Full Text of SB3441 97th General Assembly
SB3441eng 97TH GENERAL ASSEMBLY |
| | SB3441 Engrossed | | LRB097 17744 KTG 62959 b |
|
| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 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
| 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; |
| | | SB3441 Engrossed | - 2 - | LRB097 17744 KTG 62959 b |
|
| 1 | | or
| 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
| 9 | | (c) Such vendor has failed to furnish any information | 10 | | requested by
the Department regarding payments for | 11 | | providing goods or services; or
| 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
| 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
| 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, |
| | | SB3441 Engrossed | - 3 - | LRB097 17744 KTG 62959 b |
|
| 1 | | either:
| 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
| 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
| 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
| 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 | | (4) was an owner of a sole proprietorship or |
| | | SB3441 Engrossed | - 4 - | LRB097 17744 KTG 62959 b |
|
| 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
| 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:
| 16 | | (1) has engaged in practices prohibited by | 17 | | applicable federal or
State law or regulation relating | 18 | | to the medical assistance program; or
| 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
| 23 | | program; or
| 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 |
| | | SB3441 Engrossed | - 5 - | LRB097 17744 KTG 62959 b |
|
| 1 | | the time such vendor engaged in practices prohibited by
| 2 | | applicable federal or State law or regulation relating | 3 | | to the medical
assistance program; or
| 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
| 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
| 16 | | individual's spouse, child, brother, sister, parent, | 17 | | grandparent, grandchild,
uncle, aunt, niece, nephew, | 18 | | cousin, or relative by marriage.
| 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
| 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, |
| | | SB3441 Engrossed | - 6 - | LRB097 17744 KTG 62959 b |
|
| 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:
| 7 | | (1) The medical assistance program under Article V of | 8 | | this Code.
| 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.
| 12 | | (3) The Medicare program under Title XVIII of the | 13 | | Social Security Act.
| 14 | | (4) The provision of health care services.
| 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 |
| | | SB3441 Engrossed | - 7 - | LRB097 17744 KTG 62959 b |
|
| 1 | | been convicted of a felony offense related to any of the | 2 | | following:
| 3 | | (1) Murder.
| 4 | | (2) A Class X felony under the Criminal Code of 1961.
| 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:
| 10 | | (1) if such vendor is not properly licensed;
| 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
| 15 | | (3) if such vendor has been convicted of a violation of | 16 | | this Code, as
provided in Article VIIIA.
| 17 | | (C) Upon termination of a vendor of goods or services from
| 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.
| 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 |
| | | SB3441 Engrossed | - 8 - | LRB097 17744 KTG 62959 b |
|
| 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
| 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.
| 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.
| 19 | | Rules adopted by the Illinois Department to implement these
| 20 | | provisions shall specifically include a definition of the term
| 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.
| 26 | | (D) If a vendor has been suspended from the medical |
| | | SB3441 Engrossed | - 9 - | LRB097 17744 KTG 62959 b |
|
| 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
| 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.
| 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
| 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 |
| | | SB3441 Engrossed | - 10 - | LRB097 17744 KTG 62959 b |
|
| 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.
| 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.
| 16 | | If a vendor has been terminated and reinstated to the | 17 | | medical assistance
program under Article V and the vendor is | 18 | | terminated a second or subsequent
time from the medical | 19 | | assistance program, the vendor shall be barred from
| 20 | | participation for at least 2 years, except that if a vendor 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
| 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 |
| | | SB3441 Engrossed | - 11 - | LRB097 17744 KTG 62959 b |
|
| 1 | | Social Security Act, or (iv) the provision of health care
| 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
| 9 | | reinstatement for 2 years from the date the vendor's | 10 | | application for
reinstatement is denied.
| 11 | | (E) The Illinois Department may recover money improperly or
| 12 | | erroneously paid, or overpayments, either by setoff, crediting | 13 | | against
future billings or by requiring direct repayment to the | 14 | | Illinois
Department.
| 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 |
| | | SB3441 Engrossed | - 12 - | LRB097 17744 KTG 62959 b |
|
| 1 | | representation was false when made.
| 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
| 7 | | proceeding under this Section. Payments may be denied for bills
| 8 | | submitted with service dates occurring during the pendency of a
| 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
| 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.
| 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
| 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, |
| | | SB3441 Engrossed | - 13 - | LRB097 17744 KTG 62959 b |
|
| 1 | | (iii) the Medicare program under Title XVIII of the
Social | 2 | | Security Act, or (iv) the provision of health care services:
| 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.
| 7 | | (2) If the vendor is a sole proprietorship: the owner | 8 | | of the sole
proprietorship.
| 9 | | (3) If the vendor or alternate payee is a partnership: | 10 | | a partner in the partnership.
| 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
| 15 | | evidences of ownership of the entity.
| 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
| 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
| 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 |
| | | SB3441 Engrossed | - 14 - | LRB097 17744 KTG 62959 b |
|
| 1 | | release to the vendor or alternate payee all withheld payments.
| 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
| 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.
| 9 | | (G-5) Non-emergency transportation.
| 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
| 15 | | respond as established by the Department by rule.
| 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
| 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
| 23 | | prescribed by the Department of State Police. The following | 24 | | individuals shall
be subject to the check:
| 25 | | (A) In the case of a vendor that is a corporation, | 26 | | every shareholder
who owns, directly or indirectly, 5% |
| | | SB3441 Engrossed | - 15 - | LRB097 17744 KTG 62959 b |
|
| 1 | | or more of the outstanding shares of
the corporation.
| 2 | | (B) In the case of a vendor that is a partnership, | 3 | | every partner.
| 4 | | (C) In the case of a vendor that is a sole | 5 | | proprietorship, the sole
proprietor.
| 6 | | (D) Each officer or manager of the vendor.
| 7 | | Each such vendor shall be responsible for payment of | 8 | | the cost of the
criminal background check.
| 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.
| 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
| 21 | | (B) the Department has issued notification of its | 22 | | withholding of
payments pursuant to subsection (F-5) | 23 | | of this Section; or
| 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 |
| | | SB3441 Engrossed | - 16 - | LRB097 17744 KTG 62959 b |
|
| 1 | | investigation.
| 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.
| 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:
| 11 | | (1) Termination of the provider agreement.
| 12 | | (2) Temporary management.
| 13 | | (3) Denial of payment for new admissions.
| 14 | | (4) Civil money penalties.
| 15 | | (5) Closure of the facility in emergency situations or | 16 | | transfer of
residents, or both.
| 17 | | (6) State monitoring.
| 18 | | (7) Denial of all payments when the Health Care Finance | 19 | | Administration has
imposed this sanction.
| 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
| 25 | | residents require those continued payments. The Illinois | 26 | | Department may
condition those continued payments on the |
| | | SB3441 Engrossed | - 17 - | LRB097 17744 KTG 62959 b |
|
| 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.
| 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).
| 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 |
| | | SB3441 Engrossed | - 18 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 19 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 20 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 21 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 22 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 23 - | LRB097 17744 KTG 62959 b |
|
| 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 |
| | | SB3441 Engrossed | - 24 - | LRB097 17744 KTG 62959 b |
|
| 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
| 4 | | withholding of program payments within 5 days of taking | 5 | | such action. The notice must set forth the general | 6 | | allegations as to the nature of the withholding action, but | 7 | | need not disclose any specific information concerning its | 8 | | ongoing investigation. The notice must do all of the | 9 | | following: | 10 | | (1) State that payments are being withheld in
| 11 | | accordance with this subsection. | 12 | | (2) State that the withholding is for a temporary
| 13 | | period, as stated in paragraph (b) of this
subsection, | 14 | | and cite the circumstances under which
withholding | 15 | | will be terminated. | 16 | | (3) Specify, when appropriate, which type or types
| 17 | | of Medicaid claims withholding is effective. | 18 | | (4) Inform the provider or alternate payee of the
| 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.
| 26 | | (b) All withholding-of-payment actions under this
|
| | | SB3441 Engrossed | - 25 - | LRB097 17744 KTG 62959 b |
|
| 1 | | subsection shall be temporary and shall not continue after | 2 | | any of the following: | 3 | | (1) The Illinois Department or the prosecuting
| 4 | | authorities determine that there is insufficient
| 5 | | evidence of fraud or willful misrepresentation by the
| 6 | | provider or alternate payee. | 7 | | (2) Legal proceedings related to the provider's or
| 8 | | alternate payee's alleged fraud, willful
| 9 | | misrepresentation, violations of this Act, or
| 10 | | violations of the Illinois Department's administrative
| 11 | | rules are completed. | 12 | | (3) The withholding of payments for a period of 3 | 13 | | years.
| 14 | | (c) The Illinois Department may adopt all rules | 15 | | necessary
to implement this subsection (K).
| 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 |
| | | SB3441 Engrossed | - 26 - | LRB097 17744 KTG 62959 b |
|
| 1 | | medical or other health care services. | 2 | | An employer who is eligible to participate in the State's | 3 | | medical assistance program may be designated as an alternate | 4 | | payee by an individual practitioner who is employed by the | 5 | | payee. The employer who qualifies as a payee for more than 4 | 6 | | practitioners and the employer who is not licensed in the same | 7 | | profession as the practitioner in his or her employ who has | 8 | | designated the employer as an alternate payee shall be subject | 9 | | to enhanced screening and verification by the Department. A | 10 | | corporation may be named as an alternate payee. A corporation | 11 | | registered with the Secretary of State to do business in the | 12 | | State of Illinois and whose shares of ownership are not | 13 | | publicly traded in a recognized stock exchange within the | 14 | | United States of America shall be subject to enhanced screening | 15 | | and verification by the Department. | 16 | | (Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
| 17 | | Section 99. Effective date. This Act takes effect upon | 18 | | becoming law.
|
|