Full Text of SB0951 94th General Assembly
SB0951enr 94TH GENERAL ASSEMBLY
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LRB094 04634 DRJ 34663 b |
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| AN ACT concerning public aid.
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| Be it enacted by the People of the State of Illinois, | 3 |
| represented in the General Assembly:
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| Section 5. The Illinois Public Aid Code is amended by | 5 |
| changing Section 12-4.25 as follows:
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| (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
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| Sec. 12-4.25. Medical assistance program; vendor | 8 |
| participation.
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| (A) The Illinois Department may deny, suspend or
terminate | 10 |
| the eligibility of any person, firm, corporation, association,
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| agency, institution or other legal entity to participate as a | 12 |
| vendor of
goods or services to recipients under the medical | 13 |
| assistance program
under Article V, if after reasonable notice | 14 |
| and opportunity for a
hearing the Illinois Department finds:
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| (a) Such vendor is not complying with the Department's | 16 |
| policy or
rules and regulations, or with the terms and | 17 |
| conditions prescribed by
the Illinois Department in its | 18 |
| vendor agreement, which document shall be
developed by the | 19 |
| Department as a result of negotiations with each vendor
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| category, including physicians, hospitals, long term care | 21 |
| facilities,
pharmacists, optometrists, podiatrists and | 22 |
| dentists setting forth the
terms and conditions applicable | 23 |
| to the participation of each vendor
group in the program; | 24 |
| or
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| (b) Such vendor has failed to keep or make available | 26 |
| for inspection,
audit or copying, after receiving a written | 27 |
| request from the Illinois
Department, such records | 28 |
| regarding payments claimed for providing
services. This | 29 |
| section does not require vendors to make available
patient | 30 |
| records of patients for whom services are not reimbursed | 31 |
| under
this Code; or
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| (c) Such vendor has failed to furnish any information |
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| requested by
the Department regarding payments for | 2 |
| providing goods or services; or
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| (d) Such vendor has knowingly made, or caused to be | 4 |
| made, any false
statement or representation of a material | 5 |
| fact in connection with the
administration of the medical | 6 |
| assistance program; or
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| (e) Such vendor has furnished goods or services to a | 8 |
| recipient which
are (1) in excess of his or her needs, (2) | 9 |
| harmful to the recipient, or
(3) of grossly inferior | 10 |
| quality, all of such determinations to be based
upon | 11 |
| competent medical judgment and evaluations; or
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| (f) The vendor; a person with management | 13 |
| responsibility for a
vendor; an officer or person owning, | 14 |
| either directly or indirectly, 5%
or more of the shares of | 15 |
| stock or other evidences of ownership in a
corporate | 16 |
| vendor; an owner of a sole proprietorship which is a | 17 |
| vendor;
or a partner in a partnership which is a vendor, | 18 |
| either:
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| (1) was previously terminated from participation | 20 |
| in the Illinois
medical assistance program, or was | 21 |
| terminated from participation in a medical
assistance | 22 |
| program in
another state that is of the same kind as | 23 |
| the program of medical assistance
provided under | 24 |
| Article V of this Code; or
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| (2) was a person with management responsibility | 26 |
| for a vendor
previously terminated from participation | 27 |
| in the Illinois medical assistance
program, or | 28 |
| terminated from participation in a medical assistance | 29 |
| program in
another state that is of the same kind as | 30 |
| the program of medical assistance
provided under | 31 |
| Article V of this Code,
during the time of conduct | 32 |
| which was the basis for
that vendor's termination; or
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| (3) was an officer, or person owning, either | 34 |
| directly or indirectly,
5% or more of the shares of | 35 |
| stock or other evidences of ownership in a corporate | 36 |
| vendor
previously terminated from participation in the |
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| Illinois medical assistance
program, or terminated | 2 |
| from participation in a medical assistance program in
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| another state that is of the same kind as the program | 4 |
| of medical assistance
provided under Article V of this | 5 |
| Code,
during the time of conduct which
was the basis | 6 |
| for that vendor's termination; or
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| (4) was an owner of a sole proprietorship or | 8 |
| partner of a
partnership previously terminated
from | 9 |
| participation in the Illinois medical assistance | 10 |
| program, or terminated
from participation in a medical | 11 |
| assistance program in another state that is of
the same | 12 |
| kind as the program of medical assistance provided | 13 |
| under Article V of
this Code,
during the time of | 14 |
| conduct
which was the basis for that vendor's | 15 |
| termination; or
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| (g) The vendor; a person with management | 17 |
| responsibility for a
vendor; an officer or person owning, | 18 |
| either directly or indirectly, 5%
or more of the shares of | 19 |
| stock or other evidences of ownership in a
corporate | 20 |
| vendor; an owner of a sole proprietorship which is a | 21 |
| vendor;
or a partner in a partnership which is a vendor, | 22 |
| either:
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| (1) has engaged in practices prohibited by | 24 |
| applicable federal or
State law or regulation relating | 25 |
| to the medical assistance program; or
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| (2) was a person with management responsibility | 27 |
| for a vendor at the
time that such vendor engaged in | 28 |
| practices prohibited by applicable
federal or State | 29 |
| law or regulation relating to the medical assistance
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| program; or
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| (3) was an officer, or person owning, either | 32 |
| directly or indirectly,
5% or more of the shares of | 33 |
| stock or other evidences of ownership in a
vendor at | 34 |
| the time such vendor engaged in practices prohibited by
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| applicable federal or State law or regulation relating | 36 |
| to the medical
assistance program; or
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| (4) was an owner of a sole proprietorship or | 2 |
| partner of a
partnership which was a vendor at the time | 3 |
| such vendor engaged in
practices prohibited by | 4 |
| applicable federal or State law or regulation
relating | 5 |
| to the medical assistance program; or
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| (h) The direct or indirect ownership of the vendor | 7 |
| (including the
ownership of a vendor that is a sole | 8 |
| proprietorship, a partner's interest in a
vendor that is a | 9 |
| partnership, or ownership of 5% or more of the shares of | 10 |
| stock
or other
evidences of ownership in a corporate | 11 |
| vendor) has been transferred by an
individual who is | 12 |
| terminated or barred from participating as a vendor to the
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| individual's spouse, child, brother, sister, parent, | 14 |
| grandparent, grandchild,
uncle, aunt, niece, nephew, | 15 |
| cousin, or relative by marriage.
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| (A-5) The Illinois Department may deny, suspend, or | 17 |
| terminate the
eligibility
of any person, firm, corporation, | 18 |
| association, agency, institution, or other
legal entity to | 19 |
| participate as a vendor of goods or services to recipients
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| under the medical assistance program under Article V if, after | 21 |
| reasonable
notice and opportunity for a hearing, the Illinois | 22 |
| Department finds that 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 vendor; an | 26 |
| owner of a sole
proprietorship that is a vendor; or a partner | 27 |
| in a partnership that is a vendor
has been convicted of a | 28 |
| felony offense based on fraud or willful
misrepresentation | 29 |
| related to any of
the following:
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| (1) The medical assistance program under Article V of | 31 |
| this Code.
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| (2) A medical assistance program in another state that | 33 |
| is of the same kind
as the program of medical assistance | 34 |
| provided under Article V of this Code.
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| (3) The Medicare program under Title XVIII of the | 36 |
| Social Security Act.
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| (4) The provision of health care services.
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| (A-10) The Illinois Department may deny, suspend, or | 3 |
| terminate the eligibility of any person, firm, corporation, | 4 |
| association, agency, institution, or other legal entity to | 5 |
| participate as a vendor of goods or services to recipients | 6 |
| under the medical assistance program under Article V if, after | 7 |
| reasonable notice and opportunity for a hearing, the Illinois | 8 |
| Department finds that (i) the vendor, (ii) a person with | 9 |
| management responsibility for a vendor, (iii) an officer or | 10 |
| person owning, either directly or indirectly, 5% or more of the | 11 |
| shares of stock or other evidences of ownership in a corporate | 12 |
| vendor, (iv) an owner of a sole proprietorship that is a | 13 |
| vendor, or (v) a partner in a partnership that is a vendor has | 14 |
| been convicted of a felony offense related to any of the | 15 |
| following:
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| (1) Murder.
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| (2) A Class X felony under the Criminal Code of 1961.
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| (B) The Illinois Department shall deny, suspend or | 19 |
| terminate the
eligibility of any person, firm, corporation, | 20 |
| association, agency,
institution or other legal entity to | 21 |
| participate as a vendor of goods or
services to recipients | 22 |
| under the medical assistance program under
Article V:
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| (1) if such vendor is not properly licensed;
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| (2) within 30 days of the date when such vendor's | 25 |
| professional
license, certification or other authorization | 26 |
| has been refused renewal
or has been revoked, suspended or | 27 |
| otherwise terminated; or
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| (3) if such vendor has been convicted of a violation of | 29 |
| this Code, as
provided in Article VIIIA.
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| (C) Upon termination of a vendor of goods or services from
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| participation in the medical assistance program authorized by | 32 |
| this
Article, a person with management responsibility for such | 33 |
| vendor during
the time of any conduct which served as the basis | 34 |
| for that vendor's
termination is barred from participation in | 35 |
| the medical assistance
program.
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| Upon termination of a corporate vendor, the officers and |
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| persons
owning, directly or indirectly, 5% or more of the | 2 |
| shares of stock or
other evidences of ownership in the vendor | 3 |
| during the time of any
conduct which served as the basis for | 4 |
| that vendor's termination are
barred from participation in the | 5 |
| medical assistance program. A person who
owns, directly or | 6 |
| indirectly, 5% or more of the shares of stock or other
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| evidences of ownership in a terminated corporate vendor may not | 8 |
| transfer his or
her ownership interest in that vendor to his or | 9 |
| her spouse, child, brother,
sister, parent, grandparent, | 10 |
| grandchild, uncle, aunt, niece, nephew, cousin, or
relative by | 11 |
| marriage.
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| Upon termination of a sole proprietorship or partnership, | 13 |
| the owner
or partners during the time of any conduct which | 14 |
| served as the basis for
that vendor's termination are barred | 15 |
| from participation in the medical
assistance program. The owner | 16 |
| of a terminated vendor that is a sole
proprietorship, and a | 17 |
| partner in a terminated vendor that is a partnership, may
not | 18 |
| transfer his or her ownership or partnership interest in that | 19 |
| vendor to his
or her spouse, child, brother, sister, parent, | 20 |
| grandparent, grandchild, uncle,
aunt, niece, nephew, cousin, | 21 |
| or relative by marriage.
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| Rules adopted by the Illinois Department to implement these
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| provisions shall specifically include a definition of the term
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| "management responsibility" as used in this Section. Such | 25 |
| definition
shall include, but not be limited to, typical job | 26 |
| titles, and duties and
descriptions which will be considered as | 27 |
| within the definition of
individuals with management | 28 |
| responsibility for a provider.
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| (D) If a vendor has been suspended from the medical | 30 |
| assistance
program under Article V of the Code, the Director | 31 |
| may require that such
vendor correct any deficiencies which | 32 |
| served as the basis for the
suspension. The Director shall | 33 |
| specify in the suspension order a specific
period of time, | 34 |
| which shall not exceed one year from the date of the
order, | 35 |
| during which a suspended vendor shall not be eligible to
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| participate. At the conclusion of the period of suspension the |
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| Director
shall reinstate such vendor, unless he finds that such | 2 |
| vendor has not
corrected deficiencies upon which the suspension | 3 |
| was based.
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| If a vendor has been terminated from the medical assistance | 5 |
| program
under Article V, such vendor shall be barred from | 6 |
| participation for at
least one year, except that if a vendor | 7 |
| has been terminated based on a
conviction of a
violation of | 8 |
| Article VIIIA or a conviction of a felony based on fraud or a
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| willful misrepresentation related to (i) the medical | 10 |
| assistance program under
Article V, (ii) a medical assistance | 11 |
| program in another state that is of the
kind provided under | 12 |
| Article V, (iii) the Medicare program under Title XVIII of
the | 13 |
| Social Security Act, or (iv) the provision of health care | 14 |
| services, then
the vendor shall be barred from participation | 15 |
| for 5 years or for the length of
the vendor's sentence for that | 16 |
| conviction, whichever is longer. At the end of
one year a | 17 |
| vendor who has been terminated
may apply for reinstatement to | 18 |
| the program. Upon proper application to
be reinstated such | 19 |
| vendor may be deemed eligible by the Director
providing that | 20 |
| such vendor meets the requirements for eligibility under
this | 21 |
| Code. If such vendor is deemed not eligible for
reinstatement, | 22 |
| he
shall be barred from again applying for reinstatement for | 23 |
| one year from the
date his application for reinstatement is | 24 |
| denied.
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| A vendor whose termination from participation in the | 26 |
| Illinois medical
assistance program under Article V was based | 27 |
| solely on an action by a
governmental entity other than the | 28 |
| Illinois Department may, upon reinstatement
by that | 29 |
| governmental entity or upon reversal of the termination, apply | 30 |
| for
rescission of the termination from participation in the | 31 |
| Illinois medical
assistance program. Upon proper application | 32 |
| for rescission, the vendor may be
deemed eligible by the | 33 |
| Director if the vendor meets the requirements for
eligibility | 34 |
| under this Code.
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| If a vendor has been terminated and reinstated to the | 36 |
| medical assistance
program under Article V and the vendor is |
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| terminated a second or subsequent
time from the medical | 2 |
| assistance program, the vendor shall be barred from
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| participation for at least 2 years, except that if a vendor has | 4 |
| been
terminated a second time based on a
conviction of a | 5 |
| violation of Article VIIIA or a conviction of a felony based on
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| fraud or a willful misrepresentation related to (i) the medical | 7 |
| assistance
program under Article V, (ii) a medical assistance | 8 |
| program in another state
that is of the kind provided under | 9 |
| Article V, (iii) the Medicare program under
Title XVIII of the | 10 |
| Social Security Act, or (iv) the provision of health care
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| services, then the vendor shall be barred from participation | 12 |
| for life. At
the end of 2 years, a vendor who has
been | 13 |
| terminated may apply for reinstatement to the program. Upon | 14 |
| application
to be reinstated, the vendor may be deemed eligible | 15 |
| if the vendor meets the
requirements for eligibility under this | 16 |
| Code. If the vendor is deemed not
eligible for reinstatement, | 17 |
| the vendor shall be barred from again applying for
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| reinstatement for 2 years from the date the vendor's | 19 |
| application for
reinstatement is denied.
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| (E) The Illinois Department may recover money improperly or
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| erroneously paid, or overpayments, either by setoff, crediting | 22 |
| against
future billings or by requiring direct repayment to the | 23 |
| Illinois
Department.
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| If the Illinois Department of Public Aid establishes | 25 |
| through an administrative
hearing that the overpayments | 26 |
| resulted from the vendor
or alternate payee willfully making, | 27 |
| or causing to be made, a false statement or
misrepresentation | 28 |
| of a material fact in connection with billings and payments
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| under the medical assistance program under Article V, the | 30 |
| Department may
recover interest on the amount of the | 31 |
| overpayments at the rate of 5% per annum.
For purposes of this | 32 |
| paragraph,
"willfully" means that a person makes a statement or | 33 |
| representation with
actual knowledge that it was false, or | 34 |
| makes a statement or representation with
knowledge of facts or | 35 |
| information that would cause one to be aware that
the statement | 36 |
| or representation was false when made.
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| (F) The Illinois Department may withhold payments to any | 2 |
| vendor
or alternate payee during the pendency of any proceeding | 3 |
| under this Section. The Illinois Department shall
state by rule | 4 |
| with as much specificity as practicable the conditions
under | 5 |
| which payments will not be withheld during the pendency of any
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| proceeding under this Section. Payments may be denied for bills
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| submitted with service dates occurring during the pendency of a
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| proceeding where the final administrative decision is to | 9 |
| terminate
eligibility to participate in the medical assistance | 10 |
| program. The
Illinois Department shall state by rule with as | 11 |
| much specificity as
practicable the conditions under which | 12 |
| payments will not be denied for
such bills.
The Illinois
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| Department of Public Aid shall state by rule a process and | 14 |
| criteria by
which a vendor or alternate payee may request full | 15 |
| or partial release of payments withheld under
this subsection. | 16 |
| The Department must complete a proceeding under this Section
in | 17 |
| a timely manner.
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| (F-5) The Illinois Department may temporarily withhold | 19 |
| payments to
a vendor or alternate payee if any of the following | 20 |
| individuals have been indicted or
otherwise charged under a law | 21 |
| of the United States or this or any other state
with a felony | 22 |
| offense that is based on alleged fraud or willful
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| misrepresentation on the part of the individual related to (i) | 24 |
| the medical
assistance program under Article V of this Code, | 25 |
| (ii) a medical assistance
program provided in another state | 26 |
| which is of the kind provided under
Article V of this Code, | 27 |
| (iii) the Medicare program under Title XVIII of the
Social | 28 |
| Security Act, or (iv) the provision of health care services:
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| (1) If the vendor or alternate payee is a corporation: | 30 |
| an officer of the corporation
or an individual who owns, | 31 |
| either directly or indirectly, 5% or more
of the shares of | 32 |
| stock or other evidence of ownership of the
corporation.
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| (2) If the vendor is a sole proprietorship: the owner | 34 |
| of the sole
proprietorship.
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| (3) If the vendor or alternate payee is a partnership: | 36 |
| a partner in the partnership.
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| (4) If the vendor or alternate payee is any other | 2 |
| business entity authorized by law
to transact business in | 3 |
| this State: an officer of the entity or an
individual who | 4 |
| owns, either directly or indirectly, 5% or more of the
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| evidences of ownership of the entity.
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| If the Illinois Department withholds payments to a vendor | 7 |
| or alternate payee under this
subsection, the Department shall | 8 |
| not release those payments to the vendor
or alternate payee
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| while any criminal proceeding related to the indictment or | 10 |
| charge is pending
unless the Department determines that there | 11 |
| is good cause to release the
payments before completion of the | 12 |
| proceeding. If the indictment or charge
results in the | 13 |
| individual's conviction, the Illinois Department shall retain
| 14 |
| all withheld
payments, which shall be considered forfeited to | 15 |
| the Department. If the
indictment or charge does not result in | 16 |
| the individual's conviction, the
Illinois Department
shall | 17 |
| release to the vendor or alternate payee all withheld payments.
| 18 |
| (G) The provisions of the Administrative Review Law, as now | 19 |
| or hereafter
amended, and the rules adopted pursuant
thereto, | 20 |
| shall apply to and govern all proceedings for the judicial
| 21 |
| review of final administrative decisions of the Illinois | 22 |
| Department
under this Section. The term "administrative | 23 |
| decision" is defined as in
Section 3-101 of the Code of Civil | 24 |
| Procedure.
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| (G-5) Non-emergency transportation.
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| (1) Notwithstanding any other provision in this | 27 |
| Section, for non-emergency
transportation vendors, the | 28 |
| Department may terminate the vendor from
participation in | 29 |
| the medical assistance program prior
to an evidentiary | 30 |
| hearing but after reasonable notice and opportunity to
| 31 |
| respond as established by the Department by rule.
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| (2) Vendors of non-emergency medical transportation | 33 |
| services, as defined
by the Department by rule, shall | 34 |
| submit to a fingerprint-based criminal
background check on | 35 |
| current and future information available in the State
| 36 |
| system and current information available through the |
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| Federal Bureau of
Investigation's system by submitting all | 2 |
| necessary fees and information in the
form and manner
| 3 |
| prescribed by the Department of State Police. The following | 4 |
| individuals shall
be subject to the check:
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| (A) In the case of a vendor that is a corporation, | 6 |
| every shareholder
who owns, directly or indirectly, 5% | 7 |
| or more of the outstanding shares of
the corporation.
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| (B) In the case of a vendor that is a partnership, | 9 |
| every partner.
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| (C) In the case of a vendor that is a sole | 11 |
| proprietorship, the sole
proprietor.
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| (D) Each officer or manager of the vendor.
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| Each such vendor shall be responsible for payment of | 14 |
| the cost of the
criminal background check.
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| (3) Vendors of non-emergency medical transportation | 16 |
| services may be
required to post a surety bond. The | 17 |
| Department shall establish, by rule, the
criteria and | 18 |
| requirements for determining when a surety bond must be | 19 |
| posted and
the value of the bond.
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| (4) The Department, or its agents, may refuse to accept | 21 |
| requests for
non-emergency transportation authorizations, | 22 |
| including prior-approval and
post-approval requests, for a | 23 |
| specific non-emergency transportation vendor if:
| 24 |
| (A) the Department has initiated a notice of | 25 |
| termination of the
vendor from participation in the | 26 |
| medical assistance program; or
| 27 |
| (B) the Department has issued notification of its | 28 |
| withholding of
payments pursuant to subsection (F-5) | 29 |
| of this Section; or
| 30 |
| (C) the Department has issued a notification of its | 31 |
| withholding of
payments due to reliable evidence of | 32 |
| fraud or willful misrepresentation
pending | 33 |
| investigation.
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| (H) Nothing contained in this Code shall in any way limit | 35 |
| or
otherwise impair the authority or power of any State agency | 36 |
| responsible
for licensing of vendors.
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| (I) Based on a finding of noncompliance on the part of a | 2 |
| nursing home with
any requirement for certification under Title | 3 |
| XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et | 4 |
| seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department | 5 |
| may impose one or more of the following remedies after
notice | 6 |
| to the facility:
| 7 |
| (1) Termination of the provider agreement.
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| (2) Temporary management.
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| (3) Denial of payment for new admissions.
| 10 |
| (4) Civil money penalties.
| 11 |
| (5) Closure of the facility in emergency situations or | 12 |
| transfer of
residents, or both.
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| (6) State monitoring.
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| (7) Denial of all payments when the Health Care Finance | 15 |
| Administration has
imposed this sanction.
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| The Illinois Department shall by rule establish criteria | 17 |
| governing continued
payments to a nursing facility subsequent | 18 |
| to termination of the facility's
provider agreement if, in the | 19 |
| sole discretion of the Illinois Department,
circumstances | 20 |
| affecting the health, safety, and welfare of the facility's
| 21 |
| residents require those continued payments. The Illinois | 22 |
| Department may
condition those continued payments on the | 23 |
| appointment of temporary management,
sale of the facility to | 24 |
| new owners or operators, or other
arrangements that the | 25 |
| Illinois Department determines best serve the needs of
the | 26 |
| facility's residents.
| 27 |
| Except in the case of a facility that has a right to a | 28 |
| hearing on the finding
of noncompliance before an agency of the | 29 |
| federal government, a facility may
request a hearing before a | 30 |
| State agency on any finding of noncompliance within
60 days | 31 |
| after the notice of the intent to impose a remedy. Except in | 32 |
| the case
of civil money penalties, a request for a hearing | 33 |
| shall not delay imposition of
the penalty. The choice of | 34 |
| remedies is not appealable at a hearing. The level
of | 35 |
| noncompliance may be challenged only in the case of a civil | 36 |
| money penalty.
The Illinois Department shall provide by rule |
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LRB094 04634 DRJ 34663 b |
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| 1 |
| for the State agency that will
conduct the evidentiary | 2 |
| hearings.
| 3 |
| The Illinois Department may collect interest on unpaid | 4 |
| civil money penalties.
| 5 |
| The Illinois Department may adopt all rules necessary to | 6 |
| implement this
subsection (I).
| 7 |
| (J) The Illinois Department, by rule, may permit individual | 8 |
| practitioners to designate that Department payments that may be | 9 |
| due the practitioner be made to an alternate payee or alternate | 10 |
| payees. | 11 |
| (a) Such alternate payee or alternate payees shall be | 12 |
| required to register as an alternate payee in the Medical | 13 |
| Assistance Program with the Illinois Department. | 14 |
| (b) If a practitioner designates an alternate payee, | 15 |
| the alternate payee and practitioner shall be jointly and | 16 |
| severally liable to the Department for payments made to the | 17 |
| alternate payee. Pursuant to subsection (E) of this | 18 |
| Section, any Department action to recover money or | 19 |
| overpayments from an alternate payee shall be subject to an | 20 |
| administrative hearing. | 21 |
| (c) Registration as an alternate payee or alternate | 22 |
| payees in the Illinois Medical Assistance Program shall be | 23 |
| conditional. At any time, the Illinois Department may deny | 24 |
| or cancel any alternate payee's registration in the | 25 |
| Illinois Medical Assistance Program without cause. Any | 26 |
| such denial or cancellation is not subject to an | 27 |
| administrative hearing. | 28 |
| (d) The Illinois Department may seek a revocation of | 29 |
| any alternate payee, and all owners, officers, and | 30 |
| individuals with management responsibility for such | 31 |
| alternate payee shall be permanently prohibited from | 32 |
| participating as an owner, an officer, or an individual | 33 |
| with management responsibility with an alternate payee in | 34 |
| the Illinois Medical Assistance Program, if after | 35 |
| reasonable notice and opportunity for a hearing the | 36 |
| Illinois Department finds that: |
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LRB094 04634 DRJ 34663 b |
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| 1 |
| (1) the alternate payee is not complying with the | 2 |
| Department's policy or rules and regulations, or with | 3 |
| the terms and conditions prescribed by the Illinois | 4 |
| Department in its alternate payee registration | 5 |
| agreement; or | 6 |
| (2) the alternate payee has failed to keep or make | 7 |
| available for inspection, audit, or copying, after | 8 |
| receiving a written request from the Illinois | 9 |
| Department, such records regarding payments claimed as | 10 |
| an alternate payee; or | 11 |
| (3) the alternate payee has failed to furnish any | 12 |
| information requested by the Illinois Department | 13 |
| regarding payments claimed as an alternate payee; or | 14 |
| (4) the alternate payee has knowingly made, or | 15 |
| caused to be made, any false statement or | 16 |
| representation of a material fact in connection with | 17 |
| the administration of the Illinois Medical Assistance | 18 |
| Program; or | 19 |
| (5) the alternate payee, a person with management | 20 |
| responsibility for an alternate payee, an officer or | 21 |
| person owning, either directly or indirectly, 5% or | 22 |
| more of the shares of stock or other evidences of | 23 |
| ownership in a corporate alternate payee, or a partner | 24 |
| in a partnership which is an alternate payee: | 25 |
| (a) was previously terminated from | 26 |
| participation as a vendor in the Illinois Medical | 27 |
| Assistance Program, or was previously revoked as | 28 |
| an alternate payee in the Illinois Medical | 29 |
| Assistance Program, or was terminated from | 30 |
| participation as a vendor in a medical assistance | 31 |
| program in another state that is of the same kind | 32 |
| as the program of medical assistance provided | 33 |
| under Article V of this Code; or | 34 |
| (b) was a person with management | 35 |
| responsibility for a vendor previously terminated | 36 |
| from participation as a vendor in the Illinois |
|
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LRB094 04634 DRJ 34663 b |
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| 1 |
| Medical Assistance Program, or was previously | 2 |
| revoked as an alternate payee in the Illinois | 3 |
| Medical Assistance Program, or was terminated from | 4 |
| participation as a vendor in a medical assistance | 5 |
| program in another state that is of the same kind | 6 |
| as the program of medical assistance provided | 7 |
| under Article V of this Code, during the time of | 8 |
| conduct which was the basis for that vendor's | 9 |
| termination or alternate payee's revocation; or | 10 |
| (c) was an officer, or person owning, either | 11 |
| directly or indirectly, 5% or more of the shares of | 12 |
| stock or other evidences of ownership in a | 13 |
| corporate vendor previously terminated from | 14 |
| participation as a vendor in the Illinois Medical | 15 |
| Assistance Program, or was previously revoked as | 16 |
| an alternate payee in the Illinois Medical | 17 |
| Assistance Program, or was terminated from | 18 |
| participation as a vendor in a medical assistance | 19 |
| program in another state that is of the same kind | 20 |
| as the program of medical assistance provided | 21 |
| under Article V of this Code, during the time of | 22 |
| conduct which was the basis for that vendor's | 23 |
| termination; or | 24 |
| (d) was an owner of a sole proprietorship or | 25 |
| partner in a partnership previously terminated | 26 |
| from participation as a vendor in the Illinois | 27 |
| Medical Assistance Program, or was previously | 28 |
| revoked as an alternate payee in the Illinois | 29 |
| Medical Assistance Program, or was terminated from | 30 |
| participation as a vendor in a medical assistance | 31 |
| program in another state that is of the same kind | 32 |
| as the program of medical assistance provided | 33 |
| under Article V of this Code, during the time of | 34 |
| conduct which was the basis for that vendor's | 35 |
| termination or alternate payee's revocation; or | 36 |
| (6) the alternate payee, a person with management |
|
|
|
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LRB094 04634 DRJ 34663 b |
|
| 1 |
| responsibility for an alternate payee, an officer or | 2 |
| person owning, either directly or indirectly, 5% or | 3 |
| more of the shares of stock or other evidences of | 4 |
| ownership in a corporate alternate payee, or a partner | 5 |
| in a partnership which is an alternate payee: | 6 |
| (a) has engaged in conduct prohibited by | 7 |
| applicable federal or State law or regulation | 8 |
| relating to the Illinois Medical Assistance | 9 |
| Program; or | 10 |
| (b) was a person with management | 11 |
| responsibility for a vendor or alternate payee at | 12 |
| the time that the vendor or alternate payee engaged | 13 |
| in practices prohibited by applicable federal or | 14 |
| State law or regulation relating to the Illinois | 15 |
| Medical Assistance Program; or | 16 |
| (c) was an officer, or person owning, either | 17 |
| directly or indirectly, 5% or more of the shares of | 18 |
| stock or other evidences of ownership in a vendor | 19 |
| or alternate payee at the time such vendor or | 20 |
| alternate payee engaged in practices prohibited by | 21 |
| applicable federal or State law or regulation | 22 |
| relating to the Illinois Medical Assistance | 23 |
| Program; or | 24 |
| (d) was an owner of a sole proprietorship or | 25 |
| partner in a partnership which was a vendor or | 26 |
| alternate payee at the time such vendor or | 27 |
| alternate payee engaged in practices prohibited by | 28 |
| applicable federal or State law or regulation | 29 |
| relating to the Illinois Medical Assistance | 30 |
| Program; or | 31 |
| (7) the direct or indirect ownership of the vendor | 32 |
| or alternate payee (including the ownership of a vendor | 33 |
| or alternate payee that is a partner's interest in a | 34 |
| vendor or alternate payee, or ownership of 5% or more | 35 |
| of the shares of stock or other evidences of ownership | 36 |
| in a corporate vendor or alternate payee) has been |
|
|
|
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LRB094 04634 DRJ 34663 b |
|
| 1 |
| transferred by an individual who is terminated or | 2 |
| barred from participating as a vendor or is prohibited | 3 |
| or revoked as an alternate payee to the individual's | 4 |
| spouse, child, brother, sister, parent, grandparent, | 5 |
| grandchild, uncle, aunt, niece, nephew, cousin, or | 6 |
| relative by marriage. | 7 |
| (K) The Illinois Department of Healthcare and Family | 8 |
| Services may withhold payments, in whole or in part, to a | 9 |
| provider or alternate payee upon receipt of evidence, received | 10 |
| from State or federal law enforcement or federal oversight | 11 |
| agencies or from the results of a preliminary Department audit | 12 |
| and determined by the Department to be credible, that the | 13 |
| circumstances giving rise to the need for a withholding of | 14 |
| payments may involve fraud or willful misrepresentation under | 15 |
| the Illinois Medical Assistance program. The Department shall | 16 |
| by rule define what constitutes "credible" evidence for | 17 |
| purposes of this subsection. The Department may withhold | 18 |
| payments without first notifying the provider or alternate | 19 |
| payee of its intention to withhold such payments. A provider or | 20 |
| alternate payee may request a reconsideration of payment | 21 |
| withholding, and the Department must grant such a request. The | 22 |
| Department shall state by rule a process and criteria by which | 23 |
| a provider or alternate payee may request full or partial | 24 |
| release of payments withheld under this subsection. This | 25 |
| request may be made at any time after the Department first | 26 |
| withholds such payments. | 27 |
| (a) The Illinois Department must send notice of its
| 28 |
| withholding of program payments within 5 days of taking | 29 |
| such action. The notice must set forth the general | 30 |
| allegations as to the nature of the withholding action, but | 31 |
| need not disclose any specific information concerning its | 32 |
| ongoing investigation. The notice must do all of the | 33 |
| following: | 34 |
| (1) State that payments are being withheld in
| 35 |
| accordance with this subsection. | 36 |
| (2) State that the withholding is for a temporary
|
|
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|
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LRB094 04634 DRJ 34663 b |
|
| 1 |
| period, as stated in paragraph (b) of this
subsection, | 2 |
| and cite the circumstances under which
withholding | 3 |
| will be terminated. | 4 |
| (3) Specify, when appropriate, which type or types
| 5 |
| of Medicaid claims withholding is effective. | 6 |
| (4) Inform the provider or alternate payee of the
| 7 |
| right to submit written evidence for reconsideration | 8 |
| of the withholding by
the Illinois Department. | 9 |
| (5) Inform the provider or alternate payee that a | 10 |
| written request may be made to the Illinois Department | 11 |
| for full or partial release of withheld payments and | 12 |
| that such requests may be made at any time after the | 13 |
| Department first withholds such payments.
| 14 |
| (b) All withholding-of-payment actions under this
| 15 |
| subsection shall be temporary and shall not continue after | 16 |
| any of the following: | 17 |
| (1) The Illinois Department or the prosecuting
| 18 |
| authorities determine that there is insufficient
| 19 |
| evidence of fraud or willful misrepresentation by the
| 20 |
| provider or alternate payee. | 21 |
| (2) Legal proceedings related to the provider's or
| 22 |
| alternate payee's alleged fraud, willful
| 23 |
| misrepresentation, violations of this Act, or
| 24 |
| violations of the Illinois Department's administrative
| 25 |
| rules are completed. | 26 |
| (3) The withholding of payments for a period of 3 | 27 |
| years.
| 28 |
| (c) The Illinois Department may adopt all rules | 29 |
| necessary
to implement this subsection (K).
| 30 |
| (Source: P.A. 94-265, eff. 1-1-06; revised 12-15-05.)
| 31 |
| Section 99. Effective date. This Act takes effect upon | 32 |
| becoming law.
|
|