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90_SB0879
305 ILCS 5/12-4.25 from Ch. 23, par. 12-4.25
Amends the "Administration" Article of the Public Aid
Code. Makes stylistic changes in a Section concerning vendor
participation in the Medicaid program.
LRB9003200DJcc
LRB9003200DJcc
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Section 12-4.25.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Section 12-4.25 as follows:
7 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
8 Sec. 12-4.25. Medical assistance program; vendor
9 participation.
10 (A) The Illinois Department may deny, suspend or
11 terminate the eligibility of any person, firm, corporation,
12 association, agency, institution or other legal entity to
13 participate as a vendor of goods or services to recipients
14 under the medical assistance program under Article V, if
15 after reasonable notice and opportunity for a hearing the
16 Illinois Department finds:
17 (a) The Such vendor is not complying with the
18 Department's policy or rules and regulations, or with the
19 terms and conditions prescribed by the Illinois
20 Department in its vendor agreement, which document shall
21 be developed by the Department as a result of
22 negotiations with each vendor category, including
23 physicians, hospitals, long term care facilities,
24 pharmacists, optometrists, podiatrists and dentists
25 setting forth the terms and conditions applicable to the
26 participation of each vendor group in the program; or
27 (b) The Such vendor has failed to keep or make
28 available for inspection, audit or copying, after
29 receiving a written request from the Illinois Department,
30 such records regarding payments claimed for providing
31 services. This section does not require vendors to make
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1 available patient records of patients for whom services
2 are not reimbursed under this Code; or
3 (c) The Such vendor has failed to furnish any
4 information requested by the Department regarding
5 payments for providing goods or services; or
6 (d) The Such vendor has knowingly made, or caused
7 to be made, any false statement or representation of a
8 material fact in connection with the administration of
9 the medical assistance program; or
10 (e) The Such vendor has furnished goods or services
11 to a recipient which are (1) in excess of his or her
12 needs, (2) harmful to the recipient, or (3) of grossly
13 inferior quality, all of such determinations to be based
14 upon competent medical judgment and evaluations; or
15 (f) The vendor; a person with management
16 responsibility for a vendor; an officer or person owning,
17 either directly or indirectly, 5% or more of the shares
18 of stock or other evidences of ownership in a corporate
19 vendor; an owner of a sole proprietorship which is a
20 vendor; or a partner in a partnership which is a vendor,
21 either:
22 (1) was previously terminated from
23 participation in the medical assistance program; or
24 (2) was a person with management
25 responsibility for a previously terminated vendor
26 during the time of conduct which was the basis for
27 that vendor's termination from participation in the
28 medical assistance program; or
29 (3) was an officer, or person owning, either
30 directly or indirectly, 5% or more of the shares of
31 stock or other evidences of ownership in a
32 previously terminated corporate vendor during the
33 time of conduct which was the basis for that
34 vendor's termination from participation in the
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1 medical assistance program; or
2 (4) was an owner of a sole proprietorship or
3 partner of a partnership which was previously
4 terminated during the time of conduct which was the
5 basis for that vendor's termination from
6 participation in the medical assistance program; or
7 (g) The vendor; a person with management
8 responsibility for a vendor; an officer or person owning,
9 either directly or indirectly, 5% or more of the shares
10 of stock or other evidences of ownership in a corporate
11 vendor; an owner of a sole proprietorship which is a
12 vendor; or a partner in a partnership which is a vendor,
13 either:
14 (1) has engaged in practices prohibited by
15 applicable federal or State law or regulation
16 relating to the medical assistance program; or
17 (2) was a person with management
18 responsibility for a vendor at the time that such
19 vendor engaged in practices prohibited by applicable
20 federal or State law or regulation relating to the
21 medical assistance program; or
22 (3) was an officer, or person owning, either
23 directly or indirectly, 5% or more of the shares of
24 stock or other evidences of ownership in a vendor at
25 the time such vendor engaged in practices prohibited
26 by applicable federal or State law or regulation
27 relating to the medical assistance program; or
28 (4) was an owner of a sole proprietorship or
29 partner of a partnership which was a vendor at the
30 time such vendor engaged in practices prohibited by
31 applicable federal or State law or regulation
32 relating to the medical assistance program.
33 (h) The direct or indirect ownership of the vendor
34 (including the ownership of a vendor that is a sole
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1 proprietorship, a partner's interest in a vendor that is
2 a partnership, or ownership of 5% or more of the shares
3 of stock or other evidences of ownership in a corporate
4 vendor) has been transferred by an individual who is
5 terminated or barred from participating as a vendor to
6 the individual's spouse, child, brother, sister, parent,
7 grandparent, grandchild, uncle, aunt, niece, nephew,
8 cousin, or relative by marriage.
9 (B) The Illinois Department shall deny, suspend or
10 terminate the eligibility of any person, firm, corporation,
11 association, agency, institution or other legal entity to
12 participate as a vendor of goods or services to recipients
13 under the medical assistance program under Article V:
14 (1) if such vendor is not properly licensed;
15 (2) within 30 days of the date when such vendor's
16 professional license, certification or other authorization
17 has been refused renewal or has been revoked, suspended or
18 otherwise terminated; or
19 (3) if such vendor has been convicted of a
20 violation of this Code, as provided in Article VIIIA.
21 (C) Upon termination of a vendor of goods or services
22 from participation in the medical assistance program
23 authorized by this Article, a person with management
24 responsibility for such vendor during the time of any conduct
25 which served as the basis for that vendor's termination is
26 barred from participation in the medical assistance program.
27 Upon termination of a corporate vendor, the officers and
28 persons owning, directly or indirectly, 5% or more of the
29 shares of stock or other evidences of ownership in the vendor
30 during the time of any conduct which served as the basis for
31 that vendor's termination are barred from participation in
32 the medical assistance program. A person who owns, directly
33 or indirectly, 5% or more of the shares of stock or other
34 evidences of ownership in a terminated corporate vendor may
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1 not transfer his or her ownership interest in that vendor to
2 his or her spouse, child, brother, sister, parent,
3 grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
4 or relative by marriage.
5 Upon termination of a sole proprietorship or partnership,
6 the owner or partners during the time of any conduct which
7 served as the basis for that vendor's termination are barred
8 from participation in the medical assistance program. The
9 owner of a terminated vendor that is a sole proprietorship,
10 and a partner in a terminated vendor that is a partnership,
11 may not transfer his or her ownership or partnership interest
12 in that vendor to his or her spouse, child, brother, sister,
13 parent, grandparent, grandchild, uncle, aunt, niece, nephew,
14 cousin, or relative by marriage.
15 Rules adopted by the Illinois Department to implement
16 these provisions shall specifically include a definition of
17 the term "management responsibility" as used in this Section.
18 Such definition shall include, but not be limited to, typical
19 job titles, and duties and descriptions which will be
20 considered as within the definition of individuals with
21 management responsibility for a provider.
22 (D) If a vendor has been suspended from the medical
23 assistance program under Article V of the Code, the Director
24 may require that such vendor correct any deficiencies which
25 served as the basis for the suspension. The Director shall
26 specify in the suspension order a specific period of time,
27 which shall not exceed one year from the date of the order,
28 during which a suspended vendor shall not be eligible to
29 participate. At the conclusion of the period of suspension
30 the Director shall reinstate such vendor, unless he finds
31 that such vendor has not corrected deficiencies upon which
32 the suspension was based.
33 If a vendor has been terminated from the medical
34 assistance program under Article V, such vendor shall be
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1 barred from participation for at least one year. At the end
2 of one year a vendor who has been terminated may apply for
3 reinstatement to the program. Upon proper application to be
4 reinstated such vendor may be deemed eligible by the Director
5 providing that such vendor meets the requirements for
6 eligibility under this Act. If such vendor is deemed not
7 eligible for reinstatement, he shall be barred from again
8 applying for reinstatement for one year from the date his
9 application for reinstatement is denied.
10 If a vendor has been terminated and reinstated to the
11 medical assistance program under Article V and the vendor is
12 terminated a second or subsequent time from the medical
13 assistance program, the vendor shall be barred from
14 participation for at least 2 years. At the end of 2 years, a
15 vendor who has been terminated may apply for reinstatement to
16 the program. Upon application to be reinstated, the vendor
17 may be deemed eligible if the vendor meets the requirements
18 for eligibility under this Code. If the vendor is deemed not
19 eligible for reinstatement, the vendor shall be barred from
20 again applying for reinstatement for 2 years from the date
21 the vendor's application for reinstatement is denied.
22 (E) The Illinois Department may recover money improperly
23 or erroneously paid, or overpayments, either by setoff,
24 crediting against future billings or by requiring direct
25 repayment to the Illinois Department.
26 (F) The Illinois Department may withhold payments to any
27 vendor during the pendency of any proceeding under this
28 Section except that if a final administrative decision has
29 not been issued within 120 days of the initiation of such
30 proceedings, unless delay has been caused by the vendor,
31 payments can no longer be withheld, provided, however, that
32 the 120 day limit may be extended if said extension is
33 mutually agreed to by the Illinois Department and the vendor.
34 The Illinois Department shall state by rule with as much
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1 specificity as practicable the conditions under which
2 payments will not be withheld during the pendency of any
3 proceeding under this Section. Payments may be denied for
4 bills submitted with service dates occurring during the
5 pendency of a proceeding where the final administrative
6 decision is to terminate eligibility to participate in the
7 medical assistance program. The Illinois Department shall
8 state by rule with as much specificity as practicable the
9 conditions under which payments will not be denied for such
10 bills.
11 (G) The provisions of the Administrative Review Law, as
12 now or hereafter amended, and the rules adopted pursuant
13 thereto, shall apply to and govern all proceedings for the
14 judicial review of final administrative decisions of the
15 Illinois Department under this Section. The term
16 "administrative decision" is defined as in Section 3-101 of
17 the Code of Civil Procedure.
18 (H) Nothing contained in this Code shall in any way
19 limit or otherwise impair the authority or power of any State
20 agency responsible for licensing of vendors.
21 (I) Based on a finding of noncompliance on the part of a
22 nursing home with any requirement for certification under
23 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
24 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
25 Department may impose one or more of the following remedies
26 after notice to the facility:
27 (1) Termination of the provider agreement.
28 (2) Temporary management.
29 (3) Denial of payment for new admissions.
30 (4) Civil money penalties.
31 (5) Closure of the facility in emergency situations
32 or transfer of residents, or both.
33 (6) State monitoring.
34 (7) Denial of all payments when the Health Care
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1 Finance Administration has imposed this sanction.
2 The Illinois Department shall by rule establish criteria
3 governing continued payments to a nursing facility subsequent
4 to termination of the facility's provider agreement if, in
5 the sole discretion of the Illinois Department, circumstances
6 affecting the health, safety, and welfare of the facility's
7 residents require those continued payments. The Illinois
8 Department may condition those continued payments on the
9 appointment of temporary management, sale of the facility to
10 new owners or operators, or other arrangements that the
11 Illinois Department determines best serve the needs of the
12 facility's residents.
13 Except in the case of a facility that has a right to a
14 hearing on the finding of noncompliance before an agency of
15 the federal government, a facility may request a hearing
16 before a State agency on any finding of noncompliance within
17 60 days after the notice of the intent to impose a remedy.
18 Except in the case of civil money penalties, a request for a
19 hearing shall not delay imposition of the penalty. The
20 choice of remedies is not appealable at a hearing. The level
21 of noncompliance may be challenged only in the case of a
22 civil money penalty. The Illinois Department shall provide
23 by rule for the State agency that will conduct the
24 evidentiary hearings.
25 The Illinois Department may collect interest on unpaid
26 civil money penalties.
27 The Illinois Department may adopt all rules necessary to
28 implement this subsection (I).
29 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 1-1-96.)