(305 ILCS 5/11-26)
(from Ch. 23, par. 11-26)
Recipient's abuse of medical care; restrictions on access to
(a) When the Department determines, on the basis of statistical norms and
medical judgment, that a medical care recipient has received medical services
in excess of need and with such frequency or in such a manner as to constitute
an abuse of the recipient's medical care privileges, the recipient's access to
medical care may be restricted.
(b) When the Department has determined that a recipient is abusing his or
her medical care privileges as described in this Section, it may require that
the recipient designate a primary provider type of the recipient's own choosing to assume
responsibility for the recipient's care. For the purposes of this subsection, "primary provider type" means a provider type
as determined by the Department. Instead of requiring a recipient to
make a designation as provided in this subsection, the Department, pursuant to
rules adopted by the Department and without regard to any choice of an entity
that the recipient might otherwise make, may initially designate a primary provider type provided that the primary provider type is willing to provide that care.
(c) When the Department has requested that a recipient designate a
primary provider type and the recipient fails or refuses to do so, the Department
may, after a reasonable period of time, assign the recipient to a primary provider type of its own choice and determination, provided such primary provider type is willing to provide such care.
(d) When a recipient has been restricted to a designated primary provider type, the
recipient may change the primary provider type:
(1) when the designated source becomes unavailable,
as the Department shall determine by rule; or
(2) when the designated primary provider type
notifies the Department that it wishes to withdraw from any obligation as primary provider type; or
(3) in other situations, as the Department shall
The Department shall, by rule, establish procedures for providing medical or
pharmaceutical services when the designated source becomes unavailable or
wishes to withdraw from any obligation as primary provider type, shall, by rule, take into
consideration the need for emergency or temporary medical assistance and shall
ensure that the recipient has continuous and unrestricted access to medical
care from the date on which such unavailability or withdrawal becomes effective
until such time as the recipient designates a primary provider type or a primary provider type willing to provide such care is designated by the Department
consistent with subsections (b) and (c) and such restriction becomes effective.
(e) Prior to initiating any action to restrict a recipient's access to
medical or pharmaceutical care, the Department shall notify the recipient
of its intended action. Such notification shall be in writing and shall set
forth the reasons for and nature of the proposed action. In addition, the
(1) inform the recipient that (i) the recipient has a
right to designate a primary provider type of the recipient's own choosing willing to accept such designation and that the recipient's failure to do so within a reasonable time may result in such designation being made by the Department or (ii) the Department has designated a primary provider type to assume responsibility for the recipient's care; and
(2) inform the recipient that the recipient has a
right to appeal the Department's determination to restrict the recipient's access to medical care and provide the recipient with an explanation of how such appeal is to be made. The notification shall also inform the recipient of the circumstances under which unrestricted medical eligibility shall continue until a decision is made on appeal and that if the recipient chooses to appeal, the recipient will be able to review the medical payment data that was utilized by the Department to decide that the recipient's access to medical care should be restricted.
(f) The Department shall, by rule or regulation, establish procedures for
appealing a determination to restrict a recipient's access to medical care,
which procedures shall, at a minimum, provide for a reasonable opportunity
to be heard and, where the appeal is denied, for a written statement
of the reason or reasons for such denial.
(g) Except as otherwise provided in this subsection, when a recipient
has had his or her medical card restricted for 4 full quarters (without regard
to any period of ineligibility for medical assistance under this Code, or any
period for which the recipient voluntarily terminates his or her receipt of
medical assistance, that may occur before the expiration of those 4 full
quarters), the Department shall reevaluate the recipient's medical usage to
determine whether it is still in excess of need and with such frequency or in
such a manner as to constitute an abuse of the receipt of medical assistance.
If it is still in excess of need, the restriction shall be continued for
another 4 full quarters. If it is no longer in excess of need, the restriction
shall be discontinued. If a recipient's access to medical care has been
restricted under this Section and the Department then determines, either at
reevaluation or after the restriction has been discontinued, to restrict the
recipient's access to medical care a second or subsequent time, the second or
subsequent restriction may be imposed for a period of more than 4 full
quarters. If the Department restricts a recipient's access to medical care for
a period of more than 4 full quarters, as determined by rule, the Department
shall reevaluate the recipient's medical usage after the end of the restriction
period rather than after the end of 4 full quarters. The Department shall
notify the recipient, in writing, of any decision to continue the restriction
and the reason or reasons therefor. A "quarter", for purposes of this Section,
shall be defined as one of the following 3-month periods of time:
January-March, April-June, July-September or October-December.
(h) In addition to any other recipient whose acquisition of medical care
is determined to be in excess of need, the Department may restrict the medical
care privileges of the following persons:
(1) recipients found to have loaned or altered their
cards or misused or falsely represented medical coverage;
(2) recipients found in possession of blank or forged
(3) recipients who knowingly assist providers in
rendering excessive services or defrauding the medical assistance program.
The procedural safeguards in this Section shall apply to the above
(i) Restrictions under this Section shall be in addition to and shall
not in any way be limited by or limit any actions taken under Article VIIIA
of this Code.
(Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)