Article VIIIA – Public Assistance Fraud

(305 ILCS 5/Art. VIIIA heading)

ARTICLE VIIIA.
PUBLIC ASSISTANCE FRAUD

 

(305 ILCS 5/8A-1) (from Ch. 23, par. 8A-1)

Sec. 8A-1.
Legislative Intent.
Because of the pervasive nature of public
assistance fraud and its negative effect on the people of the State of Illinois
and those individuals who need public assistance, the General Assembly declares
it to be public policy that public assistance fraud be identified and dealt
with swiftly and appropriately considering the onerous nature of the crime.

(Source: P.A. 82-440.)

 

(305 ILCS 5/8A-2) (from Ch. 23, par. 8A-2)

Sec. 8A-2. Recipient Fraud.

(a) Any person, who by means of any false
statement, willful misrepresentation or failure to notify the county department
or the local governmental unit, as the case may be, of a change in his status
as required by Sections 11-18 and 11-19, or any person who knowingly causes
any applicant or recipient without knowledge to make such a false statement
or willful misrepresentation, or by withholding information causes the applicant
or recipient to fail to notify the county department or local governmental
unit as required, for the purpose of preventing the denial, cancellation
or suspension of any grant, or a variation in the amount thereof, or through
other fraudulent device obtains or attempts to obtain, or aids or abets
any person in obtaining public aid under this Code to which he is not entitled
is guilty of a violation of this Article and shall be punished as provided
in Section 8A-6.

(b) If an applicant makes and subscribes an application form under Section
11-15 which contains a written declaration that it is made under penalties
of perjury, knowing it to be false, incorrect or incomplete in respect
to any material statement or representation bearing on his eligibility,
income or resources, the offender shall be subject to the penalties for
perjury as provided in Section 32-2 of the Criminal Code of 2012.

(Source: P.A. 97-1150, eff. 1-25-13.)

 

(305 ILCS 5/8A-2.5)

Sec. 8A-2.5. Unauthorized use of medical assistance.

(a) Any person who knowingly uses, acquires, possesses, or transfers a
medical card in any manner not authorized by law or by rules and regulations of
the Illinois Department, or who knowingly alters a medical card, or who
knowingly uses, acquires, possesses, or transfers an altered medical card, is
guilty of a violation of this Article and shall be punished as provided in
Section 8A-6.

(b) Any person who knowingly obtains unauthorized medical benefits or causes to be obtained unauthorized medical benefits with or
without use of a medical card is guilty of a violation of this Article and
shall be punished as provided in Section 8A-6.

(b-5) Any vendor that knowingly assists a person in committing a violation under subsection (a) or (b) of this Section is guilty of a violation of this Article and shall be punished as provided in Section 8A-6.

(b-6) Any person (including a vendor, organization, agency, or other entity) that, in any matter related to the medical assistance program, knowingly or willfully falsifies, conceals, or omits by any trick, scheme, artifice, or device a material fact, or makes any false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with the provision of health care or related services, is guilty of a violation of this Article and shall be punished as provided in Section 8A-6.

(c) The Department may seek to recover any and all State and federal monies for which it has improperly and erroneously paid benefits as a result of a fraudulent action and any civil penalties authorized in this Section. Pursuant to Section 11-14.5 of this Code, the Department may determine the monetary value of benefits improperly and erroneously received. The Department may recover the monies paid for such benefits and interest on that amount at the rate of 5% per annum for the period from which payment was made to the date upon which repayment is made to the State. Prior to the recovery of any amount paid for benefits allegedly obtained by fraudulent means, the recipient or payee of such benefits shall be afforded an opportunity for a hearing after reasonable notice. The notice shall be served personally or by certified or registered mail or as otherwise provided by law upon the parties or their agents appointed to receive service of process and shall include the following:

• (1) A statement of the time, place and nature of the hearing.
• (2) A statement of the legal authority and jurisdiction under which the hearing is to be held.
• (3) A reference to the particular Sections of the substantive and procedural statutes and rules involved.
• (4) Except where a more detailed statement is otherwise provided for by law, a short and plain statement of the matters asserted, the consequences of a failure to respond, and the official file or other reference number.
• (5) A statement of the monetary value of the benefits fraudulently received by the person accused.
• (6) A statement that, in addition to any other penalties provided by law, a civil penalty in an amount not to exceed $2,000 may be imposed for each fraudulent claim for benefits or payments.
• (7) A statement providing that the determination of the monetary value may be contested by petitioning the Department for an administrative hearing within 30 days from the date of mailing the notice.
• (8) The names and mailing addresses of the administrative law judge, all parties, and all other persons to whom the agency gives notice of the hearing unless otherwise confidential by law.

An opportunity shall be afforded all parties to be represented by legal counsel and to respond and present evidence and argument.

Unless precluded by law, disposition may be made of any contested case by stipulation, agreed settlement, consent order, or default.

Any final order, decision, or other determination made, issued or executed by the Director under the provisions of this Article whereby any person is aggrieved shall be subject to review in accordance with the provisions of the Administrative Review Law, and the rules adopted pursuant thereto, which shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Director.

Upon entry of a final administrative decision for repayment of any benefits obtained by fraudulent means, or for any civil penalties assessed, a lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution, vendor, or other legal entity until the judgment is satisfied.

Within 18 months of the effective date of this amendatory Act of the 96th General Assembly, the Department of Healthcare and Family Services will report to the General Assembly on the number of fraud cases identified and pursued, and the fines assessed and collected. The report will also include the Department’s analysis as to the use of private sector resources to bring action, investigate, and collect monies owed.

(d) In subsections (a), (b), (b-5) and (b-6), “knowledge” has the meaning ascribed to that term in Section 4-5 of the Criminal Code of 2012. For any administrative action brought under subsection (c) pursuant to a violation of this Section, the Department shall define “knowing” by rule.

(Source: P.A. 97-23, eff. 1-1-12; 98-354, eff. 8-16-13.)

 

(305 ILCS 5/8A-3) (from Ch. 23, par. 8A-3)

Sec. 8A-3.
Vendor Fraud and Kickbacks.
(a) Any person, firm, corporation,
association, agency, institution or other legal entity that willfully, by
means of a false statement or representation, or by concealment of any material
fact or by other fraudulent scheme or device on behalf of himself or others,
obtains or attempts to obtain benefits or payments under this Code to which
he or it is not entitled, or in a greater amount than that to which he or
it is entitled, is guilty of a violation of this Article and shall be punished
as provided in Section 8A-6.

(b) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he solicits or receives any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind:

(1) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or service for which
payment may be made in whole or in part under this Code; or

(2) in return for purchasing, leasing, ordering, or arranging for or
recommending purchasing, leasing, or ordering any good, facility, service
or item for which payment may be made in whole or in part under this Code.

(c) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he offers or pays any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or
in kind to any person to induce such person:

(1) to refer an individual to a person for the furnishing or arranging
for the furnishing of any item or service for which payment may be made in
whole or in part under this Code; or

(2) to purchase, lease, order, or arrange for or recommend purchasing,
leasing, or ordering any good, facility, service, or item for which payment
may be made in whole or in part under this Code.

(d) Subsections (b) and (c) shall not apply to:

(1) a discount or other reduction in price obtained by a provider of
services or other entity under this Code if the reduction in price is
properly disclosed and appropriately reflected in the costs claimed or
charges made by the provider or entity under this Code;

(2) any amount paid by an employer to an employee who has a bona fide
employment relationship with such employer for employment in the provision
of covered items or services; or

(3) any amount
paid to or received by a physician for professional
services rendered if a physician, pursuant to a bona fide contract with
a health maintenance organization, as defined by the Health
Maintenance Organization Act, has referred a patient to another physician
for rendering professional services not covered by the health maintenance
organization.

(Source: P.A. 85-818.)

 

(305 ILCS 5/8A-3.5)

Sec. 8A-3.5. Vendor fraud and recipient fraud in medical assistance; restitution. A person convicted of recipient fraud, unauthorized use of medical assistance, vendor fraud in relation to the provision of medical assistance under Article V of this Code, or convicted of a federal criminal violation associated with defrauding the Medicaid program shall be ordered to pay
monetary
restitution to a person for any
financial loss
sustained by that person as a result of a violation of Section 8A-2, 8A-2.5, or 8A-3 of this Code, including any court costs
and attorney
fees. An order of restitution also includes expenses incurred and paid
in connection with any medical evaluation or treatment.

(Source: P.A. 94-577, eff. 1-1-06.)

 

(305 ILCS 5/8A-3.6)

Sec. 8A-3.6. Actions by State licensing agencies.

(a) All State licensing agencies, the Illinois State Police, and
the
Department of Financial and Professional Regulation shall coordinate enforcement efforts relating to acts
of recipient fraud, unauthorized use of medical assistance, or vendor fraud in relation to the provision of medical assistance under Article V of this Code.

(b) If a person who is licensed or registered under the laws of the State of
Illinois to engage in a business or profession is convicted of or pleads
guilty to engaging
in an act of recipient fraud, unauthorized use of medical assistance, or vendor fraud in relation to the provision of medical assistance under Article V of this Code, the Illinois State Police must forward
to each
State agency by which the person is licensed or registered a copy of the
conviction or
plea and all supporting evidence.

(c) Any agency that receives information under this Section shall, not later
than
6 months after the date on which it receives the information, publicly report the final action
taken
against the convicted person, including but not limited to the revocation or
suspension
of the license or any other disciplinary action taken.

(Source: P.A. 94-577, eff. 1-1-06.)

 

(305 ILCS 5/8A-4) (from Ch. 23, par. 8A-4)

Sec. 8A-4.

Penalty for Unauthorized Use of Federal Food Stamps or Federal
Food Stamp Benefits. Any
person who knowingly uses, acquires, possesses, or transfers
federal food
stamps, or federal food stamp benefits, or Electronic Benefit Transfer card
for federal food stamp benefits, or authorizations to participate in the
federal food stamp program
in any manner not authorized by law or the rules and regulations of the
Illinois Department, or who knowingly alters or uses, acquires, possesses
or transfers altered federal food stamps,
or federal food stamp benefits, or
Electronic Benefit Transfer card for federal food stamp benefits,
or authorizations to participate in the federal food stamp program,
or who
knowingly alters or falsifies electronic federal food stamp benefit data or
possesses or uses altered or falsified electronic federal food stamp benefit
data for the purpose of making claims for or receiving redemption of food stamp
benefits or for the substantiation of redemptions received,
is guilty of a violation of this Article
and shall be punished as provided in Section 8A-6.

(Source: P.A. 89-489, eff. 1-1-97.)

 

(305 ILCS 5/8A-4A) (from Ch. 23, par. 8A-4A)

Sec. 8A-4A.

Penalty for Unauthorized Use of Federal Surplus
Commodities. Any person who knowingly uses, acquires, possesses, or
transfers federal surplus food commodities or authorizations to participate
in the federal surplus food commodities program, in original or altered form, in
any manner not authorized by law or the rules and regulations of the
Illinois Department, or who knowingly alters authorizations to participate
in the federal surplus food commodities program, is guilty of a violation of
this Article and shall be punished as provided in Section 8A-6.

(Source: P.A. 85-555.)

 

(305 ILCS 5/8A-5) (from Ch. 23, par. 8A-5)

Sec. 8A-5.
Administrative Malfeasance.
(a) Any person who shall misappropriate,
misuse or unlawfully withhold or convert to his own use or to the use of
another, any public funds made available for public aid purposes under this
Code is guilty of a violation of this Article and shall be punished as provided
in Section 8A-6.

(b) Any official or employee of the Illinois Department, county department
or local governmental unit who willfully fails to report a known violation
of Sections 8A-2, 8A-3, 8A-4 or 8A-5 to the designated administrative personnel
as identified in the policy and procedures of the Illinois Department for
employees of the Illinois Department or county department, or to the State’s
Attorney for employees of a local governmental unit, shall be subject to
disciplinary proceedings pursuant to regulations of the Illinois Department
or local governmental unit.

(Source: P.A. 82-440.)

 

(305 ILCS 5/8A-5A) (from Ch. 23, par. 8A-5A)

Sec. 8A-5A.
Unauthorized possession of identification document.
Any
person who possesses for an unlawful purpose another person’s
identification document issued by the Illinois Department shall be guilty
of a Class 4 felony. For purposes of this Section, “identification
document” includes but is not limited to an authorization to participate in
the federal food stamp program or the federal surplus food commodities
program, or a card or other document which identifies a person as being
entitled to public aid under this Code.

(Source: P.A. 86-1012.)

 

(305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)

Sec. 8A-6.
Classification of violations.

(a) Any person, firm, corporation,
association, agency, institution or other legal entity that has been found
by a court to have engaged in an act, practice or course of conduct declared
unlawful under Sections 8A-2 through 8A-5 or Section 8A-13 or 8A-14 where:

• (1) the total amount of money involved in the violation, including the monetary value of federal food stamps and the value of commodities, is less than $150, shall be guilty of a Class A misdemeanor;
• (2) the total amount of money involved in the violation, including the monetary value of federal food stamps and the value of commodities, is $150 or more but less than $1,000, shall be guilty of a Class 4 felony;
• (3) the total amount of money involved in the violation, including the monetary value of federal food stamps and the value of commodities, is $1,000 or more but less than $5,000, shall be guilty of a Class 3 felony;
• (4) the total amount of money involved in the violation, including the monetary value of federal food stamps and the value of commodities, is $5,000 or more but less than $10,000, shall be guilty of a Class 2 felony; or
• (5) the total amount of money involved in the violation, including the monetary value of federal food stamps and the value of commodities, is $10,000 or more, shall be guilty of a Class 1 felony and, notwithstanding the provisions of Section 8A-8 except for Subsection (c) of Section 8A-8, shall be ineligible for financial aid under this Article for a period of two years following conviction or until the total amount of money, including the value of federal food stamps, is repaid, whichever first occurs.

(b) Any person, firm, corporation, association, agency, institution
or other legal entity that commits a subsequent violation of any of the
provisions of Sections 8A-2 through 8A-5 and:

• (1) the total amount of money involved in the subsequent violation, including the monetary value of federal food stamps and the value of commodities, is less than $150, shall be guilty of a Class 4 felony;
• (2) the total amount of money involved in the subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $150 or more but less than $1,000, shall be guilty of a Class 3 felony;
• (3) the total amount of money involved in the subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $1,000 or more but less than $5,000, shall be guilty of a Class 2 felony;
• (4) the total amount of money involved in the subsequent violation, including the monetary value of federal food stamps and the value of commodities, is $5,000 or more but less than $10,000, shall be guilty of a Class 1 felony.

(c) For purposes of determining the classification of offense under
this Section, all of the money received as a result of the unlawful act,
practice or course of conduct can be accumulated.

(Source: P.A. 90-538, eff. 12-1-97.)

 

(305 ILCS 5/8A-7) (from Ch. 23, par. 8A-7)

Sec. 8A-7. Civil Remedies. (a) A person who receives financial aid by
means of a false statement, willful misrepresentation or by his failure
to notify the county department or local governmental unit, as the case
may be, of a change in his status as required by Sections 11-18 and 11-19,
for the purpose of preventing the denial, cancellation or suspension of
his grant, or a variation in the amount thereof, or by other fraudulent
device, or a person who knowingly aids or abets any person in obtaining
financial aid for which he is not eligible, shall be answerable to the county
department or the local governmental unit, as the case may be, for refunding
the entire amount of aid received. If the refund is not made, it shall be
recoverable in a civil action from the person who received the aid, or from
anyone who willfully aided such person to obtain the aid. If an act which
would be unlawful under Section 8A-2 is proven, the court may as a penalty
assess an additional sum of money, not to exceed the entire amount of aid
provided, against the recipient or against any person who willfully aided
the recipient. If assessed, the penalty shall be included in any judgment
entered for the aid received, and paid to the county department or the
local governmental unit, as the case may be. Upon entry of the judgment a
lien shall attach to all property and assets of such person until the
judgment is satisfied.

(b) Any person, firm, corporation, association, agency, institution or
other legal entity, other than an individual recipient, that willfully,
by means of a false statement or representation, or by concealment of any
material fact or by other fraudulent scheme or device on behalf of himself
or others, obtains or attempts to obtain benefits or payments under this
Code to which he or it is not entitled, or in a greater amount than that
to which he or it is entitled, shall be liable for repayment of any excess
benefits or payments received and, in addition to any other penalties provided
by law, civil penalties consisting of (1) the interest on the amount of
excess benefits or payments at the maximum legal rate in effect on the date
the payment was made to such person, firm, corporation, association, agency,
institution or other legal entity for the period from the date upon which
payment was made to the date upon which repayment is made to the State,
(2) an amount not to exceed 3 times the amount of such excess benefits or
payments, and (3) the sum of $2,000 for each excessive claim for benefits
or payments. Upon entry of a judgment for repayment of any excess benefits
or payments, or for any civil penalties assessed by the court, a lien shall
attach to all property and assets of such person, firm, corporation,
association, agency, institution or other legal entity until the judgment is satisfied.

(c) Civil recoveries provided for in this Section may be recoverable in
court proceedings initiated by the Attorney General or, in actions
involving a local governmental unit, by the State’s Attorney.

(d) Any person who commits the offense of vendor fraud or recipient
fraud as defined in Section 8A-2 and Section 8A-3 of this Article shall
forfeit, according to the provisions
of this subsection, any monies, profits or proceeds, and any interest or
property which the sentencing court determines he has acquired or maintained,
directly or indirectly, in whole or in part as a result of such offense.
Such person shall also forfeit any interest in, securities of, claim against,
or contractual right of any kind which affords him a source of influence
over, any enterprise which he has established, operated, controlled, conducted,
or participated in conducting, where his relationship to or connection with
any such thing or activity directly or indirectly, in whole or in part,
is traceable to any thing or benefit which he has obtained or acquired through
vendor fraud or recipient fraud.

Proceedings instituted pursuant to this subsection shall be subject to
and conducted in accordance with the following procedures:

(1) The sentencing court shall, upon petition by the Attorney General
or State’s Attorney at any time following sentencing, conduct a hearing
to determine whether any property or property interest is subject to forfeiture
under this subsection. At the forfeiture hearing the People shall have
the burden of establishing, by a preponderance of the evidence, that the
property or property interests are subject to such forfeiture.

(2) In any action brought by the People of the State of Illinois under
this Section, in which any restraining order, injunction or prohibition or
any other action in connection with any property or interest subject to
forfeiture under this subsection is sought, the circuit court presiding
over the trial of the person charged with recipient fraud or
vendor fraud as defined in Sections 8A-2 or 8A-3 of this Article shall
first determine whether there is probable cause to believe that the person
so charged has committed the offense of recipient fraud or
vendor fraud and whether the property or interest is subject to forfeiture
under this subsection. To make such a determination, prior to
entering any such order, the court shall conduct a hearing without a jury,
at which the People shall establish that there is (i) probable cause that
the person so charged has committed the offense of recipient
fraud or vendor fraud and (ii) probable cause that any property or interest
may be subject to forfeiture pursuant to this subsection. Such hearing may
be conducted simultaneously with a preliminary hearing, if the prosecution
is commenced by information or complaint, or by motion of the People at any
stage in the proceedings. The court may accept a finding of probable cause
at a preliminary hearing following the filing of an information charging
the offense of recipient fraud or vendor fraud as defined in Sections 8A-2
or 8A-3 or the return of an indictment by a grand jury charging the offense
of recipient fraud or vendor fraud as defined in Sections 8A-2 or 8A-3 of
this Article as sufficient evidence of probable cause as provided in item
(i) above. Upon such a finding, the circuit court shall enter such
restraining order, injunction or prohibition, or shall take such other
action in connection with any such property or other interest subject to
forfeiture under this Act as is necessary to insure that such property is
not removed from the jurisdiction of the court, concealed, destroyed or
otherwise disposed of by the owner of that property or interest prior to a
forfeiture hearing under this subsection. The Attorney General or State’s
Attorney shall file a certified copy of such restraining order, injunction
or other prohibition with the recorder of deeds or registrar of titles of
each county where any such property of the defendant may be located. No
such injunction, restraining order or other prohibition shall affect the
rights of any bonafide purchaser, mortgagee, judgement creditor or other
lien holder arising prior to the date of such filing. The court may, at
any time, upon verified petition by the defendant, conduct a hearing to
determine whether all or portions of any such property or interest which
the court previously determined to be subject to forfeiture
or subject to any restraining order, injunction, or prohibition or other
action, should be released. The court may in its discretion release such
property to the defendant for good cause shown.

(3) Upon conviction of a person under this Article, the court shall
authorize the Director of the Illinois State Police to seize
all property or other interest declared forfeited under this subsection upon
such terms and conditions as the court shall deem proper.

(4) The Director of the Illinois State Police is
authorized to sell all property forfeited and seized pursuant to this
subsection, unless such property is
required by law to be destroyed or is harmful to the public.
After the deduction of all requisite expenses of administration and
sale, the court shall order the Director to distribute to the Illinois
Department an amount from the proceeds of the forfeited property, or monies
forfeited or seized, which will satisfy any unsatisfied court order of
restitution entered pursuant to a conviction under this Article. If the
proceeds are less than the amount necessary to satisfy the order of
restitution, the Director shall distribute to the Illinois Department the
entire amount of the remaining proceeds. The Director shall distribute any
remaining proceeds of such sale, along with any monies forfeited or seized,
in accordance with the following schedules:

(a) 25% shall be distributed to the unit of local government whose
officers or employees conducted the investigation into recipient fraud or
vendor fraud and caused the arrest or arrests and prosecution leading to
the forfeiture. Amounts distributed to units of local government shall be
used solely for enforcement matters relating to detection, investigation or
prosecution of recipient fraud or vendor fraud as defined in Section 8A-2
or 8A-3 of this Article. Where the investigation, arrest or arrests leading to
the prosecution and forfeiture is undertaken solely by the Illinois State Police, the portion provided hereunder shall be paid
into the Medicaid Fraud and Abuse Prevention Fund, which is hereby created
in the State treasury. Monies from this fund shall be used by the
Illinois State Police for the furtherance of enforcement matters
relating to detection, investigation or prosecution of recipient fraud or
vendor fraud. Monies directed to this fund shall be used in addition to,
and not as a substitute for, funds annually appropriated to the Illinois State Police for medicaid fraud enforcement.

(b) 25% shall be distributed to the county in which the prosecution and
petition for forfeiture resulting in the forfeiture was instituted,
and deposited in a special fund in the county treasury
and appropriated to the State’s Attorney for use solely in enforcement
matters relating to detection, investigation or prosecution of recipient
fraud or vendor fraud; however, if the Attorney General brought the
prosecution resulting in the forfeiture, the portion provided hereunder
shall be paid into the Medicaid Fraud and Abuse Prevention Fund, to be used
by the Medicaid Fraud Control Unit of the Illinois State Police
for enforcement matters relating to detection, investigation or prosecution
of recipient fraud or vendor fraud. Where the Attorney General and a
State’s Attorney have jointly participated in any portion of the
proceedings, 12.5% shall be distributed to the county in which the
prosecution resulting in the forfeiture was instituted, and used as
specified herein, and 12.5% shall be paid into the Medicaid Fraud and Abuse
Prevention Fund, and used as specified herein.

(c) 50% shall be transmitted to the State Treasurer for deposit in the
General Revenue Fund.

(Source: P.A. 102-538, eff. 8-20-21.)

 

(305 ILCS 5/8A-7.1) (from Ch. 23, par. 8A-7.1)

Sec. 8A-7.1. The Director, upon making a
determination based upon information in the possession of the Illinois
Department, that continuation in practice of a licensed health care
professional would constitute an immediate danger to the public, shall submit
a written communication to the Director of Professional Regulation indicating
such determination and
additionally providing a complete summary of the information upon which
such determination is based, and recommending that the Director of
Professional Regulation immediately suspend such person’s
license. All relevant evidence, or copies thereof, in the Illinois
Department’s possession may also be submitted in conjunction with the written
communication. A copy of such written communication, which is exempt from
the copying and inspection provisions of the Freedom of Information Act,
shall at the time of submittal to the Director
of Professional Regulation
be simultaneously mailed to the last known business address of such licensed
health care professional by certified or registered postage, United States
Mail, return receipt requested. Any evidence, or copies thereof, which is
submitted in conjunction with the written communication is also exempt from
the copying and inspection provisions of the Freedom of Information Act.

The Director, upon making a determination based upon information in the
possession of the Illinois Department, that a licensed health care
professional is willfully committing fraud upon the Illinois Department’s
medical assistance program, shall submit a written communication to the
Director of Professional Regulation indicating such
determination and additionally providing a complete summary of the
information upon which such determination is based. All relevant evidence,
or copies thereof, in the Illinois Department’s possession may also be
submitted in conjunction with the written communication.

Upon receipt of such written communication, the Director of
Professional Regulation shall promptly investigate the
allegations contained in such written communication. A copy of such
written communication, which is exempt from the copying and inspection
provisions of the Freedom of Information Act, shall at the time of
submission to the Director of Professional Regulation,
be simultaneously mailed to the last known address of such licensed health
care professional by certified or registered postage, United States Mail,
return receipt requested. Any evidence, or copies thereof, which
is submitted in conjunction with the written communication is also exempt
from the copying and inspection provisions of the Freedom of Information Act.

For the purposes of this Section, “licensed health care professional”
means any person licensed under the Illinois Dental Practice Act, the Nurse Practice Act, the Medical Practice Act of 1987, the
Pharmacy Practice Act, the Podiatric Medical Practice Act of 1987,
or the Illinois Optometric Practice Act of 1987.

(Source: P.A. 95-639, eff. 10-5-07; 95-689, eff. 10-29-07; 95-876, eff. 8-21-08.)

 

(305 ILCS 5/8A-8) (from Ch. 23, par. 8A-8)

Sec. 8A-8.
Future Participation in the Public Assistance Program.

(a) Any person applying for public assistance under this Code who has been
found
guilty of a violation of this Article or of any law of the United States or
of any state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs of the kind provided under this Code and who has not been previously
convicted
for a violation of this Article or of any law of the United States or of any
state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs
of the kind provided under this Code shall have applications for public
assistance
under this Code reviewed by an administrative review board to determine
the person’s eligibility and the need for administrative safeguards to prevent
any such further violations. The administrative review board shall be
composed of not less than two persons who are selected in accordance with
regulations of the Illinois Department or the local governmental unit. Hearings
conducted by the board shall:

• (1) be of an informal nature, permitting the applicant to attend at his option;
• (2) be open to the public, unless the applicant and the administrative review board determine otherwise;
• (3) be subject to reasonable time and notification requirements as determined by regulations of the Illinois Department or local governmental units; and
• (4) be held at a location convenient to the applicant.

At the hearing, the administrative review board may deny the application
based on an investigation of the person’s eligibility, or the board may
appoint a substitute payee, require more frequent visits or consultations,
more frequent financial reports or require any other action to the extent
permitted by State and federal law and regulations. A decision by the
administrative review board to deny a person’s application shall only be
based on the person’s failure to qualify under the eligibility criteria
applicable to all applicants for the public assistance program in question.
Any decision by the administrative review board may be appealed pursuant to
the provisions of this Code. In no instance shall the administrative review
board delay the hearing or its decision beyond the time allowed under State
or federal law and regulations for determining an applicant’s eligibility
for public assistance.

If the person has been determined eligible, the Illinois Department or
the local governmental unit may recoup prior payments obtained in violation
of this Article from the current cash assistance grants, unless such payments
have previously been repaid. The Illinois Department or the local governmental
unit, on a case by case basis, shall limit the amount deducted from the current
cash assistance grant so as not to cause undue hardship to the person.

(b) To the extent permitted under federal law, any person found
guilty of a first violation of this Article or of any law of the United
States
or
of any state which is substantially similar to Sections 8A-2 through 8A-5 for
violations related to public assistance or medical assistance programs of the
kind provided under this Code may be suspended from eligibility for public
aid under this Code. Any person found guilty of a second or subsequent
violation of this Article or of any law of the United States or of any state
which is substantially similar to Sections 8A-2 through 8A-5 for violations
related to public assistance or medical assistance programs of the kind
provided under this Code shall be ineligible for public aid under this
Code.

(c) In no instance shall this Section adversely affect the eligibility
of children who are in need of public aid under this Code, or the amount
of the grant received by such children. If a child’s caretaker relative
is adversely affected by this Section, a substitute payee may be appointed
until the Illinois Department can determine, by rule, that the caretaker
relative can manage the public aid in the best interest of the child.

(d) Any person, firm, corporation, association, agency, institution or
other legal entity that has been convicted of a violation of this Article
shall be prohibited from participating as a vendor of goods or services
to recipients of public aid under this Code. Such prohibition shall extend
to any person with management responsibility in a firm, corporation,
association, agency, institution, or other legal entity that has been
convicted of any such violation and to an officer or person owning, either
directly or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporation.

(e) Any employee of the Illinois Department, county department or local
governmental unit who has been found guilty of a violation of this Article
shall be terminated from employment.

(Source: P.A. 89-489, eff. 1-1-97; 90-725, eff. 8-7-98.)

 

(305 ILCS 5/8A-9) (from Ch. 23, par. 8A-9)

Sec. 8A-9.
Special Investigations Unit.
There shall be established within
the administrative staff a unit to investigate all matters pertaining to
the fraudulent acquisition of public aid, including administrative funds.
The investigation may be conducted without prior notice to the recipients,
to the personnel administering the cases or to vendors or other persons involved.
The unit shall also investigate any other matter relating to the administration
of public aid assigned to it by the Director of the Illinois Department.
The Illinois Department may make the facts revealed by any investigation
available to the Attorney General or to the appropriate State’s Attorney.

(Source: P.A. 82-440.)

 

(305 ILCS 5/8A-10) (from Ch. 23, par. 8A-10)

Sec. 8A-10.
Savings provisions.
Notwithstanding any amendments or repealer
provisions in this amendatory Act of 1981, Sections 11-21, 11-24, 12-15,
12-15.1 and 12-21.19 of “The Illinois Public Aid Code” shall remain in force
(1) for the prosecution and punishment of any person who, before the effective
date of this amendatory Act, has violated Section 11-21, 11-24, 12-15.1
or 12-21.19 of this Code, and (2) for the initiation and enforcement
of civil actions and penalties for any cause of action which accrued prior
to the effective date of this amendatory Act under Section 11-21 or 12-15
of this Code.

This amendatory Act of 1981 shall apply only to causes of action arising
from violations of this Code which occur after its effective date.

(Source: P.A. 82-440.)

 

(305 ILCS 5/8A-11) (from Ch. 23, par. 8A-11)

Sec. 8A-11. (a) No person shall:

• (1) Knowingly charge a resident of a nursing home for any services provided pursuant to Article V of the Illinois Public Aid Code, money or other consideration at a rate in excess of the rates established for covered services by the Illinois Department pursuant to Article V of the Illinois Public Aid Code; or
• (2) Knowingly charge, solicit, accept or receive, in addition to any amount otherwise authorized or required to be paid pursuant to Article V of the Illinois Public Aid Code, any gift, money, donation or other consideration:
• (i) As a precondition to admitting or expediting the admission of a recipient or applicant, pursuant to Article V of the Illinois Public Aid Code, to a long-term care facility as defined in Section 1-113 of the Nursing Home Care Act or a facility as defined in Section 1-113 of the ID/DD Community Care Act, Section 1-113 of the MC/DD Act, or Section 1-102 of the Specialized Mental Health Rehabilitation Act of 2013; and
• (ii) As a requirement for the recipient’s or applicant’s continued stay in such facility when the cost of the services provided therein to the recipient is paid for, in whole or in part, pursuant to Article V of the Illinois Public Aid Code.

(b) Nothing herein shall prohibit a person from making a voluntary
contribution, gift or donation to a long-term care facility.

(c) This paragraph shall not apply to agreements to provide continuing
care or life care between a life care facility as defined by the Life
Care Facilities Act, and a person financially eligible for benefits pursuant to
Article V of the Illinois Public Aid Code.

(d) Any person who violates this Section shall be guilty of a business
offense and fined not less than $5,000 nor more than $25,000.

(e) “Person”, as used in this Section, means an individual, corporation,
partnership, or unincorporated association.

(f) The State’s Attorney of the county in which the facility is located
and the Attorney General shall be notified by the Illinois Department of
any alleged violations of this Section known to the Department.

(g) The Illinois Department shall adopt rules and regulations to carry
out the provisions of this Section.

(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)

 

(305 ILCS 5/8A-12)

Sec. 8A-12.
Early fraud prevention and detection program.
The Illinois
Department may conduct an early fraud prevention and detection program as
provided in this Section. If conducted, the program shall apply to all
categories of assistance and all applicants for aid. The program may be
conducted in appropriate counties as determined by the Department. The
program shall have the following features:

• (1) No intimidation of applicants or recipients may occur, either by referral or threat of referral for a fraud prevention investigation.
• (2) An applicant may not be referred for a fraud prevention investigation until an application for aid is completed and signed by the applicant or any authorized representative.
• (3) An applicant may be referred to the Inspector General for a fraud prevention investigation if there are reasonable grounds to question the accuracy of any information, statements, documents, or other representations by the applicant or any authorized representative. Referrals for fraud prevention investigations shall be made in accordance with guidelines to be jointly determined by the Inspector General and the Department.

(Source: P.A. 89-118, eff. 7-7-95.)

 

(305 ILCS 5/8A-13)

Sec. 8A-13. Managed health care fraud.

(a) As used in this Section, “health plan” means any of the following:

• (1) Any health care reimbursement plan sponsored wholly or partially by the State.
• (2) Any private insurance carrier, health care cooperative or alliance, health maintenance organization, insurer, organization, entity, association, affiliation, or person that contracts to provide or provides goods or services that are reimbursed by or are a required benefit of a health benefits program funded wholly or partially by the State.
• (3) Anyone who provides or contracts to provide goods and services to an entity described in paragraph (1) or (2) of this subsection.

For purposes of item (2) in subsection (b), “representation” and “statement”
include, but are not limited to, reports, claims, certifications,
acknowledgments and ratifications of financial information, enrollment claims,
demographic statistics, encounter data, health services available or rendered,
and the qualifications of person rendering health care and ancillary services.

(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that, with the intent to obtain benefits or payments under
this Code to which the person or entity is not entitled or in a greater amount
than that to which the person or entity is entitled, knowingly or willfully:

• (1) executes or conspires to execute a scheme or artifice to defraud any State or federally funded or mandated health plan in connection with the delivery of or payment for health care benefits, items, or services;
• (2) executes or conspires to execute a scheme or artifice to obtain by means of false or fraudulent pretense, representation, statement, or promise money or anything of value in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for, reimbursed, or subsidized by, or are a required benefit of, a State or federally funded or mandated health plan;
• (3) falsifies, conceals, or covers up by any trick, scheme, or device a material fact in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan;
• (4) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan; or
• (5) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry in connection with the delivery of or payment for health care benefits, items, or services that are in whole or in part paid for or reimbursed by a State or federal health plan;
  is guilty of a
  violation of this Article and shall be punished as provided in Section 8A-6.

(Source: P.A. 98-354, eff. 8-16-13.)

 

(305 ILCS 5/8A-14)

Sec. 8A-14.
Bribery and graft in connection with health care.

(a) As used in this Section:

“Health care official” means any of the following:

• (1) An administrator, officer, trustee, fiduciary, custodian, counsel, agent, or employee of any health plan.
• (2) An officer, counsel, agent, or employee of an organization that provides, proposes to provide, or contracts to provide services to any health plan.
• (3) An official, employee, or agent of a State or federal agency having regulatory or administrative authority over any health plan.

“Health plan” has the meaning attributed to that term in Section 8A-13.

(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that

• (1) directly or indirectly gives, offers, or promises anything of value to a health care official, or offers or promises to a health care official to give anything of value to another person, with the intent
• (A) to influence or reward any act or decision of any health care official exercising any authority in any State or federally funded or mandated health plan other than as specifically allowed by law, or
• (B) to influence the official to commit, aid in the commission of, or conspire to allow any fraud in a State or federally funded or mandated health plan, or
• (C) to induce the official to engage in any conduct in violation of the official’s lawful duty, or
• (2) being a health care official, directly or indirectly demands, solicits, receives, accepts, or agrees to accept anything of value personally or for any other person or entity, the giving of which would violate paragraph (1) of this subsection,
  is guilty of a violation of this Article and shall be punished as
  provided in Section 8A-6.

(Source: P.A. 90-538, eff. 12-1-97.)

 

(305 ILCS 5/8A-15)

Sec. 8A-15. False statements relating to health care delivery. Any
person, firm, corporation, association, agency, institution, or other legal
entity that, in any matter related to a State or federally funded or mandated
health plan, knowingly and wilfully falsifies, conceals, or omits by any trick,
scheme, artifice, or device a material fact, or makes any false, fictitious, or
fraudulent statement or representation, or makes or uses any false writing or
document, knowing the same to contain any false, fictitious, or fraudulent
statement or entry in connection with the provision of health care or related
services, is guilty of a Class 4 felony.

(Source: P.A. 98-354, eff. 8-16-13.)

 

(305 ILCS 5/8A-16)

Sec. 8A-16.
Unfair or deceptive marketing practices.

(a) As used in this Section, “health plan” has the meaning attributed to
that term in Section 8A-13.

(b) It is unlawful to knowingly and willfully engage in any unfair or
deceptive marketing practice
in connection with proposing, offering, selling, soliciting, or providing any
health care service or any health plan. Unfair or deceptive marketing
practices include the following:

• (1) Making a false and misleading oral or written statement, visual description, advertisement, or other representation of any kind that has the capacity, tendency, or effect of deceiving or misleading health care consumers with respect to any health care service, health plan, or health care provider.
• (2) Making a representation that a health care plan or a health care provider offers any service, benefit, access to care, or choice that it does not in fact offer.
• (3) Making a representation that a health plan or health care provider has any status, certification, qualification, sponsorship, affiliation, or licensure that it does not have.
• (4) A failure to state a material fact if the failure deceives or tends to deceive.
• (5) Offering any kickback, bribe, reward, or benefit to any person as an inducement to select or to refrain from selecting any health care service, health plan, or health care provider, unless the benefit offered is medically necessary health care or is permitted by the Illinois Department.
• (6) The use of health care consumer or other information that is confidential or privileged or that cannot be disclosed to or obtained by the user without violating a State or federal confidentiality law, including:
• (A) medical records information; and
• (B) information that identifies the health care consumer or any member of his or her group as a recipient of any government sponsored or mandated welfare program.
• (7) The use of any device or artifice in advertising a health plan or soliciting a health care consumer that misrepresents the solicitor’s profession, status, affiliation, or mission.

(c) Any person who commits a first violation of this Section is guilty of a
Class
A misdemeanor and is subject to a fine of not more than $5,000. Any person who
commits a second or subsequent violation of this Section is guilty of a Class 4
felony and is subject to a fine of not more than $25,000.

(Source: P.A. 90-538, eff. 12-1-97.)

 

(305 ILCS 5/8A-17)

Sec. 8A-17.
Penalties enhanced for persons other than individuals.
If a
person who violates Section 8A-13, 8A-14, 8A-15, or 8A-16 is any person other
than an individual, then that person is subject to a fine of not more than
$50,000 if the violation is a misdemeanor and a fine of not more than $250,000
if the violation is a felony.

(Source: P.A. 90-538, eff. 12-1-97.)

 

(305 ILCS 5/8A-18)

Sec. 8A-18. Application assistance fraud; SNAP; AABD; TANF. It is a Class C misdemeanor for any person, including an individual, firm, corporation, association, partnership, or joint venture, or any employee or agent of any of those, to assist or represent another person in completing or submitting an application for benefits under the federal Supplemental Nutrition Assistance Program (SNAP), the State’s Aid to the Aged, Blind, or Disabled (AABD) program, or the State’s Temporary Assistance for Needy Families (TANF) program, in exchange for a portion of the applicant’s SNAP, AABD, or TANF benefits or cash or any other form of payment from any other source. An applicant who receives such assistance or representation is not in violation of this Section. Nothing in this Section shall be construed as prohibiting an applicant from receiving such assistance or representation when appealing a denial of an application for SNAP, AABD, or TANF benefits.

(Source: P.A. 98-931, eff. 8-15-14.)