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|[ Introduced ]||[ Engrossed ]||[ Senate Amendment 001 ]|
92_SB2225enr SB2225 Enrolled LRB9211341DJgc 1 AN ACT in relation to public aid. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The Illinois Public Aid Code is amended by 5 changing Sections 5-5 and 12-4.25 as follows: 6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5) 7 Sec. 5-5. Medical services. The Illinois Department, by 8 rule, shall determine the quantity and quality of and the 9 rate of reimbursement for the medical assistance for which 10 payment will be authorized, and the medical services to be 11 provided, which may include all or part of the following: (1) 12 inpatient hospital services; (2) outpatient hospital 13 services; (3) other laboratory and X-ray services; (4) 14 skilled nursing home services; (5) physicians' services 15 whether furnished in the office, the patient's home, a 16 hospital, a skilled nursing home, or elsewhere; (6) medical 17 care, or any other type of remedial care furnished by 18 licensed practitioners; (7) home health care services; (8) 19 private duty nursing service; (9) clinic services; (10) 20 dental services; (11) physical therapy and related services; 21 (12) prescribed drugs, dentures, and prosthetic devices; and 22 eyeglasses prescribed by a physician skilled in the diseases 23 of the eye, or by an optometrist, whichever the person may 24 select; (13) other diagnostic, screening, preventive, and 25 rehabilitative services; (14) transportation and such other 26 expenses as may be necessary; (15) medical treatment of 27 sexual assault survivors, as defined in Section 1a of the 28 Sexual Assault Survivors Emergency Treatment Act, for 29 injuries sustained as a result of the sexual assault, 30 including examinations and laboratory tests to discover 31 evidence which may be used in criminal proceedings arising SB2225 Enrolled -2- LRB9211341DJgc 1 from the sexual assault; (16) the diagnosis and treatment of 2 sickle cell anemia; and (17) any other medical care, and any 3 other type of remedial care recognized under the laws of this 4 State, but not including abortions, or induced miscarriages 5 or premature births, unless, in the opinion of a physician, 6 such procedures are necessary for the preservation of the 7 life of the woman seeking such treatment, or except an 8 induced premature birth intended to produce a live viable 9 child and such procedure is necessary for the health of the 10 mother or her unborn child. The Illinois Department, by rule, 11 shall prohibit any physician from providing medical 12 assistance to anyone eligible therefor under this Code where 13 such physician has been found guilty of performing an 14 abortion procedure in a wilful and wanton manner upon a woman 15 who was not pregnant at the time such abortion procedure was 16 performed. The term "any other type of remedial care" shall 17 include nursing care and nursing home service for persons who 18 rely on treatment by spiritual means alone through prayer for 19 healing. 20 Notwithstanding any other provision of this Section, a 21 comprehensive tobacco use cessation program that includes 22 purchasing prescription drugs or prescription medical devices 23 approved by the Food and Drug administration shall be covered 24 under the medical assistance program under this Article for 25 persons who are otherwise eligible for assistance under this 26 Article. 27 Notwithstanding any other provision of this Code, the 28 Illinois Department may not require, as a condition of 29 payment for any laboratory test authorized under this 30 Article, that a physician's handwritten signature appear on 31 the laboratory test order form. The Illinois Department may, 32 however, impose other appropriate requirements regarding 33 laboratory test order documentation. 34 The Illinois Department of Public Aid shall provide the SB2225 Enrolled -3- LRB9211341DJgc 1 following services to persons eligible for assistance under 2 this Article who are participating in education, training or 3 employment programs operated by the Department of Human 4 Services as successor to the Department of Public Aid: 5 (1) dental services, which shall include but not be 6 limited to prosthodontics; and 7 (2) eyeglasses prescribed by a physician skilled in 8 the diseases of the eye, or by an optometrist, whichever 9 the person may select. 10 The Illinois Department, by rule, may distinguish and 11 classify the medical services to be provided only in 12 accordance with the classes of persons designated in Section 13 5-2. 14 The Illinois Department shall authorize the provision of, 15 and shall authorize payment for, screening by low-dose 16 mammography for the presence of occult breast cancer for 17 women 35 years of age or older who are eligible for medical 18 assistance under this Article, as follows: a baseline 19 mammogram for women 35 to 39 years of age and an annual 20 mammogram for women 40 years of age or older. All screenings 21 shall include a physical breast exam, instruction on 22 self-examination and information regarding the frequency of 23 self-examination and its value as a preventative tool. As 24 used in this Section, "low-dose mammography" means the x-ray 25 examination of the breast using equipment dedicated 26 specifically for mammography, including the x-ray tube, 27 filter, compression device, image receptor, and cassettes, 28 with an average radiation exposure delivery of less than one 29 rad mid-breast, with 2 views for each breast. 30 Any medical or health care provider shall immediately 31 recommend, to any pregnant woman who is being provided 32 prenatal services and is suspected of drug abuse or is 33 addicted as defined in the Alcoholism and Other Drug Abuse 34 and Dependency Act, referral to a local substance abuse SB2225 Enrolled -4- LRB9211341DJgc 1 treatment provider licensed by the Department of Human 2 Services or to a licensed hospital which provides substance 3 abuse treatment services. The Department of Public Aid shall 4 assure coverage for the cost of treatment of the drug abuse 5 or addiction for pregnant recipients in accordance with the 6 Illinois Medicaid Program in conjunction with the Department 7 of Human Services. 8 All medical providers providing medical assistance to 9 pregnant women under this Code shall receive information from 10 the Department on the availability of services under the Drug 11 Free Families with a Future or any comparable program 12 providing case management services for addicted women, 13 including information on appropriate referrals for other 14 social services that may be needed by addicted women in 15 addition to treatment for addiction. 16 The Illinois Department, in cooperation with the 17 Departments of Human Services (as successor to the Department 18 of Alcoholism and Substance Abuse) and Public Health, through 19 a public awareness campaign, may provide information 20 concerning treatment for alcoholism and drug abuse and 21 addiction, prenatal health care, and other pertinent programs 22 directed at reducing the number of drug-affected infants born 23 to recipients of medical assistance. 24 Neither the Illinois Department of Public Aid nor the 25 Department of Human Services shall sanction the recipient 26 solely on the basis of her substance abuse. 27 The Illinois Department shall establish such regulations 28 governing the dispensing of health services under this 29 Article as it shall deem appropriate. In formulating these 30 regulations the Illinois Department shall consult with and 31 give substantial weight to the recommendations offered by the 32 Citizens Assembly/Council on Public Aid. The Department 33 should seek the advice of formal professional advisory 34 committees appointed by the Director of the Illinois SB2225 Enrolled -5- LRB9211341DJgc 1 Department for the purpose of providing regular advice on 2 policy and administrative matters, information dissemination 3 and educational activities for medical and health care 4 providers, and consistency in procedures to the Illinois 5 Department. 6 The Illinois Department may develop and contract with 7 Partnerships of medical providers to arrange medical services 8 for persons eligible under Section 5-2 of this Code. 9 Implementation of this Section may be by demonstration 10 projects in certain geographic areas. The Partnership shall 11 be represented by a sponsor organization. The Department, by 12 rule, shall develop qualifications for sponsors of 13 Partnerships. Nothing in this Section shall be construed to 14 require that the sponsor organization be a medical 15 organization. 16 The sponsor must negotiate formal written contracts with 17 medical providers for physician services, inpatient and 18 outpatient hospital care, home health services, treatment for 19 alcoholism and substance abuse, and other services determined 20 necessary by the Illinois Department by rule for delivery by 21 Partnerships. Physician services must include prenatal and 22 obstetrical care. The Illinois Department shall reimburse 23 medical services delivered by Partnership providers to 24 clients in target areas according to provisions of this 25 Article and the Illinois Health Finance Reform Act, except 26 that: 27 (1) Physicians participating in a Partnership and 28 providing certain services, which shall be determined by 29 the Illinois Department, to persons in areas covered by 30 the Partnership may receive an additional surcharge for 31 such services. 32 (2) The Department may elect to consider and 33 negotiate financial incentives to encourage the 34 development of Partnerships and the efficient delivery of SB2225 Enrolled -6- LRB9211341DJgc 1 medical care. 2 (3) Persons receiving medical services through 3 Partnerships may receive medical and case management 4 services above the level usually offered through the 5 medical assistance program. 6 Medical providers shall be required to meet certain 7 qualifications to participate in Partnerships to ensure the 8 delivery of high quality medical services. These 9 qualifications shall be determined by rule of the Illinois 10 Department and may be higher than qualifications for 11 participation in the medical assistance program. Partnership 12 sponsors may prescribe reasonable additional qualifications 13 for participation by medical providers, only with the prior 14 written approval of the Illinois Department. 15 Nothing in this Section shall limit the free choice of 16 practitioners, hospitals, and other providers of medical 17 services by clients. In order to ensure patient freedom of 18 choice, the Illinois Department shall immediately promulgate 19 all rules and take all other necessary actions so that 20 provided services may be accessed from therapeutically 21 certified optometrists to the full extent of the Illinois 22 Optometric Practice Act of 1987 without discriminating 23 between service providers. 24 The Department shall apply for a waiver from the United 25 States Health Care Financing Administration to allow for the 26 implementation of Partnerships under this Section. 27 The Illinois Department shall require health care 28 providers to maintain records that document the medical care 29 and services provided to recipients of Medical Assistance 30 under this Article. The Illinois Department shall require 31 health care providers to make available, when authorized by 32 the patient, in writing, the medical records in a timely 33 fashion to other health care providers who are treating or 34 serving persons eligible for Medical Assistance under this SB2225 Enrolled -7- LRB9211341DJgc 1 Article. All dispensers of medical services shall be 2 required to maintain and retain business and professional 3 records sufficient to fully and accurately document the 4 nature, scope, details and receipt of the health care 5 provided to persons eligible for medical assistance under 6 this Code, in accordance with regulations promulgated by the 7 Illinois Department. The rules and regulations shall require 8 that proof of the receipt of prescription drugs, dentures, 9 prosthetic devices and eyeglasses by eligible persons under 10 this Section accompany each claim for reimbursement submitted 11 by the dispenser of such medical services. No such claims for 12 reimbursement shall be approved for payment by the Illinois 13 Department without such proof of receipt, unless the Illinois 14 Department shall have put into effect and shall be operating 15 a system of post-payment audit and review which shall, on a 16 sampling basis, be deemed adequate by the Illinois Department 17 to assure that such drugs, dentures, prosthetic devices and 18 eyeglasses for which payment is being made are actually being 19 received by eligible recipients. Within 90 days after the 20 effective date of this amendatory Act of 1984, the Illinois 21 Department shall establish a current list of acquisition 22 costs for all prosthetic devices and any other items 23 recognized as medical equipment and supplies reimbursable 24 under this Article and shall update such list on a quarterly 25 basis, except that the acquisition costs of all prescription 26 drugs shall be updated no less frequently than every 30 days 27 as required by Section 5-5.12. 28 The rules and regulations of the Illinois Department 29 shall require that a written statement including the required 30 opinion of a physician shall accompany any claim for 31 reimbursement for abortions, or induced miscarriages or 32 premature births. This statement shall indicate what 33 procedures were used in providing such medical services. 34 The Illinois Department shall require
thatall dispensers SB2225 Enrolled -8- LRB9211341DJgc 1 of medical services, other than an individual practitioner or 2 group of practitioners, desiring to participate in the 3 Medical Assistance program established under this Article to 4 disclose all financial, beneficial, ownership, equity, surety 5 or other interests in any and all firms, corporations, 6 partnerships, associations, business enterprises, joint 7 ventures, agencies, institutions or other legal entities 8 providing any form of health care services in this State 9 under this Article. 10 The Illinois Department may require that all dispensers 11 of medical services desiring to participate in the medical 12 assistance program established under this Article disclose, 13 under such terms and conditions as the Illinois Department 14 may by rule establish, all inquiries from clients and 15 attorneys regarding medical bills paid by the Illinois 16 Department, which inquiries could indicate potential 17 existence of claims or liens for the Illinois Department. 18 Enrollment of a vendor that provides non-emergency 19 medical transportation, defined by the Department by rule, 20 shall be conditional for 180 days. During that time, the 21 Department of Public Aid may terminate the vendor's 22 eligibility to participate in the medical assistance program 23 without cause. That termination of eligibility is not 24 subject to the Department's hearing process. 25 The Illinois Department shall establish policies, 26 procedures, standards and criteria by rule for the 27 acquisition, repair and replacement of orthotic and 28 prosthetic devices and durable medical equipment. Such rules 29 shall provide, but not be limited to, the following services: 30 (1) immediate repair or replacement of such devices by 31 recipients without medical authorization; and (2) rental, 32 lease, purchase or lease-purchase of durable medical 33 equipment in a cost-effective manner, taking into 34 consideration the recipient's medical prognosis, the extent SB2225 Enrolled -9- LRB9211341DJgc 1 of the recipient's needs, and the requirements and costs for 2 maintaining such equipment. Such rules shall enable a 3 recipient to temporarily acquire and use alternative or 4 substitute devices or equipment pending repairs or 5 replacements of any device or equipment previously authorized 6 for such recipient by the Department. Rules under clause (2) 7 above shall not provide for purchase or lease-purchase of 8 durable medical equipment or supplies used for the purpose of 9 oxygen delivery and respiratory care. 10 The Department shall execute, relative to the nursing 11 home prescreening project, written inter-agency agreements 12 with the Department of Human Services and the Department on 13 Aging, to effect the following: (i) intake procedures and 14 common eligibility criteria for those persons who are 15 receiving non-institutional services; and (ii) the 16 establishment and development of non-institutional services 17 in areas of the State where they are not currently available 18 or are undeveloped. 19 The Illinois Department shall develop and operate, in 20 cooperation with other State Departments and agencies and in 21 compliance with applicable federal laws and regulations, 22 appropriate and effective systems of health care evaluation 23 and programs for monitoring of utilization of health care 24 services and facilities, as it affects persons eligible for 25 medical assistance under this Code. The Illinois Department 26 shall report regularly the results of the operation of such 27 systems and programs to the Citizens Assembly/Council on 28 Public Aid to enable the Committee to ensure, from time to 29 time, that these programs are effective and meaningful. 30 The Illinois Department shall report annually to the 31 General Assembly, no later than the second Friday in April of 32 1979 and each year thereafter, in regard to: 33 (a) actual statistics and trends in utilization of 34 medical services by public aid recipients; SB2225 Enrolled -10- LRB9211341DJgc 1 (b) actual statistics and trends in the provision 2 of the various medical services by medical vendors; 3 (c) current rate structures and proposed changes in 4 those rate structures for the various medical vendors; 5 and 6 (d) efforts at utilization review and control by 7 the Illinois Department. 8 The period covered by each report shall be the 3 years 9 ending on the June 30 prior to the report. The report shall 10 include suggested legislation for consideration by the 11 General Assembly. The filing of one copy of the report with 12 the Speaker, one copy with the Minority Leader and one copy 13 with the Clerk of the House of Representatives, one copy with 14 the President, one copy with the Minority Leader and one copy 15 with the Secretary of the Senate, one copy with the 16 Legislative Research Unit, such additional copies with the 17 State Government Report Distribution Center for the General 18 Assembly as is required under paragraph (t) of Section 7 of 19 the State Library Act and one copy with the Citizens 20 Assembly/Council on Public Aid or its successor shall be 21 deemed sufficient to comply with this Section. 22 (Source: P.A. 91-344, eff. 1-1-00; 91-462, eff. 8-6-99; 23 91-666, eff. 12-22-99; 92-16, eff. 6-28-01; revised 24 12-13-01.) 25 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25) 26 Sec. 12-4.25. Medical assistance program; vendor 27 participation. 28 (A) The Illinois Department may deny, suspend or 29 terminate the eligibility of any person, firm, corporation, 30 association, agency, institution or other legal entity to 31 participate as a vendor of goods or services to recipients 32 under the medical assistance program under Article V, if 33 after reasonable notice and opportunity for a hearing the SB2225 Enrolled -11- LRB9211341DJgc 1 Illinois Department finds: 2 (a) Such vendor is not complying with the 3 Department's policy or rules and regulations, or with the 4 terms and conditions prescribed by the Illinois 5 Department in its vendor agreement, which document shall 6 be developed by the Department as a result of 7 negotiations with each vendor category, including 8 physicians, hospitals, long term care facilities, 9 pharmacists, optometrists, podiatrists and dentists 10 setting forth the terms and conditions applicable to the 11 participation of each vendor group in the program; or 12 (b) Such vendor has failed to keep or make 13 available for inspection, audit or copying, after 14 receiving a written request from the Illinois Department, 15 such records regarding payments claimed for providing 16 services. This section does not require vendors to make 17 available patient records of patients for whom services 18 are not reimbursed under this Code; or 19 (c) Such vendor has failed to furnish any 20 information requested by the Department regarding 21 payments for providing goods or services; or 22 (d) Such vendor has knowingly made, or caused to be 23 made, any false statement or representation of a material 24 fact in connection with the administration of the medical 25 assistance program; or 26 (e) Such vendor has furnished goods or services to 27 a recipient which are (1) in excess of his or her needs, 28 (2) harmful to the recipient, or (3) of grossly inferior 29 quality, all of such determinations to be based upon 30 competent medical judgment and evaluations; or 31 (f) The vendor; a person with management 32 responsibility for a vendor; an officer or person owning, 33 either directly or indirectly, 5% or more of the shares 34 of stock or other evidences of ownership in a corporate SB2225 Enrolled -12- LRB9211341DJgc 1 vendor; an owner of a sole proprietorship which is a 2 vendor; or a partner in a partnership which is a vendor, 3 either: 4 (1) was previously terminated from 5 participation in the Illinois medical assistance 6 program, or was terminated from participation in a 7 medical assistance program in another state that is 8 of the same kind as the program of medical 9 assistance provided under Article V of this Code; or 10 (2) was a person with management 11 responsibility for a vendor previously terminated 12 from participation in the Illinois medical 13 assistance program, or terminated from participation 14 in a medical assistance program in another state 15 that is of the same kind as the program of medical 16 assistance provided under Article V of this Code, 17 during the time of conduct which was the basis for 18 that vendor's termination; or 19 (3) was an officer, or person owning, either 20 directly or indirectly, 5% or more of the shares of 21 stock or other evidences of ownership in a corporate 22 vendor previously terminated from participation in 23 the Illinois medical assistance program, or 24 terminated from participation in a medical 25 assistance program in another state that is of the 26 same kind as the program of medical assistance 27 provided under Article V of this Code, during the 28 time of conduct which was the basis for that 29 vendor's termination; or 30 (4) was an owner of a sole proprietorship or 31 partner of a partnership previously terminated from 32 participation in the Illinois medical assistance 33 program, or terminated from participation in a 34 medical assistance program in another state that is SB2225 Enrolled -13- LRB9211341DJgc 1 of the same kind as the program of medical 2 assistance provided under Article V of this Code, 3 during the time of conduct which was the basis for 4 that vendor's termination; or 5 (g) The vendor; a person with management 6 responsibility for a vendor; an officer or person owning, 7 either directly or indirectly, 5% or more of the shares 8 of stock or other evidences of ownership in a corporate 9 vendor; an owner of a sole proprietorship which is a 10 vendor; or a partner in a partnership which is a vendor, 11 either: 12 (1) has engaged in practices prohibited by 13 applicable federal or State law or regulation 14 relating to the medical assistance program; or 15 (2) was a person with management 16 responsibility for a vendor at the time that such 17 vendor engaged in practices prohibited by applicable 18 federal or State law or regulation relating to the 19 medical assistance program; or 20 (3) was an officer, or person owning, either 21 directly or indirectly, 5% or more of the shares of 22 stock or other evidences of ownership in a vendor at 23 the time such vendor engaged in practices prohibited 24 by applicable federal or State law or regulation 25 relating to the medical assistance program; or 26 (4) was an owner of a sole proprietorship or 27 partner of a partnership which was a vendor at the 28 time such vendor engaged in practices prohibited by 29 applicable federal or State law or regulation 30 relating to the medical assistance program; or .31 (h) The direct or indirect ownership of the vendor 32 (including the ownership of a vendor that is a sole 33 proprietorship, a partner's interest in a vendor that is 34 a partnership, or ownership of 5% or more of the shares SB2225 Enrolled -14- LRB9211341DJgc 1 of stock or other evidences of ownership in a corporate 2 vendor) has been transferred by an individual who is 3 terminated or barred from participating as a vendor to 4 the individual's spouse, child, brother, sister, parent, 5 grandparent, grandchild, uncle, aunt, niece, nephew, 6 cousin, or relative by marriage. 7 (A-5) The Illinois Department may deny, suspend, or 8 terminate the eligibility of any person, firm, corporation, 9 association, agency, institution, or other legal entity to 10 participate as a vendor of goods or services to recipients 11 under the medical assistance program under Article V if, 12 after reasonable notice and opportunity for a hearing, the 13 Illinois Department finds that the vendor; a person with 14 management responsibility for a vendor; an officer or person 15 owning, either directly or indirectly, 5% or more of the 16 shares of stock or other evidences of ownership in a 17 corporate vendor; an owner of a sole proprietorship that is a 18 vendor; or a partner in a partnership that is a vendor has 19 been convicted of a felony offense based on fraud or willful 20 misrepresentation related to any of the following: 21 (1) The medical assistance program under Article V 22 of this Code. 23 (2) A medical assistance program in another state 24 that is of the same kind as the program of medical 25 assistance provided under Article V of this Code. 26 (3) The Medicare program under Title XVIII of the 27 Social Security Act. 28 (4) The provision of health care services. 29 (B) The Illinois Department shall deny, suspend or 30 terminate the eligibility of any person, firm, corporation, 31 association, agency, institution or other legal entity to 32 participate as a vendor of goods or services to recipients 33 under the medical assistance program under Article V: 34 (1) if such vendor is not properly licensed; SB2225 Enrolled -15- LRB9211341DJgc 1 (2) within 30 days of the date when such vendor's 2 professional license, certification or other 3 authorization has been refused renewal or has been 4 revoked, suspended or otherwise terminated; or 5 (3) if such vendor has been convicted of a 6 violation of this Code, as provided in Article VIIIA. 7 (C) Upon termination of a vendor of goods or services 8 from participation in the medical assistance program 9 authorized by this Article, a person with management 10 responsibility for such vendor during the time of any conduct 11 which served as the basis for that vendor's termination is 12 barred from participation in the medical assistance program. 13 Upon termination of a corporate vendor, the officers and 14 persons owning, directly or indirectly, 5% or more of the 15 shares of stock or other evidences of ownership in the vendor 16 during the time of any conduct which served as the basis for 17 that vendor's termination are barred from participation in 18 the medical assistance program. A person who owns, directly 19 or indirectly, 5% or more of the shares of stock or other 20 evidences of ownership in a terminated corporate vendor may 21 not transfer his or her ownership interest in that vendor to 22 his or her spouse, child, brother, sister, parent, 23 grandparent, grandchild, uncle, aunt, niece, nephew, cousin, 24 or relative by marriage. 25 Upon termination of a sole proprietorship or partnership, 26 the owner or partners during the time of any conduct which 27 served as the basis for that vendor's termination are barred 28 from participation in the medical assistance program. The 29 owner of a terminated vendor that is a sole proprietorship, 30 and a partner in a terminated vendor that is a partnership, 31 may not transfer his or her ownership or partnership interest 32 in that vendor to his or her spouse, child, brother, sister, 33 parent, grandparent, grandchild, uncle, aunt, niece, nephew, 34 cousin, or relative by marriage. SB2225 Enrolled -16- LRB9211341DJgc 1 Rules adopted by the Illinois Department to implement 2 these provisions shall specifically include a definition of 3 the term "management responsibility" as used in this Section. 4 Such definition shall include, but not be limited to, typical 5 job titles, and duties and descriptions which will be 6 considered as within the definition of individuals with 7 management responsibility for a provider. 8 (D) If a vendor has been suspended from the medical 9 assistance program under Article V of the Code, the Director 10 may require that such vendor correct any deficiencies which 11 served as the basis for the suspension. The Director shall 12 specify in the suspension order a specific period of time, 13 which shall not exceed one year from the date of the order, 14 during which a suspended vendor shall not be eligible to 15 participate. At the conclusion of the period of suspension 16 the Director shall reinstate such vendor, unless he finds 17 that such vendor has not corrected deficiencies upon which 18 the suspension was based. 19 If a vendor has been terminated from the medical 20 assistance program under Article V, such vendor shall be 21 barred from participation for at least one year, except that 22 if a vendor has been terminated based on a conviction of a 23 violation of Article VIIIA or a conviction of a felony based 24 on fraud or a willful misrepresentation related to (i) the 25 medical assistance program under Article V, (ii) a medical 26 assistance program in another state that is of the kind 27 provided under Article V, (iii) the Medicare program under 28 Title XVIII of the Social Security Act, or (iv) the provision 29 of health care services, then the vendor shall be barred from 30 participation for 5 years or for the length of the vendor's 31 sentence for that conviction, whichever is longer. At the end 32 of one year a vendor who has been terminated may apply for 33 reinstatement to the program. Upon proper application to be 34 reinstated such vendor may be deemed eligible by the Director SB2225 Enrolled -17- LRB9211341DJgc 1 providing that such vendor meets the requirements for 2 eligibility under this Code. If such vendor is deemed not 3 eligible for reinstatement, he shall be barred from again 4 applying for reinstatement for one year from the date his 5 application for reinstatement is denied. 6 A vendor whose termination from participation in the 7 Illinois medical assistance program under Article V was based 8 solely on an action by a governmental entity other than the 9 Illinois Department may, upon reinstatement by that 10 governmental entity or upon reversal of the termination, 11 apply for rescission of the termination from participation in 12 the Illinois medical assistance program. Upon proper 13 application for rescission, the vendor may be deemed eligible 14 by the Director if the vendor meets the requirements for 15 eligibility under this Code. 16 If a vendor has been terminated and reinstated to the 17 medical assistance program under Article V and the vendor is 18 terminated a second or subsequent time from the medical 19 assistance program, the vendor shall be barred from 20 participation for at least 2 years, except that if a vendor 21 has been terminated a second time based on a conviction of a 22 violation of Article VIIIA or a conviction of a felony based 23 on fraud or a willful misrepresentation related to (i) the 24 medical assistance program under Article V, (ii) a medical 25 assistance program in another state that is of the kind 26 provided under Article V, (iii) the Medicare program under 27 Title XVIII of the Social Security Act, or (iv) the provision 28 of health care services, then the vendor shall be barred from 29 participation for life. At the end of 2 years, a vendor who 30 has been terminated may apply for reinstatement to the 31 program. Upon application to be reinstated, the vendor may 32 be deemed eligible if the vendor meets the requirements for 33 eligibility under this Code. If the vendor is deemed not 34 eligible for reinstatement, the vendor shall be barred from SB2225 Enrolled -18- LRB9211341DJgc 1 again applying for reinstatement for 2 years from the date 2 the vendor's application for reinstatement is denied. 3 (E) The Illinois Department may recover money improperly 4 or erroneously paid, or overpayments, either by setoff, 5 crediting against future billings or by requiring direct 6 repayment to the Illinois Department. 7 If the Department of Public Aid establishes through an 8 administrative hearing that the overpayments resulted from 9 the vendor willfully making, or causing to be made, a false 10 statement or misrepresentation of a material fact in 11 connection with billings and payments under the medical 12 assistance program under Article V, the Department may 13 recover interest on the amount of the overpayments at the 14 rate of 5% per annum. For purposes of this paragraph, 15 "willfully" means that a person makes a statement or 16 representation with actual knowledge that it was false, or 17 makes a statement or representation with knowledge of facts 18 or information that would cause one to be aware that the 19 statement or representation was false when made. 20 (F) The Illinois Department may withhold payments to any 21 vendor during the pendency of any proceeding under this 22 Section except that if a final administrative decision has23 not been issued within 120 days of the initiation of such24 proceedings, unless delay has been caused by the vendor,25 payments can no longer be withheld, provided, however, that26 the 120 day limit may be extended if said extension is27 mutually agreed to by the Illinois Department and the vendor. 28 The Illinois Department shall state by rule with as much 29 specificity as practicable the conditions under which 30 payments will not be withheld during the pendency of any 31 proceeding under this Section. Payments may be denied for 32 bills submitted with service dates occurring during the 33 pendency of a proceeding where the final administrative 34 decision is to terminate eligibility to participate in the SB2225 Enrolled -19- LRB9211341DJgc 1 medical assistance program. The Illinois Department shall 2 state by rule with as much specificity as practicable the 3 conditions under which payments will not be denied for such 4 bills. The Department of Public Aid shall state by rule a 5 process and criteria by which a vendor may request full or 6 partial release of payments withheld under this subsection. 7 The Department must complete a proceeding under this Section 8 in a timely manner. 9 (F-5) The Illinois Department may temporarily withhold 10 payments to a vendor if any of the following individuals have 11 been indicted or otherwise charged under a law of the United 12 States or this or any other state with a felony offense that 13 is based on alleged fraud or willful misrepresentation on the 14 part of the individual related to (i) the medical assistance 15 program under Article V of this Code, (ii) a medical 16 assistance program provided in another state which is of the 17 kind provided under Article V of this Code, (iii) the 18 Medicare program under Title XVIII of the Social Security 19 Act, or (iv) the provision of health care services: 20 (1) If the vendor is a corporation: an officer of 21 the corporation or an individual who owns, either 22 directly or indirectly, 5% or more of the shares of stock 23 or other evidence of ownership of the corporation. 24 (2) If the vendor is a sole proprietorship: the 25 owner of the sole proprietorship. 26 (3) If the vendor is a partnership: a partner in 27 the partnership. 28 (4) If the vendor is any other business entity 29 authorized by law to transact business in this State: an 30 officer of the entity or an individual who owns, either 31 directly or indirectly, 5% or more of the evidences of 32 ownership of the entity. 33 If the Illinois Department withholds payments to a vendor 34 under this subsection, the Department shall not release those SB2225 Enrolled -20- LRB9211341DJgc 1 payments to the vendor while any criminal proceeding related 2 to the indictment or charge is pending unless the Department 3 determines that there is good cause to release the payments 4 before completion of the proceeding. If the indictment or 5 charge results in the individual's conviction, the Illinois 6 Department shall retain all withheld payments, which shall be 7 considered forfeited to the Department. If the indictment or 8 charge does not result in the individual's conviction, the 9 Illinois Department shall release to the vendor all withheld 10 payments. 11 (G) The provisions of the Administrative Review Law, as 12 now or hereafter amended, and the rules adopted pursuant 13 thereto, shall apply to and govern all proceedings for the 14 judicial review of final administrative decisions of the 15 Illinois Department under this Section. The term 16 "administrative decision" is defined as in Section 3-101 of 17 the Code of Civil Procedure. 18 (G-5) Non-emergency transportation. 19 (1) Notwithstanding any other provision in this 20 Section, for non-emergency transportation vendors, the 21 Department may terminate the vendor from participation in 22 the medical assistance program prior to an evidentiary 23 hearing but after reasonable notice and opportunity to 24 respond as established by the Department by rule. 25 (2) Vendors of non-emergency medical transportation 26 services, as defined by the Department by rule, shall 27 submit to a fingerprint-based criminal background check 28 on current and future information available in the State 29 system and current information available through the 30 Federal Bureau of Investigation's system by submitting 31 all necessary fees and information in the form and manner 32 prescribed by the Department of State Police. The 33 following individuals shall be subject to the check: 34 (A) In the case of a vendor that is a SB2225 Enrolled -21- LRB9211341DJgc 1 corporation, every shareholder who owns, directly or 2 indirectly, 5% or more of the outstanding shares of 3 the corporation. 4 (B) In the case of a vendor that is a 5 partnership, every partner. 6 (C) In the case of a vendor that is a sole 7 proprietorship, the sole proprietor. 8 (D) Each officer or manager of the vendor. 9 Each such vendor shall be responsible for payment of 10 the cost of the criminal background check. 11 (3) Vendors of non-emergency medical transportation 12 services may be required to post a surety bond. The 13 Department shall establish, by rule, the criteria and 14 requirements for determining when a surety bond must be 15 posted and the value of the bond. 16 (4) The Department, or its agents, may refuse to 17 accept requests for non-emergency transportation 18 authorizations, including prior-approval and 19 post-approval requests, for a specific non-emergency 20 transportation vendor if: 21 (A) the Department has initiated a notice of 22 termination of the vendor from participation in the 23 medical assistance program; or 24 (B) the Department has issued notification of 25 its withholding of payments pursuant to subsection 26 (F-5) of this Section; or 27 (C) the Department has issued a notification 28 of its withholding of payments due to reliable 29 evidence of fraud or willful misrepresentation 30 pending investigation. 31 (H) Nothing contained in this Code shall in any way 32 limit or otherwise impair the authority or power of any State 33 agency responsible for licensing of vendors. 34 (I) Based on a finding of noncompliance on the part of a SB2225 Enrolled -22- LRB9211341DJgc 1 nursing home with any requirement for certification under 2 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 3 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois 4 Department may impose one or more of the following remedies 5 after notice to the facility: 6 (1) Termination of the provider agreement. 7 (2) Temporary management. 8 (3) Denial of payment for new admissions. 9 (4) Civil money penalties. 10 (5) Closure of the facility in emergency situations 11 or transfer of residents, or both. 12 (6) State monitoring. 13 (7) Denial of all payments when the Health Care 14 Finance Administration has imposed this sanction. 15 The Illinois Department shall by rule establish criteria 16 governing continued payments to a nursing facility subsequent 17 to termination of the facility's provider agreement if, in 18 the sole discretion of the Illinois Department, circumstances 19 affecting the health, safety, and welfare of the facility's 20 residents require those continued payments. The Illinois 21 Department may condition those continued payments on the 22 appointment of temporary management, sale of the facility to 23 new owners or operators, or other arrangements that the 24 Illinois Department determines best serve the needs of the 25 facility's residents. 26 Except in the case of a facility that has a right to a 27 hearing on the finding of noncompliance before an agency of 28 the federal government, a facility may request a hearing 29 before a State agency on any finding of noncompliance within 30 60 days after the notice of the intent to impose a remedy. 31 Except in the case of civil money penalties, a request for a 32 hearing shall not delay imposition of the penalty. The 33 choice of remedies is not appealable at a hearing. The level 34 of noncompliance may be challenged only in the case of a SB2225 Enrolled -23- LRB9211341DJgc 1 civil money penalty. The Illinois Department shall provide by 2 rule for the State agency that will conduct the evidentiary 3 hearings. 4 The Illinois Department may collect interest on unpaid 5 civil money penalties. 6 The Illinois Department may adopt all rules necessary to 7 implement this subsection (I). 8 (Source: P.A. 92-327, eff. 1-1-02; revised 9-18-01.) 9 Section 99. Effective date. This Act takes effect upon 10 becoming law.
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