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Public Act 92-0327
SB882 Enrolled LRB9201518DJgc
AN ACT in relation to public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Section 12-4.25 as follows:
(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor
participation.
(A) The Illinois Department may deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, if
after reasonable notice and opportunity for a hearing the
Illinois Department finds:
(a) Such vendor is not complying with the
Department's policy or rules and regulations, or with the
terms and conditions prescribed by the Illinois
Department in its vendor agreement, which document shall
be developed by the Department as a result of
negotiations with each vendor category, including
physicians, hospitals, long term care facilities,
pharmacists, optometrists, podiatrists and dentists
setting forth the terms and conditions applicable to the
participation of each vendor group in the program; or
(b) Such vendor has failed to keep or make
available for inspection, audit or copying, after
receiving a written request from the Illinois Department,
such records regarding payments claimed for providing
services. This section does not require vendors to make
available patient records of patients for whom services
are not reimbursed under this Code; or
(c) Such vendor has failed to furnish any
information requested by the Department regarding
payments for providing goods or services; or
(d) Such vendor has knowingly made, or caused to be
made, any false statement or representation of a material
fact in connection with the administration of the medical
assistance program; or
(e) Such vendor has furnished goods or services to
a recipient which are (1) in excess of his or her needs,
(2) harmful to the recipient, or (3) of grossly inferior
quality, all of such determinations to be based upon
competent medical judgment and evaluations; or
(f) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) was previously terminated from
participation in the Illinois medical assistance
program, or was terminated from participation in a
medical assistance program in another state that is
of the same kind as the program of medical
assistance provided under Article V of this Code; or
(2) was a person with management
responsibility for a previously terminated vendor
previously terminated from participation in the
Illinois medical assistance program, or terminated
from participation in a medical assistance program
in another state that is of the same kind as the
program of medical assistance provided under Article
V of this Code, during the time of conduct which was
the basis for that vendor's termination from
participation in the medical assistance program; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a
previously terminated corporate vendor previously
terminated from participation in the Illinois
medical assistance program, or terminated from
participation in a medical assistance program in
another state that is of the same kind as the
program of medical assistance provided under Article
V of this Code, during the time of conduct which was
the basis for that vendor's termination from
participation in the medical assistance program; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was previously
terminated from participation in the Illinois
medical assistance program, or terminated from
participation in a medical assistance program in
another state that is of the same kind as the
program of medical assistance provided under Article
V of this Code, during the time of conduct which was
the basis for that vendor's termination from
participation in the medical assistance program; or
(g) The vendor; a person with management
responsibility for a vendor; an officer or person owning,
either directly or indirectly, 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor; an owner of a sole proprietorship which is a
vendor; or a partner in a partnership which is a vendor,
either:
(1) has engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program; or
(2) was a person with management
responsibility for a vendor at the time that such
vendor engaged in practices prohibited by applicable
federal or State law or regulation relating to the
medical assistance program; or
(3) was an officer, or person owning, either
directly or indirectly, 5% or more of the shares of
stock or other evidences of ownership in a vendor at
the time such vendor engaged in practices prohibited
by applicable federal or State law or regulation
relating to the medical assistance program; or
(4) was an owner of a sole proprietorship or
partner of a partnership which was a vendor at the
time such vendor engaged in practices prohibited by
applicable federal or State law or regulation
relating to the medical assistance program.
(h) The direct or indirect ownership of the vendor
(including the ownership of a vendor that is a sole
proprietorship, a partner's interest in a vendor that is
a partnership, or ownership of 5% or more of the shares
of stock or other evidences of ownership in a corporate
vendor) has been transferred by an individual who is
terminated or barred from participating as a vendor to
the individual's spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
(A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V if,
after reasonable notice and opportunity for a hearing, the
Illinois Department finds that the vendor; a person with
management responsibility for a vendor; an officer or person
owning, either directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in a
corporate vendor; an owner of a sole proprietorship that is a
vendor; or a partner in a partnership that is a vendor has
been convicted of a felony offense based on fraud or willful
misrepresentation related to any of the following:
(1) The medical assistance program under Article V
of this Code.
(2) A medical assistance program in another state
that is of the same kind as the program of medical
assistance provided under Article V of this Code.
(3) The Medicare program under Title XVIII of the
Social Security Act.
(4) The provision of health care services.
(B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V:
(1) if such vendor is not properly licensed;
(2) within 30 days of the date when such vendor's
professional license, certification or other authorization
has been refused renewal or has been revoked, suspended or
otherwise terminated; or
(3) if such vendor has been convicted of a
violation of this Code, as provided in Article VIIIA.
(C) Upon termination of a vendor of goods or services
from participation in the medical assistance program
authorized by this Article, a person with management
responsibility for such vendor during the time of any conduct
which served as the basis for that vendor's termination is
barred from participation in the medical assistance program.
Upon termination of a corporate vendor, the officers and
persons owning, directly or indirectly, 5% or more of the
shares of stock or other evidences of ownership in the vendor
during the time of any conduct which served as the basis for
that vendor's termination are barred from participation in
the medical assistance program. A person who owns, directly
or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a terminated corporate vendor may
not transfer his or her ownership interest in that vendor to
his or her spouse, child, brother, sister, parent,
grandparent, grandchild, uncle, aunt, niece, nephew, cousin,
or relative by marriage.
Upon termination of a sole proprietorship or partnership,
the owner or partners during the time of any conduct which
served as the basis for that vendor's termination are barred
from participation in the medical assistance program. The
owner of a terminated vendor that is a sole proprietorship,
and a partner in a terminated vendor that is a partnership,
may not transfer his or her ownership or partnership interest
in that vendor to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
Rules adopted by the Illinois Department to implement
these provisions shall specifically include a definition of
the term "management responsibility" as used in this Section.
Such definition shall include, but not be limited to, typical
job titles, and duties and descriptions which will be
considered as within the definition of individuals with
management responsibility for a provider.
(D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension
the Director shall reinstate such vendor, unless he finds
that such vendor has not corrected deficiencies upon which
the suspension was based.
If a vendor has been terminated from the medical
assistance program under Article V, such vendor shall be
barred from participation for at least one year. At the end
of one year a vendor who has been terminated may apply for
reinstatement to the program. Upon proper application to be
reinstated such vendor may be deemed eligible by the Director
providing that such vendor meets the requirements for
eligibility under this Code Act. If such vendor is deemed
not eligible for reinstatement, he shall be barred from again
applying for reinstatement for one year from the date his
application for reinstatement is denied.
A vendor whose termination from participation in the
Illinois medical assistance program under Article V was based
solely on an action by a governmental entity other than the
Illinois Department may, upon reinstatement by that
governmental entity or upon reversal of the termination,
apply for rescission of the termination from participation in
the Illinois medical assistance program. Upon proper
application for rescission, the vendor may be deemed eligible
by the Director if the vendor meets the requirements for
eligibility under this Code.
If a vendor has been terminated and reinstated to the
medical assistance program under Article V and the vendor is
terminated a second or subsequent time from the medical
assistance program, the vendor shall be barred from
participation for at least 2 years. At the end of 2 years, a
vendor who has been terminated may apply for reinstatement to
the program. Upon application to be reinstated, the vendor
may be deemed eligible if the vendor meets the requirements
for eligibility under this Code. If the vendor is deemed not
eligible for reinstatement, the vendor shall be barred from
again applying for reinstatement for 2 years from the date
the vendor's application for reinstatement is denied.
(E) The Illinois Department may recover money improperly
or erroneously paid, or overpayments, either by setoff,
crediting against future billings or by requiring direct
repayment to the Illinois Department.
(F) The Illinois Department may withhold payments to any
vendor during the pendency of any proceeding under this
Section except that if a final administrative decision has
not been issued within 120 days of the initiation of such
proceedings, unless delay has been caused by the vendor,
payments can no longer be withheld, provided, however, that
the 120 day limit may be extended if said extension is
mutually agreed to by the Illinois Department and the vendor.
The Illinois Department shall state by rule with as much
specificity as practicable the conditions under which
payments will not be withheld during the pendency of any
proceeding under this Section. Payments may be denied for
bills submitted with service dates occurring during the
pendency of a proceeding where the final administrative
decision is to terminate eligibility to participate in the
medical assistance program. The Illinois Department shall
state by rule with as much specificity as practicable the
conditions under which payments will not be denied for such
bills.
(F-5) The Illinois Department may temporarily withhold
payments to a vendor if any of the following individuals
have been indicted or otherwise charged under a law of the
United States or this or any other state with a felony
offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to
(i) the medical assistance program under Article V of this
Code, (ii) a medical assistance program provided in another
state which is of the kind provided under Article V of this
Code, (iii) the Medicare program under Title XVIII of the
Social Security Act, or (iv) the provision of health care
services:
(1) If the vendor is a corporation: an officer of
the corporation or an individual who owns, either
directly or indirectly, 5% or more of the shares of
stock or other evidence of ownership of the corporation.
(2) If the vendor is a sole proprietorship: the
owner of the sole proprietorship.
(3) If the vendor is a partnership: a partner in the
partnership.
(4) If the vendor is any other business entity
authorized by law to transact business in this State:
an officer of the entity or an individual who owns,
either directly or indirectly, 5% or more of the
evidences of ownership of the entity.
If the Illinois Department withholds payments to a vendor
under this subsection, the Department shall not release
those payments to the vendor while any criminal proceeding
related to the indictment or charge is pending unless the
Department determines that there is good cause to release the
payments before completion of the proceeding. If the
indictment or charge results in the individual's conviction,
the Illinois Department shall retain all withheld payments,
which shall be considered forfeited to the Department. If
the indictment or charge does not result in the individual's
conviction, the Illinois Department shall release to the
vendor all withheld payments.
(G) The provisions of the Administrative Review Law, as
now or hereafter amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the
judicial review of final administrative decisions of the
Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of
the Code of Civil Procedure.
(H) Nothing contained in this Code shall in any way
limit or otherwise impair the authority or power of any State
agency responsible for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under
Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
Department may impose one or more of the following remedies
after notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.
(4) Civil money penalties.
(5) Closure of the facility in emergency situations
or transfer of residents, or both.
(6) State monitoring.
(7) Denial of all payments when the Health Care
Finance Administration has imposed this sanction.
The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in
the sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of
the federal government, a facility may request a hearing
before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy.
Except in the case of civil money penalties, a request for a
hearing shall not delay imposition of the penalty. The
choice of remedies is not appealable at a hearing. The level
of noncompliance may be challenged only in the case of a
civil money penalty. The Illinois Department shall provide
by rule for the State agency that will conduct the
evidentiary hearings.
The Illinois Department may collect interest on unpaid
civil money penalties.
The Illinois Department may adopt all rules necessary to
implement this subsection (I).
(Source: P.A. 89-21, eff. 1-1-96; 90-725, eff. 8-7-98.)
Section 99. Effective date. This Act takes effect on
January 1, 2002.
Passed in the General Assembly May 16, 2001.
Approved August 09, 2001.
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