101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB1638

 

Introduced , by Rep. Emanuel Chris Welch

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-4.2  from Ch. 23, par. 5-4.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to receive the approval of the General Assembly prior to applying for any waiver to reduce or eliminate the State's responsibility to provide emergency or non-emergency ambulance services to Medicaid beneficiaries. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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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)  (from Ch. 23, par. 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 and
15to 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 extent
20practicable 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 under
7Title XVIII of the Social Security Act (Medicare). The Illinois
8Department shall receive the approval of the General Assembly
9prior to applying for any waiver to reduce or eliminate the
10State's responsibility to provide emergency or non-emergency
11ambulance services to Medicaid beneficiaries.
12    (b) For ambulance services provided to a recipient of aid
13under this Article on or after January 1, 1996, the Illinois
14Department shall reimburse ambulance service providers based
15upon the actual distance traveled if a natural disaster,
16weather conditions, road repairs, or traffic congestion
17necessitates the use of a route other than the most direct
18route.
19    (c) For purposes of this Section, "ambulance services"
20includes medical transportation services provided by means of
21an ambulance, medi-car, service car, or taxi.
22    (c-1) For purposes of this Section, "ground ambulance
23service" means medical transportation services that are
24described as ground ambulance services by the Centers for
25Medicare and Medicaid Services and provided in a vehicle that
26is licensed as an ambulance by the Illinois Department of

 

 

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1Public Health pursuant to the Emergency Medical Services (EMS)
2Systems Act.
3    (c-2) For purposes of this Section, "ground ambulance
4service provider" means a vehicle service provider as described
5in the Emergency Medical Services (EMS) Systems Act that
6operates licensed ambulances for the purpose of providing
7emergency ambulance services, or non-emergency ambulance
8services, or both. For purposes of this Section, this includes
9both ambulance providers and ambulance suppliers as described
10by the Centers for Medicare and Medicaid Services.
11    (c-3) For purposes of this Section, "medi-car" means
12transportation services provided to a patient who is confined
13to a wheelchair and requires the use of a hydraulic or electric
14lift or ramp and wheelchair lockdown when the patient's
15condition does not require medical observation, medical
16supervision, medical equipment, the administration of
17medications, or the administration of oxygen.
18    (c-4) For purposes of this Section, "service car" means
19transportation services provided to a patient by a passenger
20vehicle where that patient does not require the specialized
21modes described in subsection (c-1) or (c-3).
22    (d) This Section does not prohibit separate billing by
23ambulance service providers for oxygen furnished while
24providing advanced life support services.
25    (e) Beginning with services rendered on or after July 1,
262008, all providers of non-emergency medi-car and service car

 

 

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1transportation must certify that the driver and employee
2attendant, as applicable, have completed a safety program
3approved by the Department to protect both the patient and the
4driver, prior to transporting a patient. The provider must
5maintain this certification in its records. The provider shall
6produce such documentation upon demand by the Department or its
7representative. Failure to produce documentation of such
8training shall result in recovery of any payments made by the
9Department for services rendered by a non-certified driver or
10employee attendant. Medi-car and service car providers must
11maintain legible documentation in their records of the driver
12and, as applicable, employee attendant that actually
13transported the patient. Providers must recertify all drivers
14and employee attendants every 3 years.
15    Notwithstanding the requirements above, any public
16transportation provider of medi-car and service car
17transportation that receives federal funding under 49 U.S.C.
185307 and 5311 need not certify its drivers and employee
19attendants under this Section, since safety training is already
20federally mandated.
21    (f) With respect to any policy or program administered by
22the Department or its agent regarding approval of non-emergency
23medical transportation by ground ambulance service providers,
24including, but not limited to, the Non-Emergency
25Transportation Services Prior Approval Program (NETSPAP), the
26Department shall establish by rule a process by which ground

 

 

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1ambulance service providers of non-emergency medical
2transportation may appeal any decision by the Department or its
3agent for which no denial was received prior to the time of
4transport that either (i) denies a request for approval for
5payment of non-emergency transportation by means of ground
6ambulance service or (ii) grants a request for approval of
7non-emergency transportation by means of ground ambulance
8service at a level of service that entitles the ground
9ambulance service provider to a lower level of compensation
10from the Department than the ground ambulance service provider
11would have received as compensation for the level of service
12requested. The rule shall be filed by December 15, 2012 and
13shall provide that, for any decision rendered by the Department
14or its agent on or after the date the rule takes effect, the
15ground ambulance service provider shall have 60 days from the
16date the decision is received to file an appeal. The rule
17established by the Department shall be, insofar as is
18practical, consistent with the Illinois Administrative
19Procedure Act. The Director's decision on an appeal under this
20Section shall be a final administrative decision subject to
21review under the Administrative Review Law.
22    (f-5) Beginning 90 days after July 20, 2012 (the effective
23date of Public Act 97-842), (i) no denial of a request for
24approval for payment of non-emergency transportation by means
25of ground ambulance service, and (ii) no approval of
26non-emergency transportation by means of ground ambulance

 

 

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1service at a level of service that entitles the ground
2ambulance service provider to a lower level of compensation
3from the Department than would have been received at the level
4of service submitted by the ground ambulance service provider,
5may be issued by the Department or its agent unless the
6Department has submitted the criteria for determining the
7appropriateness of the transport for first notice publication
8in the Illinois Register pursuant to Section 5-40 of the
9Illinois Administrative Procedure Act.
10    (g) Whenever a patient covered by a medical assistance
11program under this Code or by another medical program
12administered by the Department, including a patient covered
13under the State's Medicaid managed care program, is being
14transported from a facility and requires non-emergency
15transportation including ground ambulance, medi-car, or
16service car transportation, a Physician Certification
17Statement as described in this Section shall be required for
18each patient. Facilities shall develop procedures for a
19licensed medical professional to provide a written and signed
20Physician Certification Statement. The Physician Certification
21Statement shall specify the level of transportation services
22needed and complete a medical certification establishing the
23criteria for approval of non-emergency ambulance
24transportation, as published by the Department of Healthcare
25and Family Services, that is met by the patient. This
26certification shall be completed prior to ordering the

 

 

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1transportation service and prior to patient discharge. The
2Physician Certification Statement is not required prior to
3transport if a delay in transport can be expected to negatively
4affect the patient outcome.
5    The medical certification specifying the level and type of
6non-emergency transportation needed shall be in the form of the
7Physician Certification Statement on a standardized form
8prescribed by the Department of Healthcare and Family Services.
9Within 75 days after July 27, 2018 (the effective date of
10Public Act 100-646) this amendatory Act of the 100th General
11Assembly, the Department of Healthcare and Family Services
12shall develop a standardized form of the Physician
13Certification Statement specifying the level and type of
14transportation services needed in consultation with the
15Department of Public Health, Medicaid managed care
16organizations, a statewide association representing ambulance
17providers, a statewide association representing hospitals, 3
18statewide associations representing nursing homes, and other
19stakeholders. The Physician Certification Statement shall
20include, but is not limited to, the criteria necessary to
21demonstrate medical necessity for the level of transport needed
22as required by (i) the Department of Healthcare and Family
23Services and (ii) the federal Centers for Medicare and Medicaid
24Services as outlined in the Centers for Medicare and Medicaid
25Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap.
2610, Sec. 10.2.1, et seq. The use of the Physician Certification

 

 

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1Statement shall satisfy the obligations of hospitals under
2Section 6.22 of the Hospital Licensing Act and nursing homes
3under Section 2-217 of the Nursing Home Care Act.
4Implementation and acceptance of the Physician Certification
5Statement shall take place no later than 90 days after the
6issuance of the Physician Certification Statement by the
7Department of Healthcare and Family Services.
8    Pursuant to subsection (E) of Section 12-4.25 of this Code,
9the Department is entitled to recover overpayments paid to a
10provider or vendor, including, but not limited to, from the
11discharging physician, the discharging facility, and the
12ground ambulance service provider, in instances where a
13non-emergency ground ambulance service is rendered as the
14result of improper or false certification.
15    Beginning October 1, 2018, the Department of Healthcare and
16Family Services shall collect data from Medicaid managed care
17organizations and transportation brokers, including the
18Department's NETSPAP broker, regarding denials and appeals
19related to the missing or incomplete Physician Certification
20Statement forms and overall compliance with this subsection.
21The Department of Healthcare and Family Services shall publish
22quarterly results on its website within 15 days following the
23end of each quarter.
24    (h) On and after July 1, 2012, the Department shall reduce
25any rate of reimbursement for services or other payments or
26alter any methodologies authorized by this Code to reduce any

 

 

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1rate of reimbursement for services or other payments in
2accordance with Section 5-5e.
3    (i) On and after July 1, 2018, the Department shall
4increase the base rate of reimbursement for both base charges
5and mileage charges for ground ambulance service providers for
6medical transportation services provided by means of a ground
7ambulance to a level not lower than 112% of the base rate in
8effect as of June 30, 2018.
9(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
10revised 8-27-18.)
 
11    Section 99. Effective date. This Act takes effect upon
12becoming law.