State of Illinois
92nd General Assembly
Legislation

   [ Search ]   [ PDF text ]   [ Legislation ]   
[ Home ]   [ Back ]   [ Bottom ]


[ Engrossed ][ Enrolled ][ Senate Amendment 001 ]


92_SB2225

 
                                               LRB9211341DJgc

 1        AN ACT in relation to public aid.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 5. The Illinois Public Aid  Code  is  amended  by
 5    changing Sections 5-5 and 12-4.25 as follows:

 6        (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
 7        Sec.  5-5.  Medical services. The Illinois Department, by
 8    rule, shall determine the quantity and  quality  of  and  the
 9    rate  of  reimbursement  for the medical assistance for which
10    payment will be authorized, and the medical  services  to  be
11    provided, which may include all or part of the following: (1)
12    inpatient   hospital   services;   (2)   outpatient  hospital
13    services;  (3)  other  laboratory  and  X-ray  services;  (4)
14    skilled  nursing  home  services;  (5)  physicians'  services
15    whether furnished  in  the  office,  the  patient's  home,  a
16    hospital,  a  skilled nursing home, or elsewhere; (6) medical
17    care, or  any  other  type  of  remedial  care  furnished  by
18    licensed  practitioners;  (7)  home health care services; (8)
19    private duty  nursing  service;  (9)  clinic  services;  (10)
20    dental  services; (11) physical therapy and related services;
21    (12) prescribed drugs, dentures, and prosthetic devices;  and
22    eyeglasses  prescribed by a physician skilled in the diseases
23    of the eye, or by an optometrist, whichever  the  person  may
24    select;  (13)  other  diagnostic,  screening, preventive, and
25    rehabilitative services; (14) transportation and  such  other
26    expenses  as  may  be  necessary;  (15)  medical treatment of
27    sexual assault survivors, as defined in  Section  1a  of  the
28    Sexual   Assault   Survivors  Emergency  Treatment  Act,  for
29    injuries  sustained  as  a  result  of  the  sexual  assault,
30    including  examinations  and  laboratory  tests  to  discover
31    evidence which may be used in  criminal  proceedings  arising
 
                            -2-                LRB9211341DJgc
 1    from  the sexual assault; (16) the diagnosis and treatment of
 2    sickle cell anemia; and (17) any other medical care, and  any
 3    other type of remedial care recognized under the laws of this
 4    State,  but  not including abortions, or induced miscarriages
 5    or premature births, unless, in the opinion of  a  physician,
 6    such  procedures  are  necessary  for the preservation of the
 7    life of the  woman  seeking  such  treatment,  or  except  an
 8    induced  premature  birth  intended  to produce a live viable
 9    child and such procedure is necessary for the health  of  the
10    mother or her unborn child. The Illinois Department, by rule,
11    shall   prohibit   any   physician   from  providing  medical
12    assistance to anyone eligible therefor under this Code  where
13    such  physician  has  been  found  guilty  of  performing  an
14    abortion procedure in a wilful and wanton manner upon a woman
15    who  was not pregnant at the time such abortion procedure was
16    performed. The term "any other type of remedial  care"  shall
17    include nursing care and nursing home service for persons who
18    rely on treatment by spiritual means alone through prayer for
19    healing.
20        Notwithstanding  any  other  provision of this Section, a
21    comprehensive tobacco use  cessation  program  that  includes
22    purchasing prescription drugs or prescription medical devices
23    approved by the Food and Drug administration shall be covered
24    under  the  medical assistance program under this Article for
25    persons who are otherwise eligible for assistance under  this
26    Article.
27        Notwithstanding  any  other  provision  of this Code, the
28    Illinois Department  may  not  require,  as  a  condition  of
29    payment   for  any  laboratory  test  authorized  under  this
30    Article, that a physician's handwritten signature  appear  on
31    the laboratory test order form.  The Illinois Department may,
32    however,  impose  other  appropriate  requirements  regarding
33    laboratory test order documentation.
34        The  Illinois  Department of Public Aid shall provide the
 
                            -3-                LRB9211341DJgc
 1    following services to persons eligible for  assistance  under
 2    this  Article who are participating in education, training or
 3    employment programs  operated  by  the  Department  of  Human
 4    Services as successor to the Department of Public Aid:
 5             (1)  dental services, which shall include but not be
 6        limited to prosthodontics; and
 7             (2)  eyeglasses prescribed by a physician skilled in
 8        the  diseases of the eye, or by an optometrist, whichever
 9        the person may select.
10        The Illinois Department, by  rule,  may  distinguish  and
11    classify   the  medical  services  to  be  provided  only  in
12    accordance with the classes of persons designated in  Section
13    5-2.
14        The Illinois Department shall authorize the provision of,
15    and  shall  authorize  payment  for,  screening  by  low-dose
16    mammography  for  the  presence  of  occult breast cancer for
17    women 35 years of age or older who are eligible  for  medical
18    assistance  under  this  Article,  as  follows:   a  baseline
19    mammogram  for  women  35  to  39  years of age and an annual
20    mammogram for women 40 years of age or older.  All screenings
21    shall  include  a  physical  breast  exam,   instruction   on
22    self-examination  and  information regarding the frequency of
23    self-examination and its value as a  preventative  tool.   As
24    used  in this Section, "low-dose mammography" means the x-ray
25    examination  of  the   breast   using   equipment   dedicated
26    specifically  for  mammography,  including  the  x-ray  tube,
27    filter,  compression  device,  image receptor, and cassettes,
28    with an average radiation exposure delivery of less than  one
29    rad mid-breast, with 2 views for each breast.
30        Any  medical  or  health  care provider shall immediately
31    recommend, to  any  pregnant  woman  who  is  being  provided
32    prenatal  services  and  is  suspected  of  drug  abuse or is
33    addicted as defined in the Alcoholism and  Other  Drug  Abuse
34    and  Dependency  Act,  referral  to  a  local substance abuse
 
                            -4-                LRB9211341DJgc
 1    treatment  provider  licensed  by  the  Department  of  Human
 2    Services or to a licensed hospital which  provides  substance
 3    abuse treatment services.  The Department of Public Aid shall
 4    assure  coverage  for the cost of treatment of the drug abuse
 5    or addiction for pregnant recipients in accordance  with  the
 6    Illinois  Medicaid Program in conjunction with the Department
 7    of Human Services.
 8        All medical providers  providing  medical  assistance  to
 9    pregnant women under this Code shall receive information from
10    the Department on the availability of services under the Drug
11    Free  Families  with  a  Future  or  any  comparable  program
12    providing   case  management  services  for  addicted  women,
13    including information  on  appropriate  referrals  for  other
14    social  services  that  may  be  needed  by addicted women in
15    addition to treatment for addiction.
16        The  Illinois  Department,  in   cooperation   with   the
17    Departments of Human Services (as successor to the Department
18    of Alcoholism and Substance Abuse) and Public Health, through
19    a   public   awareness   campaign,  may  provide  information
20    concerning  treatment  for  alcoholism  and  drug  abuse  and
21    addiction, prenatal health care, and other pertinent programs
22    directed at reducing the number of drug-affected infants born
23    to recipients of medical assistance.
24        Neither the Illinois Department of  Public  Aid  nor  the
25    Department  of  Human  Services  shall sanction the recipient
26    solely on the basis of her substance abuse.
27        The Illinois Department shall establish such  regulations
28    governing  the  dispensing  of  health  services  under  this
29    Article  as  it shall deem appropriate.  In formulating these
30    regulations the Illinois Department shall  consult  with  and
31    give substantial weight to the recommendations offered by the
32    Citizens  Assembly/Council  on  Public  Aid.  The  Department
33    should  seek  the  advice  of  formal  professional  advisory
34    committees   appointed   by  the  Director  of  the  Illinois
 
                            -5-                LRB9211341DJgc
 1    Department for the purpose of  providing  regular  advice  on
 2    policy  and administrative matters, information dissemination
 3    and  educational  activities  for  medical  and  health  care
 4    providers, and consistency  in  procedures  to  the  Illinois
 5    Department.
 6        The  Illinois  Department  may  develop and contract with
 7    Partnerships of medical providers to arrange medical services
 8    for  persons  eligible  under  Section  5-2  of  this   Code.
 9    Implementation  of  this  Section  may  be  by  demonstration
10    projects  in certain geographic areas.  The Partnership shall
11    be represented by a sponsor organization.  The Department, by
12    rule,  shall   develop   qualifications   for   sponsors   of
13    Partnerships.   Nothing in this Section shall be construed to
14    require  that  the  sponsor   organization   be   a   medical
15    organization.
16        The  sponsor must negotiate formal written contracts with
17    medical  providers  for  physician  services,  inpatient  and
18    outpatient hospital care, home health services, treatment for
19    alcoholism and substance abuse, and other services determined
20    necessary by the Illinois Department by rule for delivery  by
21    Partnerships.   Physician  services must include prenatal and
22    obstetrical care.  The Illinois  Department  shall  reimburse
23    medical   services  delivered  by  Partnership  providers  to
24    clients in target  areas  according  to  provisions  of  this
25    Article  and  the  Illinois Health Finance Reform Act, except
26    that:
27             (1)  Physicians participating in a  Partnership  and
28        providing  certain services, which shall be determined by
29        the Illinois Department, to persons in areas  covered  by
30        the  Partnership  may receive an additional surcharge for
31        such services.
32             (2)  The  Department  may  elect  to  consider   and
33        negotiate   financial   incentives   to   encourage   the
34        development of Partnerships and the efficient delivery of
 
                            -6-                LRB9211341DJgc
 1        medical care.
 2             (3)  Persons   receiving  medical  services  through
 3        Partnerships may  receive  medical  and  case  management
 4        services  above  the  level  usually  offered through the
 5        medical assistance program.
 6        Medical providers  shall  be  required  to  meet  certain
 7    qualifications  to  participate in Partnerships to ensure the
 8    delivery   of   high   quality   medical   services.    These
 9    qualifications shall be determined by rule  of  the  Illinois
10    Department   and   may  be  higher  than  qualifications  for
11    participation in the medical assistance program.  Partnership
12    sponsors may prescribe reasonable  additional  qualifications
13    for  participation  by medical providers, only with the prior
14    written approval of the Illinois Department.
15        Nothing in this Section shall limit the  free  choice  of
16    practitioners,  hospitals,  and  other  providers  of medical
17    services by clients. In order to ensure  patient  freedom  of
18    choice,  the Illinois Department shall immediately promulgate
19    all rules and  take  all  other  necessary  actions  so  that
20    provided   services  may  be  accessed  from  therapeutically
21    certified optometrists to the full  extent  of  the  Illinois
22    Optometric   Practice  Act  of  1987  without  discriminating
23    between service providers.
24        The Department shall apply for a waiver from  the  United
25    States  Health Care Financing Administration to allow for the
26    implementation of Partnerships under this Section.
27        The  Illinois  Department  shall  require   health   care
28    providers  to maintain records that document the medical care
29    and services provided to  recipients  of  Medical  Assistance
30    under  this  Article.   The Illinois Department shall require
31    health care providers to make available, when  authorized  by
32    the  patient,  in  writing,  the  medical records in a timely
33    fashion to other health care providers who  are  treating  or
34    serving  persons  eligible  for Medical Assistance under this
 
                            -7-                LRB9211341DJgc
 1    Article.   All  dispensers  of  medical  services  shall   be
 2    required  to  maintain  and  retain business and professional
 3    records sufficient  to  fully  and  accurately  document  the
 4    nature,  scope,  details  and  receipt  of  the  health  care
 5    provided  to  persons  eligible  for medical assistance under
 6    this Code, in accordance with regulations promulgated by  the
 7    Illinois Department.  The rules and regulations shall require
 8    that  proof  of  the receipt of prescription drugs, dentures,
 9    prosthetic devices and eyeglasses by eligible  persons  under
10    this Section accompany each claim for reimbursement submitted
11    by the dispenser of such medical services. No such claims for
12    reimbursement  shall  be approved for payment by the Illinois
13    Department without such proof of receipt, unless the Illinois
14    Department shall have put into effect and shall be  operating
15    a  system  of post-payment audit and review which shall, on a
16    sampling basis, be deemed adequate by the Illinois Department
17    to assure that such drugs, dentures, prosthetic  devices  and
18    eyeglasses for which payment is being made are actually being
19    received  by  eligible  recipients.  Within 90 days after the
20    effective date of this amendatory Act of 1984,  the  Illinois
21    Department  shall  establish  a  current  list of acquisition
22    costs  for  all  prosthetic  devices  and  any  other   items
23    recognized  as  medical  equipment  and supplies reimbursable
24    under this Article and shall update such list on a  quarterly
25    basis,  except that the acquisition costs of all prescription
26    drugs shall be updated no less frequently than every 30  days
27    as required by Section 5-5.12.
28        The  rules  and  regulations  of  the Illinois Department
29    shall require that a written statement including the required
30    opinion  of  a  physician  shall  accompany  any  claim   for
31    reimbursement  for  abortions,  or  induced  miscarriages  or
32    premature   births.    This  statement  shall  indicate  what
33    procedures were used in providing such medical services.
34        The Illinois Department shall require that all dispensers
 
                            -8-                LRB9211341DJgc
 1    of medical services, other than an individual practitioner or
 2    group  of  practitioners,  desiring  to  participate  in  the
 3    Medical Assistance program established under this Article  to
 4    disclose all financial, beneficial, ownership, equity, surety
 5    or  other  interests  in  any  and  all  firms, corporations,
 6    partnerships,  associations,  business   enterprises,   joint
 7    ventures,  agencies,  institutions  or  other  legal entities
 8    providing any form of health  care  services  in  this  State
 9    under this Article.
10        The  Illinois  Department may require that all dispensers
11    of medical services desiring to participate  in  the  medical
12    assistance  program  established under this Article disclose,
13    under such terms and conditions as  the  Illinois  Department
14    may  by  rule  establish,  all  inquiries  from  clients  and
15    attorneys  regarding  medical  bills  paid  by  the  Illinois
16    Department,   which   inquiries   could   indicate  potential
17    existence of claims or liens for the Illinois Department.
18        Enrollment   of   a   vendor   that   provides    medical
19    transportation shall be conditional for 180 days. During that
20    time, the Department of Public Aid may terminate the vendor's
21    eligibility  to participate in the medical assistance program
22    without  cause.   That  termination  of  eligibility  is  not
23    subject to the notice and hearing requirements set  forth  in
24    Section 12-4.25.
25        The   Illinois   Department   shall  establish  policies,
26    procedures,  standards  and  criteria   by   rule   for   the
27    acquisition,   repair   and   replacement   of  orthotic  and
28    prosthetic devices and durable medical equipment.  Such rules
29    shall provide, but not be limited to, the following services:
30    (1) immediate  repair  or  replacement  of  such  devices  by
31    recipients  without  medical  authorization;  and (2) rental,
32    lease,  purchase  or  lease-purchase   of   durable   medical
33    equipment   in   a   cost-effective   manner,   taking   into
34    consideration  the  recipient's medical prognosis, the extent
 
                            -9-                LRB9211341DJgc
 1    of the recipient's needs, and the requirements and costs  for
 2    maintaining  such  equipment.   Such  rules  shall  enable  a
 3    recipient  to  temporarily  acquire  and  use  alternative or
 4    substitute  devices   or   equipment   pending   repairs   or
 5    replacements of any device or equipment previously authorized
 6    for  such recipient by the Department. Rules under clause (2)
 7    above shall not provide for  purchase  or  lease-purchase  of
 8    durable medical equipment or supplies used for the purpose of
 9    oxygen delivery and respiratory care.
10        The  Department  shall  execute,  relative to the nursing
11    home prescreening project,  written  inter-agency  agreements
12    with  the  Department of Human Services and the Department on
13    Aging, to effect the following:  (i)  intake  procedures  and
14    common   eligibility  criteria  for  those  persons  who  are
15    receiving   non-institutional   services;   and   (ii)    the
16    establishment  and  development of non-institutional services
17    in areas of the State where they are not currently  available
18    or are undeveloped.
19        The  Illinois  Department  shall  develop and operate, in
20    cooperation with other State Departments and agencies and  in
21    compliance  with  applicable  federal  laws  and regulations,
22    appropriate and effective systems of health  care  evaluation
23    and  programs  for  monitoring  of utilization of health care
24    services and facilities, as it affects persons  eligible  for
25    medical  assistance  under this Code. The Illinois Department
26    shall report regularly the results of the operation  of  such
27    systems  and  programs  to  the  Citizens Assembly/Council on
28    Public Aid to enable the Committee to ensure,  from  time  to
29    time, that these programs are effective and meaningful.
30        The  Illinois  Department  shall  report  annually to the
31    General Assembly, no later than the second Friday in April of
32    1979 and each year thereafter, in regard to:
33             (a)  actual statistics and trends in utilization  of
34        medical services by public aid recipients;
 
                            -10-               LRB9211341DJgc
 1             (b)  actual  statistics  and trends in the provision
 2        of the various medical services by medical vendors;
 3             (c)  current rate structures and proposed changes in
 4        those rate structures for the  various  medical  vendors;
 5        and
 6             (d)  efforts  at  utilization  review and control by
 7        the Illinois Department.
 8        The period covered by each report shall be  the  3  years
 9    ending  on the June 30 prior to the report.  The report shall
10    include  suggested  legislation  for  consideration  by   the
11    General  Assembly.  The filing of one copy of the report with
12    the Speaker, one copy with the Minority Leader and  one  copy
13    with the Clerk of the House of Representatives, one copy with
14    the President, one copy with the Minority Leader and one copy
15    with   the  Secretary  of  the  Senate,  one  copy  with  the
16    Legislative Research Unit, such additional  copies  with  the
17    State  Government  Report Distribution Center for the General
18    Assembly as is required under paragraph (t) of Section  7  of
19    the  State  Library  Act  and  one  copy  with  the  Citizens
20    Assembly/Council  on  Public  Aid  or  its successor shall be
21    deemed sufficient to comply with this Section.
22    (Source: P.A.  91-344,  eff.  1-1-00;  91-462,  eff.  8-6-99;
23    91-666,   eff.   12-22-99;   92-16,   eff.  6-28-01;  revised
24    12-13-01.)

25        (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
26        Sec.   12-4.25.  Medical   assistance   program;   vendor
27    participation.
28        (A)  The  Illinois  Department  may  deny,   suspend   or
29    terminate  the  eligibility of any person, firm, corporation,
30    association, agency, institution or  other  legal  entity  to
31    participate  as  a vendor of goods or  services to recipients
32    under the medical assistance  program  under  Article  V,  if
33    after  reasonable  notice  and  opportunity for a hearing the
 
                            -11-               LRB9211341DJgc
 1    Illinois Department finds:
 2             (a)  Such  vendor  is   not   complying   with   the
 3        Department's policy or rules and regulations, or with the
 4        terms   and   conditions   prescribed   by  the  Illinois
 5        Department in its vendor agreement, which document  shall
 6        be   developed   by   the   Department  as  a  result  of
 7        negotiations  with  each   vendor   category,   including
 8        physicians,   hospitals,   long   term  care  facilities,
 9        pharmacists,  optometrists,  podiatrists   and   dentists
10        setting  forth the terms and conditions applicable to the
11        participation of each vendor group in the program; or
12             (b)  Such  vendor  has  failed  to  keep   or   make
13        available   for   inspection,  audit  or  copying,  after
14        receiving a written request from the Illinois Department,
15        such records regarding  payments  claimed  for  providing
16        services.   This section does not require vendors to make
17        available patient records of patients for  whom  services
18        are not reimbursed under this Code; or
19             (c)  Such   vendor   has   failed   to  furnish  any
20        information  requested  by   the   Department   regarding
21        payments for providing goods or services; or
22             (d)  Such vendor has knowingly made, or caused to be
23        made, any false statement or representation of a material
24        fact in connection with the administration of the medical
25        assistance program; or
26             (e)  Such  vendor has furnished goods or services to
27        a recipient which are (1) in excess of his or her  needs,
28        (2)  harmful to the recipient, or (3) of grossly inferior
29        quality, all of such  determinations  to  be  based  upon
30        competent medical judgment and evaluations; or
31             (f)  The    vendor;   a   person   with   management
32        responsibility for a vendor; an officer or person owning,
33        either directly or indirectly, 5% or more of  the  shares
34        of  stock  or other evidences of ownership in a corporate
 
                            -12-               LRB9211341DJgc
 1        vendor; an owner of a  sole  proprietorship  which  is  a
 2        vendor;  or a partner in a partnership which is a vendor,
 3        either:
 4                  (1)  was     previously     terminated     from
 5             participation in  the  Illinois  medical  assistance
 6             program,  or  was terminated from participation in a
 7             medical assistance program in another state that  is
 8             of   the   same  kind  as  the  program  of  medical
 9             assistance provided under Article V of this Code; or
10                  (2)  was    a    person     with     management
11             responsibility  for  a  vendor previously terminated
12             from   participation   in   the   Illinois   medical
13             assistance program, or terminated from participation
14             in a medical assistance  program  in  another  state
15             that  is  of the same kind as the program of medical
16             assistance provided under Article V  of  this  Code,
17             during  the  time of conduct which was the basis for
18             that vendor's termination; or
19                  (3)  was an officer, or person  owning,  either
20             directly  or indirectly, 5% or more of the shares of
21             stock or other evidences of ownership in a corporate
22             vendor previously terminated from  participation  in
23             the   Illinois   medical   assistance   program,  or
24             terminated   from   participation   in   a   medical
25             assistance program in another state that is  of  the
26             same  kind  as  the  program  of  medical assistance
27             provided under Article V of this  Code,  during  the
28             time  of  conduct  which  was  the  basis  for  that
29             vendor's termination; or
30                  (4)  was  an  owner of a sole proprietorship or
31             partner of a partnership previously terminated  from
32             participation  in  the  Illinois  medical assistance
33             program,  or  terminated  from  participation  in  a
34             medical assistance program in another state that  is
 
                            -13-               LRB9211341DJgc
 1             of   the   same  kind  as  the  program  of  medical
 2             assistance provided under Article V  of  this  Code,
 3             during  the  time of conduct which was the basis for
 4             that vendor's termination; or
 5             (g)  The   vendor;   a   person   with    management
 6        responsibility for a vendor; an officer or person owning,
 7        either  directly  or indirectly, 5% or more of the shares
 8        of stock or other evidences of ownership in  a  corporate
 9        vendor;  an  owner  of  a  sole proprietorship which is a
10        vendor; or a partner in a partnership which is a  vendor,
11        either:
12                  (1)  has  engaged  in  practices  prohibited by
13             applicable  federal  or  State  law  or   regulation
14             relating to the medical assistance program; or
15                  (2)  was     a     person    with    management
16             responsibility for a vendor at the  time  that  such
17             vendor engaged in practices prohibited by applicable
18             federal  or  State law or regulation relating to the
19             medical assistance program; or
20                  (3)  was an officer, or person  owning,  either
21             directly  or indirectly, 5% or more of the shares of
22             stock or other evidences of ownership in a vendor at
23             the time such vendor engaged in practices prohibited
24             by applicable federal or  State  law  or  regulation
25             relating to the medical assistance program; or
26                  (4)  was  an  owner of a sole proprietorship or
27             partner of a partnership which was a vendor  at  the
28             time  such vendor engaged in practices prohibited by
29             applicable  federal  or  State  law  or   regulation
30             relating to the medical assistance program; or.
31             (h)  The  direct or indirect ownership of the vendor
32        (including the ownership of  a  vendor  that  is  a  sole
33        proprietorship,  a partner's interest in a vendor that is
34        a partnership, or ownership of 5% or more of  the  shares
 
                            -14-               LRB9211341DJgc
 1        of  stock  or other evidences of ownership in a corporate
 2        vendor) has been transferred  by  an  individual  who  is
 3        terminated  or  barred  from participating as a vendor to
 4        the individual's spouse, child, brother, sister,  parent,
 5        grandparent,  grandchild,  uncle,  aunt,  niece,  nephew,
 6        cousin, or relative by marriage.
 7        (A-5)  The  Illinois  Department  may  deny,  suspend, or
 8    terminate the eligibility of any person,  firm,  corporation,
 9    association,  agency,  institution,  or other legal entity to
10    participate as a vendor of goods or  services  to  recipients
11    under  the  medical  assistance  program  under Article V if,
12    after reasonable notice and opportunity for  a  hearing,  the
13    Illinois  Department  finds  that  the  vendor; a person with
14    management responsibility for a vendor; an officer or  person
15    owning,  either  directly  or  indirectly,  5% or more of the
16    shares  of  stock  or  other  evidences  of  ownership  in  a
17    corporate vendor; an owner of a sole proprietorship that is a
18    vendor; or a partner in a partnership that is  a  vendor  has
19    been  convicted of a felony offense based on fraud or willful
20    misrepresentation related to any of the following:
21             (1)  The medical assistance program under Article  V
22        of this Code.
23             (2)  A  medical  assistance program in another state
24        that is of the  same  kind  as  the  program  of  medical
25        assistance provided under Article V of this Code.
26             (3)  The  Medicare  program under Title XVIII of the
27        Social Security Act.
28             (4)  The provision of health care services.
29        (B)  The  Illinois  Department  shall  deny,  suspend  or
30    terminate the eligibility of any person,  firm,  corporation,
31    association,  agency,  institution  or  other legal entity to
32    participate as a vendor of goods or  services  to  recipients
33    under the medical assistance program under Article V:
34             (1)  if such vendor is not properly licensed;
 
                            -15-               LRB9211341DJgc
 1             (2)  within  30  days of the date when such vendor's
 2        professional    license,    certification    or     other
 3        authorization  has  been  refused  renewal  or  has  been
 4        revoked, suspended or otherwise terminated; or
 5             (3)  if   such   vendor  has  been  convicted  of  a
 6        violation of this Code, as provided in Article VIIIA.
 7        (C)  Upon termination of a vendor of  goods  or  services
 8    from   participation   in   the  medical  assistance  program
 9    authorized  by  this  Article,  a  person   with   management
10    responsibility for such vendor during the time of any conduct
11    which  served  as  the basis for that vendor's termination is
12    barred from participation in the medical assistance program.
13        Upon termination of a corporate vendor, the officers  and
14    persons  owning,  directly  or  indirectly, 5% or more of the
15    shares of stock or other evidences of ownership in the vendor
16    during the time of any conduct which served as the basis  for
17    that  vendor's  termination  are barred from participation in
18    the medical assistance program. A person who  owns,  directly
19    or  indirectly,  5%  or  more of the shares of stock or other
20    evidences of ownership in a terminated corporate  vendor  may
21    not  transfer his or her ownership interest in that vendor to
22    his  or  her  spouse,   child,   brother,   sister,   parent,
23    grandparent,  grandchild, uncle, aunt, niece, nephew, cousin,
24    or relative by marriage.
25        Upon termination of a sole proprietorship or partnership,
26    the owner or partners during the time of  any  conduct  which
27    served  as the basis for that vendor's termination are barred
28    from participation in the  medical  assistance  program.  The
29    owner  of  a terminated vendor that is a sole proprietorship,
30    and a partner in a terminated vendor that is  a  partnership,
31    may not transfer his or her ownership or partnership interest
32    in  that vendor to his or her spouse, child, brother, sister,
33    parent, grandparent, grandchild, uncle, aunt, niece,  nephew,
34    cousin, or relative by marriage.
 
                            -16-               LRB9211341DJgc
 1        Rules  adopted  by  the  Illinois Department to implement
 2    these provisions shall specifically include a  definition  of
 3    the term "management responsibility" as used in this Section.
 4    Such definition shall include, but not be limited to, typical
 5    job  titles,  and  duties  and  descriptions  which  will  be
 6    considered  as  within  the  definition  of  individuals with
 7    management responsibility for a provider.
 8        (D)  If a vendor has  been  suspended  from  the  medical
 9    assistance  program under Article V of the Code, the Director
10    may require that such vendor correct any  deficiencies  which
11    served  as  the  basis for the suspension. The Director shall
12    specify in the suspension order a specific  period  of  time,
13    which  shall  not exceed one year from the date of the order,
14    during which a suspended vendor  shall  not  be  eligible  to
15    participate.  At  the  conclusion of the period of suspension
16    the Director shall reinstate such  vendor,  unless  he  finds
17    that  such  vendor  has not corrected deficiencies upon which
18    the suspension was based.
19        If  a  vendor  has  been  terminated  from  the   medical
20    assistance  program  under  Article  V,  such vendor shall be
21    barred from participation for at least one year, except  that
22    if  a  vendor  has been terminated based on a conviction of a
23    violation of Article VIIIA or a conviction of a felony  based
24    on  fraud  or  a willful misrepresentation related to (i) the
25    medical assistance program under Article V,  (ii)  a  medical
26    assistance  program  in  another  state  that  is of the kind
27    provided under Article V, (iii) the  Medicare  program  under
28    Title XVIII of the Social Security Act, or (iv) the provision
29    of health care services, then the vendor shall be barred from
30    participation  for  5 years or for the length of the vendor's
31    sentence for that conviction, whichever is longer. At the end
32    of one year a vendor who has been terminated  may  apply  for
33    reinstatement  to  the program. Upon proper application to be
34    reinstated such vendor may be deemed eligible by the Director
 
                            -17-               LRB9211341DJgc
 1    providing  that  such  vendor  meets  the  requirements   for
 2    eligibility  under  this  Code.  If such vendor is deemed not
 3    eligible for reinstatement, he shall  be  barred  from  again
 4    applying  for  reinstatement  for  one year from the date his
 5    application for reinstatement is denied.
 6        A vendor whose  termination  from  participation  in  the
 7    Illinois medical assistance program under Article V was based
 8    solely  on  an action by a governmental entity other than the
 9    Illinois  Department  may,   upon   reinstatement   by   that
10    governmental  entity  or  upon  reversal  of the termination,
11    apply for rescission of the termination from participation in
12    the  Illinois  medical  assistance  program.    Upon   proper
13    application for rescission, the vendor may be deemed eligible
14    by  the  Director  if  the  vendor meets the requirements for
15    eligibility under this Code.
16        If a vendor has been terminated  and  reinstated  to  the
17    medical  assistance program under Article V and the vendor is
18    terminated a second  or  subsequent  time  from  the  medical
19    assistance   program,   the   vendor  shall  be  barred  from
20    participation for at least 2 years, except that if  a  vendor
21    has  been terminated a second time based on a conviction of a
22    violation of Article VIIIA or a conviction of a felony  based
23    on  fraud  or  a willful misrepresentation related to (i) the
24    medical assistance program under Article V,  (ii)  a  medical
25    assistance  program  in  another  state  that  is of the kind
26    provided under Article V, (iii) the  Medicare  program  under
27    Title XVIII of the Social Security Act, or (iv) the provision
28    of health care services, then the vendor shall be barred from
29    participation  for life.  At the end of 2 years, a vendor who
30    has been  terminated  may  apply  for  reinstatement  to  the
31    program.   Upon  application to be reinstated, the vendor may
32    be deemed eligible if the vendor meets the  requirements  for
33    eligibility  under  this  Code.   If the vendor is deemed not
34    eligible for reinstatement, the vendor shall be  barred  from
 
                            -18-               LRB9211341DJgc
 1    again  applying  for  reinstatement for 2 years from the date
 2    the vendor's application for reinstatement is denied.
 3        (E)  The Illinois Department may recover money improperly
 4    or erroneously  paid,  or  overpayments,  either  by  setoff,
 5    crediting  against  future  billings  or  by requiring direct
 6    repayment to the Illinois Department.
 7        If the Department of Public Aid  establishes  through  an
 8    administrative  hearing  that  the overpayments resulted from
 9    the vendor knowingly or through gross negligence  making,  or
10    causing to be made, a false statement or misrepresentation of
11    a  material  fact  in  connection  with billings and payments
12    under the medical assistance program  under  Article  V,  the
13    Department   may  recover  interest  on  the  amount  of  the
14    overpayments at the rate of 5% per  annum.  For  purposes  of
15    this paragraph:
16             "Knowingly" means that a person makes a statement or
17        representation  with  actual knowledge that it was false,
18        or makes a statement or representation with knowledge  of
19        facts  or  information  that  would cause one to be aware
20        that the statement or representation was false when made.
21             "Through gross negligence" means that a person makes
22        a claim for payment or a statement or representation that
23        a reasonable person would conclude  was  illegitimate  or
24        improper based on the totality of the circumstances.
25        If  the  Department  of Public Aid establishes through an
26    administrative hearing that the  overpayments  resulted  from
27    the  provision of services by an entity or individual who was
28    excluded, terminated, suspended,  or  barred  from  providing
29    services under the medical assistance program under Article V
30    or  who  was  otherwise  ineligible to provide services under
31    that program, the Department  may  recover  interest  on  the
32    amount  of  the  overpayments  at  the  rate of 5% per annum.
33    Interest is not recoverable under this paragraph, however, if
34    the vendor establishes that it confirmed the  eligibility  of
 
                            -19-               LRB9211341DJgc
 1    the  entity  or  individual  based  on  both  employment  and
 2    utilization and periodically thereafter.
 3        (F)  The Illinois Department may withhold payments to any
 4    vendor  during  the  pendency  of  any  proceeding under this
 5    Section except that if a final  administrative  decision  has
 6    not  been  issued  within  120 days of the initiation of such
 7    proceedings, unless delay has  been  caused  by  the  vendor,
 8    payments  can  no longer be withheld, provided, however, that
 9    the 120 day limit  may  be  extended  if  said  extension  is
10    mutually agreed to by the Illinois Department and the vendor.
11    The  Illinois  Department  shall  state  by rule with as much
12    specificity  as  practicable  the  conditions   under   which
13    payments  will  not  be  withheld  during the pendency of any
14    proceeding under this Section.  Payments may  be  denied  for
15    bills  submitted  with  service  dates  occurring  during the
16    pendency of  a  proceeding  where  the  final  administrative
17    decision  is  to  terminate eligibility to participate in the
18    medical assistance program.  The  Illinois  Department  shall
19    state  by  rule  with  as much specificity as practicable the
20    conditions under which payments will not be denied  for  such
21    bills.  The  Department  of  Public Aid shall state by rule a
22    process and criteria by which a vendor may  request  full  or
23    partial  release  of payments withheld under this subsection.
24    The Department must complete a proceeding under this  Section
25    in a timely manner.
26        (F-5)  The  Illinois  Department may temporarily withhold
27    payments to a vendor if any of the following individuals have
28    been indicted or otherwise charged under a law of the  United
29    States  or this or any other state with a felony offense that
30    is based on alleged fraud or willful misrepresentation on the
31    part of the individual related to (i) the medical  assistance
32    program  under  Article  V  of  this  Code,  (ii)  a  medical
33    assistance  program provided in another state which is of the
34    kind provided  under  Article  V  of  this  Code,  (iii)  the
 
                            -20-               LRB9211341DJgc
 1    Medicare  program  under  Title  XVIII of the Social Security
 2    Act, or (iv) the provision of health care services:
 3             (1)  If the vendor is a corporation: an  officer  of
 4        the   corporation  or  an  individual  who  owns,  either
 5        directly or indirectly, 5% or more of the shares of stock
 6        or other evidence of ownership of the corporation.
 7             (2)  If the vendor is  a  sole  proprietorship:  the
 8        owner of the sole proprietorship.
 9             (3)  If  the  vendor  is a partnership: a partner in
10        the partnership.
11             (4)  If the vendor  is  any  other  business  entity
12        authorized by law to transact business in this State:  an
13        officer  of  the entity or an individual who owns, either
14        directly or indirectly, 5% or more of  the  evidences  of
15        ownership of the entity.
16        If the Illinois Department withholds payments to a vendor
17    under this subsection, the Department shall not release those
18    payments  to the vendor while any criminal proceeding related
19    to the indictment or charge is pending unless the  Department
20    determines  that  there is good cause to release the payments
21    before completion of the proceeding.  If  the  indictment  or
22    charge  results  in the individual's conviction, the Illinois
23    Department shall retain all withheld payments, which shall be
24    considered forfeited to the Department.  If the indictment or
25    charge does not result in the  individual's  conviction,  the
26    Illinois  Department shall release to the vendor all withheld
27    payments.
28        (G)  The provisions of the Administrative Review Law,  as
29    now  or  hereafter  amended,  and  the rules adopted pursuant
30    thereto, shall apply to and govern all  proceedings  for  the
31    judicial  review  of  final  administrative  decisions of the
32    Illinois   Department   under   this   Section.    The   term
33    "administrative decision" is defined as in Section  3-101  of
34    the Code of Civil Procedure.
 
                            -21-               LRB9211341DJgc
 1        (H)  Nothing  contained  in  this  Code  shall in any way
 2    limit or otherwise impair the authority or power of any State
 3    agency responsible for licensing of vendors.
 4        (I)  Based on a finding of noncompliance on the part of a
 5    nursing home with any  requirement  for  certification  under
 6    Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
 7    1395  et  seq.  or 42 U.S.C. Sec. 1396 et seq.), the Illinois
 8    Department may impose one or more of the  following  remedies
 9    after notice to the facility:
10             (1)  Termination of the provider agreement.
11             (2)  Temporary management.
12             (3)  Denial of payment for new admissions.
13             (4)  Civil money penalties.
14             (5)  Closure of the facility in emergency situations
15        or transfer of residents, or both.
16             (6)  State monitoring.
17             (7)  Denial  of  all  payments  when the Health Care
18        Finance Administration has imposed this sanction.
19        The Illinois Department shall by rule establish  criteria
20    governing continued payments to a nursing facility subsequent
21    to  termination  of  the facility's provider agreement if, in
22    the sole discretion of the Illinois Department, circumstances
23    affecting the health, safety, and welfare of  the  facility's
24    residents  require  those  continued  payments.  The Illinois
25    Department may condition  those  continued  payments  on  the
26    appointment  of temporary management, sale of the facility to
27    new owners or  operators,  or  other  arrangements  that  the
28    Illinois  Department  determines  best serve the needs of the
29    facility's residents.
30        Except in the case of a facility that has a  right  to  a
31    hearing  on  the finding of noncompliance before an agency of
32    the federal government, a  facility  may  request  a  hearing
33    before  a State agency on any finding of noncompliance within
34    60 days after the notice of the intent to  impose  a  remedy.
 
                            -22-               LRB9211341DJgc
 1    Except  in the case of civil money penalties, a request for a
 2    hearing shall not  delay  imposition  of  the  penalty.   The
 3    choice of remedies is not appealable at a hearing.  The level
 4    of  noncompliance  may  be  challenged  only in the case of a
 5    civil money penalty. The Illinois Department shall provide by
 6    rule for the State agency that will conduct  the  evidentiary
 7    hearings.
 8        The  Illinois  Department  may collect interest on unpaid
 9    civil money penalties.
10        The Illinois Department may adopt all rules necessary  to
11    implement this subsection (I).
12    (Source: P.A. 92-327, eff. 1-1-02; revised 9-18-01.)

13        Section  99.  Effective date.  This Act takes effect upon
14    becoming law.

[ Top ]