Sen. Kwame Raoul

Filed: 5/25/2017

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2525

2    AMENDMENT NO. ______. Amend House Bill 2525 on page 10,
3line 1, by changing "8.1b," to "8.1b, 8.2,"; and
 
4on page 25, line 25, by replacing "In" with "The foregoing
5notwithstanding, in the case of an employee who is employed as
6a volunteer, paid-on-call, or part-time firefighter, emergency
7medical technician, or paramedic or in In"; and
 
8on page 43, by replacing lines 24 through 26 with the
9following:
10"fingers, leg, foot, or any toes, or loss under Section 8(d)2
11due to accidental injuries to the same part of the spine, such
12loss or partial loss of any such member or loss under Section
138(d)2 due to accidental injuries to the same part of the spine
14shall be deducted from any award made for the subsequent
15injury. For the permanent loss of use or the permanent partial
16loss of use of any such member or the partial loss of sight of

 

 

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1an eye or loss under Section 8(d)2 due to accidental injuries
2to the same part of the spine, for which compensation has been
3paid, then such loss shall be taken into consideration and
4deducted from any award for the subsequent injury. For purposes
5of this subdivision (e)17 only, "same part of the spine" means:
6(1) cervical spine and thoracic spine from vertebra C1 through
7T12 and (2) lumbar and sacral spine and coccyx from vertebra L1
8through S5."; and
 
9on page 44, by deleting lines 1 through 4; and
 
10on page 58, by inserting immediately below line 13 the
11following:
 
12    "(820 ILCS 305/8.2)
13    Sec. 8.2. Fee schedule.
14    (a) Except as provided for in subsection (c), for
15procedures, treatments, or services covered under this Act and
16rendered or to be rendered on and after February 1, 2006, the
17maximum allowable payment shall be 90% of the 80th percentile
18of charges and fees as determined by the Commission utilizing
19information provided by employers' and insurers' national
20databases, with a minimum of 12,000,000 Illinois line item
21charges and fees comprised of health care provider and hospital
22charges and fees as of August 1, 2004 but not earlier than
23August 1, 2002. These charges and fees are provider billed

 

 

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1amounts and shall not include discounted charges. The 80th
2percentile is the point on an ordered data set from low to high
3such that 80% of the cases are below or equal to that point and
4at most 20% are above or equal to that point. The Commission
5shall adjust these historical charges and fees as of August 1,
62004 by the Consumer Price Index-U for the period August 1,
72004 through September 30, 2005. The Commission shall establish
8fee schedules for procedures, treatments, or services for
9hospital inpatient, hospital outpatient, emergency room and
10trauma, ambulatory surgical treatment centers, and
11professional services. These charges and fees shall be
12designated by geozip or any smaller geographic unit. The data
13shall in no way identify or tend to identify any patient,
14employer, or health care provider. As used in this Section,
15"geozip" means a three-digit zip code based on data
16similarities, geographical similarities, and frequencies. A
17geozip does not cross state boundaries. As used in this
18Section, "three-digit zip code" means a geographic area in
19which all zip codes have the same first 3 digits. If a geozip
20does not have the necessary number of charges and fees to
21calculate a valid percentile for a specific procedure,
22treatment, or service, the Commission may combine data from the
23geozip with up to 4 other geozips that are demographically and
24economically similar and exhibit similarities in data and
25frequencies until the Commission reaches 9 charges or fees for
26that specific procedure, treatment, or service. In cases where

 

 

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1the compiled data contains less than 9 charges or fees for a
2procedure, treatment, or service, reimbursement shall occur at
376% of charges and fees as determined by the Commission in a
4manner consistent with the provisions of this paragraph.
5Providers of out-of-state procedures, treatments, services,
6products, or supplies shall be reimbursed at the lesser of that
7state's fee schedule amount or the fee schedule amount for the
8region in which the employee resides. If no fee schedule exists
9in that state, the provider shall be reimbursed at the lesser
10of the actual charge or the fee schedule amount for the region
11in which the employee resides. Not later than September 30 in
122006 and each year thereafter, the Commission shall
13automatically increase or decrease the maximum allowable
14payment for a procedure, treatment, or service established and
15in effect on January 1 of that year by the percentage change in
16the Consumer Price Index-U for the 12 month period ending
17August 31 of that year. The increase or decrease shall become
18effective on January 1 of the following year. As used in this
19Section, "Consumer Price Index-U" means the index published by
20the Bureau of Labor Statistics of the U.S. Department of Labor,
21that measures the average change in prices of all goods and
22services purchased by all urban consumers, U.S. city average,
23all items, 1982-84=100.
24    (a-1) Notwithstanding the provisions of subsection (a) and
25unless otherwise indicated, the following provisions shall
26apply to the medical fee schedule starting on September 1,

 

 

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12011:
2        (1) The Commission shall establish and maintain fee
3    schedules for procedures, treatments, products, services,
4    or supplies for hospital inpatient, hospital outpatient,
5    emergency room, ambulatory surgical treatment centers,
6    accredited ambulatory surgical treatment facilities,
7    prescriptions filled and dispensed outside of a licensed
8    pharmacy, dental services, and professional services. This
9    fee schedule shall be based on the fee schedule amounts
10    already established by the Commission pursuant to
11    subsection (a) of this Section. However, starting on
12    January 1, 2012, these fee schedule amounts shall be
13    grouped into geographic regions in the following manner:
14            (A) Four regions for non-hospital fee schedule
15        amounts shall be utilized:
16                (i) Cook County;
17                (ii) DuPage, Kane, Lake, and Will Counties;
18                (iii) Bond, Calhoun, Clinton, Jersey,
19            Macoupin, Madison, Monroe, Montgomery, Randolph,
20            St. Clair, and Washington Counties; and
21                (iv) All other counties of the State.
22            (B) Fourteen regions for hospital fee schedule
23        amounts shall be utilized:
24                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
25            Kendall, and Grundy Counties;
26                (ii) Kankakee County;

 

 

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1                (iii) Madison, St. Clair, Macoupin, Clinton,
2            Monroe, Jersey, Bond, and Calhoun Counties;
3                (iv) Winnebago and Boone Counties;
4                (v) Peoria, Tazewell, Woodford, Marshall, and
5            Stark Counties;
6                (vi) Champaign, Piatt, and Ford Counties;
7                (vii) Rock Island, Henry, and Mercer Counties;
8                (viii) Sangamon and Menard Counties;
9                (ix) McLean County;
10                (x) Lake County;
11                (xi) Macon County;
12                (xii) Vermilion County;
13                (xiii) Alexander County; and
14                (xiv) All other counties of the State.
15        (2) If a geozip, as defined in subsection (a) of this
16    Section, overlaps into one or more of the regions set forth
17    in this Section, then the Commission shall average or
18    repeat the charges and fees in a geozip in order to
19    designate charges and fees for each region.
20        (3) In cases where the compiled data contains less than
21    9 charges or fees for a procedure, treatment, product,
22    supply, or service or where the fee schedule amount cannot
23    be determined by the non-discounted charge data,
24    non-Medicare relative values and conversion factors
25    derived from established fee schedule amounts, coding
26    crosswalks, or other data as determined by the Commission,

 

 

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1    reimbursement shall occur at 76% of charges and fees until
2    September 1, 2011 and 53.2% of charges and fees thereafter
3    as determined by the Commission in a manner consistent with
4    the provisions of this paragraph.
5        (4) To establish additional fee schedule amounts, the
6    Commission shall utilize provider non-discounted charge
7    data, non-Medicare relative values and conversion factors
8    derived from established fee schedule amounts, and coding
9    crosswalks. The Commission may establish additional fee
10    schedule amounts based on either the charge or cost of the
11    procedure, treatment, product, supply, or service.
12        (5) Implants shall be reimbursed at 25% above the net
13    manufacturer's invoice price less rebates, plus actual
14    reasonable and customary shipping charges whether or not
15    the implant charge is submitted by a provider in
16    conjunction with a bill for all other services associated
17    with the implant, submitted by a provider on a separate
18    claim form, submitted by a distributor, or submitted by the
19    manufacturer of the implant. "Implants" include the
20    following codes or any substantially similar updated code
21    as determined by the Commission: 0274
22    (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
23    implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
24    (investigational devices); and 0636 (drugs requiring
25    detailed coding). Non-implantable devices or supplies
26    within these codes shall be reimbursed at 65% of actual

 

 

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1    charge, which is the provider's normal rates under its
2    standard chargemaster. A standard chargemaster is the
3    provider's list of charges for procedures, treatments,
4    products, supplies, or services used to bill payers in a
5    consistent manner.
6        (6) The Commission shall automatically update all
7    codes and associated rules with the version of the codes
8    and rules valid on January 1 of that year.
9    (a-2) For procedures, treatments, services, or supplies
10covered under this Act and rendered or to be rendered on or
11after September 1, 2011, the maximum allowable payment shall be
1270% of the fee schedule amounts, which shall be adjusted yearly
13by the Consumer Price Index-U, as described in subsection (a)
14of this Section.
15    (a-3) Prescriptions filled and dispensed outside of a
16licensed pharmacy shall be subject to a fee schedule that shall
17not exceed the Average Wholesale Price (AWP) plus a dispensing
18fee of $4.18. AWP or its equivalent as registered by the
19National Drug Code shall be set forth for that drug on that
20date as published in Medispan.
21    (a-4) The Commission, in consultation with the Workers'
22Compensation Medical Fee Advisory Board, shall promulgate by
23rule an evidence-based drug formulary and any rules necessary
24for its administration. Prescriptions prescribed for workers'
25compensation cases shall be limited to those prescription and
26non-prescription drugs and doses on the closed formulary.

 

 

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1    A request for a prescription that is not on the closed
2formulary shall be reviewed pursuant to Section 8.7 of this
3Act.
4    (a-5) Notwithstanding any other provision of this Section,
5on or before March 1, 2018 and on or before March 1 of each
6subsequent year, the Commission must investigate all
7procedures, treatments, and services covered under this Act for
8ambulatory surgical treatment centers and accredited
9ambulatory surgical treatment facilities and establish fee
10schedule amounts for procedures, treatments, and services for
11which fee schedule amounts have not been established. The
12Commission must adopt, in a timely and ongoing manner, all
13rules necessary to ensure that its responsibilities under this
14subsection are carried out.
15    (b) Notwithstanding the provisions of subsection (a), if
16the Commission finds that there is a significant limitation on
17access to quality health care in either a specific field of
18health care services or a specific geographic limitation on
19access to health care, it may change the Consumer Price Index-U
20increase or decrease for that specific field or specific
21geographic limitation on access to health care to address that
22limitation.
23    (c) The Commission shall establish by rule a process to
24review those medical cases or outliers that involve
25extra-ordinary treatment to determine whether to make an
26additional adjustment to the maximum payment within a fee

 

 

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1schedule for a procedure, treatment, or service.
2    (d) When a patient notifies a provider that the treatment,
3procedure, or service being sought is for a work-related
4illness or injury and furnishes the provider the name and
5address of the responsible employer, the provider shall bill
6the employer directly. The employer shall make payment and
7providers shall submit bills and records in accordance with the
8provisions of this Section.
9        (1) All payments to providers for treatment provided
10    pursuant to this Act shall be made within 30 days of
11    receipt of the bills as long as the claim contains
12    substantially all the required data elements necessary to
13    adjudicate the bills.
14        (2) If the claim does not contain substantially all the
15    required data elements necessary to adjudicate the bill, or
16    the claim is denied for any other reason, in whole or in
17    part, the employer or insurer shall provide written
18    notification, explaining the basis for the denial and
19    describing any additional necessary data elements, to the
20    provider within 30 days of receipt of the bill.
21        (3) In the case of nonpayment to a provider within 30
22    days of receipt of the bill which contained substantially
23    all of the required data elements necessary to adjudicate
24    the bill or nonpayment to a provider of a portion of such a
25    bill up to the lesser of the actual charge or the payment
26    level set by the Commission in the fee schedule established

 

 

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1    in this Section, the bill, or portion of the bill, shall
2    incur interest at a rate of 1% per month payable to the
3    provider. Any required interest payments shall be made
4    within 30 days after payment.
5    (e) Except as provided in subsections (e-5), (e-10), and
6(e-15), a provider shall not hold an employee liable for costs
7related to a non-disputed procedure, treatment, or service
8rendered in connection with a compensable injury. The
9provisions of subsections (e-5), (e-10), (e-15), and (e-20)
10shall not apply if an employee provides information to the
11provider regarding participation in a group health plan. If the
12employee participates in a group health plan, the provider may
13submit a claim for services to the group health plan. If the
14claim for service is covered by the group health plan, the
15employee's responsibility shall be limited to applicable
16deductibles, co-payments, or co-insurance. Except as provided
17under subsections (e-5), (e-10), (e-15), and (e-20), a provider
18shall not bill or otherwise attempt to recover from the
19employee the difference between the provider's charge and the
20amount paid by the employer or the insurer on a compensable
21injury, or for medical services or treatment determined by the
22Commission to be excessive or unnecessary.
23    (e-5) If an employer notifies a provider that the employer
24does not consider the illness or injury to be compensable under
25this Act, the provider may seek payment of the provider's
26actual charges from the employee for any procedure, treatment,

 

 

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1or service rendered. Once an employee informs the provider that
2there is an application filed with the Commission to resolve a
3dispute over payment of such charges, the provider shall cease
4any and all efforts to collect payment for the services that
5are the subject of the dispute. Any statute of limitations or
6statute of repose applicable to the provider's efforts to
7collect payment from the employee shall be tolled from the date
8that the employee files the application with the Commission
9until the date that the provider is permitted to resume
10collection efforts under the provisions of this Section.
11    (e-10) If an employer notifies a provider that the employer
12will pay only a portion of a bill for any procedure, treatment,
13or service rendered in connection with a compensable illness or
14disease, the provider may seek payment from the employee for
15the remainder of the amount of the bill up to the lesser of the
16actual charge, negotiated rate, if applicable, or the payment
17level set by the Commission in the fee schedule established in
18this Section. Once an employee informs the provider that there
19is an application filed with the Commission to resolve a
20dispute over payment of such charges, the provider shall cease
21any and all efforts to collect payment for the services that
22are the subject of the dispute. Any statute of limitations or
23statute of repose applicable to the provider's efforts to
24collect payment from the employee shall be tolled from the date
25that the employee files the application with the Commission
26until the date that the provider is permitted to resume

 

 

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1collection efforts under the provisions of this Section.
2    (e-15) When there is a dispute over the compensability of
3or amount of payment for a procedure, treatment, or service,
4and a case is pending or proceeding before an Arbitrator or the
5Commission, the provider may mail the employee reminders that
6the employee will be responsible for payment of any procedure,
7treatment or service rendered by the provider. The reminders
8must state that they are not bills, to the extent practicable
9include itemized information, and state that the employee need
10not pay until such time as the provider is permitted to resume
11collection efforts under this Section. The reminders shall not
12be provided to any credit rating agency. The reminders may
13request that the employee furnish the provider with information
14about the proceeding under this Act, such as the file number,
15names of parties, and status of the case. If an employee fails
16to respond to such request for information or fails to furnish
17the information requested within 90 days of the date of the
18reminder, the provider is entitled to resume any and all
19efforts to collect payment from the employee for the services
20rendered to the employee and the employee shall be responsible
21for payment of any outstanding bills for a procedure,
22treatment, or service rendered by a provider.
23    (e-20) Upon a final award or judgment by an Arbitrator or
24the Commission, or a settlement agreed to by the employer and
25the employee, a provider may resume any and all efforts to
26collect payment from the employee for the services rendered to

 

 

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1the employee and the employee shall be responsible for payment
2of any outstanding bills for a procedure, treatment, or service
3rendered by a provider as well as the interest awarded under
4subsection (d) of this Section. In the case of a procedure,
5treatment, or service deemed compensable, the provider shall
6not require a payment rate, excluding the interest provisions
7under subsection (d), greater than the lesser of the actual
8charge or the payment level set by the Commission in the fee
9schedule established in this Section. Payment for services
10deemed not covered or not compensable under this Act is the
11responsibility of the employee unless a provider and employee
12have agreed otherwise in writing. Services not covered or not
13compensable under this Act are not subject to the fee schedule
14in this Section.
15    (f) Nothing in this Act shall prohibit an employer or
16insurer from contracting with a health care provider or group
17of health care providers for reimbursement levels for benefits
18under this Act different from those provided in this Section.
19    (g) On or before January 1, 2010 the Commission shall
20provide to the Governor and General Assembly a report regarding
21the implementation of the medical fee schedule and the index
22used for annual adjustment to that schedule as described in
23this Section.
24(Source: P.A. 97-18, eff. 6-28-11.)".