Rep. Kelly M. Cassidy

Filed: 3/15/2013

 

 


 

 


 
09800HB0071ham001LRB098 02586 KTG 43206 a

1
AMENDMENT TO HOUSE BILL 71

2    AMENDMENT NO. ______. Amend House Bill 71 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Sections 8A-2.5, 8A-13, and 8A-15 as follows:
 
6    (305 ILCS 5/8A-2.5)
7    Sec. 8A-2.5. Unauthorized use of medical assistance.
8    (a) Any person who knowingly uses, acquires, possesses, or
9transfers a medical card in any manner not authorized by law or
10by rules and regulations of the Illinois Department, or who
11knowingly alters a medical card, or who knowingly uses,
12acquires, possesses, or transfers an altered medical card, is
13guilty of a violation of this Article and shall be punished as
14provided in Section 8A-6.
15    (b) Any person who knowingly obtains unauthorized medical
16benefits or causes to be obtained unauthorized medical benefits

 

 

09800HB0071ham001- 2 -LRB098 02586 KTG 43206 a

1with or without use of a medical card is guilty of a violation
2of this Article and shall be punished as provided in Section
38A-6.
4    (b-5) Any vendor that knowingly assists a person in
5committing a violation under subsection (a) or (b) of this
6Section is guilty of a violation of this Article and shall be
7punished as provided in Section 8A-6.
8    (b-6) Any person (including a vendor, organization,
9agency, or other entity) that, in any matter related to the
10medical assistance program, knowingly or willfully falsifies,
11conceals, or omits by any trick, scheme, artifice, or device a
12material fact, or makes any false, fictitious, or fraudulent
13statement or representation, or makes or uses any false writing
14or document, knowing the same to contain any false, fictitious,
15or fraudulent statement or entry in connection with the
16provision of health care or related services, is guilty of a
17violation of this Article and shall be punished as provided in
18Section 8A-6.
19    (c) The Department may seek to recover any and all State
20and federal monies for which it has improperly and erroneously
21paid benefits as a result of a fraudulent action and any civil
22penalties authorized in this Section. Pursuant to Section
2311-14.5 of this Code, the Department may determine the monetary
24value of benefits improperly and erroneously received. The
25Department may recover the monies paid for such benefits and
26interest on that amount at the rate of 5% per annum for the

 

 

09800HB0071ham001- 3 -LRB098 02586 KTG 43206 a

1period from which payment was made to the date upon which
2repayment is made to the State. Prior to the recovery of any
3amount paid for benefits allegedly obtained by fraudulent
4means, the recipient or payee of such benefits shall be
5afforded an opportunity for a hearing after reasonable notice.
6The notice shall be served personally or by certified or
7registered mail or as otherwise provided by law upon the
8parties or their agents appointed to receive service of process
9and shall include the following:
10        (1) A statement of the time, place and nature of the
11    hearing.
12        (2) A statement of the legal authority and jurisdiction
13    under which the hearing is to be held.
14        (3) A reference to the particular Sections of the
15    substantive and procedural statutes and rules involved.
16        (4) Except where a more detailed statement is otherwise
17    provided for by law, a short and plain statement of the
18    matters asserted, the consequences of a failure to respond,
19    and the official file or other reference number.
20        (5) A statement of the monetary value of the benefits
21    fraudulently received by the person accused.
22        (6) A statement that, in addition to any other
23    penalties provided by law, a civil penalty in an amount not
24    to exceed $2,000 may be imposed for each fraudulent claim
25    for benefits or payments.
26        (7) A statement providing that the determination of the

 

 

09800HB0071ham001- 4 -LRB098 02586 KTG 43206 a

1    monetary value may be contested by petitioning the
2    Department for an administrative hearing within 30 days
3    from the date of mailing the notice.
4        (8) The names and mailing addresses of the
5    administrative law judge, all parties, and all other
6    persons to whom the agency gives notice of the hearing
7    unless otherwise confidential by law.
8    An opportunity shall be afforded all parties to be
9represented by legal counsel and to respond and present
10evidence and argument.
11    Unless precluded by law, disposition may be made of any
12contested case by stipulation, agreed settlement, consent
13order, or default.
14    Any final order, decision, or other determination made,
15issued or executed by the Director under the provisions of this
16Article whereby any person is aggrieved shall be subject to
17review in accordance with the provisions of the Administrative
18Review Law, and the rules adopted pursuant thereto, which shall
19apply to and govern all proceedings for the judicial review of
20final administrative decisions of the Director.
21    Upon entry of a final administrative decision for repayment
22of any benefits obtained by fraudulent means, or for any civil
23penalties assessed, a lien shall attach to all property and
24assets of such person, firm, corporation, association, agency,
25institution, vendor, or other legal entity until the judgment
26is satisfied.

 

 

09800HB0071ham001- 5 -LRB098 02586 KTG 43206 a

1    Within 18 months of the effective date of this amendatory
2Act of the 96th General Assembly, the Department of Healthcare
3and Family Services will report to the General Assembly on the
4number of fraud cases identified and pursued, and the fines
5assessed and collected. The report will also include the
6Department's analysis as to the use of private sector resources
7to bring action, investigate, and collect monies owed.
8    (d) In subsections (a),(b),(b-5) and (b-6), "knowledge"
9has the meaning ascribed to that term in Section 4-5 of the
10Criminal Code of 2012. For any administrative action brought
11under subsection (c) pursuant to a violation of this Section,
12the Department shall define "knowing" by rule.
13(Source: P.A. 96-1501, eff. 1-25-11; 97-23, eff. 1-1-12.)
 
14    (305 ILCS 5/8A-13)
15    Sec. 8A-13. Managed health care fraud.
16    (a) As used in this Section, "health plan" means any of the
17following:
18        (1) Any health care reimbursement plan sponsored
19    wholly or partially by the State.
20        (2) Any private insurance carrier, health care
21    cooperative or alliance, health maintenance organization,
22    insurer, organization, entity, association, affiliation,
23    or person that contracts to provide or provides goods or
24    services that are reimbursed by or are a required benefit
25    of a health benefits program funded wholly or partially by

 

 

09800HB0071ham001- 6 -LRB098 02586 KTG 43206 a

1    the State.
2        (3) Anyone who provides or contracts to provide goods
3    and services to an entity described in paragraph (1) or (2)
4    of this subsection.
5    For purposes of item (2) in subsection (b),
6"representation" and "statement" include, but are not limited
7to, reports, claims, certifications, acknowledgments and
8ratifications of financial information, enrollment claims,
9demographic statistics, encounter data, health services
10available or rendered, and the qualifications of person
11rendering health care and ancillary services.
12    (b) Any person, firm, corporation, association, agency,
13institution, or other legal entity that, with the intent to
14obtain benefits or payments under this Code to which the person
15or entity is not entitled or in a greater amount than that to
16which the person or entity is entitled, knowingly or willfully:
17executes or conspires to execute a scheme or artifice
18        (1) executes or conspires to execute a scheme or
19    artifice to defraud any State or federally funded or
20    mandated health plan in connection with the delivery of or
21    payment for health care benefits, items, or services; , or
22        (2) executes or conspires to execute a scheme or
23    artifice to obtain by means of false or fraudulent
24    pretense, representation, statement, or promise money or
25    anything of value in connection with the delivery of or
26    payment for health care benefits, items, or services that

 

 

09800HB0071ham001- 7 -LRB098 02586 KTG 43206 a

1    are in whole or in part paid for, reimbursed, or subsidized
2    by, or are a required benefit of, a State or federally
3    funded or mandated health plan;
4        (3) falsifies, conceals, or covers up by any trick,
5    scheme, or device a material fact in connection with the
6    delivery of or payment for health care benefits, items, or
7    services that are in whole or in part paid for or
8    reimbursed by a State or federal health plan;
9        (4) makes any materially false, fictitious, or
10    fraudulent statements or representations, or makes or uses
11    any materially false writing or document knowing the same
12    to contain any materially false, fictitious, or fraudulent
13    statement or entry, in connection with the delivery of or
14    payment for health care benefits, items, or services that
15    are in whole or in part paid for or reimbursed by a State
16    or federal health plan; or
17        (5) makes or uses any false writing or document knowing
18    the same to contain any materially false, fictitious, or
19    fraudulent statement or entry in connection with the
20    delivery of or payment for health care benefits, items, or
21    services that are in whole or in part paid for or
22    reimbursed by a State or federal health plan;
23is guilty of a violation of this Article and shall be punished
24as provided in Section 8A-6.
25(Source: P.A. 90-538, eff. 12-1-97.)
 

 

 

09800HB0071ham001- 8 -LRB098 02586 KTG 43206 a

1    (305 ILCS 5/8A-15)
2    Sec. 8A-15. False statements relating to health care
3delivery. Any person, firm, corporation, association, agency,
4institution, or other legal entity that, in any matter related
5to a State or federally funded or mandated health plan,
6knowingly and wilfully falsifies, conceals, or omits by any
7trick, scheme, artifice, or device a material fact, or makes
8any false, fictitious, or fraudulent statement or
9representation, or makes or uses any false writing or document,
10knowing the same to contain any false, fictitious, or
11fraudulent statement or entry in connection with the provision
12of health care or related services, is guilty of a Class 4
13felony A misdemeanor.
14(Source: P.A. 90-538, eff. 12-1-97.)
 
15    Section 99. Effective date. This Act takes effect upon
16becoming law.".