Sen. Jeffrey M. Schoenberg

Filed: 2/27/2006

 

 


 

 


 
09400SB0951sam001 LRB094 04634 DRJ 56574 a

1
AMENDMENT TO SENATE BILL 951

2     AMENDMENT NO. ______. Amend Senate Bill 951 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
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;
24     or

 

 

09400SB0951sam001 - 2 - LRB094 04634 DRJ 56574 a

1         (b) Such vendor has failed to keep or make available
2     for inspection, audit or copying, after receiving a written
3     request from the Illinois Department, such records
4     regarding payments claimed for providing services. This
5     section does not require vendors to make available patient
6     records of patients for whom services are not reimbursed
7     under this Code; or
8         (c) Such vendor has failed to furnish any information
9     requested by the Department regarding payments for
10     providing goods or services; or
11         (d) Such vendor has knowingly made, or caused to be
12     made, any false statement or representation of a material
13     fact in connection with the administration of the medical
14     assistance program; or
15         (e) Such vendor has furnished goods or services to a
16     recipient which are (1) in excess of his or her needs, (2)
17     harmful to the recipient, or (3) of grossly inferior
18     quality, all of such determinations to be based upon
19     competent medical judgment and evaluations; or
20         (f) The vendor; a person with management
21     responsibility for a vendor; an officer or person owning,
22     either directly or indirectly, 5% or more of the shares of
23     stock or other evidences of ownership in a corporate
24     vendor; an owner of a sole proprietorship which is a
25     vendor; or a partner in a partnership which is a vendor,
26     either:
27             (1) was previously terminated from participation
28         in the Illinois medical assistance program, or was
29         terminated from participation in a medical assistance
30         program in another state that is of the same kind as
31         the program of medical assistance provided under
32         Article V of this Code; or
33             (2) was a person with management responsibility
34         for a vendor previously terminated from participation

 

 

09400SB0951sam001 - 3 - LRB094 04634 DRJ 56574 a

1         in the Illinois medical assistance program, or
2         terminated from participation in a medical assistance
3         program in another state that is of the same kind as
4         the program of medical assistance provided under
5         Article V of this Code, during the time of conduct
6         which was the basis for that vendor's termination; or
7             (3) was an officer, or person owning, either
8         directly or indirectly, 5% or more of the shares of
9         stock or other evidences of ownership in a corporate
10         vendor previously terminated from participation in the
11         Illinois medical assistance program, or terminated
12         from participation in a medical assistance program in
13         another state that is of the same kind as the program
14         of medical assistance provided under Article V of this
15         Code, during the time of conduct which was the basis
16         for that vendor's termination; or
17             (4) was an owner of a sole proprietorship or
18         partner of a partnership previously terminated from
19         participation in the Illinois medical assistance
20         program, or terminated from participation in a medical
21         assistance program in another state that is of the same
22         kind as the program of medical assistance provided
23         under Article V of this Code, during the time of
24         conduct which was the basis for that vendor's
25         termination; or
26         (g) The vendor; a person with management
27     responsibility for a vendor; an officer or person owning,
28     either directly or indirectly, 5% or more of the shares of
29     stock or other evidences of ownership in a corporate
30     vendor; an owner of a sole proprietorship which is a
31     vendor; or a partner in a partnership which is a vendor,
32     either:
33             (1) has engaged in practices prohibited by
34         applicable federal or State law or regulation relating

 

 

09400SB0951sam001 - 4 - LRB094 04634 DRJ 56574 a

1         to the medical assistance program; or
2             (2) was a person with management responsibility
3         for a vendor at the time that such vendor engaged in
4         practices prohibited by applicable federal or State
5         law or regulation relating to the medical assistance
6         program; or
7             (3) was an officer, or person owning, either
8         directly or indirectly, 5% or more of the shares of
9         stock or other evidences of ownership in a vendor at
10         the time such vendor engaged in practices prohibited by
11         applicable federal or State law or regulation relating
12         to the medical assistance program; or
13             (4) was an owner of a sole proprietorship or
14         partner of a partnership which was a vendor at the time
15         such vendor engaged in practices prohibited by
16         applicable federal or State law or regulation relating
17         to the medical assistance program; or
18         (h) The direct or indirect ownership of the vendor
19     (including the ownership of a vendor that is a sole
20     proprietorship, a partner's interest in a vendor that is a
21     partnership, or ownership of 5% or more of the shares of
22     stock or other evidences of ownership in a corporate
23     vendor) has been transferred by an individual who is
24     terminated or barred from participating as a vendor to the
25     individual's spouse, child, brother, sister, parent,
26     grandparent, grandchild, uncle, aunt, niece, nephew,
27     cousin, or relative by marriage.
28     (A-5) The Illinois Department may deny, suspend, or
29 terminate the eligibility of any person, firm, corporation,
30 association, agency, institution, or other legal entity to
31 participate as a vendor of goods or services to recipients
32 under the medical assistance program under Article V if, after
33 reasonable notice and opportunity for a hearing, the Illinois
34 Department finds that the vendor; a person with management

 

 

09400SB0951sam001 - 5 - LRB094 04634 DRJ 56574 a

1 responsibility for a vendor; an officer or person owning,
2 either directly or indirectly, 5% or more of the shares of
3 stock or other evidences of ownership in a corporate vendor; an
4 owner of a sole proprietorship that is a vendor; or a partner
5 in a partnership that is a vendor has been convicted of a
6 felony offense based on fraud or willful misrepresentation
7 related to any of the following:
8         (1) The medical assistance program under Article V of
9     this Code.
10         (2) A medical assistance program in another state that
11     is of the same kind as the program of medical assistance
12     provided under Article V of this Code.
13         (3) The Medicare program under Title XVIII of the
14     Social Security Act.
15         (4) The provision of health care services.
16     (B) The Illinois Department shall deny, suspend or
17 terminate the eligibility of any person, firm, corporation,
18 association, agency, institution or other legal entity to
19 participate as a vendor of goods or services to recipients
20 under the medical assistance program under Article V:
21         (1) if such vendor is not properly licensed;
22         (2) within 30 days of the date when such vendor's
23     professional license, certification or other authorization
24     has been refused renewal or has been revoked, suspended or
25     otherwise terminated; or
26         (3) if such vendor has been convicted of a violation of
27     this Code, as provided in Article VIIIA.
28     (C) Upon termination of a vendor of goods or services from
29 participation in the medical assistance program authorized by
30 this Article, a person with management responsibility for such
31 vendor during the time of any conduct which served as the basis
32 for that vendor's termination is barred from participation in
33 the medical assistance program.
34     Upon termination of a corporate vendor, the officers and

 

 

09400SB0951sam001 - 6 - LRB094 04634 DRJ 56574 a

1 persons owning, directly or indirectly, 5% or more of the
2 shares of stock or other evidences of ownership in the vendor
3 during the time of any conduct which served as the basis for
4 that vendor's termination are barred from participation in the
5 medical assistance program. A person who owns, directly or
6 indirectly, 5% or more of the shares of stock or other
7 evidences of ownership in a terminated corporate vendor may not
8 transfer his or her ownership interest in that vendor to his or
9 her spouse, child, brother, sister, parent, grandparent,
10 grandchild, uncle, aunt, niece, nephew, cousin, or relative by
11 marriage.
12     Upon termination of a sole proprietorship or partnership,
13 the owner or partners during the time of any conduct which
14 served as the basis for that vendor's termination are barred
15 from participation in the medical assistance program. The owner
16 of a terminated vendor that is a sole proprietorship, and a
17 partner in a terminated vendor that is a partnership, may not
18 transfer his or her ownership or partnership interest in that
19 vendor to his or her spouse, child, brother, sister, parent,
20 grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
21 or relative by marriage.
22     Rules adopted by the Illinois Department to implement these
23 provisions shall specifically include a definition of the term
24 "management responsibility" as used in this Section. Such
25 definition shall include, but not be limited to, typical job
26 titles, and duties and descriptions which will be considered as
27 within the definition of individuals with management
28 responsibility for a provider.
29     (D) If a vendor has been suspended from the medical
30 assistance program under Article V of the Code, the Director
31 may require that such vendor correct any deficiencies which
32 served as the basis for the suspension. The Director shall
33 specify in the suspension order a specific period of time,
34 which shall not exceed one year from the date of the order,

 

 

09400SB0951sam001 - 7 - LRB094 04634 DRJ 56574 a

1 during which a suspended vendor shall not be eligible to
2 participate. At the conclusion of the period of suspension the
3 Director shall reinstate such vendor, unless he finds that such
4 vendor has not corrected deficiencies upon which the suspension
5 was based.
6     If a vendor has been terminated from the medical assistance
7 program under Article V, such vendor shall be barred from
8 participation for at least one year, except that if a vendor
9 has been terminated based on a conviction of a violation of
10 Article VIIIA or a conviction of a felony based on fraud or a
11 willful misrepresentation related to (i) the medical
12 assistance program under Article V, (ii) a medical assistance
13 program in another state that is of the kind provided under
14 Article V, (iii) the Medicare program under Title XVIII of the
15 Social Security Act, or (iv) the provision of health care
16 services, then the vendor shall be barred from participation
17 for 5 years or for the length of the vendor's sentence for that
18 conviction, whichever is longer. At the end of one year a
19 vendor who has been terminated may apply for reinstatement to
20 the program. Upon proper application to be reinstated such
21 vendor may be deemed eligible by the Director providing that
22 such vendor meets the requirements for eligibility under this
23 Code. If such vendor is deemed not eligible for reinstatement,
24 he shall be barred from again applying for reinstatement for
25 one year from the date his application for reinstatement is
26 denied.
27     A vendor whose termination from participation in the
28 Illinois medical assistance program under Article V was based
29 solely on an action by a governmental entity other than the
30 Illinois Department may, upon reinstatement by that
31 governmental entity or upon reversal of the termination, apply
32 for rescission of the termination from participation in the
33 Illinois medical assistance program. Upon proper application
34 for rescission, the vendor may be deemed eligible by the

 

 

09400SB0951sam001 - 8 - LRB094 04634 DRJ 56574 a

1 Director if the vendor meets the requirements for eligibility
2 under this Code.
3     If a vendor has been terminated and reinstated to the
4 medical assistance program under Article V and the vendor is
5 terminated a second or subsequent time from the medical
6 assistance program, the vendor shall be barred from
7 participation for at least 2 years, except that if a vendor has
8 been terminated a second time based on a conviction of a
9 violation of Article VIIIA or a conviction of a felony based on
10 fraud or a willful misrepresentation related to (i) the medical
11 assistance program under Article V, (ii) a medical assistance
12 program in another state that is of the kind provided under
13 Article V, (iii) the Medicare program under Title XVIII of the
14 Social Security Act, or (iv) the provision of health care
15 services, then the vendor shall be barred from participation
16 for life. At the end of 2 years, a vendor who has been
17 terminated may apply for reinstatement to the program. Upon
18 application to be reinstated, the vendor may be deemed eligible
19 if the vendor meets the requirements for eligibility under this
20 Code. If the vendor is deemed not eligible for reinstatement,
21 the vendor shall be barred from again applying for
22 reinstatement for 2 years from the date the vendor's
23 application for reinstatement is denied.
24     (E) The Illinois Department may recover money improperly or
25 erroneously paid, or overpayments, either by setoff, crediting
26 against future billings or by requiring direct repayment to the
27 Illinois Department.
28     If the Illinois Department of Public Aid establishes
29 through an administrative hearing that the overpayments
30 resulted from the vendor or alternate payee willfully making,
31 or causing to be made, a false statement or misrepresentation
32 of a material fact in connection with billings and payments
33 under the medical assistance program under Article V, the
34 Department may recover interest on the amount of the

 

 

09400SB0951sam001 - 9 - LRB094 04634 DRJ 56574 a

1 overpayments at the rate of 5% per annum. For purposes of this
2 paragraph, "willfully" means that a person makes a statement or
3 representation with actual knowledge that it was false, or
4 makes a statement or representation with knowledge of facts or
5 information that would cause one to be aware that the statement
6 or representation was false when made.
7     (F) The Illinois Department may withhold payments to any
8 vendor or alternate payee during the pendency of any proceeding
9 under this Section. The Illinois Department shall state by rule
10 with as much specificity as practicable the conditions under
11 which payments will not be withheld during the pendency of any
12 proceeding under this Section. Payments may be denied for bills
13 submitted with service dates occurring during the pendency of a
14 proceeding where the final administrative decision is to
15 terminate eligibility to participate in the medical assistance
16 program. The Illinois Department shall state by rule with as
17 much specificity as practicable the conditions under which
18 payments will not be denied for such bills. The Illinois
19 Department of Public Aid shall state by rule a process and
20 criteria by which a vendor or alternate payee may request full
21 or partial release of payments withheld under this subsection.
22 The Department must complete a proceeding under this Section in
23 a timely manner.
24     (F-5) The Illinois Department may temporarily withhold
25 payments to a vendor or alternate payee if any of the following
26 individuals have been indicted or otherwise charged under a law
27 of the United States or this or any other state with a felony
28 offense that is based on alleged fraud or willful
29 misrepresentation on the part of the individual related to (i)
30 the medical assistance program under Article V of this Code,
31 (ii) a medical assistance program provided in another state
32 which is of the kind provided under Article V of this Code,
33 (iii) the Medicare program under Title XVIII of the Social
34 Security Act, or (iv) the provision of health care services:

 

 

09400SB0951sam001 - 10 - LRB094 04634 DRJ 56574 a

1         (1) If the vendor or alternate payee is a corporation:
2     an officer of the corporation or an individual who owns,
3     either directly or indirectly, 5% or more of the shares of
4     stock or other evidence of ownership of the corporation.
5         (2) If the vendor is a sole proprietorship: the owner
6     of the sole proprietorship.
7         (3) If the vendor or alternate payee is a partnership:
8     a partner in the partnership.
9         (4) If the vendor or alternate payee is any other
10     business entity authorized by law to transact business in
11     this State: an officer of the entity or an individual who
12     owns, either directly or indirectly, 5% or more of the
13     evidences of ownership of the entity.
14     If the Illinois Department withholds payments to a vendor
15 or alternate payee under this subsection, the Department shall
16 not release those payments to the vendor or alternate payee
17 while any criminal proceeding related to the indictment or
18 charge is pending unless the Department determines that there
19 is good cause to release the payments before completion of the
20 proceeding. If the indictment or charge results in the
21 individual's conviction, the Illinois Department shall retain
22 all withheld payments, which shall be considered forfeited to
23 the Department. If the indictment or charge does not result in
24 the individual's conviction, the Illinois Department shall
25 release to the vendor or alternate payee all withheld payments.
26     (G) The provisions of the Administrative Review Law, as now
27 or hereafter amended, and the rules adopted pursuant thereto,
28 shall apply to and govern all proceedings for the judicial
29 review of final administrative decisions of the Illinois
30 Department under this Section. The term "administrative
31 decision" is defined as in Section 3-101 of the Code of Civil
32 Procedure.
33     (G-5) Non-emergency transportation.
34         (1) Notwithstanding any other provision in this

 

 

09400SB0951sam001 - 11 - LRB094 04634 DRJ 56574 a

1     Section, for non-emergency transportation vendors, the
2     Department may terminate the vendor from participation in
3     the medical assistance program prior to an evidentiary
4     hearing but after reasonable notice and opportunity to
5     respond as established by the Department by rule.
6         (2) Vendors of non-emergency medical transportation
7     services, as defined by the Department by rule, shall
8     submit to a fingerprint-based criminal background check on
9     current and future information available in the State
10     system and current information available through the
11     Federal Bureau of Investigation's system by submitting all
12     necessary fees and information in the form and manner
13     prescribed by the Department of State Police. The following
14     individuals shall be subject to the check:
15             (A) In the case of a vendor that is a corporation,
16         every shareholder who owns, directly or indirectly, 5%
17         or more of the outstanding shares of the corporation.
18             (B) In the case of a vendor that is a partnership,
19         every partner.
20             (C) In the case of a vendor that is a sole
21         proprietorship, the sole proprietor.
22             (D) Each officer or manager of the vendor.
23         Each such vendor shall be responsible for payment of
24     the cost of the criminal background check.
25         (3) Vendors of non-emergency medical transportation
26     services may be required to post a surety bond. The
27     Department shall establish, by rule, the criteria and
28     requirements for determining when a surety bond must be
29     posted and the value of the bond.
30         (4) The Department, or its agents, may refuse to accept
31     requests for non-emergency transportation authorizations,
32     including prior-approval and post-approval requests, for a
33     specific non-emergency transportation vendor if:
34             (A) the Department has initiated a notice of

 

 

09400SB0951sam001 - 12 - LRB094 04634 DRJ 56574 a

1         termination of the vendor from participation in the
2         medical assistance program; or
3             (B) the Department has issued notification of its
4         withholding of payments pursuant to subsection (F-5)
5         of this Section; or
6             (C) the Department has issued a notification of its
7         withholding of payments due to reliable evidence of
8         fraud or willful misrepresentation pending
9         investigation.
10     (H) Nothing contained in this Code shall in any way limit
11 or otherwise impair the authority or power of any State agency
12 responsible for licensing of vendors.
13     (I) Based on a finding of noncompliance on the part of a
14 nursing home with any requirement for certification under Title
15 XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
16 seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
17 may impose one or more of the following remedies after notice
18 to the facility:
19         (1) Termination of the provider agreement.
20         (2) Temporary management.
21         (3) Denial of payment for new admissions.
22         (4) Civil money penalties.
23         (5) Closure of the facility in emergency situations or
24     transfer of residents, or both.
25         (6) State monitoring.
26         (7) Denial of all payments when the Health Care Finance
27     Administration has imposed this sanction.
28     The Illinois Department shall by rule establish criteria
29 governing continued payments to a nursing facility subsequent
30 to termination of the facility's provider agreement if, in the
31 sole discretion of the Illinois Department, circumstances
32 affecting the health, safety, and welfare of the facility's
33 residents require those continued payments. The Illinois
34 Department may condition those continued payments on the

 

 

09400SB0951sam001 - 13 - LRB094 04634 DRJ 56574 a

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
27     Assistance Program with the Illinois Department.
28         (b) If a practitioner designates an alternate payee,
29     the alternate payee and practitioner shall be jointly and
30     severally liable to the Department for payments made to the
31     alternate payee. Pursuant to subsection (E) of this
32     Section, any Department action to recover money or
33     overpayments from an alternate payee shall be subject to an
34     administrative hearing.

 

 

09400SB0951sam001 - 14 - LRB094 04634 DRJ 56574 a

1         (c) Registration as an alternate payee or alternate
2     payees in the Illinois Medical Assistance Program shall be
3     conditional. At any time, the Illinois Department may deny
4     or cancel any alternate payee's registration in the
5     Illinois Medical Assistance Program without cause. Any
6     such denial or cancellation is not subject to an
7     administrative hearing.
8         (d) The Illinois Department may seek a revocation of
9     any alternate payee, and all owners, officers, and
10     individuals with management responsibility for such
11     alternate payee shall be permanently prohibited from
12     participating as an owner, an officer, or an individual
13     with management responsibility with an alternate payee in
14     the Illinois Medical Assistance Program, if after
15     reasonable notice and opportunity for a hearing the
16     Illinois Department finds that:
17             (1) the alternate payee is not complying with the
18         Department's policy or rules and regulations, or with
19         the terms and conditions prescribed by the Illinois
20         Department in its alternate payee registration
21         agreement; or
22             (2) the alternate payee has failed to keep or make
23         available for inspection, audit, or copying, after
24         receiving a written request from the Illinois
25         Department, such records regarding payments claimed as
26         an alternate payee; or
27             (3) the alternate payee has failed to furnish any
28         information requested by the Illinois Department
29         regarding payments claimed as an alternate payee; or
30             (4) the alternate payee has knowingly made, or
31         caused to be made, any false statement or
32         representation of a material fact in connection with
33         the administration of the Illinois Medical Assistance
34         Program; or

 

 

09400SB0951sam001 - 15 - LRB094 04634 DRJ 56574 a

1             (5) the alternate payee, a person with management
2         responsibility for an alternate payee, an officer or
3         person owning, either directly or indirectly, 5% or
4         more of the shares of stock or other evidences of
5         ownership in a corporate alternate payee, or a partner
6         in a partnership which is an alternate payee:
7                 (a) was previously terminated from
8             participation as a vendor in the Illinois Medical
9             Assistance Program, or was previously revoked as
10             an alternate payee in the Illinois Medical
11             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; or
16                 (b) was a person with management
17             responsibility for a vendor previously terminated
18             from participation as a vendor in the Illinois
19             Medical Assistance Program, or was previously
20             revoked as an alternate payee in the Illinois
21             Medical Assistance Program, or was terminated from
22             participation as a vendor in a medical assistance
23             program in another state that is of the same kind
24             as the program of medical assistance provided
25             under Article V of this Code, during the time of
26             conduct which was the basis for that vendor's
27             termination or alternate payee's revocation; or
28                 (c) was an officer, or person owning, either
29             directly or indirectly, 5% or more of the shares of
30             stock or other evidences of ownership in a
31             corporate vendor previously terminated from
32             participation as a vendor in the Illinois Medical
33             Assistance Program, or was previously revoked as
34             an alternate payee in the Illinois Medical

 

 

09400SB0951sam001 - 16 - LRB094 04634 DRJ 56574 a

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, during the time of
6             conduct which was the basis for that vendor's
7             termination; or
8                 (d) was an owner of a sole proprietorship or
9             partner in a partnership previously terminated
10             from participation as a vendor in the Illinois
11             Medical Assistance Program, or was previously
12             revoked as an alternate payee in the Illinois
13             Medical Assistance Program, or was terminated from
14             participation as a vendor in a medical assistance
15             program in another state that is of the same kind
16             as the program of medical assistance provided
17             under Article V of this Code, during the time of
18             conduct which was the basis for that vendor's
19             termination or alternate payee's revocation; or
20             (6) 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) has engaged in conduct prohibited by
27             applicable federal or State law or regulation
28             relating to the Illinois Medical Assistance
29             Program; or
30                 (b) was a person with management
31             responsibility for a vendor or alternate payee at
32             the time that the vendor or alternate payee engaged
33             in practices prohibited by applicable federal or
34             State law or regulation relating to the Illinois

 

 

09400SB0951sam001 - 17 - LRB094 04634 DRJ 56574 a

1             Medical Assistance Program; or
2                 (c) was an officer, or person owning, either
3             directly or indirectly, 5% or more of the shares of
4             stock or other evidences of ownership in a vendor
5             or alternate payee at the time such vendor or
6             alternate payee engaged in practices prohibited by
7             applicable federal or State law or regulation
8             relating to the Illinois Medical Assistance
9             Program; or
10                 (d) was an owner of a sole proprietorship or
11             partner in a partnership which was a vendor or
12             alternate payee at the time such vendor or
13             alternate payee engaged in practices prohibited by
14             applicable federal or State law or regulation
15             relating to the Illinois Medical Assistance
16             Program; or
17             (7) the direct or indirect ownership of the vendor
18         or alternate payee (including the ownership of a vendor
19         or alternate payee that is a partner's interest in a
20         vendor or alternate payee, or ownership of 5% or more
21         of the shares of stock or other evidences of ownership
22         in a corporate vendor or alternate payee) has been
23         transferred by an individual who is terminated or
24         barred from participating as a vendor or is prohibited
25         or revoked as an alternate payee to the individual's
26         spouse, child, brother, sister, parent, grandparent,
27         grandchild, uncle, aunt, niece, nephew, cousin, or
28         relative by marriage.
29     (K) The Illinois Department of Healthcare and Family
30 Services may withhold payments, in whole or in part, to a
31 provider or alternate payee upon receipt of reliable evidence
32 that the circumstances giving rise to the need for a
33 withholding of payments may involve fraud or willful
34 misrepresentation under the Illinois Medical Assistance

 

 

09400SB0951sam001 - 18 - LRB094 04634 DRJ 56574 a

1 program. The Department may withhold payments without first
2 notifying the provider or alternate payee of its intention to
3 withhold such payments.
4         (a) The Illinois Department must send notice of its
5     withholding of program payments within 5 days of taking
6     such action. The notice must set forth the general
7     allegations as to the nature of the withholding action, but
8     need not disclose any specific information concerning its
9     ongoing investigation. The notice must do all of the
10     following:
11             (1) State that payments are being withheld in
12         accordance with this subsection.
13             (2) State that the withholding is for a temporary
14         period, as stated in paragraph (b) of this subsection,
15         and cite the circumstances under which withholding
16         will be terminated.
17             (3) Specify, when appropriate, which type or types
18         of Medicaid claims withholding is effective.
19             (4) Inform the provider or alternate payee of the
20         right to submit written evidence for consideration by
21         the Illinois Department.
22         (b) All withholding-of-payment actions under this
23     subsection shall be temporary and shall not continue after
24     any of the following:
25             (1) The Illinois Department or the prosecuting
26         authorities determine that there is insufficient
27         evidence of fraud or willful misrepresentation by the
28         provider or alternate payee.
29             (2) Legal proceedings related to the provider's or
30         alternate payee's alleged fraud, willful
31         misrepresentation, violations of this Act, or
32         violations of the Illinois Department's administrative
33         rules are completed.
34         (c) The Illinois Department may adopt all rules

 

 

09400SB0951sam001 - 19 - LRB094 04634 DRJ 56574 a

1     necessary to implement this subsection (K).
2 (Source: P.A. 94-265, eff. 1-1-06; revised 12-15-05.)
 
3     Section 99. Effective date. This Act takes effect upon
4 becoming law.".