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1     AN ACT concerning public aid.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Public Aid Code is amended by
5 changing 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. Ground ambulance Ambulance services payments.
8     (a) For purposes of this Section, the following terms have
9 the following meanings:
10     "Department" means the Illinois Department of Healthcare
11 and Family Services.
12     "Ground ambulance services provider" means a vehicle
13 service provider as described in the Emergency Medical Services
14 (EMS) Systems Act that operates licensed ambulances for the
15 purpose of providing emergency ambulance services, or
16 non-emergency ambulance services, or both. For purposes of this
17 Section, this includes both ambulance providers and ambulance
18 suppliers as described by the Centers for Medicare and Medicaid
19 Services.
20     "Ground ambulance services" means medical transportation
21 services that are described as ground ambulance services by the
22 Centers for Medicare and Medicaid Services and provided in a
23 vehicle that is licensed as an ambulance by the Illinois

 

 

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1 Department of Public Health pursuant to the Emergency Medical
2 Services (EMS) Systems Act.
3     "Rural county" means: any county not located in a U.S.
4 Bureau of the Census Metropolitan Statistical Area (MSA); or
5 any county located within a U.S. Bureau of the Census
6 Metropolitan Statistical Area but having a population of 60,000
7 or less.
8     (b) It is the intent of the General Assembly to provide for
9 the reimbursement of ground ambulance services as part of the
10 State Medicaid plan and to provide adequate reimbursement for
11 ground ambulance services under the State Medicaid plan so as
12 to ensure adequate access to ground ambulance services for both
13 recipients of aid under this Article and for the general
14 population of Illinois. Unless otherwise indicated in this
15 Section, the practices of the Department concerning payments
16 for ground ambulance services provided to recipients of aid
17 under this Article shall be consistent with the payment
18 principles of Medicare, including the statutes, regulations,
19 policies, procedures, principles, definitions, guidelines,
20 coding systems, including the ambulance condition coding
21 system, and manuals used by the Centers for Medicare and
22 Medicaid Services and the Medicare Part B Carrier for the State
23 of Illinois to determine the payment system to ground ambulance
24 services providers under Title XVIII of the Social Security
25 Act.
26     (c) For ground ambulance services provided to a recipient

 

 

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1 of aid under this Article on or after July 1, 2008, the
2 Department shall reimburse ground ambulance services providers
3 for base charges and mileage charges based on the lesser of the
4 provider's charge, as reflected on the provider's claim form,
5 or the Illinois Medicaid Ambulance Fee Schedule rates
6 calculated in accordance with this Section.
7     Effective July 1, 2008 the Illinois Medicaid Ambulance Fee
8 Schedule shall be established and shall include only the ground
9 ambulance services rates outlined in the Medicare Ambulance Fee
10 Schedule as promulgated by the Centers for Medicare and
11 Medicaid Services and adjusted for the 4 Medicare Localities in
12 Illinois, with an adjustment of 100% of the Medicare Ambulance
13 Fee Schedule rates, by Medicare Locality, for both base rates
14 and mileage for rural counties, and an adjustment of 80% of the
15 Medicare Ambulance Fee Schedule rates, by Medicare Locality,
16 for both base rates and mileage for all other counties. The
17 transition from the current payment system to the Illinois
18 Medicaid Ambulance Fee Schedule shall be by a 3-year phase-in
19 as follows:
20         (1) Effective July 1, 2008 through June 30, 2009, for
21     each individual base rate and mileage rate, the payment
22     rate for ground ambulance services shall be based on 66.7%
23     of the Medicaid rate in effect as of January 1, 2008 and
24     33.3% of the Illinois Medicaid Ambulance Fee Schedule
25     amount in effect on July 1, 2008 for the designated
26     Medicare Locality, except that any rate that was previously

 

 

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1     approved by the Department that exceeds this amount shall
2     remain in force.
3         (2) Effective July 1, 2009 through June 30, 2010, for
4     each individual base rate and mileage rate, the payment
5     rate for ground ambulance services shall be based on 33.3%
6     of the Medicaid rate in effect as of January 1, 2008 and
7     66.7% of the Illinois Medicaid Ambulance Fee Schedule
8     amount in effect on July 1, 2009 for the designated
9     Medicare Locality, except that any rate that was previously
10     approved by the Department that exceeds this amount shall
11     remain in force.
12         (3) Effective July 1, 2010, for each individual base
13     rate and mileage rate, the payment rate for ground
14     ambulance services shall be based on 100% of the Illinois
15     Medicaid Ambulance Fee Schedule amount in effect on July 1,
16     2010 for the designated Medicare Locality, except that any
17     rate that was previously approved by the Department that
18     exceeds this amount shall remain in force.
19     On July 1, 2009, and on each July 1 thereafter, the
20 Department shall update the Illinois Medicaid Ambulance Fee
21 Schedule rates to be in compliance with the Medicare Ambulance
22 Fee Schedule rates for ground ambulance services in effect at
23 the time of the update, in the manner prescribed in the second
24 paragraph of this subsection (c).
25     (d) Payment for mileage shall be per loaded mile with no
26 loaded mileage included in the base rate. If a natural

 

 

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1 disaster, weather, or other conditions necessitate a route
2 other than the most direct route, reimbursement shall be based
3 on the actual distance traveled. Although a recognized
4 deviation from the payment principles in subsection (b) of this
5 Section, it is the intent of the General Assembly that the
6 mileage rate for urban providers, as defined by the Centers for
7 Medicare and Medicaid Services, be the only mileage rate paid
8 under the Illinois Medicaid Ambulance Fee Schedule and that no
9 other mileage rates that act as enhancements to the urban
10 mileage rate, whether permanent or temporary, be recognized by
11 the Department.
12     (e) The requirement for payment of ground ambulance
13 services by the Department is deemed to be met if the services
14 are provided pursuant to a request for evaluation, treatment,
15 and transport from an individual with a condition of such a
16 nature that a prudent layperson would have reasonably expected
17 that a delay in seeking immediate medical attention would have
18 been hazardous to life or health. This standard is deemed to be
19 met if there is an emergency medical condition manifesting
20 itself by acute symptoms of sufficient severity, including but
21 not limited to severe pain, such that a prudent layperson who
22 possesses an average knowledge of medicine and health can
23 reasonably expect that the absence of immediate medical
24 attention could result in placing the health of the individual
25 or, with respect to a pregnant woman, the health of the woman
26 or her unborn child, in serious jeopardy, cause serious

 

 

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1 impairment to bodily functions, or cause serious dysfunction of
2 any bodily organ or part.
3     (f) For ground ambulance services provided to a recipient
4 enrolled in a Medicaid managed care plan by a provider that is
5 not a contracted provider to the Medicaid managed care plan in
6 question, payment for ground ambulance services by the Medicaid
7 managed care plan shall be the lesser of the provider's charge,
8 as reflected on the provider's claim form, or the Illinois
9 Medicaid Ambulance Fee Schedule rates calculated in accordance
10 with this Section.
11     (g) Nothing in this Section prohibits the Department from
12 setting reimbursement rates for out-of-State ground ambulance
13 services providers by administrative rule.
14     For ambulance services provided to a recipient of aid under
15 this Article on or after January 1, 1993, the Illinois
16 Department shall reimburse ambulance service providers at
17 rates calculated in accordance with this Section. It is the
18 intent of the General Assembly to provide adequate
19 reimbursement for ambulance services so as to ensure adequate
20 access to services for recipients of aid under this Article and
21 to provide appropriate incentives to ambulance service
22 providers to provide services in an efficient and
23 cost-effective manner. Thus, it is the intent of the General
24 Assembly that the Illinois Department implement a
25 reimbursement system for ambulance services that, to the extent
26 practicable and subject to the availability of funds

 

 

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1 appropriated by the General Assembly for this purpose, is
2 consistent with the payment principles of Medicare. To ensure
3 uniformity between the payment principles of Medicare and
4 Medicaid, the Illinois Department shall follow, to the extent
5 necessary and practicable and subject to the availability of
6 funds appropriated by the General Assembly for this purpose,
7 the statutes, laws, regulations, policies, procedures,
8 principles, definitions, guidelines, and manuals used to
9 determine the amounts paid to ambulance service providers under
10 Title XVIII of the Social Security Act (Medicare).
11     For ambulance services provided to a recipient of aid under
12 this Article on or after January 1, 1996, the Illinois
13 Department shall reimburse ambulance service providers based
14 upon the actual distance traveled if a natural disaster,
15 weather conditions, road repairs, or traffic congestion
16 necessitates the use of a route other than the most direct
17 route.
18     For purposes of this Section, "ambulance services"
19 includes medical transportation services provided by means of
20 an ambulance, medi-car, service car, or taxi.
21     This Section does not prohibit separate billing by
22 ambulance service providers for oxygen furnished while
23 providing advanced life support services.
24     (h) Beginning with services rendered on or after July 1,
25 2008, all providers of non-emergency medi-car and service car
26 transportation must certify that the driver and employee

 

 

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1 attendant, as applicable, have completed a safety program
2 approved by the Department to protect both the patient and the
3 driver, prior to transporting a patient. The provider must
4 maintain this certification in its records. The provider shall
5 produce such documentation upon demand by the Department or its
6 representative. Failure to produce documentation of such
7 training shall result in recovery of any payments made by the
8 Department for services rendered by a non-certified driver or
9 employee attendant. Medi-car and service car providers must
10 maintain legible documentation in their records of the driver
11 and, as applicable, employee attendant that actually
12 transported the patient. Providers must recertify all drivers
13 and employee attendants every 3 years.
14     Notwithstanding the requirements above, any public
15 transportation provider of medi-car and service car
16 transportation that receives federal funding under 49 U.S.C.
17 5307 and 5311 need not certify its drivers and employee
18 attendants under this Section, since safety training is already
19 federally mandated.
20 (Source: P.A. 95-501, eff. 8-28-07.)
 
21     Section 99. Effective date. This Act takes effect upon
22 becoming law.