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| | 102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022 HB1420 Introduced 2/17/2021, by Rep. Emanuel Chris Welch SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/5-4.2 | from Ch. 23, par. 5-4.2 |
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Amends the Illinois Public Aid Code. Makes a technical change in a Section concerning ambulance services payments.
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| | A BILL FOR |
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1 | | AN ACT concerning public aid.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 5. The Illinois Public Aid Code is amended by |
5 | | changing Section 5-4.2 as follows:
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6 | | (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
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7 | | Sec. 5-4.2. Ambulance services payments.
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8 | | (a) For
ambulance
services provided to a recipient of aid |
9 | | under this Article on or after
January 1, 1993, the
the |
10 | | Illinois Department shall reimburse ambulance service
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11 | | providers at rates calculated in accordance with this Section. |
12 | | It is the intent
of the General Assembly to provide adequate |
13 | | reimbursement for ambulance
services so as to ensure adequate |
14 | | access to services for recipients of aid
under this Article |
15 | | and to provide appropriate incentives to ambulance service
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16 | | providers to provide services in an efficient and |
17 | | cost-effective manner. Thus,
it is the intent of the General |
18 | | Assembly that the Illinois Department implement
a |
19 | | reimbursement system for ambulance services that, to the |
20 | | extent practicable
and subject to the availability of funds |
21 | | appropriated by the General Assembly
for this purpose, is |
22 | | consistent with the payment principles of Medicare. To
ensure |
23 | | uniformity between the payment principles of Medicare and |
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1 | | Medicaid, the
Illinois Department shall follow, to the extent |
2 | | necessary and practicable and
subject to the availability of |
3 | | funds appropriated by the General Assembly for
this purpose, |
4 | | the statutes, laws, regulations, policies, procedures,
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5 | | principles, definitions, guidelines, and manuals used to |
6 | | determine the amounts
paid to ambulance service providers |
7 | | under Title XVIII of the Social Security
Act (Medicare). |
8 | | (b) For ambulance services provided to a recipient of aid |
9 | | under this Article
on or after January 1, 1996, the Illinois |
10 | | Department shall reimburse ambulance
service providers based |
11 | | upon the actual distance traveled if a natural
disaster, |
12 | | weather conditions, road repairs, or traffic congestion |
13 | | necessitates
the use of a
route other than the most direct |
14 | | route.
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15 | | (c) For purposes of this Section, "ambulance services" |
16 | | includes medical
transportation services provided by means of |
17 | | an ambulance, medi-car, service
car, or
taxi.
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18 | | (c-1) For purposes of this Section, "ground ambulance |
19 | | service" means medical transportation services that are |
20 | | described as ground ambulance services by the Centers for |
21 | | Medicare and Medicaid Services and provided in a vehicle that |
22 | | is licensed as an ambulance by the Illinois Department of |
23 | | Public Health pursuant to the Emergency Medical Services (EMS) |
24 | | Systems Act. |
25 | | (c-2) For purposes of this Section, "ground ambulance |
26 | | service provider" means a vehicle service provider as |
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1 | | described in the Emergency Medical Services (EMS) Systems Act |
2 | | that operates licensed ambulances for the purpose of providing |
3 | | emergency ambulance services, or non-emergency ambulance |
4 | | services, or both. For purposes of this Section, this includes |
5 | | both ambulance providers and ambulance suppliers as described |
6 | | by the Centers for Medicare and Medicaid Services. |
7 | | (c-3) For purposes of this Section, "medi-car" means |
8 | | transportation services provided to a patient who is confined |
9 | | to a wheelchair and requires the use of a hydraulic or electric |
10 | | lift or ramp and wheelchair lockdown when the patient's |
11 | | condition does not require medical observation, medical |
12 | | supervision, medical equipment, the administration of |
13 | | medications, or the administration of oxygen. |
14 | | (c-4) For purposes of this Section, "service car" means |
15 | | transportation services provided to a patient by a passenger |
16 | | vehicle where that patient does not require the specialized |
17 | | modes described in subsection (c-1) or (c-3). |
18 | | (d) This Section does not prohibit separate billing by |
19 | | ambulance service
providers for oxygen furnished while |
20 | | providing advanced life support
services.
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21 | | (e) Beginning with services rendered on or after July 1, |
22 | | 2008, all providers of non-emergency medi-car and service car |
23 | | transportation must certify that the driver and employee |
24 | | attendant, as applicable, have completed a safety program |
25 | | approved by the Department to protect both the patient and the |
26 | | driver, prior to transporting a patient.
The provider must |
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1 | | maintain this certification in its records. The provider shall |
2 | | produce such documentation upon demand by the Department or |
3 | | its representative. Failure to produce documentation of such |
4 | | training shall result in recovery of any payments made by the |
5 | | Department for services rendered by a non-certified driver or |
6 | | employee attendant. Medi-car and service car providers must |
7 | | maintain legible documentation in their records of the driver |
8 | | and, as applicable, employee attendant that actually |
9 | | transported the patient. Providers must recertify all drivers |
10 | | and employee attendants every 3 years.
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11 | | Notwithstanding the requirements above, any public |
12 | | transportation provider of medi-car and service car |
13 | | transportation that receives federal funding under 49 U.S.C. |
14 | | 5307 and 5311 need not certify its drivers and employee |
15 | | attendants under this Section, since safety training is |
16 | | already federally mandated.
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17 | | (f) With respect to any policy or program administered by |
18 | | the Department or its agent regarding approval of |
19 | | non-emergency medical transportation by ground ambulance |
20 | | service providers, including, but not limited to, the |
21 | | Non-Emergency Transportation Services Prior Approval Program |
22 | | (NETSPAP), the Department shall establish by rule a process by |
23 | | which ground ambulance service providers of non-emergency |
24 | | medical transportation may appeal any decision by the |
25 | | Department or its agent for which no denial was received prior |
26 | | to the time of transport that either (i) denies a request for |
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1 | | approval for payment of non-emergency transportation by means |
2 | | of ground ambulance service or (ii) grants a request for |
3 | | approval of non-emergency transportation by means of ground |
4 | | ambulance service at a level of service that entitles the |
5 | | ground ambulance service provider to a lower level of |
6 | | compensation from the Department than the ground ambulance |
7 | | service provider would have received as compensation for the |
8 | | level of service requested. The rule shall be filed by |
9 | | December 15, 2012 and shall provide that, for any decision |
10 | | rendered by the Department or its agent on or after the date |
11 | | the rule takes effect, the ground ambulance service provider |
12 | | shall have 60 days from the date the decision is received to |
13 | | file an appeal. The rule established by the Department shall |
14 | | be, insofar as is practical, consistent with the Illinois |
15 | | Administrative Procedure Act. The Director's decision on an |
16 | | appeal under this Section shall be a final administrative |
17 | | decision subject to review under the Administrative Review |
18 | | Law. |
19 | | (f-5) Beginning 90 days after July 20, 2012 (the effective |
20 | | date of Public Act 97-842), (i) no denial of a request for |
21 | | approval for payment of non-emergency transportation by means |
22 | | of ground ambulance service, and (ii) no approval of |
23 | | non-emergency transportation by means of ground ambulance |
24 | | service at a level of service that entitles the ground |
25 | | ambulance service provider to a lower level of compensation |
26 | | from the Department than would have been received at the level |
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1 | | of service submitted by the ground ambulance service provider, |
2 | | may be issued by the Department or its agent unless the |
3 | | Department has submitted the criteria for determining the |
4 | | appropriateness of the transport for first notice publication |
5 | | in the Illinois Register pursuant to Section 5-40 of the |
6 | | Illinois Administrative Procedure Act. |
7 | | (g) Whenever a patient covered by a medical assistance |
8 | | program under this Code or by another medical program |
9 | | administered by the Department, including a patient covered |
10 | | under the State's Medicaid managed care program, is being |
11 | | transported from a facility and requires non-emergency |
12 | | transportation including ground ambulance, medi-car, or |
13 | | service car transportation, a Physician Certification |
14 | | Statement as described in this Section shall be required for |
15 | | each patient. Facilities shall develop procedures for a |
16 | | licensed medical professional to provide a written and signed |
17 | | Physician Certification Statement. The Physician Certification |
18 | | Statement shall specify the level of transportation services |
19 | | needed and complete a medical certification establishing the |
20 | | criteria for approval of non-emergency ambulance |
21 | | transportation, as published by the Department of Healthcare |
22 | | and Family Services, that is met by the patient. This |
23 | | certification shall be completed prior to ordering the |
24 | | transportation service and prior to patient discharge. The |
25 | | Physician Certification Statement is not required prior to |
26 | | transport if a delay in transport can be expected to |
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1 | | negatively affect the patient outcome. If the ground ambulance |
2 | | provider, medi-car provider, or service car provider is unable |
3 | | to obtain the required Physician Certification Statement |
4 | | within 10 calendar days following the date of the service, the |
5 | | ground ambulance provider, medi-car provider, or service car |
6 | | provider must document its attempt to obtain the requested |
7 | | certification and may then submit the claim for payment. |
8 | | Acceptable documentation includes a signed return receipt from |
9 | | the U.S. Postal Service, facsimile receipt, email receipt, or |
10 | | other similar service that evidences that the ground ambulance |
11 | | provider, medi-car provider, or service car provider attempted |
12 | | to obtain the required Physician Certification Statement. |
13 | | The medical certification specifying the level and type of |
14 | | non-emergency transportation needed shall be in the form of |
15 | | the Physician Certification Statement on a standardized form |
16 | | prescribed by the Department of Healthcare and Family |
17 | | Services. Within 75 days after July 27, 2018 (the effective |
18 | | date of Public Act 100-646), the Department of Healthcare and |
19 | | Family Services shall develop a standardized form of the |
20 | | Physician Certification Statement specifying the level and |
21 | | type of transportation services needed in consultation with |
22 | | the Department of Public Health, Medicaid managed care |
23 | | organizations, a statewide association representing ambulance |
24 | | providers, a statewide association representing hospitals, 3 |
25 | | statewide associations representing nursing homes, and other |
26 | | stakeholders. The Physician Certification Statement shall |
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1 | | include, but is not limited to, the criteria necessary to |
2 | | demonstrate medical necessity for the level of transport |
3 | | needed as required by (i) the Department of Healthcare and |
4 | | Family Services and (ii) the federal Centers for Medicare and |
5 | | Medicaid Services as outlined in the Centers for Medicare and |
6 | | Medicaid Services' Medicare Benefit Policy Manual, Pub. |
7 | | 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician |
8 | | Certification Statement shall satisfy the obligations of |
9 | | hospitals under Section 6.22 of the Hospital Licensing Act and |
10 | | nursing homes under Section 2-217 of the Nursing Home Care |
11 | | Act. Implementation and acceptance of the Physician |
12 | | Certification Statement shall take place no later than 90 days |
13 | | after the issuance of the Physician Certification Statement by |
14 | | the Department of Healthcare and Family Services. |
15 | | Pursuant to subsection (E) of Section 12-4.25 of this |
16 | | Code, the Department is entitled to recover overpayments paid |
17 | | to a provider or vendor, including, but not limited to, from |
18 | | the discharging physician, the discharging facility, and the |
19 | | ground ambulance service provider, in instances where a |
20 | | non-emergency ground ambulance service is rendered as the |
21 | | result of improper or false certification. |
22 | | Beginning October 1, 2018, the Department of Healthcare |
23 | | and Family Services shall collect data from Medicaid managed |
24 | | care organizations and transportation brokers, including the |
25 | | Department's NETSPAP broker, regarding denials and appeals |
26 | | related to the missing or incomplete Physician Certification |
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1 | | Statement forms and overall compliance with this subsection. |
2 | | The Department of Healthcare and Family Services shall publish |
3 | | quarterly results on its website within 15 days following the |
4 | | end of each quarter. |
5 | | (h) On and after July 1, 2012, the Department shall reduce |
6 | | any rate of reimbursement for services or other payments or |
7 | | alter any methodologies authorized by this Code to reduce any |
8 | | rate of reimbursement for services or other payments in |
9 | | accordance with Section 5-5e. |
10 | | (i) On and after July 1, 2018, the Department shall |
11 | | increase the base rate of reimbursement for both base charges |
12 | | and mileage charges for ground ambulance service providers for |
13 | | medical transportation services provided by means of a ground |
14 | | ambulance to a level not lower than 112% of the base rate in |
15 | | effect as of June 30, 2018. |
16 | | (Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18; |
17 | | 101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)
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