103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4878

 

Introduced 2/7/2024, by Rep. Jackie Haas

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-4.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that notwithstanding any other provision of the Code, subject to federal approval, emergency medical transportation services in cases where services are dispatched and the patient is treated but not transferred to a hospital shall be covered under the medical assistance program at a rate not less than 50% of the base rate in effect as of June 30, 2024 for persons who are otherwise eligible for medical assistance.


LRB103 36654 KTG 66763 b

 

 

A BILL FOR

 

HB4878LRB103 36654 KTG 66763 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)
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
15and to 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
20extent practicable 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

 

 

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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
7under Title 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, air 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

 

 

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1described in the Emergency Medical Services (EMS) Systems Act
2that operates 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    (c-5) For purposes of this Section, "air ambulance
19service" means medical transport by helicopter or airplane for
20patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
21that is described as an air ambulance service by the federal
22Centers for Medicare and Medicaid Services.
23    (d) This Section does not prohibit separate billing by
24ambulance service providers for oxygen furnished while
25providing advanced life support services.
26    (e) Beginning with services rendered on or after July 1,

 

 

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12008, all providers of non-emergency medi-car and service car
2transportation must certify that the driver and employee
3attendant, as applicable, have completed a safety program
4approved by the Department to protect both the patient and the
5driver, prior to transporting a patient. The provider must
6maintain this certification in its records. The provider shall
7produce such documentation upon demand by the Department or
8its representative. Failure to produce documentation of such
9training shall result in recovery of any payments made by the
10Department for services rendered by a non-certified driver or
11employee attendant. Medi-car and service car providers must
12maintain legible documentation in their records of the driver
13and, as applicable, employee attendant that actually
14transported the patient. Providers must recertify all drivers
15and employee attendants every 3 years. If they meet the
16established training components set forth by the Department,
17providers of non-emergency medi-car and service car
18transportation that are either directly or through an
19affiliated company licensed by the Department of Public Health
20shall be approved by the Department to have in-house safety
21programs for training their own staff.
22    Notwithstanding the requirements above, any public
23transportation provider of medi-car and service car
24transportation that receives federal funding under 49 U.S.C.
255307 and 5311 need not certify its drivers and employee
26attendants under this Section, since safety training is

 

 

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1already federally mandated.
2    (f) With respect to any policy or program administered by
3the Department or its agent regarding approval of
4non-emergency medical transportation by ground ambulance
5service providers, including, but not limited to, the
6Non-Emergency Transportation Services Prior Approval Program
7(NETSPAP), the Department shall establish by rule a process by
8which ground ambulance service providers of non-emergency
9medical transportation may appeal any decision by the
10Department or its agent for which no denial was received prior
11to the time of transport that either (i) denies a request for
12approval for payment of non-emergency transportation by means
13of ground ambulance service or (ii) grants a request for
14approval of non-emergency transportation by means of ground
15ambulance service at a level of service that entitles the
16ground ambulance service provider to a lower level of
17compensation from the Department than the ground ambulance
18service provider would have received as compensation for the
19level of service requested. The rule shall be filed by
20December 15, 2012 and shall provide that, for any decision
21rendered by the Department or its agent on or after the date
22the rule takes effect, the ground ambulance service provider
23shall have 60 days from the date the decision is received to
24file an appeal. The rule established by the Department shall
25be, insofar as is practical, consistent with the Illinois
26Administrative Procedure Act. The Director's decision on an

 

 

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1appeal under this Section shall be a final administrative
2decision subject to review under the Administrative Review
3Law.
4    (f-5) Beginning 90 days after July 20, 2012 (the effective
5date of Public Act 97-842), (i) no denial of a request for
6approval for payment of non-emergency transportation by means
7of ground ambulance service, and (ii) no approval of
8non-emergency transportation by means of ground ambulance
9service at a level of service that entitles the ground
10ambulance service provider to a lower level of compensation
11from the Department than would have been received at the level
12of service submitted by the ground ambulance service provider,
13may be issued by the Department or its agent unless the
14Department has submitted the criteria for determining the
15appropriateness of the transport for first notice publication
16in the Illinois Register pursuant to Section 5-40 of the
17Illinois Administrative Procedure Act.
18    (f-6) Within 90 days after June 2, 2022 (the effective
19date of Public Act 102-1037) this amendatory Act of the 102nd
20General Assembly and subject to federal approval, the
21Department shall file rules to allow for the approval of
22ground ambulance services when the sole purpose of the
23transport is for the navigation of stairs or the assisting or
24lifting of a patient at a medical facility or during a medical
25appointment in instances where the Department or a contracted
26Medicaid managed care organization or their transportation

 

 

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1broker is unable to secure transportation through any other
2transportation provider.
3    (f-7) For non-emergency ground ambulance claims properly
4denied under Department policy at the time the claim is filed
5due to failure to submit a valid Medical Certification for
6Non-Emergency Ambulance on and after December 15, 2012 and
7prior to January 1, 2021, the Department shall allot
8$2,000,000 to a pool to reimburse such claims if the provider
9proves medical necessity for the service by other means.
10Providers must submit any such denied claims for which they
11seek compensation to the Department no later than December 31,
122021 along with documentation of medical necessity. No later
13than May 31, 2022, the Department shall determine for which
14claims medical necessity was established. Such claims for
15which medical necessity was established shall be paid at the
16rate in effect at the time of the service, provided the
17$2,000,000 is sufficient to pay at those rates. If the pool is
18not sufficient, claims shall be paid at a uniform percentage
19of the applicable rate such that the pool of $2,000,000 is
20exhausted. The appeal process described in subsection (f)
21shall not be applicable to the Department's determinations
22made in accordance with this subsection.
23    (g) Whenever a patient covered by a medical assistance
24program under this Code or by another medical program
25administered by the Department, including a patient covered
26under the State's Medicaid managed care program, is being

 

 

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1transported from a facility and requires non-emergency
2transportation including ground ambulance, medi-car, or
3service car transportation, a Physician Certification
4Statement as described in this Section shall be required for
5each patient. Facilities shall develop procedures for a
6licensed medical professional to provide a written and signed
7Physician Certification Statement. The Physician Certification
8Statement shall specify the level of transportation services
9needed and complete a medical certification establishing the
10criteria for approval of non-emergency ambulance
11transportation, as published by the Department of Healthcare
12and Family Services, that is met by the patient. This
13certification shall be completed prior to ordering the
14transportation service and prior to patient discharge. The
15Physician Certification Statement is not required prior to
16transport if a delay in transport can be expected to
17negatively affect the patient outcome. If the ground ambulance
18provider, medi-car provider, or service car provider is unable
19to obtain the required Physician Certification Statement
20within 10 calendar days following the date of the service, the
21ground ambulance provider, medi-car provider, or service car
22provider must document its attempt to obtain the requested
23certification and may then submit the claim for payment.
24Acceptable documentation includes a signed return receipt from
25the U.S. Postal Service, facsimile receipt, email receipt, or
26other similar service that evidences that the ground ambulance

 

 

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1provider, medi-car provider, or service car provider attempted
2to obtain the required Physician Certification Statement.
3    The medical certification specifying the level and type of
4non-emergency transportation needed shall be in the form of
5the Physician Certification Statement on a standardized form
6prescribed by the Department of Healthcare and Family
7Services. Within 75 days after July 27, 2018 (the effective
8date of Public Act 100-646), the Department of Healthcare and
9Family Services shall develop a standardized form of the
10Physician Certification Statement specifying the level and
11type of transportation services needed in consultation with
12the Department of Public Health, Medicaid managed care
13organizations, a statewide association representing ambulance
14providers, a statewide association representing hospitals, 3
15statewide associations representing nursing homes, and other
16stakeholders. The Physician Certification Statement shall
17include, but is not limited to, the criteria necessary to
18demonstrate medical necessity for the level of transport
19needed as required by (i) the Department of Healthcare and
20Family Services and (ii) the federal Centers for Medicare and
21Medicaid Services as outlined in the Centers for Medicare and
22Medicaid Services' Medicare Benefit Policy Manual, Pub.
23100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
24Certification Statement shall satisfy the obligations of
25hospitals under Section 6.22 of the Hospital Licensing Act and
26nursing homes under Section 2-217 of the Nursing Home Care

 

 

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1Act. Implementation and acceptance of the Physician
2Certification Statement shall take place no later than 90 days
3after the issuance of the Physician Certification Statement by
4the Department of Healthcare and Family Services.
5    Pursuant to subsection (E) of Section 12-4.25 of this
6Code, the Department is entitled to recover overpayments paid
7to a provider or vendor, including, but not limited to, from
8the discharging physician, the discharging facility, and the
9ground ambulance service provider, in instances where a
10non-emergency ground ambulance service is rendered as the
11result of improper or false certification.
12    Beginning October 1, 2018, the Department of Healthcare
13and Family Services shall collect data from Medicaid managed
14care organizations and transportation brokers, including the
15Department's NETSPAP broker, regarding denials and appeals
16related to the missing or incomplete Physician Certification
17Statement forms and overall compliance with this subsection.
18The Department of Healthcare and Family Services shall publish
19quarterly results on its website within 15 days following the
20end of each quarter.
21    (h) On and after July 1, 2012, the Department shall reduce
22any rate of reimbursement for services or other payments or
23alter any methodologies authorized by this Code to reduce any
24rate of reimbursement for services or other payments in
25accordance with Section 5-5e.
26    (i) Subject to federal approval, on and after January 1,

 

 

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12024 through June 30, 2026, the Department shall increase the
2base rate of reimbursement for both base charges and mileage
3charges for ground ambulance service providers not
4participating in the Ground Emergency Medical Transportation
5(GEMT) Program for medical transportation services provided by
6means of a ground ambulance to a level not lower than 140% of
7the base rate in effect as of January 1, 2023.
8    (j) For the purpose of understanding ground ambulance
9transportation services cost structures and their impact on
10the Medical Assistance Program, the Department shall engage
11stakeholders, including, but not limited to, a statewide
12association representing private ground ambulance service
13providers in Illinois, to develop recommendations for a plan
14for the regular collection of cost data for all ground
15ambulance transportation providers reimbursed under the
16Illinois Title XIX State Plan. Cost data obtained through this
17process shall be used to inform on and to ensure the
18effectiveness and efficiency of Illinois Medicaid rates. The
19Department shall establish a process to limit public
20availability of portions of the cost report data determined to
21be proprietary. This process shall be concluded and
22recommendations shall be provided no later than April 1, 2024.
23    (k) (j) Subject to federal approval, beginning on January
241, 2024, the Department shall increase the base rate of
25reimbursement for both base charges and mileage charges for
26medical transportation services provided by means of an air

 

 

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1ambulance to a level not lower than 50% of the Medicare
2ambulance fee schedule rates, by designated Medicare locality,
3in effect on January 1, 2023.
4    (l) Notwithstanding any other provision of this Code,
5subject to federal approval, emergency medical transportation
6services in cases where services are dispatched and the
7patient is treated but not transferred to a hospital shall be
8covered under the medical assistance program at a rate not
9less than 50% of the base rate in effect as of June 30, 2024
10for persons who are otherwise eligible for medical assistance
11under this Article.
12(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;
13102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
1470, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
1580-5, eff. 1-1-24; revised 12-15-23.)