97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB3354

 

Introduced 2/7/2012, by Sen. Kwame Raoul

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/12-4.25  from Ch. 23, par. 12-4.25

    Amends the Illinois Public Aid Code. Sets forth certain circumstances under which the Department of Healthcare and Family Services may deny the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to Medicaid recipients because of an outstanding debt owed to the Department. Sets forth the conditions under which a debtor-vendor may enroll or participate in the medical assistance program. Contains provisions concerning the recovery of interest on overpayments; the withholding of payments to vendors who are not in compliance with State and federal regulations; the recovery of a debt owed by a vendor or alternate payee; the withholding of payments to vendors upon initiation of an audit; and other matters.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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, exclude, or
10terminate the eligibility of any person, firm, corporation,
11association, agency, institution or other legal entity to
12participate as a vendor of goods or services to recipients
13under the medical assistance program under Article V, if after
14reasonable notice and opportunity for a hearing the Illinois
15Department finds:
16        (a) Such vendor is not complying with the Department's
17    policy or rules and regulations, or with the terms and
18    conditions prescribed by the Illinois Department in its
19    vendor agreement, which document shall be developed by the
20    Department as a result of negotiations with each vendor
21    category, including physicians, hospitals, long term care
22    facilities, pharmacists, optometrists, podiatrists and
23    dentists setting forth the terms and conditions applicable

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1or person owning, either directly or indirectly, 5% or more of
2the shares of stock or other evidences of ownership in a
3corporate vendor, (iv) an owner of a sole proprietorship that
4is a vendor, or (v) a partner in a partnership that is a vendor
5has been convicted of a felony offense related to any of the
6following:
7        (1) Murder.
8        (2) A Class X felony under the Criminal Code of 1961.
9    (A-15) The Department may deny the eligibility of any
10person, firm, corporation, association, agency, institution,
11or other legal entity to participate as a vendor of goods or
12services to recipients under the medical assistance program
13under Article V if, after reasonable notice and opportunity for
14a hearing, the Department finds:
15        (1) The applicant or any person with management
16    responsibility for the applicant; an incorporator,
17    officer, or member of the board of directors of an
18    applicant; an entity owning (directly or indirectly) 5% or
19    more of the shares of stock or other evidences of ownership
20    in a corporate vendor applicant; an owner of a sole
21    proprietorship applicant; a partner in a partnership
22    applicant; or a technical or other advisor to an applicant
23    has a debt owed to the Department, and no payment
24    arrangements acceptable to the Department have been made.
25        (2) The applicant or any person with management
26    responsibility for the applicant; an incorporator,

 

 

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1    officer, or member of the board of directors of an
2    applicant; an entity owning (directly or indirectly) 5% or
3    more of the shares of stock or other evidences of ownership
4    in a corporate vendor applicant; an owner of a sole
5    proprietorship applicant; a partner in a partnership
6    vendor applicant; or a technical or other advisor to an
7    applicant was (i) a person with management responsibility,
8    (ii) an incorporator, officer, or member of the board of
9    directors of an applicant, (iii) an entity owning (directly
10    or indirectly) 5% or more of the shares of stock or other
11    evidences of ownership in a corporate vendor, (iv) an owner
12    of a sole proprietorship, (v) a partner in a partnership
13    vendor, or (vi) a technical or other advisor to a vendor,
14    during a period of time when the conduct of that vendor
15    resulted in a debt owed to the Department, and no payment
16    arrangements acceptable to the Department have been made by
17    that vendor.
18        (3) There is credible evidence of the use, transfer, or
19    lease of assets of any kind to an applicant from a current
20    or prior vendor who has a debt owed to the Department and
21    no payment arrangements acceptable to the Department have
22    been made by that vendor.
23        (4) There is credible evidence of a transfer of
24    management responsibilities, or direct or indirect
25    ownership, or other evidences of ownership of any kind, to
26    an applicant from a current or prior vendor who has a debt

 

 

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1    owed to the Department and no payment arrangements
2    acceptable to the Department have been made.
3        (5) There is credible evidence of the use, transfer, or
4    lease of assets of any kind to an applicant who is a
5    spouse, child, brother, sister, parent, grandparent,
6    grandchild, uncle, aunt, niece, relative by marriage,
7    nephew, cousin, or relative of a current or prior vendor
8    who has a debt owed to the Department and no payment
9    arrangements acceptable to the Department have been made.
10    The Department shall by rule define what constitutes
11"credible" evidence for purposes of this subsection. The
12Department shall state by rule a process and criteria by which
13a provider or alternate payee may request to make acceptable
14payment arrangements.
15    (B) The Illinois Department shall deny, suspend, or
16terminate, or exclude the eligibility of any person, firm,
17corporation, association, agency, institution or other legal
18entity to participate as a vendor of goods or services to
19recipients under the medical assistance program under Article
20V:
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

 

 

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1    this Code, as provided in Article VIIIA.
2    (C) Upon termination or exclusion of a vendor of goods or
3services from participation in the medical assistance program
4authorized by this Article, a person with management
5responsibility for such vendor during the time of any conduct
6which served as the basis for that vendor's termination or
7exclusion is barred from participation in the medical
8assistance program.
9    Upon termination or exclusion of a corporate vendor, the
10officers and persons owning, directly or indirectly, 5% or more
11of the shares of stock or other evidences of ownership in the
12vendor during the time of any conduct which served as the basis
13for that vendor's termination or exclusion are barred from
14participation in the medical assistance program. A person who
15owns, directly or indirectly, 5% or more of the shares of stock
16or other evidences of ownership in a terminated or excluded
17corporate vendor may not transfer his or her ownership interest
18in that vendor to his or her spouse, child, brother, sister,
19parent, grandparent, grandchild, uncle, aunt, niece, nephew,
20cousin, or relative by marriage.
21    Upon termination or exclusion of a sole proprietorship or
22partnership, the owner or partners during the time of any
23conduct which served as the basis for that vendor's termination
24or exclusion are barred from participation in the medical
25assistance program. The owner of a terminated or excluded
26vendor that is a sole proprietorship, and a partner in a

 

 

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1terminated or excluded vendor that is a partnership, may not
2transfer his or her ownership or partnership interest in that
3vendor to his or her spouse, child, brother, sister, parent,
4grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
5or relative by marriage.
6    A person who owns, directly or indirectly, 5% or more of
7the shares of stock or other evidences of ownership in a vendor
8who owes a debt to the Department and has not made acceptable
9payment arrangements shall not transfer his or her ownership
10interest in that vendor, or vendor assets of any kind, to his
11or her spouse, child, brother, sister, parent, grandparent,
12grandchild, uncle, aunt, niece, nephew, cousin, or relative by
13marriage.
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.
21    A vendor or a prior vendor who has been terminated,
22excluded, or suspended from the Illinois medical assistance
23program, or from another State program of the same kind
24provided under Article V of this Code or from the Medicare
25program under Title XVIII of the Social Security Act, and any
26individual currently or previously barred as a result of being

 

 

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1an officer or a person owning, directly or indirectly, 5% or
2more of the shares of stock or other evidences of ownership in
3a vendor during the time of any conduct which served as the
4basis for that vendor's termination, suspension, or exclusion,
5may be required to post a surety bond as part of a condition of
6enrollment or participation in the Illinois medical assistance
7program. The Department shall establish, by rule, the criteria
8and requirements for determining when a surety bond must be
9posted and the value of the bond.
10    A vendor or a prior vendor who has a debt owed to the
11Department, including debts discharged under federal or State
12bankruptcy laws, and any individual currently or previously
13barred as a result of being an officer or a person owning,
14directly or indirectly, 5% or more of the shares of stock or
15other evidences of ownership in that vendor during the time of
16any conduct which served as the basis for the debt, may be
17required to post a surety bond as part of a condition of
18enrollment or participation in the Illinois medical assistance
19program. The Department shall establish, by rule, the criteria
20and requirements for determining when a surety bond must be
21posted and the value of the bond.
22    (D) If a vendor has been suspended from the medical
23assistance program under Article V of the Code, the Director
24may require that such vendor correct any deficiencies which
25served as the basis for the suspension. The Director shall
26specify in the suspension order a specific period of time,

 

 

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

 

 

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

 

 

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1program. Upon application to be reinstated, the vendor may be
2deemed eligible if the vendor meets the requirements for
3eligibility under this Code. If the vendor is deemed not
4eligible for reinstatement, the vendor shall be barred from
5again applying for reinstatement for 2 years from the date the
6vendor's application 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    The Department may recover interest on the amount of the
12overpayment if the total overpayment is greater than $100. The
13interest on the outstanding overpayment balance shall be at a
14rate of one-half of 1% per month or fraction thereof, based on
15the date the Department first notifies the vendor or payee of
16the debt owed the Department, subject to a maximum of 6% per
17annum.
18    If the Illinois Department establishes through an
19administrative hearing that the overpayments resulted from the
20vendor or alternate payee willfully making, or causing to be
21made, a false statement or misrepresentation of a material fact
22in connection with billings and payments under the medical
23assistance program under Article V, the Department may recover
24interest on the amount of the overpayments at the rate of 5%
25per annum. For purposes of this paragraph, "willfully" means
26that a person makes a statement or representation with actual

 

 

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1knowledge that it was false, or makes a statement or
2representation with knowledge of facts or information that
3would cause one to be aware that the statement or
4representation was false when made.
5    (F) The Illinois Department may withhold payments to any
6vendor or alternate payee during the pendency of any proceeding
7under this Section, and through the pendency of any
8administrative appeal or administrative review by any court
9proceeding. The Illinois Department shall state by rule with as
10much specificity as practicable the conditions under which
11payments will not be withheld during the pendency of any
12proceeding under this Section. Payments may be denied for bills
13submitted with service dates occurring during the pendency of a
14proceeding, after a final decision has been rendered, or after
15the conclusion of any administrative appeal, where the final
16administrative decision is to terminate, exclude, or suspend
17eligibility to participate in the medical assistance program.
18The Illinois Department shall state by rule with as much
19specificity as practicable the conditions under which payments
20will not be denied for such bills. The Illinois Department
21shall state by rule a process and criteria by which a vendor or
22alternate payee may request full or partial release of payments
23withheld under this subsection. The Department must complete a
24proceeding under this Section in a timely manner.
25    Notwithstanding recovery allowed under subsection (E) of
26this Section, the Illinois Department may withhold payments to

 

 

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1any vendor or alternate payee who is not properly licensed,
2certified, or in compliance with the State or federal agency
3regulations. Payments may be denied for bills submitted with
4service dates occurring during the period of time in which a
5vendor is not properly licensed, certified, or in compliance
6with State or federal regulations.
7    (F-5) The Illinois Department may temporarily withhold
8payments to a vendor or alternate payee if any of the following
9individuals have been indicted or otherwise charged under a law
10of the United States or this or any other state with a felony
11offense that is based on alleged fraud or willful
12misrepresentation on the part of the individual related to (i)
13the medical assistance program under Article V of this Code,
14(ii) a medical assistance program provided in another state
15which is of the kind provided under Article V of this Code,
16(iii) the Medicare program under Title XVIII of the Social
17Security Act, or (iv) the provision of health care services:
18        (1) If the vendor or alternate payee is a corporation:
19    an officer of the corporation or an individual who owns,
20    either directly or indirectly, 5% or more of the shares of
21    stock or other evidence of ownership of the corporation.
22        (2) If the vendor is a sole proprietorship: the owner
23    of the sole proprietorship.
24        (3) If the vendor or alternate payee is a partnership:
25    a partner in the partnership.
26        (4) If the vendor or alternate payee is any other

 

 

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1    business entity authorized by law to transact business in
2    this State: an officer of the entity or an individual who
3    owns, either directly or indirectly, 5% or more of the
4    evidences of ownership of the entity.
5    If the Illinois Department withholds payments to a vendor
6or alternate payee under this subsection, the Department shall
7not release those payments to the vendor or alternate payee
8while any criminal proceeding related to the indictment or
9charge is pending unless the Department determines that there
10is good cause to release the payments before completion of the
11proceeding. If the indictment or charge results in the
12individual's conviction, the Illinois Department shall retain
13all withheld payments, which shall be considered forfeited to
14the Department. If the indictment or charge does not result in
15the individual's conviction, the Illinois Department shall
16release to the vendor or alternate payee all withheld payments.
17    (F-10) If the Department establishes that the vendor or
18alternate payee owes a debt to the Department, and the vendor
19or alternate payee subsequently fails to pay or make
20satisfactory payment arrangements with the Department for the
21debt owed, the Department may seek all remedies available under
22the laws of this State to recover the debt, including, but not
23limited to, wage garnishment or the filing of claims or liens
24against the vendor or alternate payee.
25    (F-15) Enforcement of judgment.
26        (1) Any fine, recovery amount, other sanction, or costs

 

 

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1    imposed, or any part of any fine, recovery amount, other
2    sanction, or costs imposed, remaining unpaid after the
3    exhaustion of or the failure to exhaust judicial review
4    procedures under the Illinois Administrative Review Law
5    are a debt due and owing the State and may be collected in
6    accordance with applicable law.
7        (2) After expiration of the period in which judicial
8    review under the Illinois Administrative Review Law may be
9    sought for a final administrative decision, unless stayed
10    by a court of competent jurisdiction, the findings,
11    decision, and order of the Director may be enforced in the
12    same manner as a judgment entered by a court of competent
13    jurisdiction.
14        (3) In any case in which any person or entity has
15    failed to comply with a judgment ordering or imposing any
16    fine or other sanction, or any expenses incurred by the
17    State agency to enforce the judgment, including, but not
18    limited to, attorney's fees, court costs, and costs related
19    to property demolition or foreclosure, after they are fixed
20    by a court of competent jurisdiction or the Director, that
21    fine or other sanction, or those expenses, shall be a debt
22    due and owing the State and may be collected in accordance
23    with applicable law. Prior to any expenses being fixed by a
24    final administrative decision pursuant to this subsection
25    (F-15), the Department shall provide notice to the
26    individual or entity that states that the individual shall

 

 

SB3354- 20 -LRB097 14548 KTG 62162 b

1    appear at a hearing before the administrative hearing
2    officer to determine whether the defendant has failed to
3    comply with the judgment. The notice shall set the date for
4    such a hearing, which shall not be less than 7 days from
5    the date that notice is served. If notice is served by
6    mail, the 7-day period shall begin to run on the date that
7    the notice was deposited in the mail.
8        (4) Upon being recorded in the manner required by
9    Article XII of the Code of Civil Procedure or by the
10    Uniform Commercial Code, a lien shall be imposed on the
11    real estate or personal estate, or both, of the individual
12    or entity in the amount of any debt due and owing the State
13    under this Section. The lien may be enforced in the same
14    manner as a judgment of a court of competent jurisdiction.
15    A lien shall attach to all property and assets of such
16    person, firm, corporation, association, agency,
17    institution, or other legal entity until the judgment is
18    satisfied.
19        (5) The Director may set aside any judgment entered by
20    default and set a new hearing date, upon a petition filed
21    within 21 days after the issuance of the order of default,
22    if the hearing officer determines that the petitioner's
23    failure to appear at the hearing was for good cause, or at
24    any time if the petitioner's failure to appear at the
25    hearing was for good cause, or at any time if the
26    petitioner established that the Department did not provide

 

 

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1    proper service of process. If any judgment is set aside
2    pursuant to this paragraph (5), the hearing officer shall
3    have authority to enter an order extinguishing any lien
4    which has been recorded for any debt due and owing the
5    State as a result of the vacated default judgment.
6    (G) The provisions of the Administrative Review Law, as now
7or hereafter amended, and the rules adopted pursuant thereto,
8shall apply to and govern all proceedings for the judicial
9review of final administrative decisions of the Illinois
10Department under this Section. The term "administrative
11decision" is defined as in Section 3-101 of the Code of Civil
12Procedure.
13    (G-5) Non-emergency transportation.
14        (1) Notwithstanding any other provision in this
15    Section, for non-emergency transportation vendors, the
16    Department may terminate or exclude the vendor from
17    participation in the medical assistance program prior to an
18    evidentiary hearing but after reasonable notice and
19    opportunity to respond as established by the Department by
20    rule.
21        (2) Vendors of non-emergency medical transportation
22    services, as defined by the Department by rule, shall
23    submit to a fingerprint-based criminal background check on
24    current and future information available in the State
25    system and current information available through the
26    Federal Bureau of Investigation's system by submitting all

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1        in a partnership which is an alternate payee:
2                (a) was previously terminated or excluded from
3            participation as a vendor in the Illinois Medical
4            Assistance Program, or was previously revoked as
5            an alternate payee in the Illinois Medical
6            Assistance Program, or was terminated or excluded
7            from participation as a vendor in a medical
8            assistance program in another state that is of the
9            same kind as the program of medical assistance
10            provided under Article V of this Code; or
11                (b) was a person with management
12            responsibility for a vendor previously terminated
13            or excluded from participation as a vendor in the
14            Illinois Medical Assistance Program, or was
15            previously revoked as an alternate payee in the
16            Illinois Medical Assistance Program, or was
17            terminated or excluded from participation as a
18            vendor in a medical assistance program in another
19            state that is of the same kind as the program of
20            medical assistance provided under Article V of
21            this Code, during the time of conduct which was the
22            basis for that vendor's termination or exclusion
23            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

 

 

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

 

 

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

 

 

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1            applicable federal or State law or regulation
2            relating to the Illinois Medical Assistance
3            Program; or
4            (7) the direct or indirect ownership of the vendor
5        or alternate payee (including the ownership of a vendor
6        or alternate payee that is a partner's interest in a
7        vendor or alternate payee, or ownership of 5% or more
8        of the shares of stock or other evidences of ownership
9        in a corporate vendor or alternate payee) has been
10        transferred by an individual who is terminated,
11        excluded, or barred from participating as a vendor or
12        is prohibited or revoked as an alternate payee to the
13        individual's spouse, child, brother, sister, parent,
14        grandparent, grandchild, uncle, aunt, niece, nephew,
15        cousin, or relative by marriage.
16    (K) The Illinois Department of Healthcare and Family
17Services may withhold payments, in whole or in part, to a
18provider or alternate payee upon receipt of evidence, received
19from State or federal law enforcement or federal oversight
20agencies or from the results of a preliminary Department audit
21and determined by the Department to be credible, that the
22circumstances giving rise to the need for a withholding of
23payments may involve fraud or willful misrepresentation under
24the Illinois Medical Assistance program. The Department shall
25by rule define what constitutes "credible" evidence for
26purposes of this subsection. The Department may withhold

 

 

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1payments without first notifying the provider or alternate
2payee of its intention to withhold such payments. A provider or
3alternate payee may request a reconsideration of payment
4withholding, and the Department must grant such a request. The
5Department shall state by rule a process and criteria by which
6a provider or alternate payee may request full or partial
7release of payments withheld under this subsection. This
8request may be made at any time after the Department first
9withholds such payments.
10        (a) The Illinois Department must send notice of its
11    withholding of program payments within 5 days of taking
12    such action. The notice must set forth the general
13    allegations as to the nature of the withholding action, but
14    need not disclose any specific information concerning its
15    ongoing investigation. The notice must do all of the
16    following:
17            (1) State that payments are being withheld in
18        accordance with this subsection.
19            (2) State that the withholding is for a temporary
20        period, as stated in paragraph (b) of this subsection,
21        and cite the circumstances under which withholding
22        will be terminated.
23            (3) Specify, when appropriate, which type or types
24        of Medicaid claims withholding is effective.
25            (4) Inform the provider or alternate payee of the
26        right to submit written evidence for reconsideration

 

 

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1        of the withholding by the Illinois Department.
2            (5) Inform the provider or alternate payee that a
3        written request may be made to the Illinois Department
4        for full or partial release of withheld payments and
5        that such requests may be made at any time after the
6        Department first withholds such payments.
7        (b) All withholding-of-payment actions under this
8    subsection shall be temporary and shall not continue after
9    any of the following:
10            (1) The Illinois Department or the prosecuting
11        authorities determine that there is insufficient
12        evidence of fraud or willful misrepresentation by the
13        provider or alternate payee.
14            (2) Legal proceedings related to the provider's or
15        alternate payee's alleged fraud, willful
16        misrepresentation, violations of this Act, or
17        violations of the Illinois Department's administrative
18        rules are completed.
19            (3) The withholding of payments for a period of 3
20        years.
21        (c) The Illinois Department may adopt all rules
22    necessary to implement this subsection (K).
23    (K-5) The Illinois Department of Healthcare and Family
24Services may withhold payments, in whole or in part, to a
25provider or alternate payee upon initiation of an audit,
26quality of care review, or investigation when there is credible

 

 

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1evidence of financial risk or the provider demonstrates a
2failure to cooperate with the Department creating
3circumstances giving rise to the need for a withholding of
4payments. The Department shall by rule define what constitutes
5"credible" evidence for purposes of this subsection. The
6Department may withhold payments without first notifying the
7provider or alternate payee of its intention to withhold such
8payments. A provider or alternate payee may request a
9reconsideration of payment withholding, and the Department
10must grant such a request. The Department shall state by rule a
11process and criteria by which a provider or alternate payee may
12request full or partial release of payments withheld under this
13subsection. This request may be made at any time after the
14Department first withholds such payments.
15        (a) The Department must send notice of its withholding
16    of program payments within 5 days of taking such action.
17    The notice must set forth the general allegations as to the
18    nature of the withholding action, but need not disclose any
19    specific information concerning its ongoing investigation.
20    The notice must do all of the following:
21            (1) State that payments are being withheld in
22        accordance with this subsection.
23            (2) State that the withholding is for a temporary
24        period, as stated in paragraph (b) of this subsection,
25        and cite the circumstances under which withholding
26        will be terminated.

 

 

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1            (3) Specify, when appropriate, which type or types
2        of Medicaid claims withholding are effective.
3            (4) Inform the provider or alternate payee of the
4        right to submit written evidence for reconsideration
5        of the withholding by the Department.
6            (5) Inform the provider or alternate payee that a
7        written request may be made to the Department for full
8        or partial release of withheld payments and that such
9        requests may be made at any time after the Department
10        first withholds such payments.
11        (b) All withholding of payment actions under this
12    subsection shall be temporary and shall not continue after
13    any of the following:
14            (1) the Department determines that there is
15        insufficient evidence of financial risk by the
16        provider or alternate payee; or
17            (2) the withholding of payments has lasted for a
18        period in excess of 3 years.
19        (c) The Department may adopt all rules necessary to
20    implement this subsection (K-5).
21(Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)