to induce such person:
(1) to refer an individual to a person for the furnishing or arranging
for the furnishing of any item or service for which payment may be made in
whole or in part under this Code; or
(2) to purchase, lease, order, or arrange for or recommend purchasing,
leasing, or ordering any good, facility, service, or item for which payment
may be made in whole or in part under this Code.
(d) Subsections (b) and (c) shall not apply to:
(1) a discount or other reduction in price obtained by a provider of
services or other entity under this Code if the reduction in price is
properly disclosed and appropriately reflected in the costs claimed or
charges made by the provider or entity under this Code;
(2) any amount paid by an employer to an employee who has a bona fide
employment relationship with such employer for employment in the provision
of covered items or services; or
(3) any amount
paid to or received by a physician for professional
services rendered if a physician, pursuant to a bona fide contract with
a health maintenance organization, as defined by the Health
Maintenance Organization Act, has referred a patient to another physician
for rendering professional services not covered by the health maintenance
organization.
(Source: P.A. 85-818.)
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(305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)
Sec. 8A-6.
Classification of violations.
(a) Any person, firm, corporation,
association, agency, institution or other legal entity that has been found
by a court to have engaged in an act, practice or course of conduct declared
unlawful under Sections 8A-2 through 8A-5 or Section 8A-13 or 8A-14 where:
(1) the total amount of money involved in the |
| violation, including the monetary value of federal food stamps and the value of commodities, is less than $150, shall be guilty of a Class A misdemeanor;
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(2) the total amount of money involved in the
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| violation, including the monetary value of federal food stamps and the value of commodities, is $150 or more but less than $1,000, shall be guilty of a Class 4 felony;
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(3) the total amount of money involved in the
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| violation, including the monetary value of federal food stamps and the value of commodities, is $1,000 or more but less than $5,000, shall be guilty of a Class 3 felony;
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(4) the total amount of money involved in the
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| violation, including the monetary value of federal food stamps and the value of commodities, is $5,000 or more but less than $10,000, shall be guilty of a Class 2 felony; or
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(5) the total amount of money involved in the
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| violation, including the monetary value of federal food stamps and the value of commodities, is $10,000 or more, shall be guilty of a Class 1 felony and, notwithstanding the provisions of Section 8A-8 except for Subsection (c) of Section 8A-8, shall be ineligible for financial aid under this Article for a period of two years following conviction or until the total amount of money, including the value of federal food stamps, is repaid, whichever first occurs.
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(b) Any person, firm, corporation, association, agency, institution
or other legal entity that commits a subsequent violation of any of the
provisions of Sections 8A-2 through 8A-5 and:
(1) the total amount of money involved in the
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| subsequent violation, including the monetary value of federal food stamps and the value of commodities, is less than $150, shall be guilty of a Class 4 felony;
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(2) the total amount of money involved in the
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| subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $150 or more but less than $1,000, shall be guilty of a Class 3 felony;
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(3) the total amount of money involved in the
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| subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $1,000 or more but less than $5,000, shall be guilty of a Class 2 felony;
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(4) the total amount of money involved in the
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| subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $5,000 or more but less than $10,000, shall be guilty of a Class 1 felony.
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(c) For purposes of determining the classification of offense under
this Section, all of the money received as a result of the unlawful act,
practice or course of conduct can be accumulated.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-7) (from Ch. 23, par. 8A-7) Sec. 8A-7. Civil remedies. (a) A person who receives financial aid by means of a false statement, willful misrepresentation or by his failure to notify the county department or local governmental unit, as the case may be, of a change in his status as required by Sections 11-18 and 11-19, for the purpose of preventing the denial, cancellation or suspension of his grant, or a variation in the amount thereof, or by other fraudulent device, or a person who knowingly aids or abets any person in obtaining financial aid for which he is not eligible, shall be answerable to the county department or the local governmental unit, as the case may be, for refunding the entire amount of aid received. If the refund is not made, it shall be recoverable in a civil action from the person who received the aid, or from anyone who willfully aided such person to obtain the aid. If an act which would be unlawful under Section 8A-2 is proven, the court may as a penalty assess an additional sum of money, not to exceed the entire amount of aid provided, against the recipient or against any person who willfully aided the recipient. If assessed, the penalty shall be included in any judgment entered for the aid received, and paid to the county department or the local governmental unit, as the case may be. Upon entry of the judgment a lien shall attach to all property and assets of such person until the judgment is satisfied. (b) Any person, firm, corporation, association, agency, institution or other legal entity, other than an individual recipient, that willfully, by means of a false statement or representation, or by concealment of any material fact or by other fraudulent scheme or device on behalf of himself or others, obtains or attempts to obtain benefits or payments under this Code to which he or it is not entitled, or in a greater amount than that to which he or it is entitled, shall be liable for repayment of any excess benefits or payments received and, in addition to any other penalties provided by law, civil penalties consisting of (1) the interest on the amount of excess benefits or payments at the maximum legal rate in effect on the date the payment was made to such person, firm, corporation, association, agency, institution or other legal entity for the period from the date upon which payment was made to the date upon which repayment is made to the State, (2) an amount not to exceed 3 times the amount of such excess benefits or payments, and (3) the sum of $2,000 for each excessive claim for benefits or payments. Upon entry of a judgment for repayment of any excess benefits or payments, or for any civil penalties assessed by the court, a lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution or other legal entity until the judgment is satisfied. (c) Civil recoveries provided for in this Section may be recoverable in court proceedings initiated by the Attorney General or, in actions involving a local governmental unit, by the State's Attorney. (d) Any person who commits the offense of vendor fraud or recipient fraud as defined in Section 8A-2 and Section 8A-3 of this Article shall forfeit, according to the provisions of this subsection, any monies, profits or proceeds, and any interest or property which the sentencing court determines he has acquired or maintained, directly or indirectly, in whole or in part as a result of such offense. Such person shall also forfeit any interest in, securities of, claim against, or contractual right of any kind which affords him a source of influence over, any enterprise which he has established, operated, controlled, conducted, or participated in conducting, where his relationship to or connection with any such thing or activity directly or indirectly, in whole or in part, is traceable to any thing or benefit which he has obtained or acquired through vendor fraud or recipient fraud. Proceedings instituted pursuant to this subsection shall be subject to and conducted in accordance with the following procedures: (1) The sentencing court shall, upon petition by the |
| Attorney General or State's Attorney at any time following sentencing, conduct a hearing to determine whether any property or property interest is subject to forfeiture under this subsection. At the forfeiture hearing the People shall have the burden of establishing, by a preponderance of the evidence, that the property or property interests are subject to such forfeiture.
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(2) In any action brought by the People of the State
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| of Illinois under this Section, in which any restraining order, injunction or prohibition or any other action in connection with any property or interest subject to forfeiture under this subsection is sought, the circuit court presiding over the trial of the person charged with recipient fraud or vendor fraud as defined in Sections 8A-2 or 8A-3 of this Article shall first determine whether there is probable cause to believe that the person so charged has committed the offense of recipient fraud or vendor fraud and whether the property or interest is subject to forfeiture under this subsection. To make such a determination, prior to entering any such order, the court shall conduct a hearing without a jury, at which the People shall establish that there is (i) probable cause that the person so charged has committed the offense of recipient fraud or vendor fraud and (ii) probable cause that any property or interest may be subject to forfeiture pursuant to this subsection. Such hearing may be conducted simultaneously with a preliminary hearing, if the prosecution is commenced by information or complaint, or by motion of the People at any stage in the proceedings. The court may accept a finding of probable cause at a preliminary hearing following the filing of an information charging the offense of recipient fraud or vendor fraud as defined in Sections 8A-2 or 8A-3 or the return of an indictment by a grand jury charging the offense of recipient fraud or vendor fraud as defined in Sections 8A-2 or 8A-3 of this Article as sufficient evidence of probable cause as provided in item (i) above. Upon such a finding, the circuit court shall enter such restraining order, injunction or prohibition, or shall take such other action in connection with any such property or other interest subject to forfeiture under this Act as is necessary to insure that such property is not removed from the jurisdiction of the court, concealed, destroyed or otherwise disposed of by the owner of that property or interest prior to a forfeiture hearing under this subsection. The Attorney General or State's Attorney shall file a certified copy of such restraining order, injunction or other prohibition with the recorder of deeds or registrar of titles of each county where any such property of the defendant may be located. No such injunction, restraining order or other prohibition shall affect the rights of any bonafide purchaser, mortgagee, judgement creditor or other lien holder arising prior to the date of such filing. The court may, at any time, upon verified petition by the defendant, conduct a hearing to determine whether all or portions of any such property or interest which the court previously determined to be subject to forfeiture or subject to any restraining order, injunction, or prohibition or other action, should be released. The court may in its discretion release such property to the defendant for good cause shown.
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(3) Upon conviction of a person under this Article,
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| the court shall authorize the Director of the Illinois State Police to seize all property or other interest declared forfeited under this subsection upon such terms and conditions as the court shall deem proper.
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(4) The Director of the Illinois State Police is
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| authorized to sell all property forfeited and seized pursuant to this subsection, unless such property is required by law to be destroyed or is harmful to the public. After the deduction of all requisite expenses of administration and sale, the court shall order the Director to distribute to the Illinois Department an amount from the proceeds of the forfeited property, or monies forfeited or seized, which will satisfy any unsatisfied court order of restitution entered pursuant to a conviction under this Article. If the proceeds are less than the amount necessary to satisfy the order of restitution, the Director shall distribute to the Illinois Department the entire amount of the remaining proceeds. The Director shall distribute any remaining proceeds of such sale, along with any monies forfeited or seized, in accordance with the following schedules:
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(a) 25% shall be distributed to the unit of local
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| government whose officers or employees conducted the investigation into recipient fraud or vendor fraud and caused the arrest or arrests and prosecution leading to the forfeiture. Amounts distributed to units of local government shall be used solely for enforcement matters relating to detection, investigation or prosecution of recipient fraud or vendor fraud as defined in Section 8A-2 or 8A-3 of this Article. Where the investigation, arrest or arrests leading to the prosecution and forfeiture is undertaken solely by the Office of the Attorney General, the portion provided hereunder shall be paid into the Medicaid Fraud and Abuse Prevention Fund, which is hereby created in the State treasury. Monies from this fund shall be used by the Office of the Attorney General for the furtherance of enforcement matters relating to detection, investigation or prosecution of recipient fraud or vendor fraud. Monies directed to this fund shall be used in addition to, and not as a substitute for, funds annually appropriated to the Office of the Attorney General for medicaid fraud enforcement.
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(b) 25% shall be distributed to the county in
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| which the prosecution and petition for forfeiture resulting in the forfeiture was instituted, and deposited in a special fund in the county treasury and appropriated to the State's Attorney for use solely in enforcement matters relating to detection, investigation or prosecution of recipient fraud or vendor fraud; however, if the Attorney General brought the prosecution resulting in the forfeiture, the portion provided hereunder shall be paid into the Medicaid Fraud and Abuse Prevention Fund, to be used by the Medicaid Fraud Control Unit of the Office of the Attorney General for enforcement matters relating to detection, investigation or prosecution of recipient fraud or vendor fraud. Where the Attorney General and a State's Attorney have jointly participated in any portion of the proceedings, 12.5% shall be distributed to the county in which the prosecution resulting in the forfeiture was instituted, and used as specified herein, and 12.5% shall be paid into the Medicaid Fraud and Abuse Prevention Fund, and used as specified herein.
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(c) 50% shall be transmitted to the State
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| Treasurer for deposit in the General Revenue Fund.
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(Source: P.A. 102-538, eff. 8-20-21; 103-145, eff. 10-1-23 .)
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(305 ILCS 5/8A-7.1) (from Ch. 23, par. 8A-7.1)
Sec. 8A-7.1. The Director, upon making a
determination based upon information in the possession of the Illinois
Department, that continuation in practice of a licensed health care
professional would constitute an immediate danger to the public, shall submit
a written communication to the Director of Professional Regulation indicating
such determination and
additionally providing a complete summary of the information upon which
such determination is based, and recommending that the Director of
Professional Regulation immediately suspend such person's
license. All relevant evidence, or copies thereof, in the Illinois
Department's possession may also be submitted in conjunction with the written
communication. A copy of such written communication, which is exempt from
the copying and inspection provisions of the Freedom of Information Act,
shall at the time of submittal to the Director
of Professional Regulation
be simultaneously mailed to the last known business address of such licensed
health care professional by certified or registered postage, United States
Mail, return receipt requested. Any evidence, or copies thereof, which is
submitted in conjunction with the written communication is also exempt from
the copying and inspection provisions of the Freedom of Information Act.
The Director, upon making a determination based upon information in the
possession of the Illinois Department, that a licensed health care
professional is willfully committing fraud upon the Illinois Department's
medical assistance program, shall submit a written communication to the
Director of Professional Regulation indicating such
determination and additionally providing a complete summary of the
information upon which such determination is based. All relevant evidence,
or copies thereof, in the Illinois Department's possession may also be
submitted in conjunction with the written communication.
Upon receipt of such written communication, the Director of
Professional Regulation shall promptly investigate the
allegations contained in such written communication. A copy of such
written communication, which is exempt from the copying and inspection
provisions of the Freedom of Information Act, shall at the time of
submission to the Director of Professional Regulation,
be simultaneously mailed to the last known address of such licensed health
care professional by certified or registered postage, United States Mail,
return receipt requested. Any evidence, or copies thereof, which
is submitted in conjunction with the written communication is also exempt
from the copying and inspection provisions of the Freedom of Information Act.
For the purposes of this Section, "licensed health care professional"
means any person licensed under the Illinois Dental Practice Act, the Nurse Practice Act, the Medical Practice Act of 1987, the
Pharmacy Practice Act, the Podiatric Medical Practice Act of 1987,
or the Illinois Optometric Practice Act of 1987.
(Source: P.A. 95-639, eff. 10-5-07; 95-689, eff. 10-29-07; 95-876, eff. 8-21-08.)
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(305 ILCS 5/8A-8) (from Ch. 23, par. 8A-8)
Sec. 8A-8.
Future Participation in the Public Assistance Program.
(a) Any person applying for public assistance under this Code who has been
found
guilty of a violation of this Article or of any law of the United States or
of any state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs of the kind provided under this Code and who has not been previously
convicted
for a violation of this Article or of any law of the United States or of any
state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs
of the kind provided under this Code shall have applications for public
assistance
under this Code reviewed by an administrative review board to determine
the person's eligibility and the need for administrative safeguards to prevent
any such further violations. The administrative review board shall be
composed of not less than two persons who are selected in accordance with
regulations of the Illinois Department or the local governmental unit. Hearings
conducted by the board shall:
(1) be of an informal nature, permitting the |
| applicant to attend at his option;
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(2) be open to the public, unless the applicant and
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| the administrative review board determine otherwise;
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(3) be subject to reasonable time and notification
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| requirements as determined by regulations of the Illinois Department or local governmental units; and
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(4) be held at a location convenient to the applicant.
At the hearing, the administrative review board may deny the application
based on an investigation of the person's eligibility, or the board may
appoint a substitute payee, require more frequent visits or consultations,
more frequent financial reports or require any other action to the extent
permitted by State and federal law and regulations. A decision by the
administrative review board to deny a person's application shall only be
based on the person's failure to qualify under the eligibility criteria
applicable to all applicants for the public assistance program in question.
Any decision by the administrative review board may be appealed pursuant to
the provisions of this Code. In no instance shall the administrative review
board delay the hearing or its decision beyond the time allowed under State
or federal law and regulations for determining an applicant's eligibility
for public assistance.
If the person has been determined eligible, the Illinois Department or
the local governmental unit may recoup prior payments obtained in violation
of this Article from the current cash assistance grants, unless such payments
have previously been repaid. The Illinois Department or the local governmental
unit, on a case by case basis, shall limit the amount deducted from the current
cash assistance grant so as not to cause undue hardship to the person.
(b) To the extent permitted under federal law, any person found
guilty of a first violation of this Article or of any law of the United
States
or
of any state which is substantially similar to Sections 8A-2 through 8A-5 for
violations related to public assistance or medical assistance programs of the
kind provided under this Code may be suspended from eligibility for public
aid under this Code. Any person found guilty of a second or subsequent
violation of this Article or of any law of the United States or of any state
which is substantially similar to Sections 8A-2 through 8A-5 for violations
related to public assistance or medical assistance programs of the kind
provided under this Code shall be ineligible for public aid under this
Code.
(c) In no instance shall this Section adversely affect the eligibility
of children who are in need of public aid under this Code, or the amount
of the grant received by such children. If a child's caretaker relative
is adversely affected by this Section, a substitute payee may be appointed
until the Illinois Department can determine, by rule, that the caretaker
relative can manage the public aid in the best interest of the child.
(d) Any person, firm, corporation, association, agency, institution or
other legal entity that has been convicted of a violation of this Article
shall be prohibited from participating as a vendor of goods or services
to recipients of public aid under this Code. Such prohibition shall extend
to any person with management responsibility in a firm, corporation,
association, agency, institution, or other legal entity that has been
convicted of any such violation and to an officer or person owning, either
directly or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporation.
(e) Any employee of the Illinois Department, county department or local
governmental unit who has been found guilty of a violation of this Article
shall be terminated from employment.
(Source: P.A. 89-489, eff. 1-1-97; 90-725, eff. 8-7-98.)
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(305 ILCS 5/8A-11) (from Ch. 23, par. 8A-11)
Sec. 8A-11. (a) No person shall:
(1) Knowingly charge a resident of a nursing home for |
| any services provided pursuant to Article V of the Illinois Public Aid Code, money or other consideration at a rate in excess of the rates established for covered services by the Illinois Department pursuant to Article V of the Illinois Public Aid Code; or
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(2) Knowingly charge, solicit, accept or receive, in
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| addition to any amount otherwise authorized or required to be paid pursuant to Article V of the Illinois Public Aid Code, any gift, money, donation or other consideration:
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(i) As a precondition to admitting or expediting
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| the admission of a recipient or applicant, pursuant to Article V of the Illinois Public Aid Code, to a long-term care facility as defined in Section 1-113 of the Nursing Home Care Act or a facility as defined in Section 1-113 of the ID/DD Community Care Act, Section 1-113 of the MC/DD Act, or Section 1-102 of the Specialized Mental Health Rehabilitation Act of 2013; and
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(ii) As a requirement for the recipient's or
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| applicant's continued stay in such facility when the cost of the services provided therein to the recipient is paid for, in whole or in part, pursuant to Article V of the Illinois Public Aid Code.
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(b) Nothing herein shall prohibit a person from making a voluntary
contribution, gift or donation to a long-term care facility.
(c) This paragraph shall not apply to agreements to provide continuing
care or life care between a life care facility as defined by the Life
Care Facilities Act, and a person financially eligible for benefits pursuant to
Article V of the Illinois Public Aid Code.
(d) Any person who violates this Section shall be guilty of a business
offense and fined not less than $5,000 nor more than $25,000.
(e) "Person", as used in this Section, means an individual, corporation,
partnership, or unincorporated association.
(f) The State's Attorney of the county in which the facility is located
and the Attorney General shall be notified by the Illinois Department of
any alleged violations of this Section known to the Department.
(g) The Illinois Department shall adopt rules and regulations to carry
out the provisions of this Section.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
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(305 ILCS 5/8A-13)
Sec. 8A-13. Managed health care fraud.
(a) As used in this Section, "health plan" means any of the following:
(1) Any health care reimbursement plan sponsored |
| wholly or partially by the State.
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(2) Any private insurance carrier, health care
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| cooperative or alliance, health maintenance organization, insurer, organization, entity, association, affiliation, or person that contracts to provide or provides goods or services that are reimbursed by or are a required benefit of a health benefits program funded wholly or partially by the State.
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(3) Anyone who provides or contracts to provide goods
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| and services to an entity described in paragraph (1) or (2) of this subsection.
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For purposes of item (2) in subsection (b), "representation" and "statement"
include, but are not limited to, reports, claims, certifications,
acknowledgments and ratifications of financial information, enrollment claims,
demographic statistics, encounter data, health services available or rendered,
and the qualifications of person rendering health care and ancillary services.
(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that, with the intent to obtain benefits or payments under
this Code to which the person or entity is not entitled or in a greater amount
than that to which the person or entity is entitled, knowingly or willfully:
(1) executes or conspires to execute a scheme or
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| artifice to defraud any State or federally funded or mandated health plan in connection with the delivery of or payment for health care benefits, items, or services;
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(2) executes or conspires to execute a scheme or
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| artifice to obtain by means of false or fraudulent pretense, representation, statement, or promise money or anything of value in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for, reimbursed, or subsidized by, or are a required benefit of, a State or federally funded or mandated health plan;
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(3) falsifies, conceals, or covers up by any trick,
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| scheme, or device a material fact in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan;
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(4) makes any materially false, fictitious, or
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| fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan; or
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(5) makes or uses any false writing or document
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| knowing the same to contain any materially false, fictitious, or fraudulent statement or entry in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan;
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is guilty of a
violation of this Article and shall be punished as provided in Section 8A-6.
(Source: P.A. 98-354, eff. 8-16-13.)
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(305 ILCS 5/8A-14)
Sec. 8A-14.
Bribery and graft in connection with health care.
(a) As used in this Section:
"Health care official" means any of the following:
(1) An administrator, officer, trustee, fiduciary, |
| custodian, counsel, agent, or employee of any health plan.
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(2) An officer, counsel, agent, or employee of an
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| organization that provides, proposes to provide, or contracts to provide services to any health plan.
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(3) An official, employee, or agent of a State or
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| federal agency having regulatory or administrative authority over any health plan.
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"Health plan" has the meaning attributed to that term in Section 8A-13.
(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that
(1) directly or indirectly gives, offers, or promises
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| anything of value to a health care official, or offers or promises to a health care official to give anything of value to another person, with the intent
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(A) to influence or reward any act or decision of
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| any health care official exercising any authority in any State or federally funded or mandated health plan other than as specifically allowed by law, or
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(B) to influence the official to commit, aid in
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| the commission of, or conspire to allow any fraud in a State or federally funded or mandated health plan, or
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(C) to induce the official to engage in any
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| conduct in violation of the official's lawful duty, or
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(2) being a health care official, directly or
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| indirectly demands, solicits, receives, accepts, or agrees to accept anything of value personally or for any other person or entity, the giving of which would violate paragraph (1) of this subsection,
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is guilty of a violation of this Article and shall be punished as
provided in Section 8A-6.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-16)
Sec. 8A-16.
Unfair or deceptive marketing practices.
(a) As used in this Section, "health plan" has the meaning attributed to
that term in Section 8A-13.
(b) It is unlawful to knowingly and willfully engage in any unfair or
deceptive marketing practice
in connection with proposing, offering, selling, soliciting, or providing any
health care service or any health plan. Unfair or deceptive marketing
practices include the following:
(1) Making a false and misleading oral or written |
| statement, visual description, advertisement, or other representation of any kind that has the capacity, tendency, or effect of deceiving or misleading health care consumers with respect to any health care service, health plan, or health care provider.
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(2) Making a representation that a health care plan
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| or a health care provider offers any service, benefit, access to care, or choice that it does not in fact offer.
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(3) Making a representation that a health plan or
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| health care provider has any status, certification, qualification, sponsorship, affiliation, or licensure that it does not have.
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(4) A failure to state a material fact if the failure
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| deceives or tends to deceive.
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(5) Offering any kickback, bribe, reward, or benefit
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| to any person as an inducement to select or to refrain from selecting any health care service, health plan, or health care provider, unless the benefit offered is medically necessary health care or is permitted by the Illinois Department.
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(6) The use of health care consumer or other
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| information that is confidential or privileged or that cannot be disclosed to or obtained by the user without violating a State or federal confidentiality law, including:
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(A) medical records information; and
(B) information that identifies the health care
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| consumer or any member of his or her group as a recipient of any government sponsored or mandated welfare program.
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(7) The use of any device or artifice in advertising
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| a health plan or soliciting a health care consumer that misrepresents the solicitor's profession, status, affiliation, or mission.
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(c) Any person who commits a first violation of this Section is guilty of a
Class
A misdemeanor and is subject to a fine of not more than $5,000. Any person who
commits a second or subsequent violation of this Section is guilty of a Class 4
felony and is subject to a fine of not more than $25,000.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/9-1) (from Ch. 23, par. 9-1)
Sec. 9-1. Declaration of Purpose. It is the purpose
of this Article to aid applicants for and
recipients of public aid under Articles III, IV, V, and VI, to
increase their capacities for self-support, self-care, and responsible
citizenship, and to assist them in maintaining and strengthening family
life. If authorized pursuant to Section 9-8, this Article may be
extended to former and potential recipients and to persons whose income
does not exceed the standard established to determine eligibility for
aid as a medically indigent person under Article V. The Department, with
the written consent of the Governor, may also:
(a) extend this Article to individuals and their |
| families with income closely related to national indices of poverty who have special needs resulting from institutionalization of a family member or conditions that may lead to institutionalization or who live in impoverished areas or in facilities developed to serve persons of low income;
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(b) establish, where indicated, schedules of payment
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| for service provided based on ability to pay;
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(c) provide for the coordinated delivery of the
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| services described in this Article and related services offered by other public or private agencies or institutions, and cooperate with the Illinois Department on Aging to enable it to properly execute and fulfill its duties pursuant to the provisions of Section 4.01 of the "Illinois Act on the Aging", as now or hereafter amended;
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(d) provide in-home care services, such as chore and
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| housekeeping services or homemaker services, to recipients of public aid under Articles IV and VI, the scope and eligibility criteria for such services to be determined by rule;
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(e) contract with other State agencies for the
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| purchase of social service under Title XX of the Social Security Act, such services to be provided pursuant to such other agencies' enabling legislation; and
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(f) cooperate with the Department of Healthcare and
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| Family Services to provide services to public aid recipients for the treatment and prevention of alcoholism and substance abuse.
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(Source: P.A. 95-331, eff. 8-21-07.)
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