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Public Act 92-0789
SB2225 Enrolled LRB9211341DJgc
AN ACT in relation to public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Sections 5-5 and 12-4.25 as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the
rate of reimbursement for the medical assistance for which
payment will be authorized, and the medical services to be
provided, which may include all or part of the following: (1)
inpatient hospital services; (2) outpatient hospital
services; (3) other laboratory and X-ray services; (4)
skilled nursing home services; (5) physicians' services
whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical
care, or any other type of remedial care furnished by
licensed practitioners; (7) home health care services; (8)
private duty nursing service; (9) clinic services; (10)
dental services; (11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases
of the eye, or by an optometrist, whichever the person may
select; (13) other diagnostic, screening, preventive, and
rehabilitative services; (14) transportation and such other
expenses as may be necessary; (15) medical treatment of
sexual assault survivors, as defined in Section 1a of the
Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault,
including examinations and laboratory tests to discover
evidence which may be used in criminal proceedings arising
from the sexual assault; (16) the diagnosis and treatment of
sickle cell anemia; and (17) any other medical care, and any
other type of remedial care recognized under the laws of this
State, but not including abortions, or induced miscarriages
or premature births, unless, in the opinion of a physician,
such procedures are necessary for the preservation of the
life of the woman seeking such treatment, or except an
induced premature birth intended to produce a live viable
child and such procedure is necessary for the health of the
mother or her unborn child. The Illinois Department, by rule,
shall prohibit any physician from providing medical
assistance to anyone eligible therefor under this Code where
such physician has been found guilty of performing an
abortion procedure in a wilful and wanton manner upon a woman
who was not pregnant at the time such abortion procedure was
performed. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who
rely on treatment by spiritual means alone through prayer for
healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of
payment for any laboratory test authorized under this
Article, that a physician's handwritten signature appear on
the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding
laboratory test order documentation.
The Illinois Department of Public Aid shall provide the
following services to persons eligible for assistance under
this Article who are participating in education, training or
employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
(1) dental services, which shall include but not be
limited to prosthodontics; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
women 35 years of age or older who are eligible for medical
assistance under this Article, as follows: a baseline
mammogram for women 35 to 39 years of age and an annual
mammogram for women 40 years of age or older. All screenings
shall include a physical breast exam, instruction on
self-examination and information regarding the frequency of
self-examination and its value as a preventative tool. As
used in this Section, "low-dose mammography" means the x-ray
examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube,
filter, compression device, image receptor, and cassettes,
with an average radiation exposure delivery of less than one
rad mid-breast, with 2 views for each breast.
Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided
prenatal services and is suspected of drug abuse or is
addicted as defined in the Alcoholism and Other Drug Abuse
and Dependency Act, referral to a local substance abuse
treatment provider licensed by the Department of Human
Services or to a licensed hospital which provides substance
abuse treatment services. The Department of Public Aid shall
assure coverage for the cost of treatment of the drug abuse
or addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free Families with a Future or any comparable program
providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women in
addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Illinois Department of Public Aid nor the
Department of Human Services shall sanction the recipient
solely on the basis of her substance abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this
Article as it shall deem appropriate. In formulating these
regulations the Illinois Department shall consult with and
give substantial weight to the recommendations offered by the
Citizens Assembly/Council on Public Aid. The Department
should seek the advice of formal professional advisory
committees appointed by the Director of the Illinois
Department for the purpose of providing regular advice on
policy and administrative matters, information dissemination
and educational activities for medical and health care
providers, and consistency in procedures to the Illinois
Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to
clients in target areas according to provisions of this
Article and the Illinois Health Finance Reform Act, except
that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and
negotiate financial incentives to encourage the
development of Partnerships and the efficient delivery of
medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating
between service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. The Illinois Department shall require
health care providers to make available, when authorized by
the patient, in writing, the medical records in a timely
fashion to other health care providers who are treating or
serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be
required to maintain and retain business and professional
records sufficient to fully and accurately document the
nature, scope, details and receipt of the health care
provided to persons eligible for medical assistance under
this Code, in accordance with regulations promulgated by the
Illinois Department. The rules and regulations shall require
that proof of the receipt of prescription drugs, dentures,
prosthetic devices and eyeglasses by eligible persons under
this Section accompany each claim for reimbursement submitted
by the dispenser of such medical services. No such claims for
reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois
Department shall have put into effect and shall be operating
a system of post-payment audit and review which shall, on a
sampling basis, be deemed adequate by the Illinois Department
to assure that such drugs, dentures, prosthetic devices and
eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after the
effective date of this amendatory Act of 1984, the Illinois
Department shall establish a current list of acquisition
costs for all prosthetic devices and any other items
recognized as medical equipment and supplies reimbursable
under this Article and shall update such list on a quarterly
basis, except that the acquisition costs of all prescription
drugs shall be updated no less frequently than every 30 days
as required by Section 5-5.12.
The rules and regulations of the Illinois Department
shall require that a written statement including the required
opinion of a physician shall accompany any claim for
reimbursement for abortions, or induced miscarriages or
premature births. This statement shall indicate what
procedures were used in providing such medical services.
The Illinois Department shall require that all dispensers
of medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the
Medical Assistance program established under this Article to
disclose all financial, beneficial, ownership, equity, surety
or other interests in any and all firms, corporations,
partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities
providing any form of health care services in this State
under this Article.
The Illinois Department may require that all dispensers
of medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department
may by rule establish, all inquiries from clients and
attorneys regarding medical bills paid by the Illinois
Department, which inquiries could indicate potential
existence of claims or liens for the Illinois Department.
Enrollment of a vendor that provides non-emergency
medical transportation, defined by the Department by rule,
shall be conditional for 180 days. During that time, the
Department of Public Aid may terminate the vendor's
eligibility to participate in the medical assistance program
without cause. That termination of eligibility is not
subject to the Department's hearing process.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and
prosthetic devices and durable medical equipment. Such rules
shall provide, but not be limited to, the following services:
(1) immediate repair or replacement of such devices by
recipients without medical authorization; and (2) rental,
lease, purchase or lease-purchase of durable medical
equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent
of the recipient's needs, and the requirements and costs for
maintaining such equipment. Such rules shall enable a
recipient to temporarily acquire and use alternative or
substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department. Rules under clause (2)
above shall not provide for purchase or lease-purchase of
durable medical equipment or supplies used for the purpose of
oxygen delivery and respiratory care.
The Department shall execute, relative to the nursing
home prescreening project, written inter-agency agreements
with the Department of Human Services and the Department on
Aging, to effect the following: (i) intake procedures and
common eligibility criteria for those persons who are
receiving non-institutional services; and (ii) the
establishment and development of non-institutional services
in areas of the State where they are not currently available
or are undeveloped.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code. The Illinois Department
shall report regularly the results of the operation of such
systems and programs to the Citizens Assembly/Council on
Public Aid to enable the Committee to ensure, from time to
time, that these programs are effective and meaningful.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision
of the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors;
and
(d) efforts at utilization review and control by
the Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the
General Assembly. The filing of one copy of the report with
the Speaker, one copy with the Minority Leader and one copy
with the Clerk of the House of Representatives, one copy with
the President, one copy with the Minority Leader and one copy
with the Secretary of the Senate, one copy with the
Legislative Research Unit, such additional copies with the
State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of
the State Library Act and one copy with the Citizens
Assembly/Council on Public Aid or its successor shall be
deemed sufficient to comply with this Section.
(Source: P.A. 91-344, eff. 1-1-00; 91-462, eff. 8-6-99;
91-666, eff. 12-22-99; 92-16, eff. 6-28-01; revised
12-13-01.)
(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor
participation.
(A) The Illinois Department may deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, if
after reasonable notice and opportunity for a hearing the
Illinois Department finds:
(a) Such vendor is not complying with the
Department's policy or rules and regulations, or with the
terms and conditions prescribed by the Illinois
Department in its vendor agreement, which document shall
be developed by the Department as a result of
negotiations with each vendor category, including
physicians, hospitals, long term care facilities,
pharmacists, optometrists, podiatrists and dentists
setting forth the terms and conditions applicable to the
participation of each vendor group in the program; or
(b) Such vendor has failed to keep or make
available for inspection, audit or copying, after
receiving a written request from the Illinois Department,
such records regarding payments claimed for providing
services. This section does not require vendors to make
available patient records of patients for whom services
are not reimbursed under this Code; or
(c) Such vendor has failed to furnish any
information requested by the Department regarding
payments for providing goods or services; or
(d) Such vendor has knowingly made, or caused to be
made, any false statement or representation of a material
fact in connection with the administration of the medical
assistance program; or
(e) Such vendor has furnished goods or services to
a recipient which are (1) in excess of his or her needs,
(2) harmful to the recipient, or (3) of grossly inferior
quality, all of such determinations to be based upon
competent medical judgment and evaluations; or
(f) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) was previously terminated from
participation in the Illinois medical assistance
program, or was terminated from participation in a
medical assistance program in another state that is
of the same kind as the program of medical
assistance provided under Article V of this Code; or
(2) was a person with management
responsibility for a vendor previously terminated
from participation in the Illinois medical
assistance program, or terminated from participation
in a medical assistance program in another state
that is of the same kind as the program of medical
assistance provided under Article V of this Code,
during the time of conduct which was the basis for
that vendor's termination; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate
vendor previously terminated from participation in
the Illinois medical assistance program, or
terminated from participation in a medical
assistance program in another state that is of the
same kind as the program of medical assistance
provided under Article V of this Code, during the
time of conduct which was the basis for that
vendor's termination; or
(4) was an owner of a sole proprietorship or
partner of a partnership previously terminated from
participation in the Illinois medical assistance
program, or terminated from participation in a
medical assistance program in another state that is
of the same kind as the program of medical
assistance provided under Article V of this Code,
during the time of conduct which was the basis for
that vendor's termination; or
(g) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) has engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program; or
(2) was a person with management
responsibility for a vendor at the time that such
vendor engaged in practices prohibited by applicable
federal or State law or regulation relating to the
medical assistance program; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a vendor at
the time such vendor engaged in practices prohibited
by applicable federal or State law or regulation
relating to the medical assistance program; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was a vendor at the
time such vendor engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program; or.
(h) The direct or indirect ownership of the vendor
(including the ownership of a vendor that is a sole
proprietorship, a partner's interest in a vendor that is
a partnership, or ownership of 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor) has been transferred by an individual who is
terminated or barred from participating as a vendor to
the individual's spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
(A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V if,
after reasonable notice and opportunity for a hearing, the
Illinois Department finds that the vendor; a person with
management responsibility for a vendor; an officer or person
owning, either directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in a
corporate vendor; an owner of a sole proprietorship that is a
vendor; or a partner in a partnership that is a vendor has
been convicted of a felony offense based on fraud or willful
misrepresentation related to any of the following:
(1) The medical assistance program under Article V
of this Code.
(2) A medical assistance program in another state
that is of the same kind as the program of medical
assistance provided under Article V of this Code.
(3) The Medicare program under Title XVIII of the
Social Security Act.
(4) The provision of health care services.
(B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V:
(1) if such vendor is not properly licensed;
(2) within 30 days of the date when such vendor's
professional license, certification or other
authorization has been refused renewal or has been
revoked, suspended or otherwise terminated; or
(3) if such vendor has been convicted of a
violation of this Code, as provided in Article VIIIA.
(C) Upon termination of a vendor of goods or services
from participation in the medical assistance program
authorized by this Article, a person with management
responsibility for such vendor during the time of any conduct
which served as the basis for that vendor's termination is
barred from participation in the medical assistance program.
Upon termination of a corporate vendor, the officers and
persons owning, directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in the vendor
during the time of any conduct which served as the basis for
that vendor's termination are barred from participation in
the medical assistance program. A person who owns, directly
or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a terminated corporate vendor may
not transfer his or her ownership interest in that vendor to
his or her spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
or relative by marriage.
Upon termination of a sole proprietorship or partnership,
the owner or partners during the time of any conduct which
served as the basis for that vendor's termination are barred
from participation in the medical assistance program. The
owner of a terminated vendor that is a sole proprietorship,
and a partner in a terminated vendor that is a partnership,
may not transfer his or her ownership or partnership interest
in that vendor to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Rules adopted by the Illinois Department to implement
these provisions shall specifically include a definition of
the term "management responsibility" as used in this Section.
Such definition shall include, but not be limited to, typical
job titles, and duties and descriptions which will be
considered as within the definition of individuals with
management responsibility for a provider.
(D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension
the Director shall reinstate such vendor, unless he finds
that such vendor has not corrected deficiencies upon which
the suspension was based.
If a vendor has been terminated from the medical
assistance program under Article V, such vendor shall be
barred from participation for at least one year, except that
if a vendor has been terminated based on a conviction of a
violation of Article VIIIA or a conviction of a felony based
on fraud or a willful misrepresentation related to (i) the
medical assistance program under Article V, (ii) a medical
assistance program in another state that is of the kind
provided under Article V, (iii) the Medicare program under
Title XVIII of the Social Security Act, or (iv) the provision
of health care services, then the vendor shall be barred from
participation for 5 years or for the length of the vendor's
sentence for that conviction, whichever is longer. At the end
of one year a vendor who has been terminated may apply for
reinstatement to the program. Upon proper application to be
reinstated such vendor may be deemed eligible by the Director
providing that such vendor meets the requirements for
eligibility under this Code. If such vendor is deemed not
eligible for reinstatement, he shall be barred from again
applying for reinstatement for one year from the date his
application for reinstatement is denied.
A vendor whose termination from participation in the
Illinois medical assistance program under Article V was based
solely on an action by a governmental entity other than the
Illinois Department may, upon reinstatement by that
governmental entity or upon reversal of the termination,
apply for rescission of the termination from participation in
the Illinois medical assistance program. Upon proper
application for rescission, the vendor may be deemed eligible
by the Director if the vendor meets the requirements for
eligibility under this Code.
If a vendor has been terminated and reinstated to the
medical assistance program under Article V and the vendor is
terminated a second or subsequent time from the medical
assistance program, the vendor shall be barred from
participation for at least 2 years, except that if a vendor
has been terminated a second time based on a conviction of a
violation of Article VIIIA or a conviction of a felony based
on fraud or a willful misrepresentation related to (i) the
medical assistance program under Article V, (ii) a medical
assistance program in another state that is of the kind
provided under Article V, (iii) the Medicare program under
Title XVIII of the Social Security Act, or (iv) the provision
of health care services, then the vendor shall be barred from
participation for life. At the end of 2 years, a vendor who
has been terminated may apply for reinstatement to the
program. Upon application to be reinstated, the vendor may
be deemed eligible if the vendor meets the requirements for
eligibility under this Code. If the vendor is deemed not
eligible for reinstatement, the vendor shall be barred from
again applying for reinstatement for 2 years from the date
the vendor's application for reinstatement is denied.
(E) The Illinois Department may recover money improperly
or erroneously paid, or overpayments, either by setoff,
crediting against future billings or by requiring direct
repayment to the Illinois Department.
If the Department of Public Aid establishes through an
administrative hearing that the overpayments resulted from
the vendor willfully making, or causing to be made, a false
statement or misrepresentation of a material fact in
connection with billings and payments under the medical
assistance program under Article V, the Department may
recover interest on the amount of the overpayments at the
rate of 5% per annum. For purposes of this paragraph,
"willfully" means that a person makes a statement or
representation with actual knowledge that it was false, or
makes a statement or representation with knowledge of facts
or information that would cause one to be aware that the
statement or representation was false when made.
(F) The Illinois Department may withhold payments to any
vendor during the pendency of any proceeding under this
Section except that if a final administrative decision has
not been issued within 120 days of the initiation of such
proceedings, unless delay has been caused by the vendor,
payments can no longer be withheld, provided, however, that
the 120 day limit may be extended if said extension is
mutually agreed to by the Illinois Department and the vendor.
The Illinois Department shall state by rule with as much
specificity as practicable the conditions under which
payments will not be withheld during the pendency of any
proceeding under this Section. Payments may be denied for
bills submitted with service dates occurring during the
pendency of a proceeding where the final administrative
decision is to terminate eligibility to participate in the
medical assistance program. The Illinois Department shall
state by rule with as much specificity as practicable the
conditions under which payments will not be denied for such
bills. The Department of Public Aid shall state by rule a
process and criteria by which a vendor may request full or
partial release of payments withheld under this subsection.
The Department must complete a proceeding under this Section
in a timely manner.
(F-5) The Illinois Department may temporarily withhold
payments to a vendor if any of the following individuals have
been indicted or otherwise charged under a law of the United
States or this or any other state with a felony offense that
is based on alleged fraud or willful misrepresentation on the
part of the individual related to (i) the medical assistance
program under Article V of this Code, (ii) a medical
assistance program provided in another state which is of the
kind provided under Article V of this Code, (iii) the
Medicare program under Title XVIII of the Social Security
Act, or (iv) the provision of health care services:
(1) If the vendor is a corporation: an officer of
the corporation or an individual who owns, either
directly or indirectly, 5% or more of the shares of stock
or other evidence of ownership of the corporation.
(2) If the vendor is a sole proprietorship: the
owner of the sole proprietorship.
(3) If the vendor is a partnership: a partner in
the partnership.
(4) If the vendor is any other business entity
authorized by law to transact business in this State: an
officer of the entity or an individual who owns, either
directly or indirectly, 5% or more of the evidences of
ownership of the entity.
If the Illinois Department withholds payments to a vendor
under this subsection, the Department shall not release those
payments to the vendor while any criminal proceeding related
to the indictment or charge is pending unless the Department
determines that there is good cause to release the payments
before completion of the proceeding. If the indictment or
charge results in the individual's conviction, the Illinois
Department shall retain all withheld payments, which shall be
considered forfeited to the Department. If the indictment or
charge does not result in the individual's conviction, the
Illinois Department shall release to the vendor all withheld
payments.
(G) The provisions of the Administrative Review Law, as
now or hereafter amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the
judicial review of final administrative decisions of the
Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of
the Code of Civil Procedure.
(G-5) Non-emergency transportation.
(1) Notwithstanding any other provision in this
Section, for non-emergency transportation vendors, the
Department may terminate the vendor from participation in
the medical assistance program prior to an evidentiary
hearing but after reasonable notice and opportunity to
respond as established by the Department by rule.
(2) Vendors of non-emergency medical transportation
services, as defined by the Department by rule, shall
submit to a fingerprint-based criminal background check
on current and future information available in the State
system and current information available through the
Federal Bureau of Investigation's system by submitting
all necessary fees and information in the form and manner
prescribed by the Department of State Police. The
following individuals shall be subject to the check:
(A) In the case of a vendor that is a
corporation, every shareholder who owns, directly or
indirectly, 5% or more of the outstanding shares of
the corporation.
(B) In the case of a vendor that is a
partnership, every partner.
(C) In the case of a vendor that is a sole
proprietorship, the sole proprietor.
(D) Each officer or manager of the vendor.
Each such vendor shall be responsible for payment of
the cost of the criminal background check.
(3) Vendors of non-emergency medical transportation
services may be required to post a surety bond. The
Department shall establish, by rule, the criteria and
requirements for determining when a surety bond must be
posted and the value of the bond.
(4) The Department, or its agents, may refuse to
accept requests for non-emergency transportation
authorizations, including prior-approval and
post-approval requests, for a specific non-emergency
transportation vendor if:
(A) the Department has initiated a notice of
termination of the vendor from participation in the
medical assistance program; or
(B) the Department has issued notification of
its withholding of payments pursuant to subsection
(F-5) of this Section; or
(C) the Department has issued a notification
of its withholding of payments due to reliable
evidence of fraud or willful misrepresentation
pending investigation.
(H) Nothing contained in this Code shall in any way
limit or otherwise impair the authority or power of any State
agency responsible for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under
Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
Department may impose one or more of the following remedies
after notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.
(4) Civil money penalties.
(5) Closure of the facility in emergency situations
or transfer of residents, or both.
(6) State monitoring.
(7) Denial of all payments when the Health Care
Finance Administration has imposed this sanction.
The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in
the sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of
the federal government, a facility may request a hearing
before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy.
Except in the case of civil money penalties, a request for a
hearing shall not delay imposition of the penalty. The
choice of remedies is not appealable at a hearing. The level
of noncompliance may be challenged only in the case of a
civil money penalty. The Illinois Department shall provide by
rule for the State agency that will conduct the evidentiary
hearings.
The Illinois Department may collect interest on unpaid
civil money penalties.
The Illinois Department may adopt all rules necessary to
implement this subsection (I).
(Source: P.A. 92-327, eff. 1-1-02; revised 9-18-01.)
Section 99. Effective date. This Act takes effect upon
becoming law.
Passed in the General Assembly May 29, 2002.
Approved August 06, 2002.
Effective August 06, 2002.
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