Full Text of HB1489 97th General Assembly
HB1489sam001 97TH GENERAL ASSEMBLY | Sen. Ira I. Silverstein Filed: 5/2/2011
| | 09700HB1489sam001 | | LRB097 09341 KTG 54147 a |
|
| 1 | | AMENDMENT TO HOUSE BILL 1489
| 2 | | AMENDMENT NO. ______. Amend House Bill 1489 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 12-4.25 as follows:
| 6 | | (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
| 7 | | Sec. 12-4.25. Medical assistance program; vendor | 8 | | participation.
| 9 | | (A) The Illinois Department may deny, suspend or
terminate | 10 | | the eligibility of any person, firm, corporation, association,
| 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:
| 15 | | (a) Such vendor is not complying with the Department's | 16 | | policy or
rules and regulations, or with the terms and |
| | | 09700HB1489sam001 | - 2 - | LRB097 09341 KTG 54147 a |
|
| 1 | | conditions prescribed by
the Illinois Department in its | 2 | | vendor agreement, which document shall be
developed by the | 3 | | Department as a result of negotiations with each vendor
| 4 | | category, including physicians, hospitals, long term care | 5 | | facilities,
pharmacists, optometrists, podiatrists and | 6 | | dentists setting forth the
terms and conditions applicable | 7 | | to the participation of each vendor
group in the program; | 8 | | or
| 9 | | (b) Such vendor has failed to keep or make available | 10 | | for inspection,
audit or copying, after receiving a written | 11 | | request from the Illinois
Department, such records | 12 | | regarding payments claimed for providing
services. This | 13 | | section does not require vendors to make available
patient | 14 | | records of patients for whom services are not reimbursed | 15 | | under
this Code; or
| 16 | | (c) Such vendor has failed to furnish any information | 17 | | requested by
the Department regarding payments for | 18 | | providing goods or services; or
| 19 | | (d) Such vendor has knowingly made, or caused to be | 20 | | made, any false
statement or representation of a material | 21 | | fact in connection with the
administration of the medical | 22 | | assistance program; or
| 23 | | (e) Such vendor has furnished goods or services to a | 24 | | recipient which
are (1) in excess of his or her needs, (2) | 25 | | harmful to the recipient, or
(3) of grossly inferior | 26 | | quality, all of such determinations to be based
upon |
| | | 09700HB1489sam001 | - 3 - | LRB097 09341 KTG 54147 a |
|
| 1 | | competent medical judgment and evaluations; or
| 2 | | (f) The vendor; a person with management | 3 | | responsibility for a
vendor; an officer or person owning, | 4 | | either directly or indirectly, 5%
or more of the shares of | 5 | | stock or other evidences of ownership in a
corporate | 6 | | vendor; an owner of a sole proprietorship which is a | 7 | | vendor;
or a partner in a partnership which is a vendor, | 8 | | either:
| 9 | | (1) was previously terminated from participation | 10 | | in the Illinois
medical assistance program, or was | 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; or
| 15 | | (2) was a person with management responsibility at | 16 | | the time such vendor was for a vendor
previously | 17 | | terminated from participation in the Illinois medical | 18 | | assistance
program and was found culpable by the | 19 | | Illinois Department for the conduct which was the basis | 20 | | for the vendor's termination , or terminated from | 21 | | participation in a medical assistance program in
| 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
| 26 | | (3) was an officer, or person owning, either |
| | | 09700HB1489sam001 | - 4 - | LRB097 09341 KTG 54147 a |
|
| 1 | | directly or indirectly,
5% or more of the shares of | 2 | | stock or other evidences of ownership in a corporate | 3 | | vendor
at the time such vendor was previously | 4 | | terminated from participation in the Illinois medical | 5 | | assistance
program and was found culpable by the | 6 | | Illinois Department for the conduct which was the basis | 7 | | for the vendor's termination , or terminated from | 8 | | participation in a medical assistance program in
| 9 | | another state that is of the same kind as the program | 10 | | of medical assistance
provided under Article V of this | 11 | | Code,
during the time of conduct which
was the basis | 12 | | for that vendor's termination; or
| 13 | | (4) was an owner of a sole proprietorship or | 14 | | partner of a
partnership at the time such vendor was | 15 | | previously terminated
from participation in the | 16 | | Illinois medical assistance program and was found | 17 | | culpable by the Illinois Department for the conduct | 18 | | which was the basis for the vendor's termination , or | 19 | | terminated
from participation in a medical assistance | 20 | | program in another state that is of
the same kind as | 21 | | the program of medical assistance provided under | 22 | | Article V of
this Code,
during the time of conduct
| 23 | | which was the basis for that vendor's termination; or
| 24 | | (g) The vendor; a person with management | 25 | | responsibility for a
vendor; an officer or person owning, | 26 | | either directly or indirectly, 5%
or more of the shares of |
| | | 09700HB1489sam001 | - 5 - | LRB097 09341 KTG 54147 a |
|
| 1 | | stock or other evidences of ownership in a
corporate | 2 | | vendor; an owner of a sole proprietorship which is a | 3 | | vendor;
or a partner in a partnership which is a vendor, | 4 | | either:
| 5 | | (1) has engaged in practices prohibited by | 6 | | applicable federal or
State law or regulation relating | 7 | | to the medical assistance program; or
| 8 | | (2) was a person with management responsibility | 9 | | for a vendor at the
time that such vendor engaged in | 10 | | practices prohibited by applicable
federal or State | 11 | | law or regulation relating to the medical assistance
| 12 | | program and was found culpable by the Illinois | 13 | | Department for such practices ; or
| 14 | | (3) was an officer, or person owning, either | 15 | | directly or indirectly,
5% or more of the shares of | 16 | | stock or other evidences of ownership in a
vendor at | 17 | | the time such vendor engaged in practices prohibited by
| 18 | | applicable federal or State law or regulation relating | 19 | | to the medical
assistance program and was found | 20 | | culpable by the Illinois Department for such | 21 | | practices ; or
| 22 | | (4) was an owner of a sole proprietorship or | 23 | | partner of a
partnership which was a vendor at the time | 24 | | such vendor engaged in
practices prohibited by | 25 | | applicable federal or State law or regulation
relating | 26 | | to the medical assistance program and was found |
| | | 09700HB1489sam001 | - 6 - | LRB097 09341 KTG 54147 a |
|
| 1 | | culpable by the Illinois Department for such | 2 | | practices ; or
| 3 | | (h) The direct or indirect ownership of the vendor | 4 | | (including the
ownership of a vendor that is a sole | 5 | | proprietorship, a partner's interest in a
vendor that is a | 6 | | partnership, or ownership of 5% or more of the shares of | 7 | | stock
or other
evidences of ownership in a corporate | 8 | | vendor) has been transferred by an
individual who is | 9 | | terminated or barred from participating as a vendor to the
| 10 | | individual's spouse, child, brother, sister, parent, | 11 | | grandparent, grandchild,
uncle, aunt, niece, nephew, | 12 | | cousin, or relative by marriage.
| 13 | | (A-2) Notwithstanding the provisions of paragraph (A), and | 14 | | in addition thereto, any person with management responsibility | 15 | | for a vendor; an officer or person owning, either directly or | 16 | | indirectly, 5% or more of the shares of stock or other | 17 | | evidences of ownership in a corporate vendor; an owner of a | 18 | | sole proprietorship which is a vendor; or a partner in a | 19 | | partnership which is a vendor who is found culpable in the | 20 | | vendor's act of willfully failing to keep and maintain, or | 21 | | willfully failing to produce for inspection, audit, or copying, | 22 | | books and records, or willfully failing to furnish any | 23 | | information requested by the Illinois Department regarding | 24 | | payments for providing goods or services, is guilty of a Class | 25 | | A misdemeanor. A second or subsequent violation of this Section | 26 | | shall be punishable as a Class A felony. |
| | | 09700HB1489sam001 | - 7 - | LRB097 09341 KTG 54147 a |
|
| 1 | | (A-3) Any person with management responsibility for a | 2 | | vendor; an officer or person owning, either directly or | 3 | | indirectly, 5% or more of the shares of stock or other | 4 | | evidences of ownership in a corporate vendor; an owner of a | 5 | | sole proprietorship which is a vendor; or a partner in a | 6 | | partnership which is a vendor who is found culpable in the | 7 | | vendor's act of willfully filing or willfully causing to be | 8 | | filed any false statement or representation of a material fact | 9 | | in connection with the administration of the medical assistance | 10 | | program, is guilty of a Class A misdemeanor. | 11 | | (A-5) The Illinois Department may deny, suspend, or | 12 | | terminate the
eligibility
of any person, firm, corporation, | 13 | | association, agency, institution, or other
legal entity to | 14 | | participate as a vendor of goods or services to recipients
| 15 | | under the medical assistance program under Article V if, after | 16 | | reasonable
notice and opportunity for a hearing, the Illinois | 17 | | Department finds that the
vendor; a person with management | 18 | | responsibility for a vendor; an officer or
person owning, | 19 | | either directly or indirectly, 5% or more of the shares of | 20 | | stock
or other evidences of ownership in a corporate vendor; an | 21 | | owner of a sole
proprietorship that is a vendor; or a partner | 22 | | in a partnership that is a vendor
has been convicted of a | 23 | | felony offense based on fraud or willful
misrepresentation | 24 | | related to any of
the following:
| 25 | | (1) The medical assistance program under Article V of | 26 | | this Code.
|
| | | 09700HB1489sam001 | - 8 - | LRB097 09341 KTG 54147 a |
|
| 1 | | (2) A medical assistance program in another state that | 2 | | is of the same kind
as the program of medical assistance | 3 | | provided under Article V of this Code.
| 4 | | (3) The Medicare program under Title XVIII of the | 5 | | Social Security Act.
| 6 | | (4) The provision of health care services.
| 7 | | (A-10) The Illinois Department may deny, suspend, or | 8 | | terminate the eligibility of any person, firm, corporation, | 9 | | association, agency, institution, or other legal entity to | 10 | | participate as a vendor of goods or services to recipients | 11 | | under the medical assistance program under Article V if, after | 12 | | reasonable notice and opportunity for a hearing, the Illinois | 13 | | Department finds that (i) the vendor, (ii) a person with | 14 | | management responsibility for a vendor, (iii) an officer or | 15 | | person owning, either directly or indirectly, 5% or more of the | 16 | | shares of stock or other evidences of ownership in a corporate | 17 | | vendor, (iv) an owner of a sole proprietorship that is a | 18 | | vendor, or (v) a partner in a partnership that is a vendor has | 19 | | been convicted of a felony offense related to any of the | 20 | | following:
| 21 | | (1) Murder.
| 22 | | (2) A Class X felony under the Criminal Code of 1961.
| 23 | | (B) The Illinois Department shall deny, suspend or | 24 | | terminate the
eligibility of any person, firm, corporation, | 25 | | association, agency,
institution or other legal entity to | 26 | | participate as a vendor of goods or
services to recipients |
| | | 09700HB1489sam001 | - 9 - | LRB097 09341 KTG 54147 a |
|
| 1 | | under the medical assistance program under
Article V:
| 2 | | (1) if such vendor is not properly licensed;
| 3 | | (2) within 30 days of the date when such vendor's | 4 | | professional
license, certification or other authorization | 5 | | has been refused renewal
or has been revoked, suspended or | 6 | | otherwise terminated; or
| 7 | | (3) if such vendor has been convicted of a violation of | 8 | | this Code, as
provided in Article VIIIA.
| 9 | | (C) Upon termination of a vendor of goods or services from
| 10 | | participation in the medical assistance program authorized by | 11 | | this
Article, a person with management responsibility for such | 12 | | vendor during
the time of any conduct which served as the basis | 13 | | for that vendor's
termination and who was found culpable of | 14 | | such conduct by the Illinois Department may be is barred from | 15 | | participation in the medical assistance
program.
| 16 | | Upon termination of a corporate vendor, the officers and | 17 | | persons
owning, directly or indirectly, 5% or more of the | 18 | | shares of stock or
other evidences of ownership in the vendor | 19 | | during the time of any
conduct which served as the basis for | 20 | | that vendor's termination and who were found culpable of such | 21 | | conduct by the Illinois Department may be are
barred from | 22 | | participation in the medical assistance program. A person who
| 23 | | owns, directly or indirectly, 5% or more of the shares of stock | 24 | | or other
evidences of ownership in a terminated corporate | 25 | | vendor may not transfer his or
her ownership interest in that | 26 | | vendor to his or her spouse, child, brother,
sister, parent, |
| | | 09700HB1489sam001 | - 10 - | LRB097 09341 KTG 54147 a |
|
| 1 | | grandparent, grandchild, uncle, aunt, niece, nephew, cousin, | 2 | | or
relative by marriage.
| 3 | | Upon termination of a sole proprietorship or partnership, | 4 | | the owner
or partners during the time of any conduct which | 5 | | served as the basis for
that vendor's termination and who were | 6 | | found culpable of such conduct by the Illinois Department may | 7 | | be are barred from participation in the medical
assistance | 8 | | program. The owner of a terminated vendor that is a sole
| 9 | | proprietorship, and a partner in a terminated vendor that is a | 10 | | partnership, may
not transfer his or her ownership or | 11 | | partnership interest in that vendor to his
or her spouse, | 12 | | child, brother, sister, parent, grandparent, grandchild, | 13 | | uncle,
aunt, niece, nephew, cousin, or relative by marriage.
| 14 | | Rules adopted by the Illinois Department to implement these
| 15 | | provisions shall specifically include a definition of the term
| 16 | | "management responsibility" as used in this Section. Such | 17 | | definition
shall include, but not be limited to, typical job | 18 | | titles, and duties and
descriptions which will be considered as | 19 | | within the definition of
individuals with management | 20 | | responsibility for a provider. Prior to barring any individuals | 21 | | from participation in the medical assistance program pursuant | 22 | | to this Section, such individuals shall have a right to a | 23 | | hearing on the individual's culpability for the conduct which | 24 | | served as the basis for the vendor's termination. In | 25 | | determining culpability, the Department shall consider the | 26 | | nature, circumstances, extent, and gravity of the conduct which |
| | | 09700HB1489sam001 | - 11 - | LRB097 09341 KTG 54147 a |
|
| 1 | | served as the basis for the vendor's termination and the degree | 2 | | of the individual's participation in such conduct, including | 3 | | whether there was an intent to defraud the program or other | 4 | | criminal conduct, and the individual's history of prior | 5 | | offenses, its effect on the individual's ability to continue | 6 | | business, and such other matters as justice may require. Errors | 7 | | in record keeping and billing alone shall not be a sufficient | 8 | | basis to bar an individual from the medical assistance program.
| 9 | | (D) If a vendor has been suspended from the medical | 10 | | assistance
program under Article V of the Code, the Director | 11 | | may require that such
vendor correct any deficiencies which | 12 | | served as the basis for the
suspension. The Director shall | 13 | | specify in the suspension order a specific
period of time, | 14 | | which shall not exceed one year from the date of the
order, | 15 | | during which a suspended vendor shall not be eligible to
| 16 | | participate. At the conclusion of the period of suspension the | 17 | | Director
shall reinstate such vendor, unless he finds that such | 18 | | vendor has not
corrected deficiencies upon which the suspension | 19 | | was based.
| 20 | | If a vendor has been terminated from the medical assistance | 21 | | program
under Article V, such vendor shall be barred from | 22 | | participation for at
least one year, except that if a vendor | 23 | | has been terminated based on a
conviction of a
violation of | 24 | | Article VIIIA or a conviction of a felony based on fraud or a
| 25 | | willful misrepresentation related to (i) the medical | 26 | | assistance program under
Article V, (ii) a medical assistance |
| | | 09700HB1489sam001 | - 12 - | LRB097 09341 KTG 54147 a |
|
| 1 | | program in another state that is of the
kind provided under | 2 | | Article V, (iii) the Medicare program under Title XVIII of
the | 3 | | Social Security Act, or (iv) the provision of health care | 4 | | services, then
the vendor shall be barred from participation | 5 | | for 5 years or for the length of
the vendor's sentence for that | 6 | | conviction, whichever is longer. At the end of
one year a | 7 | | vendor who has been terminated
may apply for reinstatement to | 8 | | the program. Upon proper application to
be reinstated such | 9 | | vendor may be deemed eligible by the Director
providing that | 10 | | such vendor meets the requirements for eligibility under
this | 11 | | Code. If such vendor is deemed not eligible for
reinstatement, | 12 | | he
shall be barred from again applying for reinstatement for | 13 | | one year from the
date his application for reinstatement is | 14 | | denied. An individual who is a person with management | 15 | | responsibility for a vendor; an officer or person owning, | 16 | | either directly or indirectly, 5% or more of the shares of | 17 | | stock or other evidences of ownership in a corporate vendor; an | 18 | | owner of a sole proprietorship that is a vendor; or a partner | 19 | | in a partnership that is a vendor, who was previously | 20 | | terminated prior to the effective date of this amendatory Act | 21 | | of the 97th General Assembly, may apply for reinstatement to | 22 | | the program and the Department shall hold a hearing to | 23 | | determine the individual's culpability in the conduct that | 24 | | resulted in the vendor's termination. If the Director | 25 | | determines that the individual was not culpable for the conduct | 26 | | which served as the basis for the vendor's termination, the |
| | | 09700HB1489sam001 | - 13 - | LRB097 09341 KTG 54147 a |
|
| 1 | | individual shall be reinstated to the program.
| 2 | | A vendor whose termination from participation in the | 3 | | Illinois medical
assistance program under Article V was based | 4 | | solely on an action by a
governmental entity other than the | 5 | | Illinois Department may, upon reinstatement
by that | 6 | | governmental entity or upon reversal of the termination, apply | 7 | | for
rescission of the termination from participation in the | 8 | | Illinois medical
assistance program. Upon proper application | 9 | | for rescission, the vendor may be
deemed eligible by the | 10 | | Director if the vendor meets the requirements for
eligibility | 11 | | under this Code.
| 12 | | If a vendor has been terminated and reinstated to the | 13 | | medical assistance
program under Article V and the vendor is | 14 | | terminated a second or subsequent
time from the medical | 15 | | assistance program, the vendor shall be barred from
| 16 | | participation for at least 2 years, except that if a vendor has | 17 | | been
terminated a second time based on a
conviction of a | 18 | | violation of Article VIIIA or a conviction of a felony based on
| 19 | | fraud or a willful misrepresentation related to (i) the medical | 20 | | assistance
program under Article V, (ii) a medical assistance | 21 | | program in another state
that is of the kind provided under | 22 | | Article V, (iii) the Medicare program under
Title XVIII of the | 23 | | Social Security Act, or (iv) the provision of health care
| 24 | | services, then the vendor shall be barred from participation | 25 | | for life. At
the end of 2 years, a vendor who has
been | 26 | | terminated may apply for reinstatement to the program. Upon |
| | | 09700HB1489sam001 | - 14 - | LRB097 09341 KTG 54147 a |
|
| 1 | | application
to be reinstated, the vendor may be deemed eligible | 2 | | if the vendor meets the
requirements for eligibility under this | 3 | | Code. If the vendor is deemed not
eligible for reinstatement, | 4 | | the vendor shall be barred from again applying for
| 5 | | reinstatement for 2 years from the date the vendor's | 6 | | application for
reinstatement is denied.
| 7 | | (E) The Illinois Department may recover money improperly or
| 8 | | erroneously paid, or overpayments, either by setoff, crediting | 9 | | against
future billings or by requiring direct repayment to the | 10 | | Illinois
Department.
| 11 | | If the Illinois Department establishes through an | 12 | | administrative
hearing that the overpayments resulted from the | 13 | | vendor
or alternate payee willfully making, or causing to be | 14 | | made, a false statement or
misrepresentation of a material fact | 15 | | in connection with billings and payments
under the medical | 16 | | assistance program under Article V, the Department may
recover | 17 | | interest on the amount of the overpayments at the rate of 5% | 18 | | per annum.
For purposes of this paragraph,
"willfully" means | 19 | | that a person makes a statement or representation with
actual | 20 | | knowledge that it was false, or makes a statement or | 21 | | representation with
knowledge of facts or information that | 22 | | would cause one to be aware that
the statement or | 23 | | representation was false when made.
| 24 | | (F) The Illinois Department may withhold payments to any | 25 | | vendor
or alternate payee during the pendency of any proceeding | 26 | | under this Section. The Illinois Department shall
state by rule |
| | | 09700HB1489sam001 | - 15 - | LRB097 09341 KTG 54147 a |
|
| 1 | | with as much specificity as practicable the conditions
under | 2 | | which payments will not be withheld during the pendency of any
| 3 | | proceeding under this Section and shall provide the vendor with | 4 | | a detail of the payments being withheld . Payments may be denied | 5 | | for bills
submitted with service dates occurring during the | 6 | | pendency of a
proceeding where the final administrative | 7 | | decision is to terminate
eligibility to participate in the | 8 | | medical assistance program. If the final administrative | 9 | | decision is to allow the vendor to continue to participate in | 10 | | the medical assistance program, the Department shall release to | 11 | | the vendor or the alternate payee all withheld payments, | 12 | | including payments for bills submitted with service dates | 13 | | occurring during the pendency of the proceeding. The
Illinois | 14 | | Department shall state by rule with as much specificity as
| 15 | | practicable the conditions under which payments will not be | 16 | | denied for
such bills.
The Illinois
Department shall state by | 17 | | rule a process and criteria by
which a vendor or alternate | 18 | | payee may request full or partial release of payments withheld | 19 | | under
this subsection. The Department must complete a | 20 | | proceeding under this Section
in a timely manner.
| 21 | | (F-5) The Illinois Department may temporarily withhold | 22 | | payments to
a vendor or alternate payee if any of the following | 23 | | individuals have been indicted or
otherwise charged under a law | 24 | | of the United States or this or any other state
with a felony | 25 | | offense that is based on alleged fraud or willful
| 26 | | misrepresentation on the part of the individual related to (i) |
| | | 09700HB1489sam001 | - 16 - | LRB097 09341 KTG 54147 a |
|
| 1 | | the medical
assistance program under Article V of this Code, | 2 | | (ii) a medical assistance
program provided in another state | 3 | | which is of the kind provided under
Article V of this Code, | 4 | | (iii) the Medicare program under Title XVIII of the
Social | 5 | | Security Act, or (iv) the provision of health care services:
| 6 | | (1) If the vendor or alternate payee is a corporation: | 7 | | an officer of the corporation
or an individual who owns, | 8 | | either directly or indirectly, 5% or more
of the shares of | 9 | | stock or other evidence of ownership of the
corporation.
| 10 | | (2) If the vendor is a sole proprietorship: the owner | 11 | | of the sole
proprietorship.
| 12 | | (3) If the vendor or alternate payee is a partnership: | 13 | | a partner in the partnership.
| 14 | | (4) If the vendor or alternate payee is any other | 15 | | business entity authorized by law
to transact business in | 16 | | this State: an officer of the entity or an
individual who | 17 | | owns, either directly or indirectly, 5% or more of the
| 18 | | evidences of ownership of the entity.
| 19 | | If the Illinois Department withholds payments to a vendor | 20 | | or alternate payee under this
subsection, the Department shall | 21 | | not release those payments to the vendor
or alternate payee
| 22 | | while any criminal proceeding related to the indictment or | 23 | | charge is pending
unless the Department determines that there | 24 | | is good cause to release the
payments before completion of the | 25 | | proceeding. If the indictment or charge
results in the | 26 | | individual's conviction, the Illinois Department shall retain
|
| | | 09700HB1489sam001 | - 17 - | LRB097 09341 KTG 54147 a |
|
| 1 | | all withheld
payments, which shall be considered forfeited to | 2 | | the Department. If the
indictment or charge does not result in | 3 | | the individual's conviction, the
Illinois Department
shall | 4 | | release to the vendor or alternate payee all withheld payments.
| 5 | | (G) The provisions of the Administrative Review Law, as now | 6 | | or hereafter
amended, and the rules adopted pursuant
thereto, | 7 | | shall apply to and govern all proceedings for the judicial
| 8 | | review of final administrative decisions of the Illinois | 9 | | Department
under this Section. The term "administrative | 10 | | decision" is defined as in
Section 3-101 of the Code of Civil | 11 | | Procedure.
| 12 | | (G-5) Non-emergency transportation.
| 13 | | (1) (Blank). Notwithstanding any other provision in | 14 | | this Section, for non-emergency
transportation vendors, | 15 | | the Department may terminate the vendor from
participation | 16 | | in the medical assistance program prior
to an evidentiary | 17 | | hearing but after reasonable notice and opportunity to
| 18 | | respond as established by the Department by rule.
| 19 | | (2) Vendors of non-emergency medical transportation | 20 | | services, as defined
by the Department by rule, shall | 21 | | submit to a fingerprint-based criminal
background check on | 22 | | current and future information available in the State
| 23 | | system and current information available through the | 24 | | Federal Bureau of
Investigation's system by submitting all | 25 | | necessary fees and information in the
form and manner
| 26 | | prescribed by the Department of State Police. The following |
| | | 09700HB1489sam001 | - 18 - | LRB097 09341 KTG 54147 a |
|
| 1 | | individuals shall
be subject to the check:
| 2 | | (A) In the case of a vendor that is a corporation, | 3 | | every shareholder
who owns, directly or indirectly, 5% | 4 | | or more of the outstanding shares of
the corporation.
| 5 | | (B) In the case of a vendor that is a partnership, | 6 | | every partner.
| 7 | | (C) In the case of a vendor that is a sole | 8 | | proprietorship, the sole
proprietor.
| 9 | | (D) Each officer or manager of the vendor.
| 10 | | Each such vendor shall be responsible for payment of | 11 | | the cost of the
criminal background check.
| 12 | | (3) Vendors of non-emergency medical transportation | 13 | | services may be
required to post a surety bond. The | 14 | | Department shall establish, by rule, the
criteria and | 15 | | requirements for determining when a surety bond must be | 16 | | posted and
the value of the bond.
| 17 | | (4) The Department, or its agents, may refuse to accept | 18 | | requests for
non-emergency transportation authorizations, | 19 | | including prior-approval and
post-approval requests, for a | 20 | | specific non-emergency transportation vendor if:
| 21 | | (A) the Department has initiated a notice of | 22 | | termination of the
vendor from participation in the | 23 | | medical assistance program; or
| 24 | | (B) the Department has issued notification of its | 25 | | withholding of
payments pursuant to subsection (F-5) | 26 | | of this Section; or
|
| | | 09700HB1489sam001 | - 19 - | LRB097 09341 KTG 54147 a |
|
| 1 | | (C) the Department has issued a notification of its | 2 | | withholding of
payments due to reliable evidence of | 3 | | fraud or willful misrepresentation
pending | 4 | | investigation.
| 5 | | (H) Nothing contained in this Code shall in any way limit | 6 | | or
otherwise impair the authority or power of any State agency | 7 | | responsible
for licensing of vendors.
| 8 | | (I) Based on a finding of noncompliance on the part of a | 9 | | nursing home with
any requirement for certification under Title | 10 | | XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et | 11 | | seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department | 12 | | may impose one or more of the following remedies after
notice | 13 | | to the facility:
| 14 | | (1) Termination of the provider agreement.
| 15 | | (2) Temporary management.
| 16 | | (3) Denial of payment for new admissions.
| 17 | | (4) Civil money penalties.
| 18 | | (5) Closure of the facility in emergency situations or | 19 | | transfer of
residents, or both.
| 20 | | (6) State monitoring.
| 21 | | (7) Denial of all payments when the Health Care Finance | 22 | | Administration has
imposed this sanction.
| 23 | | The Illinois Department shall by rule establish criteria | 24 | | governing continued
payments to a nursing facility subsequent | 25 | | to termination of the facility's
provider agreement if, in the | 26 | | sole discretion of the Illinois Department,
circumstances |
| | | 09700HB1489sam001 | - 20 - | LRB097 09341 KTG 54147 a |
|
| 1 | | affecting the health, safety, and welfare of the facility's
| 2 | | residents require those continued payments. The Illinois | 3 | | Department may
condition those continued payments on the | 4 | | appointment of temporary management,
sale of the facility to | 5 | | new owners or operators, or other
arrangements that the | 6 | | Illinois Department determines best serve the needs of
the | 7 | | facility's residents.
| 8 | | Except in the case of a facility that has a right to a | 9 | | hearing on the finding
of noncompliance before an agency of the | 10 | | federal government, a facility may
request a hearing before a | 11 | | State agency on any finding of noncompliance within
60 days | 12 | | after the notice of the intent to impose a remedy. Except in | 13 | | the case
of civil money penalties, a request for a hearing | 14 | | shall not delay imposition of
the penalty. The choice of | 15 | | remedies is not appealable at a hearing. The level
of | 16 | | noncompliance may be challenged only in the case of a civil | 17 | | money penalty.
The Illinois Department shall provide by rule | 18 | | for the State agency that will
conduct the evidentiary | 19 | | hearings.
| 20 | | The Illinois Department may collect interest on unpaid | 21 | | civil money penalties.
| 22 | | The Illinois Department may adopt all rules necessary to | 23 | | implement this
subsection (I).
| 24 | | (J) The Illinois Department, by rule, may permit individual | 25 | | practitioners to designate that Department payments that may be | 26 | | due the practitioner be made to an alternate payee or alternate |
| | | 09700HB1489sam001 | - 21 - | LRB097 09341 KTG 54147 a |
|
| 1 | | payees. | 2 | | (a) Such alternate payee or alternate payees shall be | 3 | | required to register as an alternate payee in the Medical | 4 | | Assistance Program with the Illinois Department. | 5 | | (b) If a practitioner designates an alternate payee, | 6 | | the alternate payee and practitioner shall be jointly and | 7 | | severally liable to the Department for payments made to the | 8 | | alternate payee. Pursuant to subsection (E) of this | 9 | | Section, any Department action to recover money or | 10 | | overpayments from an alternate payee shall be subject to an | 11 | | administrative hearing. | 12 | | (c) Registration as an alternate payee or alternate | 13 | | payees in the Illinois Medical Assistance Program shall be | 14 | | conditional. At any time, the Illinois Department may deny | 15 | | or cancel any alternate payee's registration in the | 16 | | Illinois Medical Assistance Program without cause. Any | 17 | | such denial or cancellation is not subject to an | 18 | | administrative hearing. | 19 | | (d) The Illinois Department may seek a revocation of | 20 | | any alternate payee, and all owners, officers, and | 21 | | individuals with management responsibility for such | 22 | | alternate payee shall be permanently prohibited from | 23 | | participating as an owner, an officer, or an individual | 24 | | with management responsibility with an alternate payee in | 25 | | the Illinois Medical Assistance Program, if after | 26 | | reasonable notice and opportunity for a hearing the |
| | | 09700HB1489sam001 | - 22 - | LRB097 09341 KTG 54147 a |
|
| 1 | | Illinois Department finds that: | 2 | | (1) the alternate payee is not complying with the | 3 | | Department's policy or rules and regulations, or with | 4 | | the terms and conditions prescribed by the Illinois | 5 | | Department in its alternate payee registration | 6 | | agreement; or | 7 | | (2) the alternate payee has failed to keep or make | 8 | | available for inspection, audit, or copying, after | 9 | | receiving a written request from the Illinois | 10 | | Department, such records regarding payments claimed as | 11 | | an alternate payee; or | 12 | | (3) the alternate payee has failed to furnish any | 13 | | information requested by the Illinois Department | 14 | | regarding payments claimed as an alternate payee; or | 15 | | (4) the alternate payee has knowingly made, or | 16 | | caused to be made, any false statement or | 17 | | representation of a material fact in connection with | 18 | | the administration of the Illinois Medical Assistance | 19 | | Program; or | 20 | | (5) the alternate payee, a person with management | 21 | | responsibility for an alternate payee, an officer or | 22 | | person owning, either directly or indirectly, 5% or | 23 | | more of the shares of stock or other evidences of | 24 | | ownership in a corporate alternate payee, or a partner | 25 | | in a partnership which is an alternate payee: | 26 | | (a) was previously terminated from |
| | | 09700HB1489sam001 | - 23 - | LRB097 09341 KTG 54147 a |
|
| 1 | | participation as a vendor in the Illinois Medical | 2 | | Assistance Program, or was previously revoked as | 3 | | an alternate payee in the Illinois Medical | 4 | | Assistance Program, or was terminated from | 5 | | participation as a vendor in a medical assistance | 6 | | program in another state that is of the same kind | 7 | | as the program of medical assistance provided | 8 | | under Article V of this Code; or | 9 | | (b) was a person with management | 10 | | responsibility for a vendor at the time the vendor | 11 | | was previously terminated from participation as a | 12 | | vendor in the Illinois Medical Assistance Program | 13 | | and was found culpable by the Illinois Department | 14 | | for the conduct which was the basis for the | 15 | | vendor's termination , or was previously revoked as | 16 | | an alternate payee in the Illinois Medical | 17 | | Assistance Program, or was terminated from | 18 | | participation as a vendor in a medical assistance | 19 | | program in another state that is of the same kind | 20 | | as the program of medical assistance provided | 21 | | under Article V of this Code, during the time of | 22 | | conduct which was the basis for that vendor's | 23 | | termination or alternate payee's revocation; or | 24 | | (c) 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 |
| | | 09700HB1489sam001 | - 24 - | LRB097 09341 KTG 54147 a |
|
| 1 | | corporate vendor at the time the vendor was | 2 | | previously terminated from participation as a | 3 | | vendor in the Illinois Medical Assistance Program | 4 | | and was found culpable by the Illinois Department | 5 | | for the conduct which was the basis for the | 6 | | vendor's termination , or was previously revoked as | 7 | | an alternate payee in the Illinois Medical | 8 | | Assistance Program, or was terminated from | 9 | | participation as a vendor in a medical assistance | 10 | | program in another state that is of the same kind | 11 | | as the program of medical assistance provided | 12 | | under Article V of this Code, during the time of | 13 | | conduct which was the basis for that vendor's | 14 | | termination; or | 15 | | (d) was an owner of a sole proprietorship or | 16 | | partner in a partnership at the time the vendor was | 17 | | previously terminated from participation as a | 18 | | vendor in the Illinois Medical Assistance Program | 19 | | and was found culpable by the Illinois Department | 20 | | for the conduct which was the basis for the | 21 | | vendor's termination , or was previously revoked as | 22 | | an alternate payee in the Illinois Medical | 23 | | Assistance Program, or was terminated from | 24 | | participation as a vendor in a medical assistance | 25 | | program in another state that is of the same kind | 26 | | as the program of medical assistance provided |
| | | 09700HB1489sam001 | - 25 - | LRB097 09341 KTG 54147 a |
|
| 1 | | under Article V of this Code, during the time of | 2 | | conduct which was the basis for that vendor's | 3 | | termination or alternate payee's revocation; or | 4 | | (6) the alternate payee, a person with management | 5 | | responsibility for an alternate payee, an officer or | 6 | | person owning, either directly or indirectly, 5% or | 7 | | more of the shares of stock or other evidences of | 8 | | ownership in a corporate alternate payee, or a partner | 9 | | in a partnership which is an alternate payee: | 10 | | (a) has engaged in conduct prohibited by | 11 | | applicable federal or State law or regulation | 12 | | relating to the Illinois Medical Assistance | 13 | | Program; or | 14 | | (b) was a person with management | 15 | | responsibility for a vendor or alternate payee at | 16 | | the time that the vendor or alternate payee engaged | 17 | | in practices prohibited by applicable federal or | 18 | | State law or regulation relating to the Illinois | 19 | | Medical Assistance Program and was found culpable | 20 | | by the Illinois Department for the conduct which | 21 | | was the basis for the vendor's termination ; or | 22 | | (c) was an officer, or person owning, either | 23 | | directly or indirectly, 5% or more of the shares of | 24 | | stock or other evidences of ownership in a vendor | 25 | | or alternate payee at the time such vendor or | 26 | | alternate payee engaged in practices prohibited by |
| | | 09700HB1489sam001 | - 26 - | LRB097 09341 KTG 54147 a |
|
| 1 | | applicable federal or State law or regulation | 2 | | relating to the Illinois Medical Assistance | 3 | | Program and was found culpable by the Illinois | 4 | | Department for the conduct which was the basis for | 5 | | the vendor's termination ; or | 6 | | (d) was an owner of a sole proprietorship or | 7 | | partner in a partnership which was a vendor or | 8 | | alternate payee at the time such vendor or | 9 | | alternate payee engaged in practices prohibited by | 10 | | applicable federal or State law or regulation | 11 | | relating to the Illinois Medical Assistance | 12 | | Program and was found culpable by the Illinois | 13 | | Department for the conduct which was the basis for | 14 | | the vendor's termination ; or | 15 | | (7) the direct or indirect ownership of the vendor | 16 | | or alternate payee (including the ownership of a vendor | 17 | | or alternate payee that is a partner's interest in a | 18 | | vendor or alternate payee, or ownership of 5% or more | 19 | | of the shares of stock or other evidences of ownership | 20 | | in a corporate vendor or alternate payee) has been | 21 | | transferred by an individual who is terminated or | 22 | | barred from participating as a vendor or is prohibited | 23 | | or revoked as an alternate payee to the individual's | 24 | | spouse, child, brother, sister, parent, grandparent, | 25 | | grandchild, uncle, aunt, niece, nephew, cousin, or | 26 | | relative by marriage. |
| | | 09700HB1489sam001 | - 27 - | LRB097 09341 KTG 54147 a |
|
| 1 | | (K) The Illinois Department of Healthcare and Family | 2 | | Services may withhold payments, in whole or in part, to a | 3 | | provider or alternate payee upon receipt of evidence, received | 4 | | from State or federal law enforcement or federal oversight | 5 | | agencies or from the results of a preliminary Department audit | 6 | | and determined by the Department to be credible, that the | 7 | | circumstances giving rise to the need for a withholding of | 8 | | payments may involve fraud or willful misrepresentation under | 9 | | the Illinois Medical Assistance program. The Department shall | 10 | | by rule define what constitutes "credible" evidence for | 11 | | purposes of this subsection. The Department may withhold | 12 | | payments without first notifying the provider or alternate | 13 | | payee of its intention to withhold such payments. A provider or | 14 | | alternate payee may request a reconsideration of payment | 15 | | withholding, and the Department must grant such a request. The | 16 | | Department shall state by rule a process and criteria by which | 17 | | a provider or alternate payee may request full or partial | 18 | | release of payments withheld under this subsection. This | 19 | | request may be made at any time after the Department first | 20 | | withholds such payments. | 21 | | (a) The Illinois Department must send notice of its
| 22 | | withholding of program payments within 5 days of taking | 23 | | such action. The notice must set forth the general | 24 | | allegations as to the nature of the withholding action, but | 25 | | need not disclose any specific information concerning its | 26 | | ongoing investigation. The notice must do all of the |
| | | 09700HB1489sam001 | - 28 - | LRB097 09341 KTG 54147 a |
|
| 1 | | following: | 2 | | (1) State that payments are being withheld in
| 3 | | accordance with this subsection. | 4 | | (2) State that the withholding is for a temporary
| 5 | | period, as stated in paragraph (b) of this
subsection, | 6 | | and cite the circumstances under which
withholding | 7 | | will be terminated. | 8 | | (3) Specify, when appropriate, which type or types
| 9 | | of Medicaid claims withholding is effective. | 10 | | (4) Inform the provider or alternate payee of the
| 11 | | right to submit written evidence for reconsideration | 12 | | of the withholding by
the Illinois Department. | 13 | | (5) Inform the provider or alternate payee that a | 14 | | written request may be made to the Illinois Department | 15 | | for full or partial release of withheld payments and | 16 | | that such requests may be made at any time after the | 17 | | Department first withholds such payments.
| 18 | | (b) All withholding-of-payment actions under this
| 19 | | subsection shall be temporary and shall not continue after | 20 | | any of the following: | 21 | | (1) The Illinois Department or the prosecuting
| 22 | | authorities determine that there is insufficient
| 23 | | evidence of fraud or willful misrepresentation by the
| 24 | | provider or alternate payee. | 25 | | (2) Legal proceedings related to the provider's or
| 26 | | alternate payee's alleged fraud, willful
|
| | | 09700HB1489sam001 | - 29 - | LRB097 09341 KTG 54147 a |
|
| 1 | | misrepresentation, violations of this Act, or
| 2 | | violations of the Illinois Department's administrative
| 3 | | rules are completed. | 4 | | (3) The withholding of payments for a period of 3 | 5 | | years.
| 6 | | (c) The Illinois Department may adopt all rules | 7 | | necessary
to implement this subsection (K).
| 8 | | (Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
| 9 | | Section 99. Effective date. This Act takes effect upon | 10 | | becoming law.".
|
|