Current through Register Vol. 48, No. 38, September 20, 2024
a) The Department
may deny an application to participate in the Medical Assistance Program if the
vendor has engaged in activities which constitute grounds for termination,
suspension or exclusion under Section
140.16.
If the activities were engaged in prior to December 1, 1977, they may be used
as the basis for denial of an application only if the vendor had actual or
constructive knowledge of the requirements which applied to his conduct or
activities.
b) Denial of
Application
1) The Department may deny an
application submitted by a vendor if:
A) the
vendor cannot reasonably be expected to meet the written requirements of the
Department including those set forth in the Medical Assistance Program
Handbooks and the Department's manuals, bulletins and releases; or
B) the Department determines, after reviewing
the activities that served as the basis for the earlier termination or barring,
that the application should not be approved. Factors to be considered by the
Department in making this determination shall include:
i) length of time the vendor has not
participated in the Medical Assistance Program;
ii) magnitude and severity of the activities
that led to the binding administrative decision which served as the basis for
the vendor's termination, barring or denied participation;
iii) mitigating circumstances presented by
the vendor;
iv) whether the
deficiencies that served as the basis for the vendor to be terminated, barred
or denied participation are corrected;
v) whether the vendor demonstrates a fitness
to participate in the Medical Assistance Program; and
vi) the extent to which any legally
enforceable debts owed to the Department by the applicant or an entity in which
the applicant or his or her nominee held a substantial ownership interest have
been paid.
2)
These factors must be established by submission of documentary evidence in
support of the application.
c) The Department may deny an application of
a previously terminated or barred applicant if the applicant, without special
permission from the Department, has already become a vendor, an entity with
management responsibility for a vendor, an incorporator, officer or member of
the board of directors of a vendor, an entity owning (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 vendor, a partner in a
partnership vendor, a technical or other advisor to a vendor, or an investor in
a vendor.
d) Effective July 1,
2012, the Department shall deny an application to participate in the Medical
Assistance Program of any person, firm, corporation, association, agency,
institution or other legal entity:
1)
immediately, if the vendor is not properly licensed, certified or
authorized;
2) within 30 days after
the date when the vendor's professional license, certification or other
authorization has been refused renewal, restricted or revoked, suspended or
otherwise terminated; or
3) if the
vendor has been convicted of a violation of the Public Aid Code, as provided in
Article VIIIA of the Code.
e) Effective July 1, 2012, the Department may
deny the eligibility of any person, firm, corporation, association, agency,
institution or other legal entity to participate as a vendor if, after
reasonable notice and opportunity for a hearing, the Department finds:
1) The applicant or any person with
management responsibility for the applicant; an officer or member of the board
of directors of an applicant; an entity owning (directly or indirectly) 5% or
more of the shares of stock or other evidences of ownership in a corporate
vendor applicant; an owner of a sole proprietorship applicant; a partner in a
partnership applicant; or a technical or other advisor to an applicant has a
debt owed to the Department, and no payment arrangements acceptable to the
Department have been made by the applicant.
2) The applicant or any person with
management responsibility for the applicant; an officer or member of the board
of directors of an applicant; an entity owning (directly or indirectly) 5% or
more of the shares of stock or other evidences of ownership in a corporate
vendor applicant; an owner of a sole proprietorship applicant; a partner in a
partnership vendor applicant; or a technical or other advisor to an applicant,
during a period of time when the conduct of that vendor resulted in a debt owed
to the Department and no payment arrangements acceptable to the Department have
been made by that vendor, was:
A) a person
with management responsibility;
B)
an officer or member of the board of directors of an applicant;
C) an entity owning (directly or indirectly)
5% or more of the shares of stock or other evidences of ownership in a
corporate vendor;
D) an owner of a
sole proprietorship;
E) a partner
in a partnership vendor; or
F) a
technical or other advisor to a vendor.
3) There is a credible allegation, as defined
in Section
140.13, of the use,
transfer or lease of assets of any kind to an applicant from a current or prior
vendor who has a debt owed to the Department, no payment arrangements
acceptable to the Department have been made by that vendor or the vendor's
alternate payee, and the applicant knows or should have known of the
debt.
4) There is a credible
allegation of a transfer of management responsibilities, or direct or indirect
ownership, to an applicant from a current or prior vendor who has debt owed to
the Department, and no payment arrangements acceptable to the Department have
been made by the vendor or the vendor's alternate payee, and the applicant
knows or should have known of the debt.
5) There is a credible allegation of the use,
transfer or lease of assets of any kind to an applicant who is a spouse, child,
brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, relative
by marriage, nephew, cousin or other relative of a current or prior vendor who
has a debt owed to the Department and no payment arrangements acceptable to the
Department have been made.
6) There
is a credible allegation that the applicant's previous affiliations with a
provider of medical services that has an uncollected debt, a provider that has
been or is subject to a payment suspension under a federal health care program,
or a provider that has been previously excluded from participation in the
Medical Assistance Program, poses a risk of fraud, waste or abuse to the
Department.
