SB2300eng 95TH GENERAL ASSEMBLY

SB2300 Engrossed LRB095 19766 DRJ 46140 b

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by changing Section 5-4.2 as follows:

(305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)

Sec. 5-4.2. Ground ambulance Ambulance services payments.

(a) For purposes of this Section, the following terms have the following meanings:

"Department" means the Illinois Department of Healthcare and Family Services.

"Ground ambulance services provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services.

"Ground ambulance services" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act.

"Rural county" means: any county not located in a U.S. Bureau of the Census Metropolitan Statistical Area (MSA); or any county located within a U.S. Bureau of the Census Metropolitan Statistical Area but having a population of 60,000 or less.

(b) It is the intent of the General Assembly to provide for the reimbursement of ground ambulance services as part of the State Medicaid plan and to provide adequate reimbursement for ground ambulance services under the State Medicaid plan so as to ensure adequate access to ground ambulance services for both recipients of aid under this Article and for the general population of Illinois. Unless otherwise indicated in this Section, the practices of the Department concerning payments for ground ambulance services provided to recipients of aid under this Article shall be consistent with the payment principles of Medicare, including the statutes, regulations, policies, procedures, principles, definitions, guidelines, coding systems, including the ambulance condition coding system, and manuals used by the Centers for Medicare and Medicaid Services and the Medicare Part B Carrier for the State of Illinois to determine the payment system to ground ambulance services providers under Title XVIII of the Social Security Act.

(c) For ground ambulance services provided to a recipient of aid under this Article on or after July 1, 2008, the Department shall reimburse ground ambulance services providers for base charges and mileage charges based on the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule rates calculated in accordance with this Section.

Effective July 1, 2008 the Illinois Medicaid Ambulance Fee Schedule shall be established and shall include only the ground ambulance services rates outlined in the Medicare Ambulance Fee Schedule as promulgated by the Centers for Medicare and Medicaid Services and adjusted for the 4 Medicare Localities in Illinois, with an adjustment of 100% of the Medicare Ambulance Fee Schedule rates, by Medicare Locality, for both base rates and mileage for rural counties, and an adjustment of 80% of the Medicare Ambulance Fee Schedule rates, by Medicare Locality, for both base rates and mileage for all other counties. The transition from the current payment system to the Illinois Medicaid Ambulance Fee Schedule shall be by a 3-year phase-in as follows:

(1) Effective July 1, 2008 through June 30, 2009, for each individual base rate and mileage rate, the payment rate for ground ambulance services shall be based on 66.7% of the Medicaid rate in effect as of January 1, 2008 and 33.3% of the Illinois Medicaid Ambulance Fee Schedule amount in effect on July 1, 2008 for the designated Medicare Locality, except that any rate that was previously approved by the Department that exceeds this amount shall remain in force.

(2) Effective July 1, 2009 through June 30, 2010, for each individual base rate and mileage rate, the payment rate for ground ambulance services shall be based on 33.3% of the Medicaid rate in effect as of January 1, 2008 and 66.7% of the Illinois Medicaid Ambulance Fee Schedule amount in effect on July 1, 2009 for the designated Medicare Locality, except that any rate that was previously approved by the Department that exceeds this amount shall remain in force.

(3) Effective July 1, 2010, for each individual base rate and mileage rate, the payment rate for ground ambulance services shall be based on 100% of the Illinois Medicaid Ambulance Fee Schedule amount in effect on July 1, 2010 for the designated Medicare Locality, except that any rate that was previously approved by the Department that exceeds this amount shall remain in force.

On July 1, 2009, and on each July 1 thereafter, the Department shall update the Illinois Medicaid Ambulance Fee Schedule rates to be in compliance with the Medicare Ambulance Fee Schedule rates for ground ambulance services in effect at the time of the update, in the manner prescribed in the second paragraph of this subsection (c).

(d) Payment for mileage shall be per loaded mile with no loaded mileage included in the base rate. If a natural disaster, weather, or other conditions necessitate a route other than the most direct route, reimbursement shall be based on the actual distance traveled. Although a recognized deviation from the payment principles in subsection (b) of this Section, it is the intent of the General Assembly that the mileage rate for urban providers, as defined by the Centers for Medicare and Medicaid Services, be the only mileage rate paid under the Illinois Medicaid Ambulance Fee Schedule and that no other mileage rates that act as enhancements to the urban mileage rate, whether permanent or temporary, be recognized by the Department.

(e) The requirement for payment of ground ambulance services by the Department is deemed to be met if the services are provided pursuant to a request for evaluation, treatment, and transport from an individual with a condition of such a nature that a prudent layperson would have reasonably expected that a delay in seeking immediate medical attention would have been hazardous to life or health. This standard is deemed to be met if there is an emergency medical condition manifesting itself by acute symptoms of sufficient severity, including but not limited to severe pain, such that a prudent layperson who possesses an average knowledge of medicine and health can reasonably expect that the absence of immediate medical attention could result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part.

(f) For ground ambulance services provided to a recipient enrolled in a Medicaid managed care plan by a provider that is not a contracted provider to the Medicaid managed care plan in question, payment for ground ambulance services by the Medicaid managed care plan shall be the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule rates calculated in accordance with this Section.

(g) Nothing in this Section prohibits the Department from setting reimbursement rates for out-of-State ground ambulance services providers by administrative rule.

For ambulance services provided to a recipient of aid under this Article on or after January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section. It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for recipients of aid under this Article and to provide appropriate incentives to ambulance service providers to provide services in an efficient and cost-effective manner. Thus, it is the intent of the General Assembly that the Illinois Department implement a reimbursement system for ambulance services that, to the extent practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, is consistent with the payment principles of Medicare. To ensure uniformity between the payment principles of Medicare and Medicaid, the Illinois Department shall follow, to the extent necessary and practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, and manuals used to determine the amounts paid to ambulance service providers under Title XVIII of the Social Security Act (Medicare).

For ambulance services provided to a recipient of aid under this Article on or after January 1, 1996, the Illinois Department shall reimburse ambulance service providers based upon the actual distance traveled if a natural disaster, weather conditions, road repairs, or traffic congestion necessitates the use of a route other than the most direct route.

For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, medi-car, service car, or taxi.

This Section does not prohibit separate billing by ambulance service providers for oxygen furnished while providing advanced life support services.

(h) Beginning with services rendered on or after July 1, 2008, all providers of non-emergency medi-car and service car transportation must certify that the driver and employee attendant, as applicable, have completed a safety program approved by the Department to protect both the patient and the driver, prior to transporting a patient. The provider must maintain this certification in its records. The provider shall produce such documentation upon demand by the Department or its representative. Failure to produce documentation of such training shall result in recovery of any payments made by the Department for services rendered by a non-certified driver or employee attendant. Medi-car and service car providers must maintain legible documentation in their records of the driver and, as applicable, employee attendant that actually transported the patient. Providers must recertify all drivers and employee attendants every 3 years.

Notwithstanding the requirements above, any public transportation provider of medi-car and service car transportation that receives federal funding under 49 U.S.C. 5307 and 5311 need not certify its drivers and employee attendants under this Section, since safety training is already federally mandated.

(Source: P.A. 95-501, eff. 8-28-07.)

Section 99. Effective date. This Act takes effect upon becoming law.