Public Act 90-0725 of the 90th General Assembly
Public Act 90-0725
SB1711 Enrolled LRB9008936DJgc
AN ACT to amend the Illinois Public Aid Code by changing
Sections 8A-8, 12-4.25, and 12-13.1.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Sections 8A-8, 12-4.25, and 12-13.1 as follows:
(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;
(2) be open to the public, unless the applicant and
the administrative review board determine otherwise;
(3) be subject to reasonable time and notification
requirements as determined by regulations of the Illinois
Department or local governmental units; and
(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.)
(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor
participation.
(A) The Illinois Department may deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, if
after reasonable notice and opportunity for a hearing the
Illinois Department finds:
(a) Such vendor is not complying with the
Department's policy or rules and regulations, or with the
terms and conditions prescribed by the Illinois
Department in its vendor agreement, which document shall
be developed by the Department as a result of
negotiations with each vendor category, including
physicians, hospitals, long term care facilities,
pharmacists, optometrists, podiatrists and dentists
setting forth the terms and conditions applicable to the
participation of each vendor group in the program; or
(b) Such vendor has failed to keep or make
available for inspection, audit or copying, after
receiving a written request from the Illinois Department,
such records regarding payments claimed for providing
services. This section does not require vendors to make
available patient records of patients for whom services
are not reimbursed under this Code; or
(c) Such vendor has failed to furnish any
information requested by the Department regarding
payments for providing goods or services; or
(d) Such vendor has knowingly made, or caused to be
made, any false statement or representation of a material
fact in connection with the administration of the medical
assistance program; or
(e) Such vendor has furnished goods or services to
a recipient which are (1) in excess of his or her needs,
(2) harmful to the recipient, or (3) of grossly inferior
quality, all of such determinations to be based upon
competent medical judgment and evaluations; or
(f) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) was previously terminated from
participation in the medical assistance program; or
(2) was a person with management
responsibility for a previously terminated vendor
during the time of conduct which was the basis for
that vendor's termination from participation in the
medical assistance program; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a
previously terminated corporate vendor during the
time of conduct which was the basis for that
vendor's termination from participation in the
medical assistance program; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was previously
terminated during the time of conduct which was the
basis for that vendor's termination from
participation in the medical assistance program; or
(g) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) has engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program; or
(2) was a person with management
responsibility for a vendor at the time that such
vendor engaged in practices prohibited by applicable
federal or State law or regulation relating to the
medical assistance program; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a vendor at
the time such vendor engaged in practices prohibited
by applicable federal or State law or regulation
relating to the medical assistance program; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was a vendor at the
time such vendor engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program.
(h) The direct or indirect ownership of the vendor
(including the ownership of a vendor that is a sole
proprietorship, a partner's interest in a vendor that is
a partnership, or ownership of 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor) has been transferred by an individual who is
terminated or barred from participating as a vendor to
the individual's spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
(B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V:
(1) if such vendor is not properly licensed;
(2) within 30 days of the date when such vendor's
professional license, certification or other authorization
has been refused renewal or has been revoked, suspended or
otherwise terminated; or
(3) if such vendor has been convicted of a
violation of this Code, as provided in Article VIIIA.
(C) Upon termination of a vendor of goods or services
from participation in the medical assistance program
authorized by this Article, a person with management
responsibility for such vendor during the time of any conduct
which served as the basis for that vendor's termination is
barred from participation in the medical assistance program.
Upon termination of a corporate vendor, the officers and
persons owning, directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in the vendor
during the time of any conduct which served as the basis for
that vendor's termination are barred from participation in
the medical assistance program. A person who owns, directly
or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a terminated corporate vendor may
not transfer his or her ownership interest in that vendor to
his or her spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
or relative by marriage.
Upon termination of a sole proprietorship or partnership,
the owner or partners during the time of any conduct which
served as the basis for that vendor's termination are barred
from participation in the medical assistance program. The
owner of a terminated vendor that is a sole proprietorship,
and a partner in a terminated vendor that is a partnership,
may not transfer his or her ownership or partnership interest
in that vendor to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Rules adopted by the Illinois Department to implement
these provisions shall specifically include a definition of
the term "management responsibility" as used in this Section.
Such definition shall include, but not be limited to, typical
job titles, and duties and descriptions which will be
considered as within the definition of individuals with
management responsibility for a provider.
(D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension
the Director shall reinstate such vendor, unless he finds
that such vendor has not corrected deficiencies upon which
the suspension was based.
If a vendor has been terminated from the medical
assistance program under Article V, such vendor shall be
barred from participation for at least one year. At the end
of one year a vendor who has been terminated may apply for
reinstatement to the program. Upon proper application to be
reinstated such vendor may be deemed eligible by the Director
providing that such vendor meets the requirements for
eligibility under this Act. If such vendor is deemed not
eligible for reinstatement, he shall be barred from again
applying for reinstatement for one year from the date his
application for reinstatement is denied.
If a vendor has been terminated and reinstated to the
medical assistance program under Article V and the vendor is
terminated a second or subsequent time from the medical
assistance program, the vendor shall be barred from
participation for at least 2 years. At the end of 2 years, a
vendor who has been terminated may apply for reinstatement to
the program. Upon application to be reinstated, the vendor
may be deemed eligible if the vendor meets the requirements
for eligibility under this Code. If the vendor is deemed not
eligible for reinstatement, the vendor shall be barred from
again applying for reinstatement for 2 years from the date
the vendor's application for reinstatement is denied.
(E) The Illinois Department may recover money improperly
or erroneously paid, or overpayments, either by setoff,
crediting against future billings or by requiring direct
repayment to the Illinois Department.
(F) The Illinois Department may withhold payments to any
vendor during the pendency of any proceeding under this
Section except that if a final administrative decision has
not been issued within 120 days of the initiation of such
proceedings, unless delay has been caused by the vendor,
payments can no longer be withheld, provided, however, that
the 120 day limit may be extended if said extension is
mutually agreed to by the Illinois Department and the vendor.
The Illinois Department shall state by rule with as much
specificity as practicable the conditions under which
payments will not be withheld during the pendency of any
proceeding under this Section. Payments may be denied for
bills submitted with service dates occurring during the
pendency of a proceeding where the final administrative
decision is to terminate eligibility to participate in the
medical assistance program. The Illinois Department shall
state by rule with as much specificity as practicable the
conditions under which payments will not be denied for such
bills.
(F-5) The Illinois Department may temporarily withhold
payments to a vendor if any of the following individuals
have been indicted or otherwise charged under a law of the
United States or this or any other state with a felony
offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to
(i) the medical assistance program under Article V of this
Code, (ii) a medical assistance program provided in another
state which is of the kind provided under Article V of this
Code, (iii) the Medicare program under Title XVIII of the
Social Security Act, or (iv) the provision of health care
services:
(1) If the vendor is a corporation: an officer of
the corporation or an individual who owns, either
directly or indirectly, 5% or more of the shares of
stock or other evidence of ownership of the corporation.
(2) If the vendor is a sole proprietorship: the
owner of the sole proprietorship.
(3) If the vendor is a partnership: a partner in the
partnership.
(4) If the vendor is any other business entity
authorized by law to transact business in this State:
an officer of the entity or an individual who owns,
either directly or indirectly, 5% or more of the
evidences of ownership of the entity.
If the Illinois Department withholds payments to a vendor
under this subsection, the Department shall not release
those payments to the vendor while any criminal proceeding
related to the indictment or charge is pending unless the
Department determines that there is good cause to release the
payments before completion of the proceeding. If the
indictment or charge results in the individual's conviction,
the Illinois Department shall retain all withheld payments,
which shall be considered forfeited to the Department. If
the indictment or charge does not result in the individual's
conviction, the Illinois Department shall release to the
vendor all withheld payments.
(G) The provisions of the Administrative Review Law, as
now or hereafter amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the
judicial review of final administrative decisions of the
Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of
the Code of Civil Procedure.
(H) Nothing contained in this Code shall in any way
limit or otherwise impair the authority or power of any State
agency responsible for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under
Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
Department may impose one or more of the following remedies
after notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.
(4) Civil money penalties.
(5) Closure of the facility in emergency situations
or transfer of residents, or both.
(6) State monitoring.
(7) Denial of all payments when the Health Care
Finance Administration has imposed this sanction.
The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in
the sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of
the federal government, a facility may request a hearing
before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy.
Except in the case of civil money penalties, a request for a
hearing shall not delay imposition of the penalty. The
choice of remedies is not appealable at a hearing. The level
of noncompliance may be challenged only in the case of a
civil money penalty. The Illinois Department shall provide
by rule for the State agency that will conduct the
evidentiary hearings.
The Illinois Department may collect interest on unpaid
civil money penalties.
The Illinois Department may adopt all rules necessary to
implement this subsection (I).
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 1-1-96.)
(305 ILCS 5/12-13.1)
Sec. 12-13.1. Inspector General.
(a) The Governor shall appoint, and the Senate shall
confirm, an Inspector General who shall function within the
Illinois Department of Public Aid and report to the Governor.
The term of the Inspector General shall expire on the third
Monday of January, 1997 and every 4 years thereafter.
(b) In order to prevent, detect, and eliminate fraud,
waste, abuse, mismanagement, and misconduct, the Inspector
General shall oversee the Illinois Department of Public Aid's
integrity functions, which include, but are not limited to,
the following:
(1) Investigation of misconduct by employees,
vendors, contractors and medical providers.
(2) Audits of medical providers related to ensuring
that appropriate payments are made for services rendered
and to the recovery of overpayments.
(3) Monitoring of quality assurance programs
generally related to the medical assistance program and
specifically related to any managed care program.
(4) Quality control measurements of the programs
administered by the Illinois Department of Public Aid.
(5) Investigations of fraud or intentional program
violations committed by clients of the Illinois
Department of Public Aid.
(6) Actions initiated against contractors or
medical providers for any of the following reasons:
(A) Violations of the medical assistance
program.
(B) Sanctions against providers brought in
conjunction with the Department of Public Health or
the Department of Human Services (as successor to
the Department of Mental Health and Developmental
Disabilities).
(C) Recoveries of assessments against
hospitals and long-term care facilities.
(D) Sanctions mandated by the United States
Department of Health and Human Services against
medical providers.
(E) Violations of contracts related to any
managed care programs.
(7) Representation of the Illinois Department of
Public Aid at hearings with the Illinois Department of
Professional Regulation in actions taken against
professional licenses held by persons who are in
violation of orders for child support payments.
(b-5) At the request of the Secretary of Human Services,
the Inspector General shall, in relation to any function
performed by the Department of Human Services as successor to
the Department of Public Aid, exercise one or more of the
powers provided under this Section as if those powers related
to the Department of Human Services; in such matters, the
Inspector General shall report his or her findings to the
Secretary of Human Services.
(c) The Inspector General shall have access to all
information, personnel and facilities of the Illinois
Department of Public Aid and the Department of Human Services
(as successor to the Department of Public Aid), their
employees, vendors, contractors and medical providers and any
federal, State or local governmental agency that are
necessary to perform the duties of the Office as directly
related to public assistance programs administered by those
departments. No medical provider shall be compelled,
however, to provide individual medical records of patients
who are not clients of the Medical Assistance Program. State
and local governmental agencies are authorized and directed
to provide the requested information, assistance or
cooperation.
(d) The Inspector General shall serve as the Illinois
Department of Public Aid's primary liaison with law
enforcement, investigatory and prosecutorial agencies,
including but not limited to the following:
(1) The Department of State Police.
(2) The Federal Bureau of Investigation and other
federal law enforcement agencies.
(3) The various Inspectors General of federal
agencies overseeing the programs administered by the
Illinois Department of Public Aid.
(4) The various Inspectors General of any other
State agencies with responsibilities for portions of
programs primarily administered by the Illinois
Department of Public Aid.
(5) The Offices of the several United States
Attorneys in Illinois.
(6) The several State's Attorneys.
The Inspector General shall meet on a regular basis with
these entities to share information regarding possible
misconduct by any persons or entities involved with the
public aid programs administered by the Illinois Department
of Public Aid.
(e) All investigations conducted by the Inspector
General shall be conducted in a manner that ensures the
preservation of evidence for use in criminal prosecutions.
If the Inspector General determines that a possible criminal
act relating to fraud in the provision or administration of
the medical assistance program has been committed, the
Inspector General shall immediately notify the Medicaid Fraud
Control Unit. If the Inspector General determines that a
possible criminal act has been committed within the
jurisdiction of the Office, the Inspector General may request
the special expertise of the Department of State Police. The
Inspector General may present for prosecution the findings of
any criminal investigation to the Office of the Attorney
General, the Offices of the several United State Attorneys in
Illinois or the several State's Attorneys.
(f) To carry out his or her duties as described in this
Section, the Inspector General and his or her designees shall
have the power to compel by subpoena the attendance and
testimony of witnesses and the production of books,
electronic records and papers as directly related to public
assistance programs administered by the Illinois Department
of Public Aid or the Department of Human Services (as
successor to the Department of Public Aid). No medical
provider shall be compelled, however, to provide individual
medical records of patients who are not clients of the
Medical Assistance Program.
(g) The Inspector General shall report all convictions,
terminations, and suspensions taken against vendors,
contractors and medical providers to the Illinois Department
of Public Aid and to any agency responsible for licensing or
regulating those persons or entities.
(h) The Inspector General shall make annual quarterly
reports, findings, and recommendations regarding the Office's
investigations into reports of fraud, waste, abuse,
mismanagement, or misconduct relating to any public aid
programs administered by the Illinois Department of Public
Aid or the Department of Human Services (as successor to the
Department of Public Aid) to the General Assembly and the
Governor. These reports shall include, but not be limited
to, the following information:
(1) Aggregate provider billing and payment
information, including the number of providers at various
Medicaid earning levels.
(2) The number of audits of the medical assistance
program and the dollar savings resulting from those
audits.
(3) The number of prescriptions rejected annually
under the Illinois Department of Public Aid's Refill Too
Soon program and the dollar savings resulting from that
program.
(4) Provider sanctions, in the aggregate, including
terminations and suspensions.
(5) A detailed summary of the investigations
undertaken in the previous fiscal year. These summaries
shall comply with all laws and rules regarding
maintaining confidentiality in the public aid programs.
(i) Nothing in this Section shall limit investigations
by the Illinois Department of Public Aid or the Department of
Human Services that may otherwise be required by law or that
may be necessary in their capacity as the central
administrative authorities responsible for administration of
public aid programs in this State.
(Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
Section 99. Effective date. This Act takes effect upon
becoming law.