Illinois General Assembly - Full Text of SB2840
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Full Text of SB2840  97th General Assembly


Sen. John G. Mulroe

Filed: 3/2/2012





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2    AMENDMENT NO. ______. Amend Senate Bill 2840 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5, 11-13, 11-26, and 12-13.1 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial



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1care furnished by licensed practitioners; (7) home health care
2services; (8) private duty nursing service; (9) clinic
3services; (10) dental services, including prevention and
4treatment of periodontal disease and dental caries disease for
5pregnant women, provided by an individual licensed to practice
6dentistry or dental surgery; for purposes of this item (10),
7"dental services" means diagnostic, preventive, or corrective
8procedures provided by or under the supervision of a dentist in
9the practice of his or her profession; (11) physical therapy
10and related services; (12) prescribed drugs, dentures, and
11prosthetic devices; and eyeglasses prescribed by a physician
12skilled in the diseases of the eye, or by an optometrist,
13whichever the person may select; (13) other diagnostic,
14screening, preventive, and rehabilitative services, for
15children and adults; (14) transportation and such other
16expenses as may be necessary; (15) medical treatment of sexual
17assault survivors, as defined in Section 1a of the Sexual
18Assault Survivors Emergency Treatment Act, for injuries
19sustained as a result of the sexual assault, including
20examinations and laboratory tests to discover evidence which
21may be used in criminal proceedings arising from the sexual
22assault; (16) the diagnosis and treatment of sickle cell
23anemia; and (17) any other medical care, and any other type of
24remedial care recognized under the laws of this State, but not
25including abortions, or induced miscarriages or premature
26births, unless, in the opinion of a physician, such procedures



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1are necessary for the preservation of the life of the woman
2seeking such treatment, or except an induced premature birth
3intended to produce a live viable child and such procedure is
4necessary for the health of the mother or her unborn child. The
5Illinois Department, by rule, shall prohibit any physician from
6providing medical assistance to anyone eligible therefor under
7this Code where such physician has been found guilty of
8performing an abortion procedure in a wilful and wanton manner
9upon a woman who was not pregnant at the time such abortion
10procedure was performed. The term "any other type of remedial
11care" shall include nursing care and nursing home service for
12persons who rely on treatment by spiritual means alone through
13prayer for healing.
14    Notwithstanding any other provision of this Section, a
15comprehensive tobacco use cessation program that includes
16purchasing prescription drugs or prescription medical devices
17approved by the Food and Drug Administration shall be covered
18under the medical assistance program under this Article for
19persons who are otherwise eligible for assistance under this
21    Notwithstanding any other provision of this Code, the
22Illinois Department may not require, as a condition of payment
23for any laboratory test authorized under this Article, that a
24physician's handwritten signature appear on the laboratory
25test order form. The Illinois Department may, however, impose
26other appropriate requirements regarding laboratory test order



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2    The Department of Healthcare and Family Services shall
3provide the following services to persons eligible for
4assistance under this Article who are participating in
5education, training or employment programs operated by the
6Department of Human Services as successor to the Department of
7Public Aid:
8        (1) dental services provided by or under the
9    supervision of a dentist; and
10        (2) eyeglasses prescribed by a physician skilled in the
11    diseases of the eye, or by an optometrist, whichever the
12    person may select.
13    Notwithstanding any other provision of this Code and
14subject to federal approval, the Department may adopt rules to
15allow a dentist who is volunteering his or her service at no
16cost to render dental services through an enrolled
17not-for-profit health clinic without the dentist personally
18enrolling as a participating provider in the medical assistance
19program. A not-for-profit health clinic shall include a public
20health clinic or Federally Qualified Health Center or other
21enrolled provider, as determined by the Department, through
22which dental services covered under this Section are performed.
23The Department shall establish a process for payment of claims
24for reimbursement for covered dental services rendered under
25this provision.
26    The Illinois Department, by rule, may distinguish and



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1classify the medical services to be provided only in accordance
2with the classes of persons designated in Section 5-2.
3    The Department of Healthcare and Family Services must
4provide coverage and reimbursement for amino acid-based
5elemental formulas, regardless of delivery method, for the
6diagnosis and treatment of (i) eosinophilic disorders and (ii)
7short bowel syndrome when the prescribing physician has issued
8a written order stating that the amino acid-based elemental
9formula is medically necessary.
10    The Illinois Department shall authorize the provision of,
11and shall authorize payment for, screening by low-dose
12mammography for the presence of occult breast cancer for women
1335 years of age or older who are eligible for medical
14assistance under this Article, as follows:
15        (A) A baseline mammogram for women 35 to 39 years of
16    age.
17        (B) An annual mammogram for women 40 years of age or
18    older.
19        (C) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.
24        (D) A comprehensive ultrasound screening of an entire
25    breast or breasts if a mammogram demonstrates
26    heterogeneous or dense breast tissue, when medically



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1    necessary as determined by a physician licensed to practice
2    medicine in all of its branches.
3    All screenings shall include a physical breast exam,
4instruction on self-examination and information regarding the
5frequency of self-examination and its value as a preventative
6tool. For purposes of this Section, "low-dose mammography"
7means the x-ray examination of the breast using equipment
8dedicated specifically for mammography, including the x-ray
9tube, filter, compression device, and image receptor, with an
10average radiation exposure delivery of less than one rad per
11breast for 2 views of an average size breast. The term also
12includes digital mammography.
13    On and after January 1, 2012, providers participating in a
14quality improvement program approved by the Department shall be
15reimbursed for screening and diagnostic mammography at the same
16rate as the Medicare program's rates, including the increased
17reimbursement for digital mammography.
18    The Department shall convene an expert panel including
19representatives of hospitals, free-standing mammography
20facilities, and doctors, including radiologists, to establish
21quality standards.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities.



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1    The Department shall establish a methodology to remind
2women who are age-appropriate for screening mammography, but
3who have not received a mammogram within the previous 18
4months, of the importance and benefit of screening mammography.
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot program
14in areas of the State with the highest incidence of mortality
15related to breast cancer. At least one pilot program site shall
16be in the metropolitan Chicago area and at least one site shall
17be outside the metropolitan Chicago area. An evaluation of the
18pilot program shall be carried out measuring health outcomes
19and cost of care for those served by the pilot program compared
20to similarly situated patients who are not served by the pilot
22    Any medical or health care provider shall immediately
23recommend, to any pregnant woman who is being provided prenatal
24services and is suspected of drug abuse or is addicted as
25defined in the Alcoholism and Other Drug Abuse and Dependency
26Act, referral to a local substance abuse treatment provider



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1licensed by the Department of Human Services or to a licensed
2hospital which provides substance abuse treatment services.
3The Department of Healthcare and Family Services shall assure
4coverage for the cost of treatment of the drug abuse or
5addiction for pregnant recipients in accordance with the
6Illinois Medicaid Program in conjunction with the Department of
7Human Services.
8    All medical providers providing medical assistance to
9pregnant women under this Code shall receive information from
10the Department on the availability of services under the Drug
11Free Families with a Future or any comparable program providing
12case management services for addicted women, including
13information on appropriate referrals for other social services
14that may be needed by addicted women in addition to treatment
15for addiction.
16    The Illinois Department, in cooperation with the
17Departments of Human Services (as successor to the Department
18of Alcoholism and Substance Abuse) and Public Health, through a
19public awareness campaign, may provide information concerning
20treatment for alcoholism and drug abuse and addiction, prenatal
21health care, and other pertinent programs directed at reducing
22the number of drug-affected infants born to recipients of
23medical assistance.
24    Neither the Department of Healthcare and Family Services
25nor the Department of Human Services shall sanction the
26recipient solely on the basis of her substance abuse.



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1    The Illinois Department shall establish such regulations
2governing the dispensing of health services under this Article
3as it shall deem appropriate. The Department should seek the
4advice of formal professional advisory committees appointed by
5the Director of the Illinois Department for the purpose of
6providing regular advice on policy and administrative matters,
7information dissemination and educational activities for
8medical and health care providers, and consistency in
9procedures to the Illinois Department.
10    Notwithstanding any other provision of law, a health care
11provider under the medical assistance program may elect, in
12lieu of receiving direct payment for services provided under
13that program, to participate in the State Employees Deferred
14Compensation Plan adopted under Article 24 of the Illinois
15Pension Code. A health care provider who elects to participate
16in the plan does not have a cause of action against the State
17for any damages allegedly suffered by the provider as a result
18of any delay by the State in crediting the amount of any
19contribution to the provider's plan account.
20    The Illinois Department may develop and contract with
21Partnerships of medical providers to arrange medical services
22for persons eligible under Section 5-2 of this Code.
23Implementation of this Section may be by demonstration projects
24in certain geographic areas. The Partnership shall be
25represented by a sponsor organization. The Department, by rule,
26shall develop qualifications for sponsors of Partnerships.



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1Nothing in this Section shall be construed to require that the
2sponsor organization be a medical organization.
3    The sponsor must negotiate formal written contracts with
4medical providers for physician services, inpatient and
5outpatient hospital care, home health services, treatment for
6alcoholism and substance abuse, and other services determined
7necessary by the Illinois Department by rule for delivery by
8Partnerships. Physician services must include prenatal and
9obstetrical care. The Illinois Department shall reimburse
10medical services delivered by Partnership providers to clients
11in target areas according to provisions of this Article and the
12Illinois Health Finance Reform Act, except that:
13        (1) Physicians participating in a Partnership and
14    providing certain services, which shall be determined by
15    the Illinois Department, to persons in areas covered by the
16    Partnership may receive an additional surcharge for such
17    services.
18        (2) The Department may elect to consider and negotiate
19    financial incentives to encourage the development of
20    Partnerships and the efficient delivery of medical care.
21        (3) Persons receiving medical services through
22    Partnerships may receive medical and case management
23    services above the level usually offered through the
24    medical assistance program.
25    Medical providers shall be required to meet certain
26qualifications to participate in Partnerships to ensure the



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1delivery of high quality medical services. These
2qualifications shall be determined by rule of the Illinois
3Department and may be higher than qualifications for
4participation in the medical assistance program. Partnership
5sponsors may prescribe reasonable additional qualifications
6for participation by medical providers, only with the prior
7written approval of the Illinois Department.
8    Nothing in this Section shall limit the free choice of
9practitioners, hospitals, and other providers of medical
10services by clients. In order to ensure patient freedom of
11choice, the Illinois Department shall immediately promulgate
12all rules and take all other necessary actions so that provided
13services may be accessed from therapeutically certified
14optometrists to the full extent of the Illinois Optometric
15Practice Act of 1987 without discriminating between service
17    The Department shall apply for a waiver from the United
18States Health Care Financing Administration to allow for the
19implementation of Partnerships under this Section.
20    The Illinois Department shall require health care
21providers to maintain records that document the medical care
22and services provided to recipients of Medical Assistance under
23this Article. Such records must be retained for a period of not
24less than 6 years from the date of service or as provided by
25applicable State law, whichever period is longer, except that
26if an audit is initiated within the required retention period



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1then the records must be retained until the audit is completed
2and every exception is resolved. The Illinois Department shall
3require health care providers to make available, when
4authorized by the patient, in writing, the medical records in a
5timely fashion to other health care providers who are treating
6or serving persons eligible for Medical Assistance under this
7Article. All dispensers of medical services shall be required
8to maintain and retain business and professional records
9sufficient to fully and accurately document the nature, scope,
10details and receipt of the health care provided to persons
11eligible for medical assistance under this Code, in accordance
12with regulations promulgated by the Illinois Department. The
13rules and regulations shall require that proof of the receipt
14of prescription drugs, dentures, prosthetic devices and
15eyeglasses by eligible persons under this Section accompany
16each claim for reimbursement submitted by the dispenser of such
17medical services. No such claims for reimbursement shall be
18approved for payment by the Illinois Department without such
19proof of receipt, unless the Illinois Department shall have put
20into effect and shall be operating a system of post-payment
21audit and review which shall, on a sampling basis, be deemed
22adequate by the Illinois Department to assure that such drugs,
23dentures, prosthetic devices and eyeglasses for which payment
24is being made are actually being received by eligible
25recipients. Within 90 days after the effective date of this
26amendatory Act of 1984, the Illinois Department shall establish



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1a current list of acquisition costs for all prosthetic devices
2and any other items recognized as medical equipment and
3supplies reimbursable under this Article and shall update such
4list on a quarterly basis, except that the acquisition costs of
5all prescription drugs shall be updated no less frequently than
6every 30 days as required by Section 5-5.12.
7    The rules and regulations of the Illinois Department shall
8require that a written statement including the required opinion
9of a physician shall accompany any claim for reimbursement for
10abortions, or induced miscarriages or premature births. This
11statement shall indicate what procedures were used in providing
12such medical services.
13    The Illinois Department shall require all dispensers of
14medical services, other than an individual practitioner or
15group of practitioners, desiring to participate in the Medical
16Assistance program established under this Article to disclose
17all financial, beneficial, ownership, equity, surety or other
18interests in any and all firms, corporations, partnerships,
19associations, business enterprises, joint ventures, agencies,
20institutions or other legal entities providing any form of
21health care services in this State under this Article.
22    The Illinois Department may require that all dispensers of
23medical services desiring to participate in the medical
24assistance program established under this Article disclose,
25under such terms and conditions as the Illinois Department may
26by rule establish, all inquiries from clients and attorneys



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1regarding medical bills paid by the Illinois Department, which
2inquiries could indicate potential existence of claims or liens
3for the Illinois Department.
4    The Illinois Department shall have the authority to
5establish by rule the necessary procedures and policies to
6comply with the federal Patient Protection and Affordable Care
7Act as amended by the Health Care and Education Reconciliation
8Act of 2010, and with subsequent federal statutes, rules, and
9regulations pertaining to Department functions.
10    Prior to enrollment in the medical assistance program, all
11vendors shall be subject to enhanced oversight, screening, and
12review based on categories of risk of fraud, waste, and abuse.
13The Illinois Department shall establish by rule the procedures
14for such screening and review.
15    Enrollment of a vendor that provides non-emergency medical
16transportation, defined by the Department by rule, shall be
17subject to a provisional period and shall be conditional for
18one year 180 days. During the period of conditional enrollment
19that time, the Department of Healthcare and Family Services may
20terminate the vendor's eligibility to participate in, or may
21disenroll the vendor from, the medical assistance program
22without cause. Such That termination of eligibility or
23disenrollment is not subject to the Department's hearing
25    Prior to enrollment and during the conditional enrollment
26period, a vendor shall be subject to enhanced oversight based



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1on risk categories that may include, but are not limited to,
2criminal and financial background checks; fingerprinting;
3license, certification, and authorization verifications;
4unscheduled or unannounced site visits; database checks;
5prepayment audit reviews; audits; payment caps; payment
6suspensions; and other screening as required by federal or
7State law.
8    To be eligible for payment consideration, a provider's
9vendor-payment claim or bill, either as an initial or
10resubmitted claim following prior rejection, must be received
11by the Illinois Department, or its fiscal intermediary, no
12later than 90 days after the date on which medical goods or
13services were provided, with the following exception: the
14Illinois Department must receive a claim after disposition by
15Medicare or its fiscal intermediary no later than 24 months
16after the date on which medical goods or services were
18    For claims for services rendered during a period for which
19a recipient received retroactive eligibility, claims must be
20filed within 90 days after the recipient was made eligible. For
21claims for which the Illinois Department is not the primary
22payer, claims must be submitted to the Illinois Department
23within 90 days after the final adjudication by the primary
24payer, but in no event more than 1 year after the date of
26    Claims that are not submitted and received in compliance



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1with the foregoing requirement shall not be eligible for
2payment under the medical assistance program, and the State
3shall have no liability for payment of those claims.
4    To the extent consistent with applicable information,
5privacy, security, and disclosure laws, State and federal
6agencies shall provide the Illinois Department access to
7confidential and other information and data necessary to
8perform eligibility and payment verifications and other
9Illinois Department functions. This includes, but is not
10limited to, information pertaining to licensure;
11certification; earnings; immigration status; citizenship; wage
12reporting; unearned and earned income; pension income;
13employment; supplemental security income; social security
14numbers; National Provider Identifier (NPI) numbers; the
15National Practitioner Data Bank (NPDB); program and agency
16exclusions; taxpayer identification numbers; tax delinquency;
17corporate information; and death records.
18    The Illinois Department shall enter into agreements with
19State and federal agencies and Departments under which such
20agencies shall share data necessary for program integrity
21functions and oversight. The Illinois Department shall
22develop, in cooperation with other State departments and
23agencies, and in compliance with applicable federal laws and
24regulations, appropriate and effective methods to share such
25data. At a minimum, and to the extent necessary to provide data
26sharing, the Illinois Department shall enter into agreements



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1with State and federal agencies, including but not limited to,
2the Secretary of State; the Department of Revenue; the
3Department of Public Health; the Department of Human Services;
4and the Department of Financial and Professional Regulation.
5    Beginning in fiscal year 2013, the Illinois Department
6shall set forth a request for information to identify the
7benefits of a pre-payment, post-adjudication, and post-edit
8claims system with the goals of streamlining claims processing
9and provider reimbursement, reducing the number of pending or
10rejected claims, and helping to ensure a more transparent
11adjudication process through the utilization of: (i) provider
12data verification and provider screening technology; and (ii)
13clinical code editing. Such request for information shall not
14be considered as a request for proposal, or as an obligation on
15the part of the Illinois Department to take any action or
16acquire any products or services.
17    The Illinois Department shall establish policies,
18procedures, standards and criteria by rule for the acquisition,
19repair and replacement of orthotic and prosthetic devices and
20durable medical equipment. Such rules shall provide, but not be
21limited to, the following services: (1) immediate repair or
22replacement of such devices by recipients without medical
23authorization; and (2) rental, lease, purchase or
24lease-purchase of durable medical equipment in a
25cost-effective manner, taking into consideration the
26recipient's medical prognosis, the extent of the recipient's



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1needs, and the requirements and costs for maintaining such
2equipment. Such rules shall enable a recipient to temporarily
3acquire and use alternative or substitute devices or equipment
4pending repairs or replacements of any device or equipment
5previously authorized for such recipient by the Department.
6    The Department shall execute, relative to the nursing home
7prescreening project, written inter-agency agreements with the
8Department of Human Services and the Department on Aging, to
9effect the following: (i) intake procedures and common
10eligibility criteria for those persons who are receiving
11non-institutional services; and (ii) the establishment and
12development of non-institutional services in areas of the State
13where they are not currently available or are undeveloped.
14    The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation and
18programs for monitoring of utilization of health care services
19and facilities, as it affects persons eligible for medical
20assistance under this Code.
21    The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24        (a) actual statistics and trends in utilization of
25    medical services by public aid recipients;
26        (b) actual statistics and trends in the provision of



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1    the various medical services by medical vendors;
2        (c) current rate structures and proposed changes in
3    those rate structures for the various medical vendors; and
4        (d) efforts at utilization review and control by the
5    Illinois Department.
6    The period covered by each report shall be the 3 years
7ending on the June 30 prior to the report. The report shall
8include suggested legislation for consideration by the General
9Assembly. The filing of one copy of the report with the
10Speaker, one copy with the Minority Leader and one copy with
11the Clerk of the House of Representatives, one copy with the
12President, one copy with the Minority Leader and one copy with
13the Secretary of the Senate, one copy with the Legislative
14Research Unit, and such additional copies with the State
15Government Report Distribution Center for the General Assembly
16as is required under paragraph (t) of Section 7 of the State
17Library Act shall be deemed sufficient to comply with this
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
26eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,



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1eff. 1-1-12.)
2    (305 ILCS 5/11-13)  (from Ch. 23, par. 11-13)
3    Sec. 11-13. Conditions For Receipt of Vendor Payments -
4Limitation Period For Vendor Action - Penalty For Violation. A
5vendor payment, as defined in Section 2-5 of Article II, shall
6constitute payment in full for the goods or services covered
7thereby. Acceptance of the payment by or in behalf of the
8vendor shall bar him from obtaining, or attempting to obtain,
9additional payment therefor from the recipient or any other
10person. A vendor payment shall not, however, bar recovery of
11the value of goods and services the obligation for which, under
12the rules and regulations of the Illinois Department, is to be
13met from the income and resources available to the recipient,
14and in respect to which the vendor payment of the Illinois
15Department or the local governmental unit represents
16supplementation of such available income and resources.
17    Vendors seeking to enforce obligations of a governmental
18unit or the Illinois Department for goods or services (1)
19furnished to or in behalf of recipients and (2) subject to a
20vendor payment as defined in Section 2-5, shall commence their
21actions in the appropriate Circuit Court or the Court of
22Claims, as the case may require, within one year next after the
23cause of action accrued.
24    A cause of action accrues within the meaning of this
25Section upon the following date:



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1    (1) If the vendor can prove that he submitted a bill for
2the service rendered to the Illinois Department or a
3governmental unit within 90 days after 12 months of the date
4the service was rendered, then (a) upon the date the Illinois
5Department or a governmental unit mails to the vendor
6information that it is paying a bill in part or is refusing to
7pay a bill in whole or in part, or (b) upon the date one year
8following the date the vendor submitted such bill if the
9Illinois Department or a governmental unit fails to mail to the
10vendor such payment information within one year following the
11date the vendor submitted the bill; or
12    (2) If the vendor cannot prove that he submitted a bill for
13the service rendered within 90 days after 12 months of the date
14the service was rendered, then upon the date 12 months
15following the date the vendor rendered the service to the
17    This paragraph governs only vendor payments as defined in
18this Code and as limited by regulations of the Illinois
19Department; it does not apply to goods or services purchased or
20contracted for by a recipient under circumstances in which the
21payment is to be made directly by the recipient.
22    Any vendor who accepts a vendor payment and who knowingly
23obtains or attempts to obtain additional payment for the goods
24or services covered by the vendor payment from the recipient or
25any other person shall be guilty of a Class B misdemeanor.
26(Source: P.A. 86-430.)



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1    (305 ILCS 5/11-26)  (from Ch. 23, par. 11-26)
2    Sec. 11-26. Recipient's abuse of medical care;
3restrictions on access to medical care.
4        (a) When the Department determines, on the basis of
5statistical norms and medical judgment, that a medical care
6recipient has received medical services in excess of need and
7with such frequency or in such a manner as to constitute an
8abuse of the recipient's medical care privileges, the
9recipient's access to medical care may be restricted.
10    (b) When the Department has determined that a recipient is
11abusing his or her medical care privileges as described in this
12Section, it may require that the recipient designate a primary
13provider type of the recipient's own choosing to assume
14responsibility for the recipient's care. For the purposes of
15this subsection, "primary provider type" means a provider type
16as determined by the Department primary care provider, primary
17care pharmacy, primary dentist, primary podiatrist, or primary
18durable medical equipment provider. Instead of requiring a
19recipient to make a designation as provided in this subsection,
20the Department, pursuant to rules adopted by the Department and
21without regard to any choice of an entity that the recipient
22might otherwise make, may initially designate a primary
23provider type provided that the primary provider type is
24willing to provide that care.
25    (c) When the Department has requested that a recipient



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1designate a primary provider type and the recipient fails or
2refuses to do so, the Department may, after a reasonable period
3of time, assign the recipient to a primary provider type of its
4own choice and determination, provided such primary provider
5type is willing to provide such care.
6    (d) When a recipient has been restricted to a designated
7primary provider type, the recipient may change the primary
8provider type:
9        (1) when the designated source becomes unavailable, as
10    the Department shall determine by rule; or
11        (2) when the designated primary provider type notifies
12    the Department that it wishes to withdraw from any
13    obligation as primary provider type; or
14        (3) in other situations, as the Department shall
15    provide by rule.
16    The Department shall, by rule, establish procedures for
17providing medical or pharmaceutical services when the
18designated source becomes unavailable or wishes to withdraw
19from any obligation as primary provider type, shall, by rule,
20take into consideration the need for emergency or temporary
21medical assistance and shall ensure that the recipient has
22continuous and unrestricted access to medical care from the
23date on which such unavailability or withdrawal becomes
24effective until such time as the recipient designates a primary
25provider type or a primary provider type willing to provide
26such care is designated by the Department consistent with



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1subsections (b) and (c) and such restriction becomes effective.
2    (e) Prior to initiating any action to restrict a
3recipient's access to medical or pharmaceutical care, the
4Department shall notify the recipient of its intended action.
5Such notification shall be in writing and shall set forth the
6reasons for and nature of the proposed action. In addition, the
7notification shall:
8        (1) inform the recipient that (i) the recipient has a
9    right to designate a primary provider type of the
10    recipient's own choosing willing to accept such
11    designation and that the recipient's failure to do so
12    within a reasonable time may result in such designation
13    being made by the Department or (ii) the Department has
14    designated a primary provider type to assume
15    responsibility for the recipient's care; and
16        (2) inform the recipient that the recipient has a right
17    to appeal the Department's determination to restrict the
18    recipient's access to medical care and provide the
19    recipient with an explanation of how such appeal is to be
20    made. The notification shall also inform the recipient of
21    the circumstances under which unrestricted medical
22    eligibility shall continue until a decision is made on
23    appeal and that if the recipient chooses to appeal, the
24    recipient will be able to review the medical payment data
25    that was utilized by the Department to decide that the
26    recipient's access to medical care should be restricted.



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1    (f) The Department shall, by rule or regulation, establish
2procedures for appealing a determination to restrict a
3recipient's access to medical care, which procedures shall, at
4a minimum, provide for a reasonable opportunity to be heard
5and, where the appeal is denied, for a written statement of the
6reason or reasons for such denial.
7    (g) Except as otherwise provided in this subsection, when a
8recipient has had his or her medical card restricted for 4 full
9quarters (without regard to any period of ineligibility for
10medical assistance under this Code, or any period for which the
11recipient voluntarily terminates his or her receipt of medical
12assistance, that may occur before the expiration of those 4
13full quarters), the Department shall reevaluate the
14recipient's medical usage to determine whether it is still in
15excess of need and with such frequency or in such a manner as
16to constitute an abuse of the receipt of medical assistance. If
17it is still in excess of need, the restriction shall be
18continued for another 4 full quarters. If it is no longer in
19excess of need, the restriction shall be discontinued. If a
20recipient's access to medical care has been restricted under
21this Section and the Department then determines, either at
22reevaluation or after the restriction has been discontinued, to
23restrict the recipient's access to medical care a second or
24subsequent time, the second or subsequent restriction may be
25imposed for a period of more than 4 full quarters. If the
26Department restricts a recipient's access to medical care for a



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1period of more than 4 full quarters, as determined by rule, the
2Department shall reevaluate the recipient's medical usage
3after the end of the restriction period rather than after the
4end of 4 full quarters. The Department shall notify the
5recipient, in writing, of any decision to continue the
6restriction and the reason or reasons therefor. A "quarter",
7for purposes of this Section, shall be defined as one of the
8following 3-month periods of time: January-March, April-June,
9July-September or October-December.
10    (h) In addition to any other recipient whose acquisition of
11medical care is determined to be in excess of need, the
12Department may restrict the medical care privileges of the
13following persons:
14        (1) recipients found to have loaned or altered their
15    cards or misused or falsely represented medical coverage;
16        (2) recipients found in possession of blank or forged
17    prescription pads;
18        (3) recipients who knowingly assist providers in
19    rendering excessive services or defrauding the medical
20    assistance program.
21    The procedural safeguards in this Section shall apply to
22the above individuals.
23    (i) Restrictions under this Section shall be in addition to
24and shall not in any way be limited by or limit any actions
25taken under Article VIII-A of this Code.
26(Source: P.A. 96-1501, eff. 1-25-11.)



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1    (305 ILCS 5/12-13.1)
2    Sec. 12-13.1. Inspector General.
3    (a) The Governor shall appoint, and the Senate shall
4confirm, an Inspector General who shall function within the
5Illinois Department of Public Aid (now Healthcare and Family
6Services) and report to the Governor. The term of the Inspector
7General shall expire on the third Monday of January, 1997 and
8every 4 years thereafter.
9    (b) In order to prevent, detect, and eliminate fraud,
10waste, abuse, mismanagement, and misconduct, the Inspector
11General shall oversee the Department of Healthcare and Family
12Services' integrity functions, which include, but are not
13limited to, the following:
14        (1) Investigation of misconduct by employees, vendors,
15    contractors and medical providers, except for allegations
16    of violations of the State Officials and Employees Ethics
17    Act which shall be referred to the Office of the Governor's
18    Executive Inspector General for investigation.
19        (2) Prepayment and post-payment audits Audits of
20    medical providers related to ensuring that appropriate
21    payments are made for services rendered and to the
22    prevention and recovery of overpayments.
23        (3) Monitoring of quality assurance programs
24    administered by the Department of Healthcare and Family
25    Services generally related to the medical assistance



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1    program and specifically related to any managed care
2    program.
3        (4) Quality control measurements of the programs
4    administered by the Department of Healthcare and Family
5    Services.
6        (5) Investigations of fraud or intentional program
7    violations committed by clients of the Department of
8    Healthcare and Family Services.
9        (6) Actions initiated against contractors, vendors, or
10    medical providers for any of the following reasons:
11            (A) Violations of the medical assistance program.
12            (B) Sanctions against providers brought in
13        conjunction with the Department of Public Health or the
14        Department of Human Services (as successor to the
15        Department of Mental Health and Developmental
16        Disabilities).
17            (C) Recoveries of assessments against hospitals
18        and long-term care facilities.
19            (D) Sanctions mandated by the United States
20        Department of Health and Human Services against
21        medical providers.
22            (E) Violations of contracts related to any
23        programs administered by the Department of Healthcare
24        and Family Services managed care programs.
25        (7) Representation of the Department of Healthcare and
26    Family Services at hearings with the Illinois Department of



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1    Financial and Professional Regulation in actions taken
2    against professional licenses held by persons who are in
3    violation of orders for child support payments.
4    (b-5) At the request of the Secretary of Human Services,
5the Inspector General shall, in relation to any function
6performed by the Department of Human Services as successor to
7the Department of Public Aid, exercise one or more of the
8powers provided under this Section as if those powers related
9to the Department of Human Services; in such matters, the
10Inspector General shall report his or her findings to the
11Secretary of Human Services.
12    (c) Notwithstanding, and in addition to, any other
13provision of law, the The Inspector General shall have access
14to all information, personnel and facilities of the Department
15of Healthcare and Family Services and the Department of Human
16Services (as successor to the Department of Public Aid), their
17employees, vendors, contractors and medical providers and any
18federal, State or local governmental agency that are necessary
19to perform the duties of the Office as directly related to
20public assistance programs administered by those departments.
21No medical provider shall be compelled, however, to provide
22individual medical records of patients who are not clients of
23the programs administered by the Department of Healthcare and
24Family Services Medical Assistance Program. State and local
25governmental agencies are authorized and directed to provide
26the requested information, assistance or cooperation.



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1    For purposes of enhanced program integrity functions and
2oversight, and to the extent consistent with applicable
3information, privacy, security, and disclosure laws, State and
4federal agencies shall provide the Inspector General access to
5confidential and other information and data. This includes, but
6is not limited to, information pertaining to licensure;
7certification; earnings; immigration status; citizenship; wage
8reporting; unearned and earned income; pension income;
9employment; supplemental security income; social security
10numbers; National Provider Identifier (NPI) numbers; the
11National Practitioner Data Bank (NPDB); program and agency
12exclusions; taxpayer identification numbers; tax delinquency;
13corporate information; and death records.
14    The Department of Healthcare and Family Services shall
15enter into agreements with State and federal agencies under
16which such agencies share data necessary for vendor screening,
17vendor review, and payment verification. The Department shall
18develop, in cooperation with other State and federal
19departments and agencies, and in compliance with applicable
20federal laws and regulations, appropriate and effective
21methods to share such data necessary for vendor screening,
22vendor review, and payment verification. The Department shall
23enter into agreements with State and federal agencies,
24including but not limited to, the Secretary of State; the
25Department of Revenue; the Department of Public Health; the
26Department of Human Services; and the Department of Financial



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1and Professional Regulation.
2    The Inspector General shall have the authority to deny
3payment, prevent overpayments, and recover overpayments.
4    The Inspector General shall have the authority to deny or
5suspend payment to, and deny, terminate, or suspend the
6eligibility of, any vendor who fails to grant the Inspector
7General timely access to full and complete records in
8accordance with Section 140.28 of Title 89 of the Illinois
9Administrative Code, and other information for the purpose of
10audits, investigations, or other program integrity functions,
11after reasonable written request by the Inspector General.
12    The Inspector General shall have the authority to establish
13by rule the necessary procedures and policies to comply with
14the federal Patient Protection and Affordable Care Act as
15amended by the Health Care and Education Reconciliation Act of
162010, and with subsequent federal statutes and rules pertaining
17to state program integrity requirements.
18    (d) The Inspector General shall serve as the Department of
19Healthcare and Family Services' primary liaison with law
20enforcement, investigatory and prosecutorial agencies,
21including but not limited to the following:
22        (1) The Department of State Police.
23        (2) The Federal Bureau of Investigation and other
24    federal law enforcement agencies.
25        (3) The various Inspectors General of federal agencies
26    overseeing the programs administered by the Department of



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1    Healthcare and Family Services.
2        (4) The various Inspectors General of any other State
3    agencies with responsibilities for portions of programs
4    primarily administered by the Department of Healthcare and
5    Family Services.
6        (5) The Offices of the several United States Attorneys
7    in Illinois.
8        (6) The several State's Attorneys.
9        (7) The offices of the Centers for Medicare and
10    Medicaid Services that administer the Medicare and
11    Medicaid integrity programs.
12    The Inspector General shall meet on a regular basis with
13these entities to share information regarding possible
14misconduct by any persons or entities involved with the public
15aid programs administered by the Department of Healthcare and
16Family Services.
17    (e) All investigations conducted by the Inspector General
18shall be conducted in a manner that ensures the preservation of
19evidence for use in criminal prosecutions. If the Inspector
20General determines that a possible criminal act relating to
21fraud in the provision or administration of the medical
22assistance program has been committed, the Inspector General
23shall immediately notify the Medicaid Fraud Control Unit. If
24the Inspector General determines that a possible criminal act
25has been committed within the jurisdiction of the Office, the
26Inspector General may request the special expertise of the



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1Department of State Police. The Inspector General may present
2for prosecution the findings of any criminal investigation to
3the Office of the Attorney General, the Offices of the several
4United States Attorneys in Illinois or the several State's
6    (f) To carry out his or her duties as described in this
7Section, the Inspector General and his or her designees shall
8have the power to compel by subpoena the attendance and
9testimony of witnesses and the production of books, electronic
10records and papers as directly related to public assistance
11programs administered by the Department of Healthcare and
12Family Services or the Department of Human Services (as
13successor to the Department of Public Aid). No medical provider
14shall be compelled, however, to provide individual medical
15records of patients who are not clients of the Medical
16Assistance Program.
17    (g) The Inspector General shall report all convictions,
18terminations, and suspensions taken against vendors,
19contractors and medical providers to the Department of
20Healthcare and Family Services and to any agency responsible
21for licensing or regulating those persons or entities.
22    (h) The Inspector General shall make annual reports,
23findings, and recommendations regarding the Office's
24investigations into reports of fraud, waste, abuse,
25mismanagement, or misconduct relating to any public aid
26programs administered by the Department of Healthcare and



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1Family Services or the Department of Human Services (as
2successor to the Department of Public Aid) to the General
3Assembly and the Governor. These reports shall include, but not
4be limited to, the following information:
5        (1) Aggregate provider billing and payment
6    information, including the number of providers at various
7    Medicaid earning levels.
8        (2) The number of audits of the medical assistance
9    program and the dollar savings resulting from those audits.
10        (3) The number of prescriptions rejected annually
11    under the Department of Healthcare and Family Services'
12    Refill Too Soon program and the dollar savings resulting
13    from that program.
14        (4) Provider sanctions, in the aggregate, including
15    terminations and suspensions.
16        (5) A detailed summary of the investigations
17    undertaken in the previous fiscal year. These summaries
18    shall comply with all laws and rules regarding maintaining
19    confidentiality in the public aid programs.
20    (i) Nothing in this Section shall limit investigations by
21the Department of Healthcare and Family Services or the
22Department of Human Services that may otherwise be required by
23law or that may be necessary in their capacity as the central
24administrative authorities responsible for administration of
25their agency's public aid programs in this State.
26    (j) The Inspector General may issue shields or other



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1distinctive identification to his or her employees not
2exercising the powers of a peace officer if the Inspector
3General determines that a shield or distinctive identification
4is needed by an employee to carry out his or her
6(Source: P.A. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09;
796-1316, eff. 1-1-11.)
8    Section 99. Effective date. This Act takes effect upon
9becoming law.".