Ill. Admin. Code tit. 89, § 140.12 - Participation Requirements for Medical Providers
The provider shall agree to:
a) Verify eligibility of recipients prior to
providing each service;
b) Allow
recipients the choice of accepting or rejecting medical or surgical care or
treatment;
c) Provide supplies and
services in full compliance with all applicable provisions of State and federal
laws and regulations pertaining to nondiscrimination and equal employment
opportunity including but not limited to:
1)
Full compliance with Title VI of the Civil Rights Act of 1964, which prohibits
discrimination on the basis of race, color or national origin;
2) Full compliance with Section 504 of the
Rehabilitation Act of 1973 and 45 CFR 84, which prohibit discrimination on the
basis of handicap; and
3) Without
discrimination on the basis of religious belief, political affiliation, sex,
age or disability;
d)
Comply with the requirements of applicable federal and State laws and not
engage in practices prohibited by such laws;
e) Provide, and upon demand present
documentation of, education of employees, contractors and agents regarding the
federal False Claims Act (
31
USC 3729 -
3733
) that complies with all requirements of
42 USC
1396 a(a)(68). Providers subject to this
requirement include a governmental agency, organization, unit, corporation,
partnership, or other business arrangement (including any Medicaid managed care
organization, irrespective of the form of business structure or arrangement by
which it exists), whether for-profit or not-for-profit, that receives or makes
payments totaling at least $5 million annually;
f) Hold confidential, and use for authorized
program purposes only, all Medical Assistance information regarding
recipients;
g) Furnish to the
Department, in the form and manner requested by it, any information it requests
regarding payments for providing goods or services, or in connection with the
rendering of goods or services or supplies to recipients by the provider, his
agent, employer or employee;
h)
Make charges for the provision of services and supplies to recipients in
amounts not to exceed the provider's usual and customary charges and in the
same quality and mode of delivery as are provided to the general
public;
i) Accept as payment in
full the amounts established by the Department.
1) If a provider accepts an individual
eligible for medical assistance from the Department as a Medicaid recipient,
such provider shall not bill, demand or otherwise seek reimbursement from that
individual or from a financially responsible relative or representative of the
individual for any service for which reimbursement would have been available
from the Department if the provider had timely and properly billed the
Department. For purposes of this subsection, "accepts" shall be deemed to
include:
A) an affirmative representation to
an individual that payment for services will be sought from the
Department;
B) an individual
presents the provider with his or her medical card and the provider does not
indicate that other payment arrangements will be necessary; or
C) billing the Department for the covered
medical service provided an eligible individual.
2) If an eligible individual is entitled to
medical assistance with respect to a service for which a third party is liable
for payment, the provider furnishing the service may not seek to collect from
the individual payment for that service if the total liability of the third
party for that service is at least equal to the amount payable for that service
by the Department.
j)
Accept assignment of Medicare benefits for public aid recipients eligible for
Medicare, when payment for services to such persons is sought from the
Department;
k) Complete an MCH
(Maternal and Child Health) Primary Care Provider Agreement in order to
participate in the Maternal and Child Health Program (see Section
140.924(a)(1)(D)
); and
l) In the case of long term care providers,
assume liability for repayment to the Department of any overpayment made to a
facility regardless of whether the overpayment was incurred by a current owner
or operator or by a previous owner or operator. Liability of current and
previous providers to the Department shall be joint and several. Recoveries by
the Department under this Section may be made pursuant to Sections
140.15
and
140.25.
A current or previous owner or lessee may request from the Department a list of
all known outstanding liabilities due the Department by the facility and of any
known pending Department actions against a facility that may result in further
liability. For purposes of this Section, "overpayment" shall include, but not
be limited to:
1) Amounts established by
final administrative decisions pursuant to 89 Ill. Adm. Code 104;
2) Overpayments resulting from advance C-13
payments made pursuant to Section
140.71;
3) Liabilities resulting from nonpayment or
delinquent payment of assessments pursuant to Sections
140.82,
140.84
and
140.94;
and
4) Amounts identified during
past, pending or future audits that pertain to audit periods prior to a change
in ownership and are conducted pursuant to Sections
140.30
and
140.590.
Liability of current owners or operators for amounts identified during such
audits shall be as follows:
A) For past
audits (audits completed before changes in ownership), liability shall be the
amount established by final administrative decision.
B) For pending audits (audits initiated, but
not completed prior to the change in ownership), liability shall be limited to
the lesser of the amounts established by final administrative decision or two
months of service revenue. Two months of service revenue is defined as the most
recent two months of Medicaid patient days multiplied by the total Medicaid
rate in effect on the date the new owner or operator is enrolled in the Program
as a provider by the Department. The Medicaid rate in effect on the date of
enrollment shall be used even if that rate is subsequently changed.
C) For future audits (audits initiated after
the change in ownership but pertaining to an audit period prior to a change in
ownership), liability shall be limited as described in subsection (l)(4)(B) of
this Section.
m) A provider that is eligible to participate
in the 340B federal Drug Pricing Program under section 340B of the federal
Public Health Service Act (
47 USC 201 et
seq.), shall enroll in that program. No entity participating in the federal
Drug Pricing Program under section 340B of the federal Public Health Services
Act may exclude Medicaid from their participation in that program. A provider
enrolled in the 340B federal Drug Pricing Program must charge the Department no
more than its actual acquisition cost for the drug product, plus the Department
established dispensing fee. This requirement is effective October 1, 2012 for
340B providers who own and/or operate a pharmacy that bills the Department for
drugs, unless the 340B provider is a Hemophilia Treatment Center (HTC); July 1,
2013 for providers who are eligible to participate in the 340B program as HTCs;
and January 1, 2013 for all other 340B-eligible providers who bill the
Department for drugs. Contract pharmacies are exempt from the requirements of
this subsection (m).
Notes
Amended at 37 Ill. Reg. 10282, effective June 27, 2013
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