101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB4974

 

Introduced 2/18/2020, by Rep. Ryan Spain

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-4.2  from Ch. 23, par. 5-4.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions requiring facilities to complete a Physician Certification Statement prior to ordering non-emergency transportation service for a patient scheduled for discharge, provides that if a ground ambulance provider, medi-car provider, or service car provider is unable to obtain the required Physician Certification Statement within 10 calendar days following the date of the service, the ground ambulance provider, medi-car provider, or service car provider must document its attempt to obtain the requested certification and may then submit the claim for payment. Provides that acceptable documentation includes a signed return receipt from the U.S. Postal Service, facsimile receipt, email receipt, or other similar service that evidences that the ground ambulance provider, medi-car provider, or service car provider attempted to obtain the required Physician Certification Statement.


LRB101 19184 KTG 68647 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4974LRB101 19184 KTG 68647 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-4.2 as follows:
 
6    (305 ILCS 5/5-4.2)  (from Ch. 23, par. 5-4.2)
7    Sec. 5-4.2. Ambulance services payments.
8    (a) For ambulance services provided to a recipient of aid
9under this Article on or after January 1, 1993, the Illinois
10Department shall reimburse ambulance service providers at
11rates calculated in accordance with this Section. It is the
12intent of the General Assembly to provide adequate
13reimbursement for ambulance services so as to ensure adequate
14access to services for recipients of aid under this Article and
15to provide appropriate incentives to ambulance service
16providers to provide services in an efficient and
17cost-effective manner. Thus, it is the intent of the General
18Assembly that the Illinois Department implement a
19reimbursement system for ambulance services that, to the extent
20practicable and subject to the availability of funds
21appropriated by the General Assembly for this purpose, is
22consistent with the payment principles of Medicare. To ensure
23uniformity between the payment principles of Medicare and

 

 

HB4974- 2 -LRB101 19184 KTG 68647 b

1Medicaid, the Illinois Department shall follow, to the extent
2necessary and practicable and subject to the availability of
3funds appropriated by the General Assembly for this purpose,
4the statutes, laws, regulations, policies, procedures,
5principles, definitions, guidelines, and manuals used to
6determine the amounts paid to ambulance service providers under
7Title XVIII of the Social Security Act (Medicare).
8    (b) For ambulance services provided to a recipient of aid
9under this Article on or after January 1, 1996, the Illinois
10Department shall reimburse ambulance service providers based
11upon the actual distance traveled if a natural disaster,
12weather conditions, road repairs, or traffic congestion
13necessitates the use of a route other than the most direct
14route.
15    (c) For purposes of this Section, "ambulance services"
16includes medical transportation services provided by means of
17an ambulance, medi-car, service car, or taxi.
18    (c-1) For purposes of this Section, "ground ambulance
19service" means medical transportation services that are
20described as ground ambulance services by the Centers for
21Medicare and Medicaid Services and provided in a vehicle that
22is licensed as an ambulance by the Illinois Department of
23Public Health pursuant to the Emergency Medical Services (EMS)
24Systems Act.
25    (c-2) For purposes of this Section, "ground ambulance
26service provider" means a vehicle service provider as described

 

 

HB4974- 3 -LRB101 19184 KTG 68647 b

1in the Emergency Medical Services (EMS) Systems Act that
2operates licensed ambulances for the purpose of providing
3emergency ambulance services, or non-emergency ambulance
4services, or both. For purposes of this Section, this includes
5both ambulance providers and ambulance suppliers as described
6by the Centers for Medicare and Medicaid Services.
7    (c-3) For purposes of this Section, "medi-car" means
8transportation services provided to a patient who is confined
9to a wheelchair and requires the use of a hydraulic or electric
10lift or ramp and wheelchair lockdown when the patient's
11condition does not require medical observation, medical
12supervision, medical equipment, the administration of
13medications, or the administration of oxygen.
14    (c-4) For purposes of this Section, "service car" means
15transportation services provided to a patient by a passenger
16vehicle where that patient does not require the specialized
17modes described in subsection (c-1) or (c-3).
18    (d) This Section does not prohibit separate billing by
19ambulance service providers for oxygen furnished while
20providing advanced life support services.
21    (e) Beginning with services rendered on or after July 1,
222008, all providers of non-emergency medi-car and service car
23transportation must certify that the driver and employee
24attendant, as applicable, have completed a safety program
25approved by the Department to protect both the patient and the
26driver, prior to transporting a patient. The provider must

 

 

HB4974- 4 -LRB101 19184 KTG 68647 b

1maintain this certification in its records. The provider shall
2produce such documentation upon demand by the Department or its
3representative. Failure to produce documentation of such
4training shall result in recovery of any payments made by the
5Department for services rendered by a non-certified driver or
6employee attendant. Medi-car and service car providers must
7maintain legible documentation in their records of the driver
8and, as applicable, employee attendant that actually
9transported the patient. Providers must recertify all drivers
10and employee attendants every 3 years.
11    Notwithstanding the requirements above, any public
12transportation provider of medi-car and service car
13transportation that receives federal funding under 49 U.S.C.
145307 and 5311 need not certify its drivers and employee
15attendants under this Section, since safety training is already
16federally mandated.
17    (f) With respect to any policy or program administered by
18the Department or its agent regarding approval of non-emergency
19medical transportation by ground ambulance service providers,
20including, but not limited to, the Non-Emergency
21Transportation Services Prior Approval Program (NETSPAP), the
22Department shall establish by rule a process by which ground
23ambulance service providers of non-emergency medical
24transportation may appeal any decision by the Department or its
25agent for which no denial was received prior to the time of
26transport that either (i) denies a request for approval for

 

 

HB4974- 5 -LRB101 19184 KTG 68647 b

1payment of non-emergency transportation by means of ground
2ambulance service or (ii) grants a request for approval of
3non-emergency transportation by means of ground ambulance
4service at a level of service that entitles the ground
5ambulance service provider to a lower level of compensation
6from the Department than the ground ambulance service provider
7would have received as compensation for the level of service
8requested. The rule shall be filed by December 15, 2012 and
9shall provide that, for any decision rendered by the Department
10or its agent on or after the date the rule takes effect, the
11ground ambulance service provider shall have 60 days from the
12date the decision is received to file an appeal. The rule
13established by the Department shall be, insofar as is
14practical, consistent with the Illinois Administrative
15Procedure Act. The Director's decision on an appeal under this
16Section shall be a final administrative decision subject to
17review under the Administrative Review Law.
18    (f-5) Beginning 90 days after July 20, 2012 (the effective
19date of Public Act 97-842), (i) no denial of a request for
20approval for payment of non-emergency transportation by means
21of ground ambulance service, and (ii) no approval of
22non-emergency transportation by means of ground ambulance
23service at a level of service that entitles the ground
24ambulance service provider to a lower level of compensation
25from the Department than would have been received at the level
26of service submitted by the ground ambulance service provider,

 

 

HB4974- 6 -LRB101 19184 KTG 68647 b

1may be issued by the Department or its agent unless the
2Department has submitted the criteria for determining the
3appropriateness of the transport for first notice publication
4in the Illinois Register pursuant to Section 5-40 of the
5Illinois Administrative Procedure Act.
6    (g) Whenever a patient covered by a medical assistance
7program under this Code or by another medical program
8administered by the Department, including a patient covered
9under the State's Medicaid managed care program, is being
10transported from a facility and requires non-emergency
11transportation including ground ambulance, medi-car, or
12service car transportation, a Physician Certification
13Statement as described in this Section shall be required for
14each patient. Facilities shall develop procedures for a
15licensed medical professional to provide a written and signed
16Physician Certification Statement. The Physician Certification
17Statement shall specify the level of transportation services
18needed and complete a medical certification establishing the
19criteria for approval of non-emergency ambulance
20transportation, as published by the Department of Healthcare
21and Family Services, that is met by the patient. This
22certification shall be completed prior to ordering the
23transportation service and prior to patient discharge. The
24Physician Certification Statement is not required prior to
25transport if a delay in transport can be expected to negatively
26affect the patient outcome. If the ground ambulance provider,

 

 

HB4974- 7 -LRB101 19184 KTG 68647 b

1medi-car provider, or service car provider is unable to obtain
2the required Physician Certification Statement within 10
3calendar days following the date of the service, the ground
4ambulance provider, medi-car provider, or service car provider
5must document its attempt to obtain the requested certification
6and may then submit the claim for payment. Acceptable
7documentation includes a signed return receipt from the U.S.
8Postal Service, facsimile receipt, email receipt, or other
9similar service that evidences that the ground ambulance
10provider, medi-car provider, or service car provider attempted
11to obtain the required Physician Certification Statement.
12    The medical certification specifying the level and type of
13non-emergency transportation needed shall be in the form of the
14Physician Certification Statement on a standardized form
15prescribed by the Department of Healthcare and Family Services.
16Within 75 days after July 27, 2018 (the effective date of
17Public Act 100-646), the Department of Healthcare and Family
18Services shall develop a standardized form of the Physician
19Certification Statement specifying the level and type of
20transportation services needed in consultation with the
21Department of Public Health, Medicaid managed care
22organizations, a statewide association representing ambulance
23providers, a statewide association representing hospitals, 3
24statewide associations representing nursing homes, and other
25stakeholders. The Physician Certification Statement shall
26include, but is not limited to, the criteria necessary to

 

 

HB4974- 8 -LRB101 19184 KTG 68647 b

1demonstrate medical necessity for the level of transport needed
2as required by (i) the Department of Healthcare and Family
3Services and (ii) the federal Centers for Medicare and Medicaid
4Services as outlined in the Centers for Medicare and Medicaid
5Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap.
610, Sec. 10.2.1, et seq. The use of the Physician Certification
7Statement shall satisfy the obligations of hospitals under
8Section 6.22 of the Hospital Licensing Act and nursing homes
9under Section 2-217 of the Nursing Home Care Act.
10Implementation and acceptance of the Physician Certification
11Statement shall take place no later than 90 days after the
12issuance of the Physician Certification Statement by the
13Department of Healthcare and Family Services.
14    Pursuant to subsection (E) of Section 12-4.25 of this Code,
15the Department is entitled to recover overpayments paid to a
16provider or vendor, including, but not limited to, from the
17discharging physician, the discharging facility, and the
18ground ambulance service provider, in instances where a
19non-emergency ground ambulance service is rendered as the
20result of improper or false certification.
21    Beginning October 1, 2018, the Department of Healthcare and
22Family Services shall collect data from Medicaid managed care
23organizations and transportation brokers, including the
24Department's NETSPAP broker, regarding denials and appeals
25related to the missing or incomplete Physician Certification
26Statement forms and overall compliance with this subsection.

 

 

HB4974- 9 -LRB101 19184 KTG 68647 b

1The Department of Healthcare and Family Services shall publish
2quarterly results on its website within 15 days following the
3end of each quarter.
4    (h) On and after July 1, 2012, the Department shall reduce
5any rate of reimbursement for services or other payments or
6alter any methodologies authorized by this Code to reduce any
7rate of reimbursement for services or other payments in
8accordance with Section 5-5e.
9    (i) On and after July 1, 2018, the Department shall
10increase the base rate of reimbursement for both base charges
11and mileage charges for ground ambulance service providers for
12medical transportation services provided by means of a ground
13ambulance to a level not lower than 112% of the base rate in
14effect as of June 30, 2018.
15(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
16101-81, eff. 7-12-19.)