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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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