Illinois General Assembly - Full Text of Public Act 094-0265
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Public Act 094-0265


 

Public Act 0265 94TH GENERAL ASSEMBLY



 


 
Public Act 094-0265
 
HB2490 Enrolled LRB094 03692 DRJ 41250 b

    AN ACT concerning public aid.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Public Aid Code is amended by
changing Section 12-4.25 as follows:
 
    (305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
    Sec. 12-4.25. Medical assistance program; vendor
participation.
    (A) The Illinois Department may deny, suspend or terminate
the eligibility of any person, firm, corporation, association,
agency, institution or other legal entity to participate as a
vendor of goods or services to recipients under the medical
assistance program under Article V, if after reasonable notice
and opportunity for a hearing the Illinois Department finds:
        (a) Such vendor is not complying with the Department's
    policy or rules and regulations, or with the terms and
    conditions prescribed by the Illinois Department in its
    vendor agreement, which document shall be developed by the
    Department as a result of negotiations with each vendor
    category, including physicians, hospitals, long term care
    facilities, pharmacists, optometrists, podiatrists and
    dentists setting forth the terms and conditions applicable
    to the participation of each vendor group in the program;
    or
        (b) Such vendor has failed to keep or make available
    for inspection, audit or copying, after receiving a written
    request from the Illinois Department, such records
    regarding payments claimed for providing services. This
    section does not require vendors to make available patient
    records of patients for whom services are not reimbursed
    under this Code; or
        (c) Such vendor has failed to furnish any information
    requested by the Department regarding payments for
    providing goods or services; or
        (d) Such vendor has knowingly made, or caused to be
    made, any false statement or representation of a material
    fact in connection with the administration of the medical
    assistance program; or
        (e) Such vendor has furnished goods or services to a
    recipient which are (1) in excess of his or her needs, (2)
    harmful to the recipient, or (3) of grossly inferior
    quality, all of such determinations to be based upon
    competent medical judgment and evaluations; or
        (f) The vendor; a person with management
    responsibility for a vendor; an officer or person owning,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidences of ownership in a corporate
    vendor; an owner of a sole proprietorship which is a
    vendor; or a partner in a partnership which is a vendor,
    either:
            (1) was previously terminated from participation
        in the Illinois medical assistance program, or was
        terminated from participation in a medical assistance
        program in another state that is of the same kind as
        the program of medical assistance provided under
        Article V of this Code; or
            (2) was a person with management responsibility
        for a vendor previously terminated from participation
        in the Illinois medical assistance program, or
        terminated from participation in a medical assistance
        program in another state that is of the same kind as
        the program of medical assistance provided under
        Article V of this Code, during the time of conduct
        which was the basis for that vendor's termination; or
            (3) was an officer, or person owning, either
        directly or indirectly, 5% or more of the shares of
        stock or other evidences of ownership in a corporate
        vendor previously terminated from participation in the
        Illinois medical assistance program, or terminated
        from participation in a medical assistance program in
        another state that is of the same kind as the program
        of medical assistance provided under Article V of this
        Code, during the time of conduct which was the basis
        for that vendor's termination; or
            (4) was an owner of a sole proprietorship or
        partner of a partnership previously terminated from
        participation in the Illinois medical assistance
        program, or terminated from participation in a medical
        assistance program in another state that is of the same
        kind as the program of medical assistance provided
        under Article V of this Code, during the time of
        conduct which was the basis for that vendor's
        termination; or
        (g) The vendor; a person with management
    responsibility for a vendor; an officer or person owning,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidences of ownership in a corporate
    vendor; an owner of a sole proprietorship which is a
    vendor; or a partner in a partnership which is a vendor,
    either:
            (1) has engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
            (2) was a person with management responsibility
        for a vendor at the time that such vendor engaged in
        practices prohibited by applicable federal or State
        law or regulation relating to the medical assistance
        program; or
            (3) was an officer, or person owning, either
        directly or indirectly, 5% or more of the shares of
        stock or other evidences of ownership in a vendor at
        the time such vendor engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
            (4) was an owner of a sole proprietorship or
        partner of a partnership which was a vendor at the time
        such vendor engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
        (h) The direct or indirect ownership of the vendor
    (including the ownership of a vendor that is a sole
    proprietorship, a partner's interest in a vendor that is a
    partnership, or ownership of 5% or more of the shares of
    stock or other evidences of ownership in a corporate
    vendor) has been transferred by an individual who is
    terminated or barred from participating as a vendor to the
    individual's spouse, child, brother, sister, parent,
    grandparent, grandchild, uncle, aunt, niece, nephew,
    cousin, or relative by marriage.
    (A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V if, after
reasonable notice and opportunity for a hearing, the Illinois
Department finds that the vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a corporate vendor; an
owner of a sole proprietorship that is a vendor; or a partner
in a partnership that is a vendor has been convicted of a
felony offense based on fraud or willful misrepresentation
related to any of the following:
        (1) The medical assistance program under Article V of
    this Code.
        (2) A medical assistance program in another state that
    is of the same kind as the program of medical assistance
    provided under Article V of this Code.
        (3) The Medicare program under Title XVIII of the
    Social Security Act.
        (4) The provision of health care services.
    (B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V:
        (1) if such vendor is not properly licensed;
        (2) within 30 days of the date when such vendor's
    professional license, certification or other authorization
    has been refused renewal or has been revoked, suspended or
    otherwise terminated; or
        (3) if such vendor has been convicted of a violation of
    this Code, as provided in Article VIIIA.
    (C) Upon termination of a vendor of goods or services from
participation in the medical assistance program authorized by
this Article, a person with management responsibility for such
vendor during the time of any conduct which served as the basis
for that vendor's termination is barred from participation in
the medical assistance program.
    Upon termination of a corporate vendor, the officers and
persons owning, directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in the vendor
during the time of any conduct which served as the basis for
that vendor's termination are barred from participation in the
medical assistance program. A person who owns, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a terminated corporate vendor may not
transfer his or her ownership interest in that vendor to his or
her spouse, child, brother, sister, parent, grandparent,
grandchild, uncle, aunt, niece, nephew, cousin, or relative by
marriage.
    Upon termination of a sole proprietorship or partnership,
the owner or partners during the time of any conduct which
served as the basis for that vendor's termination are barred
from participation in the medical assistance program. The owner
of a terminated vendor that is a sole proprietorship, and a
partner in a terminated vendor that is a partnership, may not
transfer his or her ownership or partnership interest in that
vendor to his or her spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
or relative by marriage.
    Rules adopted by the Illinois Department to implement these
provisions shall specifically include a definition of the term
"management responsibility" as used in this Section. Such
definition shall include, but not be limited to, typical job
titles, and duties and descriptions which will be considered as
within the definition of individuals with management
responsibility for a provider.
    (D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension the
Director shall reinstate such vendor, unless he finds that such
vendor has not corrected deficiencies upon which the suspension
was based.
    If a vendor has been terminated from the medical assistance
program under Article V, such vendor shall be barred from
participation for at least one year, except that if a vendor
has been terminated based on a conviction of a violation of
Article VIIIA or a conviction of a felony based on fraud or a
willful misrepresentation related to (i) the medical
assistance program under Article V, (ii) a medical assistance
program in another state that is of the kind provided under
Article V, (iii) the Medicare program under Title XVIII of the
Social Security Act, or (iv) the provision of health care
services, then the vendor shall be barred from participation
for 5 years or for the length of the vendor's sentence for that
conviction, whichever is longer. At the end of one year a
vendor who has been terminated may apply for reinstatement to
the program. Upon proper application to be reinstated such
vendor may be deemed eligible by the Director providing that
such vendor meets the requirements for eligibility under this
Code. If such vendor is deemed not eligible for reinstatement,
he shall be barred from again applying for reinstatement for
one year from the date his application for reinstatement is
denied.
    A vendor whose termination from participation in the
Illinois medical assistance program under Article V was based
solely on an action by a governmental entity other than the
Illinois Department may, upon reinstatement by that
governmental entity or upon reversal of the termination, apply
for rescission of the termination from participation in the
Illinois medical assistance program. Upon proper application
for rescission, the vendor may be deemed eligible by the
Director if the vendor meets the requirements for eligibility
under this Code.
    If a vendor has been terminated and reinstated to the
medical assistance program under Article V and the vendor is
terminated a second or subsequent time from the medical
assistance program, the vendor shall be barred from
participation for at least 2 years, except that if a vendor has
been terminated a second time based on a conviction of a
violation of Article VIIIA or a conviction of a felony based on
fraud or a willful misrepresentation related to (i) the medical
assistance program under Article V, (ii) a medical assistance
program in another state that is of the kind provided under
Article V, (iii) the Medicare program under Title XVIII of the
Social Security Act, or (iv) the provision of health care
services, then the vendor shall be barred from participation
for life. At the end of 2 years, a vendor who has been
terminated may apply for reinstatement to the program. Upon
application to be reinstated, the vendor may be deemed eligible
if the vendor meets the requirements for eligibility under this
Code. If the vendor is deemed not eligible for reinstatement,
the vendor shall be barred from again applying for
reinstatement for 2 years from the date the vendor's
application for reinstatement is denied.
    (E) The Illinois Department may recover money improperly or
erroneously paid, or overpayments, either by setoff, crediting
against future billings or by requiring direct repayment to the
Illinois Department.
    If the Department of Public Aid establishes through an
administrative hearing that the overpayments resulted from the
vendor or alternate payee willfully making, or causing to be
made, a false statement or misrepresentation of a material fact
in connection with billings and payments under the medical
assistance program under Article V, the Department may recover
interest on the amount of the overpayments at the rate of 5%
per annum. For purposes of this paragraph, "willfully" means
that a person makes a statement or representation with actual
knowledge that it was false, or makes a statement or
representation with knowledge of facts or information that
would cause one to be aware that the statement or
representation was false when made.
    (F) The Illinois Department may withhold payments to any
vendor or alternate payee during the pendency of any proceeding
under this Section. The Illinois Department shall state by rule
with as much specificity as practicable the conditions under
which payments will not be withheld during the pendency of any
proceeding under this Section. Payments may be denied for bills
submitted with service dates occurring during the pendency of a
proceeding where the final administrative decision is to
terminate eligibility to participate in the medical assistance
program. The Illinois Department shall state by rule with as
much specificity as practicable the conditions under which
payments will not be denied for such bills. The Department of
Public Aid shall state by rule a process and criteria by which
a vendor or alternate payee may request full or partial release
of payments withheld under this subsection. The Department must
complete a proceeding under this Section in a timely manner.
    (F-5) The Illinois Department may temporarily withhold
payments to a vendor or alternate payee if any of the following
individuals have been indicted or otherwise charged under a law
of the United States or this or any other state with a felony
offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to (i)
the medical assistance program under Article V of this Code,
(ii) a medical assistance program provided in another state
which is of the kind provided under Article V of this Code,
(iii) the Medicare program under Title XVIII of the Social
Security Act, or (iv) the provision of health care services:
        (1) If the vendor or alternate payee is a corporation:
    an officer of the corporation or an individual who owns,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidence of ownership of the corporation.
        (2) If the vendor is a sole proprietorship: the owner
    of the sole proprietorship.
        (3) If the vendor or alternate payee is a partnership:
    a partner in the partnership.
        (4) If the vendor or alternate payee is any other
    business entity authorized by law to transact business in
    this State: an officer of the entity or an individual who
    owns, either directly or indirectly, 5% or more of the
    evidences of ownership of the entity.
    If the Illinois Department withholds payments to a vendor
or alternate payee under this subsection, the Department shall
not release those payments to the vendor or alternate payee
while any criminal proceeding related to the indictment or
charge is pending unless the Department determines that there
is good cause to release the payments before completion of the
proceeding. If the indictment or charge results in the
individual's conviction, the Illinois Department shall retain
all withheld payments, which shall be considered forfeited to
the Department. If the indictment or charge does not result in
the individual's conviction, the Illinois Department shall
release to the vendor or alternate payee all withheld payments.
    (G) The provisions of the Administrative Review Law, as now
or hereafter amended, and the rules adopted pursuant thereto,
shall apply to and govern all proceedings for the judicial
review of final administrative decisions of the Illinois
Department under this Section. The term "administrative
decision" is defined as in Section 3-101 of the Code of Civil
Procedure.
    (G-5) Non-emergency transportation.
        (1) Notwithstanding any other provision in this
    Section, for non-emergency transportation vendors, the
    Department may terminate the vendor from participation in
    the medical assistance program prior to an evidentiary
    hearing but after reasonable notice and opportunity to
    respond as established by the Department by rule.
        (2) Vendors of non-emergency medical transportation
    services, as defined by the Department by rule, shall
    submit to a fingerprint-based criminal background check on
    current and future information available in the State
    system and current information available through the
    Federal Bureau of Investigation's system by submitting all
    necessary fees and information in the form and manner
    prescribed by the Department of State Police. The following
    individuals shall be subject to the check:
            (A) In the case of a vendor that is a corporation,
        every shareholder who owns, directly or indirectly, 5%
        or more of the outstanding shares of the corporation.
            (B) In the case of a vendor that is a partnership,
        every partner.
            (C) In the case of a vendor that is a sole
        proprietorship, the sole proprietor.
            (D) Each officer or manager of the vendor.
        Each such vendor shall be responsible for payment of
    the cost of the criminal background check.
        (3) Vendors of non-emergency medical transportation
    services may be required to post a surety bond. The
    Department shall establish, by rule, the criteria and
    requirements for determining when a surety bond must be
    posted and the value of the bond.
        (4) The Department, or its agents, may refuse to accept
    requests for non-emergency transportation authorizations,
    including prior-approval and post-approval requests, for a
    specific non-emergency transportation vendor if:
            (A) the Department has initiated a notice of
        termination of the vendor from participation in the
        medical assistance program; or
            (B) the Department has issued notification of its
        withholding of payments pursuant to subsection (F-5)
        of this Section; or
            (C) the Department has issued a notification of its
        withholding of payments due to reliable evidence of
        fraud or willful misrepresentation pending
        investigation.
    (H) Nothing contained in this Code shall in any way limit
or otherwise impair the authority or power of any State agency
responsible for licensing of vendors.
    (I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under Title
XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
may impose one or more of the following remedies after notice
to the facility:
        (1) Termination of the provider agreement.
        (2) Temporary management.
        (3) Denial of payment for new admissions.
        (4) Civil money penalties.
        (5) Closure of the facility in emergency situations or
    transfer of residents, or both.
        (6) State monitoring.
        (7) Denial of all payments when the Health Care Finance
    Administration has imposed this sanction.
    The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in the
sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
    Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of the
federal government, a facility may request a hearing before a
State agency on any finding of noncompliance within 60 days
after the notice of the intent to impose a remedy. Except in
the case of civil money penalties, a request for a hearing
shall not delay imposition of the penalty. The choice of
remedies is not appealable at a hearing. The level of
noncompliance may be challenged only in the case of a civil
money penalty. The Illinois Department shall provide by rule
for the State agency that will conduct the evidentiary
hearings.
    The Illinois Department may collect interest on unpaid
civil money penalties.
    The Illinois Department may adopt all rules necessary to
implement this subsection (I).
    (J) The Illinois Department, by rule, may permit individual
practitioners to designate that Department payments that may be
due the practitioner be made to an alternate payee or alternate
payees.
        (a) Such alternate payee or alternate payees shall be
    required to register as an alternate payee in the Medical
    Assistance Program with the Illinois Department.
        (b) If a practitioner designates an alternate payee,
    the alternate payee and practitioner shall be jointly and
    severally liable to the Department for payments made to the
    alternate payee. Pursuant to subsection (E) of this
    Section, any Department action to recover money or
    overpayments from an alternate payee shall be subject to an
    administrative hearing.
        (c) Registration as an alternate payee or alternate
    payees in the Illinois Medical Assistance Program shall be
    conditional. At any time, the Illinois Department may deny
    or cancel any alternate payee's registration in the
    Illinois Medical Assistance Program without cause. Any
    such denial or cancellation is not subject to an
    administrative hearing.
        (d) The Illinois Department may seek a revocation of
    any alternate payee, and all owners, officers, and
    individuals with management responsibility for such
    alternate payee shall be permanently prohibited from
    participating as an owner, an officer, or an individual
    with management responsibility with an alternate payee in
    the Illinois Medical Assistance Program, if after
    reasonable notice and opportunity for a hearing the
    Illinois Department finds that:
            (1) the alternate payee is not complying with the
        Department's policy or rules and regulations, or with
        the terms and conditions prescribed by the Illinois
        Department in its alternate payee registration
        agreement; or
            (2) the alternate payee has failed to keep or make
        available for inspection, audit, or copying, after
        receiving a written request from the Illinois
        Department, such records regarding payments claimed as
        an alternate payee; or
            (3) the alternate payee has failed to furnish any
        information requested by the Illinois Department
        regarding payments claimed as an alternate payee; or
            (4) the alternate payee has knowingly made, or
        caused to be made, any false statement or
        representation of a material fact in connection with
        the administration of the Illinois Medical Assistance
        Program; or
            (5) the alternate payee, a person with management
        responsibility for an alternate payee, an officer or
        person owning, either directly or indirectly, 5% or
        more of the shares of stock or other evidences of
        ownership in a corporate alternate payee, or a partner
        in a partnership which is an alternate payee:
                (a) was previously terminated from
            participation as a vendor in the Illinois Medical
            Assistance Program, or was previously revoked as
            an alternate payee in the Illinois Medical
            Assistance Program, or was terminated from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code; or
                (b) was a person with management
            responsibility for a vendor previously terminated
            from participation as a vendor in the Illinois
            Medical Assistance Program, or was previously
            revoked as an alternate payee in the Illinois
            Medical Assistance Program, or was terminated from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination or alternate payee's revocation; or
                (c) was an officer, or person owning, either
            directly or indirectly, 5% or more of the shares of
            stock or other evidences of ownership in a
            corporate vendor previously terminated from
            participation as a vendor in the Illinois Medical
            Assistance Program, or was previously revoked as
            an alternate payee in the Illinois Medical
            Assistance Program, or was terminated from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination; or
                (d) was an owner of a sole proprietorship or
            partner in a partnership previously terminated
            from participation as a vendor in the Illinois
            Medical Assistance Program, or was previously
            revoked as an alternate payee in the Illinois
            Medical Assistance Program, or was terminated from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination or alternate payee's revocation; or
            (6) the alternate payee, a person with management
        responsibility for an alternate payee, an officer or
        person owning, either directly or indirectly, 5% or
        more of the shares of stock or other evidences of
        ownership in a corporate alternate payee, or a partner
        in a partnership which is an alternate payee:
                (a) has engaged in conduct prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
                (b) was a person with management
            responsibility for a vendor or alternate payee at
            the time that the vendor or alternate payee engaged
            in practices prohibited by applicable federal or
            State law or regulation relating to the Illinois
            Medical Assistance Program; or
                (c) was an officer, or person owning, either
            directly or indirectly, 5% or more of the shares of
            stock or other evidences of ownership in a vendor
            or alternate payee at the time such vendor or
            alternate payee engaged in practices prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
                (d) was an owner of a sole proprietorship or
            partner in a partnership which was a vendor or
            alternate payee at the time such vendor or
            alternate payee engaged in practices prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
            (7) the direct or indirect ownership of the vendor
        or alternate payee (including the ownership of a vendor
        or alternate payee that is a partner's interest in a
        vendor or alternate payee, or ownership of 5% or more
        of the shares of stock or other evidences of ownership
        in a corporate vendor or alternate payee) has been
        transferred by an individual who is terminated or
        barred from participating as a vendor or is prohibited
        or revoked as an alternate payee to the individual's
        spouse, child, brother, sister, parent, grandparent,
        grandchild, uncle, aunt, niece, nephew, cousin, or
        relative by marriage.
(Source: P.A. 92-327, eff. 1-1-02; 92-651, eff. 7-11-02;
92-789, eff 8-6-02.)

Effective Date: 1/1/2006