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1 | | AN ACT concerning public aid.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 5. The Illinois Public Aid Code is amended by |
5 | | changing Section 12-4.25 as follows:
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6 | | (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
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7 | | Sec. 12-4.25. Medical assistance program; vendor |
8 | | participation.
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9 | | (A) The Illinois Department may deny, suspend or
terminate |
10 | | the eligibility of any person, firm, corporation, association,
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11 | | agency, institution or other legal entity to participate as a |
12 | | vendor of
goods or services to recipients under the medical |
13 | | assistance program
under Article V, if after reasonable notice |
14 | | and opportunity for a
hearing the Illinois Department finds:
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15 | | (a) Such vendor is not complying with the Department's |
16 | | policy or
rules and regulations, or with the terms and |
17 | | conditions prescribed by
the Illinois Department in its |
18 | | vendor agreement, which document shall be
developed by the |
19 | | Department as a result of negotiations with each vendor
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20 | | category, including physicians, hospitals, long term care |
21 | | facilities,
pharmacists, optometrists, podiatrists and |
22 | | dentists setting forth the
terms and conditions applicable |
23 | | to the participation of each vendor
group in the program; |
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1 | | or
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2 | | (b) Such vendor has failed to keep or make available |
3 | | for inspection,
audit or copying, after receiving a written |
4 | | request from the Illinois
Department, such records |
5 | | regarding payments claimed for providing
services. This |
6 | | section does not require vendors to make available
patient |
7 | | records of patients for whom services are not reimbursed |
8 | | under
this Code; or
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9 | | (c) Such vendor has failed to furnish any information |
10 | | requested by
the Department regarding payments for |
11 | | providing goods or services; or
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12 | | (d) Such vendor has knowingly made, or caused to be |
13 | | made, any false
statement or representation of a material |
14 | | fact in connection with the
administration of the medical |
15 | | assistance program; or
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16 | | (e) Such vendor has furnished goods or services to a |
17 | | recipient which
are (1) in excess of his or her needs, (2) |
18 | | harmful to the recipient, or
(3) of grossly inferior |
19 | | quality, all of such determinations to be based
upon |
20 | | competent medical judgment and evaluations; or
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21 | | (f) The vendor; a person with management |
22 | | responsibility for a
vendor; an officer or person owning, |
23 | | either directly or indirectly, 5%
or more of the shares of |
24 | | stock or other evidences of ownership in a
corporate |
25 | | vendor; an owner of a sole proprietorship which is a |
26 | | vendor;
or a partner in a partnership which is a vendor, |
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1 | | either:
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2 | | (1) was previously terminated from participation |
3 | | in the Illinois
medical assistance program, or was |
4 | | terminated from participation in a medical
assistance |
5 | | program in
another state that is of the same kind as |
6 | | the program of medical assistance
provided under |
7 | | Article V of this Code; or
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8 | | (2) was a person with management responsibility |
9 | | for a vendor
previously terminated from participation |
10 | | in the Illinois medical assistance
program, or |
11 | | terminated from participation in a medical assistance |
12 | | program in
another state that is of the same kind as |
13 | | the program of medical assistance
provided under |
14 | | Article V of this Code,
during the time of conduct |
15 | | which was the basis for
that vendor's termination; or
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16 | | (3) was an officer, or person owning, either |
17 | | directly or indirectly,
5% or more of the shares of |
18 | | stock or other evidences of ownership in a corporate |
19 | | vendor
previously terminated from participation in the |
20 | | Illinois medical assistance
program, or terminated |
21 | | from participation in a medical assistance program in
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22 | | another state that is of the same kind as the program |
23 | | of medical assistance
provided under Article V of this |
24 | | Code,
during the time of conduct which
was the basis |
25 | | for that vendor's termination; or
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26 | | (4) was an owner of a sole proprietorship or |
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1 | | partner of a
partnership previously terminated
from |
2 | | participation in the Illinois medical assistance |
3 | | program, or terminated
from participation in a medical |
4 | | assistance program in another state that is of
the same |
5 | | kind as the program of medical assistance provided |
6 | | under Article V of
this Code,
during the time of |
7 | | conduct
which was the basis for that vendor's |
8 | | termination; or
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9 | | (g) The vendor; a person with management |
10 | | responsibility for a
vendor; an officer or person owning, |
11 | | either directly or indirectly, 5%
or more of the shares of |
12 | | stock or other evidences of ownership in a
corporate |
13 | | vendor; an owner of a sole proprietorship which is a |
14 | | vendor;
or a partner in a partnership which is a vendor, |
15 | | either:
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16 | | (1) has engaged in practices prohibited by |
17 | | applicable federal or
State law or regulation relating |
18 | | to the medical assistance program; or
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19 | | (2) was a person with management responsibility |
20 | | for a vendor at the
time that such vendor engaged in |
21 | | practices prohibited by applicable
federal or State |
22 | | law or regulation relating to the medical assistance
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23 | | program; or
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24 | | (3) was an officer, or person owning, either |
25 | | directly or indirectly,
5% or more of the shares of |
26 | | stock or other evidences of ownership in a
vendor at |
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1 | | the time such vendor engaged in practices prohibited by
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2 | | applicable federal or State law or regulation relating |
3 | | to the medical
assistance program; or
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4 | | (4) was an owner of a sole proprietorship or |
5 | | partner of a
partnership which was a vendor at the time |
6 | | such vendor engaged in
practices prohibited by |
7 | | applicable federal or State law or regulation
relating |
8 | | to the medical assistance program; or
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9 | | (h) The direct or indirect ownership of the vendor |
10 | | (including the
ownership of a vendor that is a sole |
11 | | proprietorship, a partner's interest in a
vendor that is a |
12 | | partnership, or ownership of 5% or more of the shares of |
13 | | stock
or other
evidences of ownership in a corporate |
14 | | vendor) has been transferred by an
individual who is |
15 | | terminated or barred from participating as a vendor to the
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16 | | individual's spouse, child, brother, sister, parent, |
17 | | grandparent, grandchild,
uncle, aunt, niece, nephew, |
18 | | cousin, or relative by marriage.
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19 | | (A-5) The Illinois Department may deny, suspend, or |
20 | | terminate the
eligibility
of any person, firm, corporation, |
21 | | association, agency, institution, or other
legal entity to |
22 | | participate as a vendor of goods or services to recipients
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23 | | under the medical assistance program under Article V if, after |
24 | | reasonable
notice and opportunity for a hearing, the Illinois |
25 | | Department finds that the
vendor; a person with management |
26 | | responsibility for a vendor; an officer or
person owning, |
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1 | | either directly or indirectly, 5% or more of the shares of |
2 | | stock
or other evidences of ownership in a corporate vendor; an |
3 | | owner of a sole
proprietorship that is a vendor; or a partner |
4 | | in a partnership that is a vendor
has been convicted of a |
5 | | felony offense based on fraud or willful
misrepresentation |
6 | | related to any of
the following:
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7 | | (1) The medical assistance program under Article V of |
8 | | this Code.
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9 | | (2) A medical assistance program in another state that |
10 | | is of the same kind
as the program of medical assistance |
11 | | provided under Article V of this Code.
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12 | | (3) The Medicare program under Title XVIII of the |
13 | | Social Security Act.
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14 | | (4) The provision of health care services.
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15 | | (A-10) The Illinois Department may deny, suspend, or |
16 | | terminate the eligibility of any person, firm, corporation, |
17 | | association, agency, institution, or other legal entity to |
18 | | participate as a vendor of goods or services to recipients |
19 | | under the medical assistance program under Article V if, after |
20 | | reasonable notice and opportunity for a hearing, the Illinois |
21 | | Department finds that (i) the vendor, (ii) a person with |
22 | | management responsibility for a vendor, (iii) an officer or |
23 | | person owning, either directly or indirectly, 5% or more of the |
24 | | shares of stock or other evidences of ownership in a corporate |
25 | | vendor, (iv) an owner of a sole proprietorship that is a |
26 | | vendor, or (v) a partner in a partnership that is a vendor has |
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1 | | been convicted of a felony offense related to any of the |
2 | | following:
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3 | | (1) Murder.
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4 | | (2) A Class X felony under the Criminal Code of 1961.
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5 | | (B) The Illinois Department shall deny, suspend or |
6 | | terminate the
eligibility of any person, firm, corporation, |
7 | | association, agency,
institution or other legal entity to |
8 | | participate as a vendor of goods or
services to recipients |
9 | | under the medical assistance program under
Article V:
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10 | | (1) if such vendor is not properly licensed;
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11 | | (2) within 30 days of the date when such vendor's |
12 | | professional
license, certification or other authorization |
13 | | has been refused renewal
or has been revoked, suspended or |
14 | | otherwise terminated; or
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15 | | (3) if such vendor has been convicted of a violation of |
16 | | this Code, as
provided in Article VIIIA.
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17 | | (C) Upon termination of a vendor of goods or services from
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18 | | participation in the medical assistance program authorized by |
19 | | this
Article, a person with management responsibility for such |
20 | | vendor during
the time of any conduct which served as the basis |
21 | | for that vendor's
termination is barred from participation in |
22 | | the medical assistance
program.
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23 | | Upon termination of a corporate vendor, the officers and |
24 | | persons
owning, directly or indirectly, 5% or more of the |
25 | | shares of stock or
other evidences of ownership in the vendor |
26 | | during the time of any
conduct which served as the basis for |
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1 | | that vendor's termination are
barred from participation in the |
2 | | medical assistance program. A person who
owns, directly or |
3 | | indirectly, 5% or more of the shares of stock or other
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4 | | evidences of ownership in a terminated corporate vendor may not |
5 | | transfer his or
her ownership interest in that vendor to his or |
6 | | her spouse, child, brother,
sister, parent, grandparent, |
7 | | grandchild, uncle, aunt, niece, nephew, cousin, or
relative by |
8 | | marriage.
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9 | | Upon termination of a sole proprietorship or partnership, |
10 | | the owner
or partners during the time of any conduct which |
11 | | served as the basis for
that vendor's termination are barred |
12 | | from participation in the medical
assistance program. The owner |
13 | | of a terminated vendor that is a sole
proprietorship, and a |
14 | | partner in a terminated vendor that is a partnership, may
not |
15 | | transfer his or her ownership or partnership interest in that |
16 | | vendor to his
or her spouse, child, brother, sister, parent, |
17 | | grandparent, grandchild, uncle,
aunt, niece, nephew, cousin, |
18 | | or relative by marriage.
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19 | | Rules adopted by the Illinois Department to implement these
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20 | | provisions shall specifically include a definition of the term
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21 | | "management responsibility" as used in this Section. Such |
22 | | definition
shall include, but not be limited to, typical job |
23 | | titles, and duties and
descriptions which will be considered as |
24 | | within the definition of
individuals with management |
25 | | responsibility for a provider.
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26 | | (D) If a vendor has been suspended from the medical |
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1 | | assistance
program under Article V of the Code, the Director |
2 | | may require that such
vendor correct any deficiencies which |
3 | | served as the basis for the
suspension. The Director shall |
4 | | specify in the suspension order a specific
period of time, |
5 | | which shall not exceed one year from the date of the
order, |
6 | | during which a suspended vendor shall not be eligible to
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7 | | participate. At the conclusion of the period of suspension the |
8 | | Director
shall reinstate such vendor, unless he finds that such |
9 | | vendor has not
corrected deficiencies upon which the suspension |
10 | | was based.
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11 | | If a vendor has been terminated from the medical assistance |
12 | | program
under Article V, such vendor shall be barred from |
13 | | participation for at
least one year, except that if a vendor |
14 | | has been terminated based on a
conviction of a
violation of |
15 | | Article VIIIA or a conviction of a felony based on fraud or a
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16 | | willful misrepresentation related to (i) the medical |
17 | | assistance program under
Article V, (ii) a medical assistance |
18 | | program in another state that is of the
kind provided under |
19 | | Article V, (iii) the Medicare program under Title XVIII of
the |
20 | | Social Security Act, or (iv) the provision of health care |
21 | | services, then
the vendor shall be barred from participation |
22 | | for 5 years or for the length of
the vendor's sentence for that |
23 | | conviction, whichever is longer. At the end of
one year a |
24 | | vendor who has been terminated
may apply for reinstatement to |
25 | | the program. Upon proper application to
be reinstated such |
26 | | vendor may be deemed eligible by the Director
providing that |
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1 | | such vendor meets the requirements for eligibility under
this |
2 | | Code. If such vendor is deemed not eligible for
reinstatement, |
3 | | he
shall be barred from again applying for reinstatement for |
4 | | one year from the
date his application for reinstatement is |
5 | | denied.
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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, apply |
11 | | for
rescission of the termination from participation in the |
12 | | Illinois medical
assistance program. Upon proper application |
13 | | for rescission, the vendor may be
deemed eligible by the |
14 | | Director if the vendor meets the requirements for
eligibility |
15 | | under this Code.
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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
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20 | | participation for at least 2 years, except that if a vendor has |
21 | | been
terminated a second time based on a
conviction of a |
22 | | violation of Article VIIIA or a conviction of a felony based on
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23 | | fraud or a willful misrepresentation related to (i) the medical |
24 | | assistance
program under Article V, (ii) a medical assistance |
25 | | program in another state
that is of the kind provided under |
26 | | Article V, (iii) the Medicare program under
Title XVIII of the |
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1 | | Social Security Act, or (iv) the provision of health care
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2 | | services, then the vendor shall be barred from participation |
3 | | for life. At
the end of 2 years, a vendor who has
been |
4 | | terminated may apply for reinstatement to the program. Upon |
5 | | application
to be reinstated, the vendor may be deemed eligible |
6 | | if the vendor meets the
requirements for eligibility under this |
7 | | Code. If the vendor is deemed not
eligible for reinstatement, |
8 | | the vendor shall be barred from again applying for
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9 | | reinstatement for 2 years from the date the vendor's |
10 | | application for
reinstatement is denied.
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11 | | (E) The Illinois Department may recover money improperly or
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12 | | erroneously paid, or overpayments, either by setoff, crediting |
13 | | against
future billings or by requiring direct repayment to the |
14 | | Illinois
Department.
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15 | | If the Illinois Department establishes through an |
16 | | administrative
hearing that the overpayments resulted from the |
17 | | vendor
or alternate payee willfully making, or causing to be |
18 | | made, a false statement or
misrepresentation of a material fact |
19 | | in connection with billings and payments
under the medical |
20 | | assistance program under Article V, the Department may
recover |
21 | | interest on the amount of the overpayments at the rate of 5% |
22 | | per annum.
For purposes of this paragraph,
"willfully" means |
23 | | that a person makes a statement or representation with
actual |
24 | | knowledge that it was false, or makes a statement or |
25 | | representation with
knowledge of facts or information that |
26 | | would cause one to be aware that
the statement or |
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1 | | representation was false when made.
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2 | | (F) The Illinois Department may withhold payments to any |
3 | | vendor
or alternate payee during the pendency of any proceeding |
4 | | under this Section. The Illinois Department shall
state by rule |
5 | | with as much specificity as practicable the conditions
under |
6 | | which payments will not be withheld during the pendency of any
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7 | | proceeding under this Section. Payments may be denied for bills
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8 | | submitted with service dates occurring during the pendency of a
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9 | | proceeding where the final administrative decision is to |
10 | | terminate
eligibility to participate in the medical assistance |
11 | | program. The
Illinois Department shall state by rule with as |
12 | | much specificity as
practicable the conditions under which |
13 | | payments will not be denied for
such bills.
The Illinois
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14 | | Department shall state by rule a process and criteria by
which |
15 | | a vendor or alternate payee may request full or partial release |
16 | | of payments withheld under
this subsection. The Department must |
17 | | complete a proceeding under this Section
in a timely manner.
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18 | | (F-5) The Illinois Department may temporarily withhold |
19 | | payments to
a vendor or alternate payee if any of the following |
20 | | individuals have been indicted or
otherwise charged under a law |
21 | | of the United States or this or any other state
with a felony |
22 | | offense that is based on alleged fraud or willful
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23 | | misrepresentation on the part of the individual related to (i) |
24 | | the medical
assistance program under Article V of this Code, |
25 | | (ii) a medical assistance
program provided in another state |
26 | | which is of the kind provided under
Article V of this Code, |
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1 | | (iii) the Medicare program under Title XVIII of the
Social |
2 | | Security Act, or (iv) the provision of health care services:
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3 | | (1) If the vendor or alternate payee is a corporation: |
4 | | an officer of the corporation
or an individual who owns, |
5 | | either directly or indirectly, 5% or more
of the shares of |
6 | | stock or other evidence of ownership of the
corporation.
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7 | | (2) If the vendor is a sole proprietorship: the owner |
8 | | of the sole
proprietorship.
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9 | | (3) If the vendor or alternate payee is a partnership: |
10 | | a partner in the partnership.
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11 | | (4) If the vendor or alternate payee is any other |
12 | | business entity authorized by law
to transact business in |
13 | | this State: an officer of the entity or an
individual who |
14 | | owns, either directly or indirectly, 5% or more of the
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15 | | evidences of ownership of the entity.
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16 | | If the Illinois Department withholds payments to a vendor |
17 | | or alternate payee under this
subsection, the Department shall |
18 | | not release those payments to the vendor
or alternate payee
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19 | | while any criminal proceeding related to the indictment or |
20 | | charge is pending
unless the Department determines that there |
21 | | is good cause to release the
payments before completion of the |
22 | | proceeding. If the indictment or charge
results in the |
23 | | individual's conviction, the Illinois Department shall retain
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24 | | all withheld
payments, which shall be considered forfeited to |
25 | | the Department. If the
indictment or charge does not result in |
26 | | the individual's conviction, the
Illinois Department
shall |
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1 | | release to the vendor or alternate payee all withheld payments.
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2 | | (G) The provisions of the Administrative Review Law, as now |
3 | | or hereafter
amended, and the rules adopted pursuant
thereto, |
4 | | shall apply to and govern all proceedings for the judicial
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5 | | review of final administrative decisions of the Illinois |
6 | | Department
under this Section. The term "administrative |
7 | | decision" is defined as in
Section 3-101 of the Code of Civil |
8 | | Procedure.
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9 | | (G-5) Non-emergency transportation.
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10 | | (1) Notwithstanding any other provision in this |
11 | | Section, for non-emergency
transportation vendors, the |
12 | | Department may terminate the vendor from
participation in |
13 | | the medical assistance program prior
to an evidentiary |
14 | | hearing but after reasonable notice and opportunity to
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15 | | respond as established by the Department by rule.
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16 | | (2) Vendors of non-emergency medical transportation |
17 | | services, as defined
by the Department by rule, shall |
18 | | submit to a fingerprint-based criminal
background check on |
19 | | current and future information available in the State
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20 | | system and current information available through the |
21 | | Federal Bureau of
Investigation's system by submitting all |
22 | | necessary fees and information in the
form and manner
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23 | | prescribed by the Department of State Police. The following |
24 | | individuals shall
be subject to the check:
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25 | | (A) In the case of a vendor that is a corporation, |
26 | | every shareholder
who owns, directly or indirectly, 5% |
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1 | | or more of the outstanding shares of
the corporation.
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2 | | (B) In the case of a vendor that is a partnership, |
3 | | every partner.
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4 | | (C) In the case of a vendor that is a sole |
5 | | proprietorship, the sole
proprietor.
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6 | | (D) Each officer or manager of the vendor.
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7 | | Each such vendor shall be responsible for payment of |
8 | | the cost of the
criminal background check.
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9 | | (3) Vendors of non-emergency medical transportation |
10 | | services may be
required to post a surety bond. The |
11 | | Department shall establish, by rule, the
criteria and |
12 | | requirements for determining when a surety bond must be |
13 | | posted and
the value of the bond.
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14 | | (4) The Department, or its agents, may refuse to accept |
15 | | requests for
non-emergency transportation authorizations, |
16 | | including prior-approval and
post-approval requests, for a |
17 | | specific non-emergency transportation vendor if:
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18 | | (A) the Department has initiated a notice of |
19 | | termination of the
vendor from participation in the |
20 | | medical assistance program; or
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21 | | (B) the Department has issued notification of its |
22 | | withholding of
payments pursuant to subsection (F-5) |
23 | | of this Section; or
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24 | | (C) the Department has issued a notification of its |
25 | | withholding of
payments due to reliable evidence of |
26 | | fraud or willful misrepresentation
pending |
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1 | | investigation.
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2 | | (H) Nothing contained in this Code shall in any way limit |
3 | | or
otherwise impair the authority or power of any State agency |
4 | | responsible
for licensing of vendors.
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5 | | (I) Based on a finding of noncompliance on the part of a |
6 | | nursing home with
any requirement for certification under Title |
7 | | XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et |
8 | | seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department |
9 | | may impose one or more of the following remedies after
notice |
10 | | to the facility:
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11 | | (1) Termination of the provider agreement.
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12 | | (2) Temporary management.
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13 | | (3) Denial of payment for new admissions.
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14 | | (4) Civil money penalties.
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15 | | (5) Closure of the facility in emergency situations or |
16 | | transfer of
residents, or both.
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17 | | (6) State monitoring.
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18 | | (7) Denial of all payments when the Health Care Finance |
19 | | Administration has
imposed this sanction.
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20 | | The Illinois Department shall by rule establish criteria |
21 | | governing continued
payments to a nursing facility subsequent |
22 | | to termination of the facility's
provider agreement if, in the |
23 | | sole discretion of the Illinois Department,
circumstances |
24 | | affecting the health, safety, and welfare of the facility's
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25 | | residents require those continued payments. The Illinois |
26 | | Department may
condition those continued payments on the |
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1 | | appointment of temporary management,
sale of the facility to |
2 | | new owners or operators, or other
arrangements that the |
3 | | Illinois Department determines best serve the needs of
the |
4 | | facility's residents.
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5 | | Except in the case of a facility that has a right to a |
6 | | hearing on the finding
of noncompliance before an agency of the |
7 | | federal government, a facility may
request a hearing before a |
8 | | State agency on any finding of noncompliance within
60 days |
9 | | after the notice of the intent to impose a remedy. Except in |
10 | | the case
of civil money penalties, a request for a hearing |
11 | | shall not delay imposition of
the penalty. The choice of |
12 | | remedies is not appealable at a hearing. The level
of |
13 | | noncompliance may be challenged only in the case of a civil |
14 | | money penalty.
The Illinois Department shall provide by rule |
15 | | for the State agency that will
conduct the evidentiary |
16 | | hearings.
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17 | | The Illinois Department may collect interest on unpaid |
18 | | civil money penalties.
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19 | | The Illinois Department may adopt all rules necessary to |
20 | | implement this
subsection (I).
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21 | | (J) The Illinois Department, by rule, may permit individual |
22 | | practitioners to designate that Department payments that may be |
23 | | due the practitioner be made to an alternate payee or alternate |
24 | | payees. |
25 | | (a) Such alternate payee or alternate payees shall be |
26 | | required to register as an alternate payee in the Medical |
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1 | | Assistance Program with the Illinois Department. |
2 | | (b) If a practitioner designates an alternate payee, |
3 | | the alternate payee and practitioner shall be jointly and |
4 | | severally liable to the Department for payments made to the |
5 | | alternate payee. Pursuant to subsection (E) of this |
6 | | Section, any Department action to recover money or |
7 | | overpayments from an alternate payee shall be subject to an |
8 | | administrative hearing. |
9 | | (c) Registration as an alternate payee or alternate |
10 | | payees in the Illinois Medical Assistance Program shall be |
11 | | conditional. At any time, the Illinois Department may deny |
12 | | or cancel any alternate payee's registration in the |
13 | | Illinois Medical Assistance Program without cause. Any |
14 | | such denial or cancellation is not subject to an |
15 | | administrative hearing. |
16 | | (d) The Illinois Department may seek a revocation of |
17 | | any alternate payee, and all owners, officers, and |
18 | | individuals with management responsibility for such |
19 | | alternate payee shall be permanently prohibited from |
20 | | participating as an owner, an officer, or an individual |
21 | | with management responsibility with an alternate payee in |
22 | | the Illinois Medical Assistance Program, if after |
23 | | reasonable notice and opportunity for a hearing the |
24 | | Illinois Department finds that: |
25 | | (1) the alternate payee is not complying with the |
26 | | Department's policy or rules and regulations, or with |
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1 | | the terms and conditions prescribed by the Illinois |
2 | | Department in its alternate payee registration |
3 | | agreement; or |
4 | | (2) the alternate payee has failed to keep or make |
5 | | available for inspection, audit, or copying, after |
6 | | receiving a written request from the Illinois |
7 | | Department, such records regarding payments claimed as |
8 | | an alternate payee; or |
9 | | (3) the alternate payee has failed to furnish any |
10 | | information requested by the Illinois Department |
11 | | regarding payments claimed as an alternate payee; or |
12 | | (4) the alternate payee has knowingly made, or |
13 | | caused to be made, any false statement or |
14 | | representation of a material fact in connection with |
15 | | the administration of the Illinois Medical Assistance |
16 | | Program; or |
17 | | (5) the alternate payee, a person with management |
18 | | responsibility for an alternate payee, an officer or |
19 | | person owning, either directly or indirectly, 5% or |
20 | | more of the shares of stock or other evidences of |
21 | | ownership in a corporate alternate payee, or a partner |
22 | | in a partnership which is an alternate payee: |
23 | | (a) was previously terminated from |
24 | | participation as a vendor in the Illinois Medical |
25 | | Assistance Program, or was previously revoked as |
26 | | an alternate payee in the Illinois Medical |
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1 | | Assistance Program, or was terminated from |
2 | | participation as a vendor in a medical assistance |
3 | | program in another state that is of the same kind |
4 | | as the program of medical assistance provided |
5 | | under Article V of this Code; or |
6 | | (b) was a person with management |
7 | | responsibility for a vendor previously terminated |
8 | | from participation as a vendor in the Illinois |
9 | | Medical Assistance Program, or was previously |
10 | | revoked as an alternate payee in the Illinois |
11 | | Medical Assistance Program, or was terminated from |
12 | | participation as a vendor in a medical assistance |
13 | | program in another state that is of the same kind |
14 | | as the program of medical assistance provided |
15 | | under Article V of this Code, during the time of |
16 | | conduct which was the basis for that vendor's |
17 | | termination or alternate payee's revocation; or |
18 | | (c) was an officer, or person owning, either |
19 | | directly or indirectly, 5% or more of the shares of |
20 | | stock or other evidences of ownership in a |
21 | | corporate vendor previously terminated from |
22 | | participation as a vendor in the Illinois Medical |
23 | | Assistance Program, or was previously revoked as |
24 | | an alternate payee in the Illinois Medical |
25 | | Assistance Program, or was terminated from |
26 | | participation as a vendor in a medical assistance |
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1 | | program in another state that is of the same kind |
2 | | as the program of medical assistance provided |
3 | | under Article V of this Code, during the time of |
4 | | conduct which was the basis for that vendor's |
5 | | termination; or |
6 | | (d) was an owner of a sole proprietorship or |
7 | | partner in a partnership previously terminated |
8 | | from participation as a vendor in the Illinois |
9 | | Medical Assistance Program, or was previously |
10 | | revoked as an alternate payee in the Illinois |
11 | | Medical Assistance Program, or was terminated from |
12 | | participation as a vendor in a medical assistance |
13 | | program in another state that is of the same kind |
14 | | as the program of medical assistance provided |
15 | | under Article V of this Code, during the time of |
16 | | conduct which was the basis for that vendor's |
17 | | termination or alternate payee's revocation; or |
18 | | (6) the alternate payee, a person with management |
19 | | responsibility for an alternate payee, an officer or |
20 | | person owning, either directly or indirectly, 5% or |
21 | | more of the shares of stock or other evidences of |
22 | | ownership in a corporate alternate payee, or a partner |
23 | | in a partnership which is an alternate payee: |
24 | | (a) has engaged in conduct prohibited by |
25 | | applicable federal or State law or regulation |
26 | | relating to the Illinois Medical Assistance |
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1 | | Program; or |
2 | | (b) was a person with management |
3 | | responsibility for a vendor or alternate payee at |
4 | | the time that the vendor or alternate payee engaged |
5 | | in practices prohibited by applicable federal or |
6 | | State law or regulation relating to the Illinois |
7 | | Medical Assistance Program; or |
8 | | (c) was an officer, or person owning, either |
9 | | directly or indirectly, 5% or more of the shares of |
10 | | stock or other evidences of ownership in a vendor |
11 | | or alternate payee at the time such vendor or |
12 | | alternate payee engaged in practices prohibited by |
13 | | applicable federal or State law or regulation |
14 | | relating to the Illinois Medical Assistance |
15 | | Program; or |
16 | | (d) was an owner of a sole proprietorship or |
17 | | partner in a partnership which was a vendor or |
18 | | alternate payee at the time such vendor or |
19 | | alternate payee engaged in practices prohibited by |
20 | | applicable federal or State law or regulation |
21 | | relating to the Illinois Medical Assistance |
22 | | Program; or |
23 | | (7) the direct or indirect ownership of the vendor |
24 | | or alternate payee (including the ownership of a vendor |
25 | | or alternate payee that is a partner's interest in a |
26 | | vendor or alternate payee, or ownership of 5% or more |
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1 | | of the shares of stock or other evidences of ownership |
2 | | in a corporate vendor or alternate payee) has been |
3 | | transferred by an individual who is terminated or |
4 | | barred from participating as a vendor or is prohibited |
5 | | or revoked as an alternate payee to the individual's |
6 | | spouse, child, brother, sister, parent, grandparent, |
7 | | grandchild, uncle, aunt, niece, nephew, cousin, or |
8 | | relative by marriage. |
9 | | (K) The Illinois Department of Healthcare and Family |
10 | | Services may withhold payments, in whole or in part, to a |
11 | | provider or alternate payee upon receipt of evidence, received |
12 | | from State or federal law enforcement or federal oversight |
13 | | agencies or from the results of a preliminary Department audit |
14 | | and determined by the Department to be credible, that the |
15 | | circumstances giving rise to the need for a withholding of |
16 | | payments may involve fraud or willful misrepresentation under |
17 | | the Illinois Medical Assistance program. The Department shall |
18 | | by rule define what constitutes "credible" evidence for |
19 | | purposes of this subsection. The Department may withhold |
20 | | payments without first notifying the provider or alternate |
21 | | payee of its intention to withhold such payments. A provider or |
22 | | alternate payee may request a reconsideration of payment |
23 | | withholding, and the Department must grant such a request. The |
24 | | Department shall state by rule a process and criteria by which |
25 | | a provider or alternate payee may request full or partial |
26 | | release of payments withheld under this subsection. This |
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1 | | request may be made at any time after the Department first |
2 | | withholds such payments. |
3 | | (a) The Illinois Department must send notice of its
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4 | | withholding of program payments within 5 days of taking |
5 | | such action. The notice must set forth the general |
6 | | allegations as to the nature of the withholding action, but |
7 | | need not disclose any specific information concerning its |
8 | | ongoing investigation. The notice must do all of the |
9 | | following: |
10 | | (1) State that payments are being withheld in
|
11 | | accordance with this subsection. |
12 | | (2) State that the withholding is for a temporary
|
13 | | period, as stated in paragraph (b) of this
subsection, |
14 | | and cite the circumstances under which
withholding |
15 | | will be terminated. |
16 | | (3) Specify, when appropriate, which type or types
|
17 | | of Medicaid claims withholding is effective. |
18 | | (4) Inform the provider or alternate payee of the
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19 | | right to submit written evidence for reconsideration |
20 | | of the withholding by
the Illinois Department. |
21 | | (5) Inform the provider or alternate payee that a |
22 | | written request may be made to the Illinois Department |
23 | | for full or partial release of withheld payments and |
24 | | that such requests may be made at any time after the |
25 | | Department first withholds such payments.
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26 | | (b) All withholding-of-payment actions under this
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1 | | subsection shall be temporary and shall not continue after |
2 | | any of the following: |
3 | | (1) The Illinois Department or the prosecuting
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4 | | authorities determine that there is insufficient
|
5 | | evidence of fraud or willful misrepresentation by the
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6 | | provider or alternate payee. |
7 | | (2) Legal proceedings related to the provider's or
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8 | | alternate payee's alleged fraud, willful
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9 | | misrepresentation, violations of this Act, or
|
10 | | violations of the Illinois Department's administrative
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11 | | rules are completed. |
12 | | (3) The withholding of payments for a period of 3 |
13 | | years.
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14 | | (c) The Illinois Department may adopt all rules |
15 | | necessary
to implement this subsection (K).
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16 | | (L) The Department of Healthcare and Family Services shall |
17 | | not require a practitioner-owned group practice, partnership, |
18 | | or corporation to have a set number of licensed |
19 | | practitioner-owners who are eligible to provide medical |
20 | | services under this Code in order for the practitioner-owned |
21 | | group practice, partnership, or corporation to qualify as an |
22 | | alternate payee under the State's medical assistance program. |
23 | | The Department shall not prohibit a corporate entity that |
24 | | employs health care providers from participating as an |
25 | | alternate payee under the State's medical assistance program if |
26 | | the corporation is organized for the purpose of providing |
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1 | | medical or other health care services. |
2 | | An employer who is eligible to participate in the State's |
3 | | medical assistance program may be designated as an alternate |
4 | | payee by an individual practitioner who is employed by the |
5 | | payee. The employer who qualifies as a payee for more than 4 |
6 | | practitioners and the employer who is not licensed in the same |
7 | | profession as the practitioner in his or her employ who has |
8 | | designated the employer as an alternate payee shall be subject |
9 | | to enhanced screening and verification by the Department. A |
10 | | corporation may be named as an alternate payee. A corporation |
11 | | registered with the Secretary of State to do business in the |
12 | | State of Illinois and whose shares of ownership are not |
13 | | publicly traded in a recognized stock exchange within the |
14 | | United States of America shall be subject to enhanced screening |
15 | | and verification by the Department. |
16 | | (Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
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17 | | Section 99. Effective date. This Act takes effect upon |
18 | | becoming law.
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