|
| | 97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012 SB3441 Introduced 2/7/2012, by Sen. David Koehler SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/12-4.25 | from Ch. 23, par. 12-4.25 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Prohibits the Department of Healthcare and Family Services from requiring a practitioner-owned group practice, partnership, or corporation to have a set number of licensed practitioner-owners who are eligible to provide medical services under the Code in order for the practitioner-owned group practice, partnership, or corporation to qualify as an alternate payee under the State's medical assistance program. Provides that the Department shall not prohibit a corporate entity that employs health care providers from participating as an alternate payee under the State's medical assistance program if the corporation is organized for the purpose of providing medical or other health care services. Effective immediately.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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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:
|
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.
|
17 | | The Illinois Department may collect interest on unpaid |
18 | | civil money penalties.
|
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
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11 | | accordance with this subsection. |
12 | | (2) State that the withholding is for a temporary
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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
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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
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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 |