Sen. Ira I. Silverstein

Filed: 5/2/2011

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1489

2    AMENDMENT NO. ______. Amend House Bill 1489 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing 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
8participation.
9    (A) The Illinois Department may deny, suspend or terminate
10the eligibility of any person, firm, corporation, association,
11agency, institution or other legal entity to participate as a
12vendor of goods or services to recipients under the medical
13assistance program under Article V, if after reasonable notice
14and 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

 

 

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1    conditions prescribed by the Illinois Department in its
2    vendor agreement, which document shall be developed by the
3    Department as a result of negotiations with each vendor
4    category, including physicians, hospitals, long term care
5    facilities, pharmacists, optometrists, podiatrists and
6    dentists setting forth the terms and conditions applicable
7    to the participation of each vendor group in the program;
8    or
9        (b) Such vendor has failed to keep or make available
10    for inspection, audit or copying, after receiving a written
11    request from the Illinois Department, such records
12    regarding payments claimed for providing services. This
13    section does not require vendors to make available patient
14    records of patients for whom services are not reimbursed
15    under this Code; or
16        (c) Such vendor has failed to furnish any information
17    requested by the Department regarding payments for
18    providing goods or services; or
19        (d) Such vendor has knowingly made, or caused to be
20    made, any false statement or representation of a material
21    fact in connection with the administration of the medical
22    assistance program; or
23        (e) Such vendor has furnished goods or services to a
24    recipient which are (1) in excess of his or her needs, (2)
25    harmful to the recipient, or (3) of grossly inferior
26    quality, all of such determinations to be based upon

 

 

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1    competent medical judgment and evaluations; or
2        (f) The vendor; a person with management
3    responsibility for a vendor; an officer or person owning,
4    either directly or indirectly, 5% or more of the shares of
5    stock or other evidences of ownership in a corporate
6    vendor; an owner of a sole proprietorship which is a
7    vendor; or a partner in a partnership which is a vendor,
8    either:
9            (1) was previously terminated from participation
10        in the Illinois medical assistance program, or was
11        terminated from participation in a medical assistance
12        program in another state that is of the same kind as
13        the program of medical assistance provided under
14        Article V of this Code; or
15            (2) was a person with management responsibility at
16        the time such vendor was for a vendor previously
17        terminated from participation in the Illinois medical
18        assistance program and was found culpable by the
19        Illinois Department for the conduct which was the basis
20        for the vendor's termination, or terminated from
21        participation in a medical assistance program in
22        another state that is of the same kind as the program
23        of medical assistance provided under Article V of this
24        Code, during the time of conduct which was the basis
25        for that vendor's termination; or
26            (3) was an officer, or person owning, either

 

 

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1        directly or indirectly, 5% or more of the shares of
2        stock or other evidences of ownership in a corporate
3        vendor at the time such vendor was previously
4        terminated from participation in the Illinois medical
5        assistance program and was found culpable by the
6        Illinois Department for the conduct which was the basis
7        for the vendor's termination, or terminated from
8        participation in a medical assistance program in
9        another state that is of the same kind as the program
10        of medical assistance provided under Article V of this
11        Code, during the time of conduct which was the basis
12        for that vendor's termination; or
13            (4) was an owner of a sole proprietorship or
14        partner of a partnership at the time such vendor was
15        previously terminated from participation in the
16        Illinois medical assistance program and was found
17        culpable by the Illinois Department for the conduct
18        which was the basis for the vendor's termination, or
19        terminated from participation in a medical assistance
20        program in another state that is of the same kind as
21        the program of medical assistance provided under
22        Article V of this Code, during the time of conduct
23        which was the basis for that vendor's termination; or
24        (g) The vendor; a person with management
25    responsibility for a vendor; an officer or person owning,
26    either directly or indirectly, 5% or more of the shares of

 

 

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1    stock or other evidences of ownership in a corporate
2    vendor; an owner of a sole proprietorship which is a
3    vendor; or a partner in a partnership which is a vendor,
4    either:
5            (1) has engaged in practices prohibited by
6        applicable federal or State law or regulation relating
7        to the medical assistance program; or
8            (2) was a person with management responsibility
9        for a vendor at the time that such vendor engaged in
10        practices prohibited by applicable federal or State
11        law or regulation relating to the medical assistance
12        program and was found culpable by the Illinois
13        Department for such practices; or
14            (3) was an officer, or person owning, either
15        directly or indirectly, 5% or more of the shares of
16        stock or other evidences of ownership in a vendor at
17        the time such vendor engaged in practices prohibited by
18        applicable federal or State law or regulation relating
19        to the medical assistance program and was found
20        culpable by the Illinois Department for such
21        practices; or
22            (4) was an owner of a sole proprietorship or
23        partner of a partnership which was a vendor at the time
24        such vendor engaged in practices prohibited by
25        applicable federal or State law or regulation relating
26        to the medical assistance program and was found

 

 

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1        culpable by the Illinois Department for such
2        practices; or
3        (h) The direct or indirect ownership of the vendor
4    (including the ownership of a vendor that is a sole
5    proprietorship, a partner's interest in a vendor that is a
6    partnership, or ownership of 5% or more of the shares of
7    stock or other evidences of ownership in a corporate
8    vendor) has been transferred by an individual who is
9    terminated or barred from participating as a vendor to the
10    individual's spouse, child, brother, sister, parent,
11    grandparent, grandchild, uncle, aunt, niece, nephew,
12    cousin, or relative by marriage.
13    (A-2) Notwithstanding the provisions of paragraph (A), and
14in addition thereto, any person with management responsibility
15for a vendor; an officer or person owning, either directly or
16indirectly, 5% or more of the shares of stock or other
17evidences of ownership in a corporate vendor; an owner of a
18sole proprietorship which is a vendor; or a partner in a
19partnership which is a vendor who is found culpable in the
20vendor's act of willfully failing to keep and maintain, or
21willfully failing to produce for inspection, audit, or copying,
22books and records, or willfully failing to furnish any
23information requested by the Illinois Department regarding
24payments for providing goods or services, is guilty of a Class
25A misdemeanor. A second or subsequent violation of this Section
26shall be punishable as a Class A felony.

 

 

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1    (A-3) Any person with management responsibility for a
2vendor; an officer or person owning, either directly or
3indirectly, 5% or more of the shares of stock or other
4evidences of ownership in a corporate vendor; an owner of a
5sole proprietorship which is a vendor; or a partner in a
6partnership which is a vendor who is found culpable in the
7vendor's act of willfully filing or willfully causing to be
8filed any false statement or representation of a material fact
9in connection with the administration of the medical assistance
10program, is guilty of a Class A misdemeanor.
11    (A-5) The Illinois Department may deny, suspend, or
12terminate the eligibility of any person, firm, corporation,
13association, agency, institution, or other legal entity to
14participate as a vendor of goods or services to recipients
15under the medical assistance program under Article V if, after
16reasonable notice and opportunity for a hearing, the Illinois
17Department finds that the vendor; a person with management
18responsibility for a vendor; an officer or person owning,
19either directly or indirectly, 5% or more of the shares of
20stock or other evidences of ownership in a corporate vendor; an
21owner of a sole proprietorship that is a vendor; or a partner
22in a partnership that is a vendor has been convicted of a
23felony offense based on fraud or willful misrepresentation
24related to any of the following:
25        (1) The medical assistance program under Article V of
26    this Code.

 

 

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1        (2) A medical assistance program in another state that
2    is of the same kind as the program of medical assistance
3    provided under Article V of this Code.
4        (3) The Medicare program under Title XVIII of the
5    Social Security Act.
6        (4) The provision of health care services.
7    (A-10) The Illinois Department may deny, suspend, or
8terminate the eligibility of any person, firm, corporation,
9association, agency, institution, or other legal entity to
10participate as a vendor of goods or services to recipients
11under the medical assistance program under Article V if, after
12reasonable notice and opportunity for a hearing, the Illinois
13Department finds that (i) the vendor, (ii) a person with
14management responsibility for a vendor, (iii) an officer or
15person owning, either directly or indirectly, 5% or more of the
16shares of stock or other evidences of ownership in a corporate
17vendor, (iv) an owner of a sole proprietorship that is a
18vendor, or (v) a partner in a partnership that is a vendor has
19been convicted of a felony offense related to any of the
20following:
21        (1) Murder.
22        (2) A Class X felony under the Criminal Code of 1961.
23    (B) The Illinois Department shall deny, suspend or
24terminate the eligibility of any person, firm, corporation,
25association, agency, institution or other legal entity to
26participate as a vendor of goods or services to recipients

 

 

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1under the medical assistance program under Article V:
2        (1) if such vendor is not properly licensed;
3        (2) within 30 days of the date when such vendor's
4    professional license, certification or other authorization
5    has been refused renewal or has been revoked, suspended or
6    otherwise terminated; or
7        (3) if such vendor has been convicted of a violation of
8    this Code, as provided in Article VIIIA.
9    (C) Upon termination of a vendor of goods or services from
10participation in the medical assistance program authorized by
11this Article, a person with management responsibility for such
12vendor during the time of any conduct which served as the basis
13for that vendor's termination and who was found culpable of
14such conduct by the Illinois Department may be is barred from
15participation in the medical assistance program.
16    Upon termination of a corporate vendor, the officers and
17persons owning, directly or indirectly, 5% or more of the
18shares of stock or other evidences of ownership in the vendor
19during the time of any conduct which served as the basis for
20that vendor's termination and who were found culpable of such
21conduct by the Illinois Department may be are barred from
22participation in the medical assistance program. A person who
23owns, directly or indirectly, 5% or more of the shares of stock
24or other evidences of ownership in a terminated corporate
25vendor may not transfer his or her ownership interest in that
26vendor to his or her spouse, child, brother, sister, parent,

 

 

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1grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
2or relative by marriage.
3    Upon termination of a sole proprietorship or partnership,
4the owner or partners during the time of any conduct which
5served as the basis for that vendor's termination and who were
6found culpable of such conduct by the Illinois Department may
7be are barred from participation in the medical assistance
8program. The owner of a terminated vendor that is a sole
9proprietorship, and a partner in a terminated vendor that is a
10partnership, may not transfer his or her ownership or
11partnership interest in that vendor to his or her spouse,
12child, brother, sister, parent, grandparent, grandchild,
13uncle, aunt, niece, nephew, cousin, or relative by marriage.
14    Rules adopted by the Illinois Department to implement these
15provisions shall specifically include a definition of the term
16"management responsibility" as used in this Section. Such
17definition shall include, but not be limited to, typical job
18titles, and duties and descriptions which will be considered as
19within the definition of individuals with management
20responsibility for a provider. Prior to barring any individuals
21from participation in the medical assistance program pursuant
22to this Section, such individuals shall have a right to a
23hearing on the individual's culpability for the conduct which
24served as the basis for the vendor's termination. In
25determining culpability, the Department shall consider the
26nature, circumstances, extent, and gravity of the conduct which

 

 

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1served as the basis for the vendor's termination and the degree
2of the individual's participation in such conduct, including
3whether there was an intent to defraud the program or other
4criminal conduct, and the individual's history of prior
5offenses, its effect on the individual's ability to continue
6business, and such other matters as justice may require. Errors
7in record keeping and billing alone shall not be a sufficient
8basis to bar an individual from the medical assistance program.
9    (D) If a vendor has been suspended from the medical
10assistance program under Article V of the Code, the Director
11may require that such vendor correct any deficiencies which
12served as the basis for the suspension. The Director shall
13specify in the suspension order a specific period of time,
14which shall not exceed one year from the date of the order,
15during which a suspended vendor shall not be eligible to
16participate. At the conclusion of the period of suspension the
17Director shall reinstate such vendor, unless he finds that such
18vendor has not corrected deficiencies upon which the suspension
19was based.
20    If a vendor has been terminated from the medical assistance
21program under Article V, such vendor shall be barred from
22participation for at least one year, except that if a vendor
23has been terminated based on a conviction of a violation of
24Article VIIIA or a conviction of a felony based on fraud or a
25willful misrepresentation related to (i) the medical
26assistance program under Article V, (ii) a medical assistance

 

 

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1program in another state that is of the kind provided under
2Article V, (iii) the Medicare program under Title XVIII of the
3Social Security Act, or (iv) the provision of health care
4services, then the vendor shall be barred from participation
5for 5 years or for the length of the vendor's sentence for that
6conviction, whichever is longer. At the end of one year a
7vendor who has been terminated may apply for reinstatement to
8the program. Upon proper application to be reinstated such
9vendor may be deemed eligible by the Director providing that
10such vendor meets the requirements for eligibility under this
11Code. If such vendor is deemed not eligible for reinstatement,
12he shall be barred from again applying for reinstatement for
13one year from the date his application for reinstatement is
14denied. An individual who is a person with management
15responsibility for a vendor; an officer or person owning,
16either directly or indirectly, 5% or more of the shares of
17stock or other evidences of ownership in a corporate vendor; an
18owner of a sole proprietorship that is a vendor; or a partner
19in a partnership that is a vendor, who was previously
20terminated prior to the effective date of this amendatory Act
21of the 97th General Assembly, may apply for reinstatement to
22the program and the Department shall hold a hearing to
23determine the individual's culpability in the conduct that
24resulted in the vendor's termination. If the Director
25determines that the individual was not culpable for the conduct
26which served as the basis for the vendor's termination, the

 

 

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1individual shall be reinstated to the program.
2    A vendor whose termination from participation in the
3Illinois medical assistance program under Article V was based
4solely on an action by a governmental entity other than the
5Illinois Department may, upon reinstatement by that
6governmental entity or upon reversal of the termination, apply
7for rescission of the termination from participation in the
8Illinois medical assistance program. Upon proper application
9for rescission, the vendor may be deemed eligible by the
10Director if the vendor meets the requirements for eligibility
11under this Code.
12    If a vendor has been terminated and reinstated to the
13medical assistance program under Article V and the vendor is
14terminated a second or subsequent time from the medical
15assistance program, the vendor shall be barred from
16participation for at least 2 years, except that if a vendor has
17been terminated a second time based on a conviction of a
18violation of Article VIIIA or a conviction of a felony based on
19fraud or a willful misrepresentation related to (i) the medical
20assistance program under Article V, (ii) a medical assistance
21program in another state that is of the kind provided under
22Article V, (iii) the Medicare program under Title XVIII of the
23Social Security Act, or (iv) the provision of health care
24services, then the vendor shall be barred from participation
25for life. At the end of 2 years, a vendor who has been
26terminated may apply for reinstatement to the program. Upon

 

 

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1application to be reinstated, the vendor may be deemed eligible
2if the vendor meets the requirements for eligibility under this
3Code. If the vendor is deemed not eligible for reinstatement,
4the vendor shall be barred from again applying for
5reinstatement for 2 years from the date the vendor's
6application for reinstatement is denied.
7    (E) The Illinois Department may recover money improperly or
8erroneously paid, or overpayments, either by setoff, crediting
9against future billings or by requiring direct repayment to the
10Illinois Department.
11    If the Illinois Department establishes through an
12administrative hearing that the overpayments resulted from the
13vendor or alternate payee willfully making, or causing to be
14made, a false statement or misrepresentation of a material fact
15in connection with billings and payments under the medical
16assistance program under Article V, the Department may recover
17interest on the amount of the overpayments at the rate of 5%
18per annum. For purposes of this paragraph, "willfully" means
19that a person makes a statement or representation with actual
20knowledge that it was false, or makes a statement or
21representation with knowledge of facts or information that
22would cause one to be aware that the statement or
23representation was false when made.
24    (F) The Illinois Department may withhold payments to any
25vendor or alternate payee during the pendency of any proceeding
26under this Section. The Illinois Department shall state by rule

 

 

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1with as much specificity as practicable the conditions under
2which payments will not be withheld during the pendency of any
3proceeding under this Section and shall provide the vendor with
4a detail of the payments being withheld. Payments may be denied
5for bills submitted with service dates occurring during the
6pendency of a proceeding where the final administrative
7decision is to terminate eligibility to participate in the
8medical assistance program. If the final administrative
9decision is to allow the vendor to continue to participate in
10the medical assistance program, the Department shall release to
11the vendor or the alternate payee all withheld payments,
12including payments for bills submitted with service dates
13occurring during the pendency of the proceeding. The Illinois
14Department shall state by rule with as much specificity as
15practicable the conditions under which payments will not be
16denied for such bills. The Illinois Department shall state by
17rule a process and criteria by which a vendor or alternate
18payee may request full or partial release of payments withheld
19under this subsection. The Department must complete a
20proceeding under this Section in a timely manner.
21    (F-5) The Illinois Department may temporarily withhold
22payments to a vendor or alternate payee if any of the following
23individuals have been indicted or otherwise charged under a law
24of the United States or this or any other state with a felony
25offense that is based on alleged fraud or willful
26misrepresentation on the part of the individual related to (i)

 

 

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1the medical assistance program under Article V of this Code,
2(ii) a medical assistance program provided in another state
3which is of the kind provided under Article V of this Code,
4(iii) the Medicare program under Title XVIII of the Social
5Security Act, or (iv) the provision of health care services:
6        (1) If the vendor or alternate payee is a corporation:
7    an officer of the corporation or an individual who owns,
8    either directly or indirectly, 5% or more of the shares of
9    stock or other evidence of ownership of the corporation.
10        (2) If the vendor is a sole proprietorship: the owner
11    of the sole proprietorship.
12        (3) If the vendor or alternate payee is a partnership:
13    a partner in the partnership.
14        (4) If the vendor or alternate payee is any other
15    business entity authorized by law to transact business in
16    this State: an officer of the entity or an individual who
17    owns, either directly or indirectly, 5% or more of the
18    evidences of ownership of the entity.
19    If the Illinois Department withholds payments to a vendor
20or alternate payee under this subsection, the Department shall
21not release those payments to the vendor or alternate payee
22while any criminal proceeding related to the indictment or
23charge is pending unless the Department determines that there
24is good cause to release the payments before completion of the
25proceeding. If the indictment or charge results in the
26individual's conviction, the Illinois Department shall retain

 

 

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1all withheld payments, which shall be considered forfeited to
2the Department. If the indictment or charge does not result in
3the individual's conviction, the Illinois Department shall
4release to the vendor or alternate payee all withheld payments.
5    (G) The provisions of the Administrative Review Law, as now
6or hereafter amended, and the rules adopted pursuant thereto,
7shall apply to and govern all proceedings for the judicial
8review of final administrative decisions of the Illinois
9Department under this Section. The term "administrative
10decision" is defined as in Section 3-101 of the Code of Civil
11Procedure.
12    (G-5) Non-emergency transportation.
13        (1) (Blank). Notwithstanding any other provision in
14    this Section, for non-emergency transportation vendors,
15    the Department may terminate the vendor from participation
16    in the medical assistance program prior to an evidentiary
17    hearing but after reasonable notice and opportunity to
18    respond as established by the Department by rule.
19        (2) Vendors of non-emergency medical transportation
20    services, as defined by the Department by rule, shall
21    submit to a fingerprint-based criminal background check on
22    current and future information available in the State
23    system and current information available through the
24    Federal Bureau of Investigation's system by submitting all
25    necessary fees and information in the form and manner
26    prescribed by the Department of State Police. The following

 

 

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1    individuals shall be subject to the check:
2            (A) In the case of a vendor that is a corporation,
3        every shareholder who owns, directly or indirectly, 5%
4        or more of the outstanding shares of the corporation.
5            (B) In the case of a vendor that is a partnership,
6        every partner.
7            (C) In the case of a vendor that is a sole
8        proprietorship, the sole proprietor.
9            (D) Each officer or manager of the vendor.
10        Each such vendor shall be responsible for payment of
11    the cost of the criminal background check.
12        (3) Vendors of non-emergency medical transportation
13    services may be required to post a surety bond. The
14    Department shall establish, by rule, the criteria and
15    requirements for determining when a surety bond must be
16    posted and the value of the bond.
17        (4) The Department, or its agents, may refuse to accept
18    requests for non-emergency transportation authorizations,
19    including prior-approval and post-approval requests, for a
20    specific non-emergency transportation vendor if:
21            (A) the Department has initiated a notice of
22        termination of the vendor from participation in the
23        medical assistance program; or
24            (B) the Department has issued notification of its
25        withholding of payments pursuant to subsection (F-5)
26        of this Section; or

 

 

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

 

 

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1affecting the health, safety, and welfare of the facility's
2residents require those continued payments. The Illinois
3Department may condition those continued payments on the
4appointment of temporary management, sale of the facility to
5new owners or operators, or other arrangements that the
6Illinois Department determines best serve the needs of the
7facility's residents.
8    Except in the case of a facility that has a right to a
9hearing on the finding of noncompliance before an agency of the
10federal government, a facility may request a hearing before a
11State agency on any finding of noncompliance within 60 days
12after the notice of the intent to impose a remedy. Except in
13the case of civil money penalties, a request for a hearing
14shall not delay imposition of the penalty. The choice of
15remedies is not appealable at a hearing. The level of
16noncompliance may be challenged only in the case of a civil
17money penalty. The Illinois Department shall provide by rule
18for the State agency that will conduct the evidentiary
19hearings.
20    The Illinois Department may collect interest on unpaid
21civil money penalties.
22    The Illinois Department may adopt all rules necessary to
23implement this subsection (I).
24    (J) The Illinois Department, by rule, may permit individual
25practitioners to designate that Department payments that may be
26due the practitioner be made to an alternate payee or alternate

 

 

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1payees.
2        (a) Such alternate payee or alternate payees shall be
3    required to register as an alternate payee in the Medical
4    Assistance Program with the Illinois Department.
5        (b) If a practitioner designates an alternate payee,
6    the alternate payee and practitioner shall be jointly and
7    severally liable to the Department for payments made to the
8    alternate payee. Pursuant to subsection (E) of this
9    Section, any Department action to recover money or
10    overpayments from an alternate payee shall be subject to an
11    administrative hearing.
12        (c) Registration as an alternate payee or alternate
13    payees in the Illinois Medical Assistance Program shall be
14    conditional. At any time, the Illinois Department may deny
15    or cancel any alternate payee's registration in the
16    Illinois Medical Assistance Program without cause. Any
17    such denial or cancellation is not subject to an
18    administrative hearing.
19        (d) The Illinois Department may seek a revocation of
20    any alternate payee, and all owners, officers, and
21    individuals with management responsibility for such
22    alternate payee shall be permanently prohibited from
23    participating as an owner, an officer, or an individual
24    with management responsibility with an alternate payee in
25    the Illinois Medical Assistance Program, if after
26    reasonable notice and opportunity for a hearing the

 

 

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1    Illinois Department finds that:
2            (1) the alternate payee is not complying with the
3        Department's policy or rules and regulations, or with
4        the terms and conditions prescribed by the Illinois
5        Department in its alternate payee registration
6        agreement; or
7            (2) the alternate payee has failed to keep or make
8        available for inspection, audit, or copying, after
9        receiving a written request from the Illinois
10        Department, such records regarding payments claimed as
11        an alternate payee; or
12            (3) the alternate payee has failed to furnish any
13        information requested by the Illinois Department
14        regarding payments claimed as an alternate payee; or
15            (4) the alternate payee has knowingly made, or
16        caused to be made, any false statement or
17        representation of a material fact in connection with
18        the administration of the Illinois Medical Assistance
19        Program; or
20            (5) the alternate payee, a person with management
21        responsibility for an alternate payee, an officer or
22        person owning, either directly or indirectly, 5% or
23        more of the shares of stock or other evidences of
24        ownership in a corporate alternate payee, or a partner
25        in a partnership which is an alternate payee:
26                (a) was previously terminated from

 

 

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

 

 

09700HB1489sam001- 24 -LRB097 09341 KTG 54147 a

1            corporate vendor at the time the vendor was
2            previously terminated from participation as a
3            vendor in the Illinois Medical Assistance Program
4            and was found culpable by the Illinois Department
5            for the conduct which was the basis for the
6            vendor's termination, or was previously revoked as
7            an alternate payee in the Illinois Medical
8            Assistance Program, or was terminated from
9            participation as a vendor in a medical assistance
10            program in another state that is of the same kind
11            as the program of medical assistance provided
12            under Article V of this Code, during the time of
13            conduct which was the basis for that vendor's
14            termination; or
15                (d) was an owner of a sole proprietorship or
16            partner in a partnership at the time the vendor was
17            previously terminated from participation as a
18            vendor in the Illinois Medical Assistance Program
19            and was found culpable by the Illinois Department
20            for the conduct which was the basis for the
21            vendor's termination, or was previously revoked as
22            an alternate payee in the Illinois Medical
23            Assistance Program, or was terminated from
24            participation as a vendor in a medical assistance
25            program in another state that is of the same kind
26            as the program of medical assistance provided

 

 

09700HB1489sam001- 25 -LRB097 09341 KTG 54147 a

1            under Article V of this Code, during the time of
2            conduct which was the basis for that vendor's
3            termination or alternate payee's revocation; or
4            (6) the alternate payee, a person with management
5        responsibility for an alternate payee, an officer or
6        person owning, either directly or indirectly, 5% or
7        more of the shares of stock or other evidences of
8        ownership in a corporate alternate payee, or a partner
9        in a partnership which is an alternate payee:
10                (a) has engaged in conduct prohibited by
11            applicable federal or State law or regulation
12            relating to the Illinois Medical Assistance
13            Program; or
14                (b) was a person with management
15            responsibility for a vendor or alternate payee at
16            the time that the vendor or alternate payee engaged
17            in practices prohibited by applicable federal or
18            State law or regulation relating to the Illinois
19            Medical Assistance Program and was found culpable
20            by the Illinois Department for the conduct which
21            was the basis for the vendor's termination; or
22                (c) was an officer, or person owning, either
23            directly or indirectly, 5% or more of the shares of
24            stock or other evidences of ownership in a vendor
25            or alternate payee at the time such vendor or
26            alternate payee engaged in practices prohibited by

 

 

09700HB1489sam001- 26 -LRB097 09341 KTG 54147 a

1            applicable federal or State law or regulation
2            relating to the Illinois Medical Assistance
3            Program and was found culpable by the Illinois
4            Department for the conduct which was the basis for
5            the vendor's termination; or
6                (d) was an owner of a sole proprietorship or
7            partner in a partnership which was a vendor or
8            alternate payee at the time such vendor or
9            alternate payee engaged in practices prohibited by
10            applicable federal or State law or regulation
11            relating to the Illinois Medical Assistance
12            Program and was found culpable by the Illinois
13            Department for the conduct which was the basis for
14            the vendor's termination; or
15            (7) the direct or indirect ownership of the vendor
16        or alternate payee (including the ownership of a vendor
17        or alternate payee that is a partner's interest in a
18        vendor or alternate payee, or ownership of 5% or more
19        of the shares of stock or other evidences of ownership
20        in a corporate vendor or alternate payee) has been
21        transferred by an individual who is terminated or
22        barred from participating as a vendor or is prohibited
23        or revoked as an alternate payee to the individual's
24        spouse, child, brother, sister, parent, grandparent,
25        grandchild, uncle, aunt, niece, nephew, cousin, or
26        relative by marriage.

 

 

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1    (K) The Illinois Department of Healthcare and Family
2Services may withhold payments, in whole or in part, to a
3provider or alternate payee upon receipt of evidence, received
4from State or federal law enforcement or federal oversight
5agencies or from the results of a preliminary Department audit
6and determined by the Department to be credible, that the
7circumstances giving rise to the need for a withholding of
8payments may involve fraud or willful misrepresentation under
9the Illinois Medical Assistance program. The Department shall
10by rule define what constitutes "credible" evidence for
11purposes of this subsection. The Department may withhold
12payments without first notifying the provider or alternate
13payee of its intention to withhold such payments. A provider or
14alternate payee may request a reconsideration of payment
15withholding, and the Department must grant such a request. The
16Department shall state by rule a process and criteria by which
17a provider or alternate payee may request full or partial
18release of payments withheld under this subsection. This
19request may be made at any time after the Department first
20withholds such payments.
21        (a) The Illinois Department must send notice of its
22    withholding of program payments within 5 days of taking
23    such action. The notice must set forth the general
24    allegations as to the nature of the withholding action, but
25    need not disclose any specific information concerning its
26    ongoing investigation. The notice must do all of the

 

 

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1    following:
2            (1) State that payments are being withheld in
3        accordance with this subsection.
4            (2) State that the withholding is for a temporary
5        period, as stated in paragraph (b) of this subsection,
6        and cite the circumstances under which withholding
7        will be terminated.
8            (3) Specify, when appropriate, which type or types
9        of Medicaid claims withholding is effective.
10            (4) Inform the provider or alternate payee of the
11        right to submit written evidence for reconsideration
12        of the withholding by the Illinois Department.
13            (5) Inform the provider or alternate payee that a
14        written request may be made to the Illinois Department
15        for full or partial release of withheld payments and
16        that such requests may be made at any time after the
17        Department first withholds such payments.
18        (b) All withholding-of-payment actions under this
19    subsection shall be temporary and shall not continue after
20    any of the following:
21            (1) The Illinois Department or the prosecuting
22        authorities determine that there is insufficient
23        evidence of fraud or willful misrepresentation by the
24        provider or alternate payee.
25            (2) Legal proceedings related to the provider's or
26        alternate payee's alleged fraud, willful

 

 

09700HB1489sam001- 29 -LRB097 09341 KTG 54147 a

1        misrepresentation, violations of this Act, or
2        violations of the Illinois Department's administrative
3        rules are completed.
4            (3) The withholding of payments for a period of 3
5        years.
6        (c) The Illinois Department may adopt all rules
7    necessary to implement this subsection (K).
8(Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
 
9    Section 99. Effective date. This Act takes effect upon
10becoming law.".