HB1409eng 102ND GENERAL ASSEMBLY

HB1409 Engrossed LRB102 03425 KTG 13438 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 Emergency Medical Services (EMS) Systems Act is amended by changing Section 3.10 as follows:

(210 ILCS 50/3.10)

Sec. 3.10. Scope of services.

(a) "Advanced Life Support (ALS) Services" means an advanced level of pre-hospital and inter-hospital emergency care and non-emergency medical services that includes basic life support care, cardiac monitoring, cardiac defibrillation, electrocardiography, intravenous therapy, administration of medications, drugs and solutions, use of adjunctive medical devices, trauma care, and other authorized techniques and procedures, as outlined in the provisions of the National EMS Education Standards relating to Advanced Life Support and any modifications to that curriculum specified in rules adopted by the Department pursuant to this Act.

That care shall be initiated as authorized by the EMS Medical Director in a Department approved advanced life support EMS System, under the written or verbal direction of a physician licensed to practice medicine in all of its branches or under the verbal direction of an Emergency Communications Registered Nurse.

(b) "Intermediate Life Support (ILS) Services" means an intermediate level of pre-hospital and inter-hospital emergency care and non-emergency medical services that includes basic life support care plus intravenous cannulation and fluid therapy, invasive airway management, trauma care, and other authorized techniques and procedures, as outlined in the Intermediate Life Support national curriculum of the United States Department of Transportation and any modifications to that curriculum specified in rules adopted by the Department pursuant to this Act.

That care shall be initiated as authorized by the EMS Medical Director in a Department approved intermediate or advanced life support EMS System, under the written or verbal direction of a physician licensed to practice medicine in all of its branches or under the verbal direction of an Emergency Communications Registered Nurse.

(c) "Basic Life Support (BLS) Services" means a basic level of pre-hospital and inter-hospital emergency care and non-emergency medical services that includes medical monitoring, clinical observation, airway management, cardiopulmonary resuscitation (CPR), control of shock and bleeding and splinting of fractures, as outlined in the provisions of the National EMS Education Standards relating to Basic Life Support and any modifications to that curriculum specified in rules adopted by the Department pursuant to this Act.

That care shall be initiated, where authorized by the EMS Medical Director in a Department approved EMS System, under the written or verbal direction of a physician licensed to practice medicine in all of its branches or under the verbal direction of an Emergency Communications Registered Nurse.

(d) "Emergency Medical Responder Services" means a preliminary level of pre-hospital emergency care that includes cardiopulmonary resuscitation (CPR), monitoring vital signs and control of bleeding, as outlined in the Emergency Medical Responder (EMR) curriculum of the National EMS Education Standards and any modifications to that curriculum specified in rules adopted by the Department pursuant to this Act.

(e) "Pre-hospital care" means those medical services rendered to patients for analytic, resuscitative, stabilizing, or preventive purposes, precedent to and during transportation of such patients to health care facilities.

(f) "Inter-hospital care" means those medical services rendered to patients for analytic, resuscitative, stabilizing, or preventive purposes, during transportation of such patients from one hospital to another hospital.

(f-5) "Critical care transport" means transportation which includes the provision of pre-hospital or inter-hospital emergency care or non-emergency medical services to transportation of a critically injured or ill patient by a vehicle service provider, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the Paramedic. When medically indicated for a patient, as determined by a physician licensed to practice medicine in all of its branches, an advanced practice registered nurse, or a physician physician's assistant, in compliance with subsections (b) and (c) of Section 3.155 of this Act, critical care transport may be provided by:

(1) Department-approved critical care transport providers, not owned or operated by a hospital, utilizing Paramedics with additional training, nurses, or other qualified health professionals; or

(2) Hospitals, when utilizing any vehicle service provider or any hospital-owned or operated vehicle service provider. Nothing in Public Act 96-1469 requires a hospital to use, or to be, a Department-approved critical care transport provider when transporting patients, including those critically injured or ill. Nothing in this Act shall restrict or prohibit a hospital from providing, or arranging for, the medically appropriate transport of any patient, as determined by a physician licensed to practice in all of its branches, an advanced practice registered nurse, or a physician physician's assistant.

(g) "Non-emergency medical services" means the provision of, and all actions necessary before and after the provision of, Basic Life Support (BLS) Services, Advanced Life Support (ALS) Services, and critical care transport to patients whose conditions do not meet this Act's definition of emergency, before, after, or during transportation of such patients to or from health care facilities visited for the purpose of obtaining medical or health care services which are not emergency in nature, using a vehicle regulated by this Act and personnel licensed under this Act.

(g-5) The Department shall have the authority to promulgate minimum standards for critical care transport providers through rules adopted pursuant to this Act. All critical care transport providers must function within a Department-approved EMS System. Nothing in Department rules shall restrict a hospital's ability to furnish personnel, equipment, and medical supplies to any vehicle service provider, including a critical care transport provider. Minimum critical care transport provider standards shall include, but are not limited to:

(1) Personnel staffing and licensure.

(2) Education, certification, and experience.

(3) Medical equipment and supplies.

(4) Vehicular standards.

(5) Treatment and transport protocols.

(6) Quality assurance and data collection.

(h) The provisions of this Act shall not apply to the use of an ambulance or SEMSV, unless and until emergency or non-emergency medical services are needed during the use of the ambulance or SEMSV.

(Source: P.A. 102-623, eff. 8-27-21; revised 12-1-21.)

Section 10. The Illinois Public Aid Code is amended by changing Section 5-4.2 and by adding Section 5-30c as follows:

(305 ILCS 5/5-4.2)

Sec. 5-4.2. Ambulance services payments.

(a) 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).

(b) 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.

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

(c-1) For purposes of this Section, "ground ambulance service" 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.

(c-2) For purposes of this Section, "ground ambulance service 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.

(c-3) For purposes of this Section, "medi-car" means transportation services provided to a patient who is confined to a wheelchair and requires the use of a hydraulic or electric lift or ramp and wheelchair lockdown when the patient's condition does not require medical observation, medical supervision, medical equipment, the administration of medications, or the administration of oxygen.

(c-4) For purposes of this Section, "service car" means transportation services provided to a patient by a passenger vehicle where that patient does not require the specialized modes described in subsection (c-1) or (c-3).

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

(e) 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. If they meet the established training components set forth by the Department, providers of non-emergency medi-car and service car transportation that are either directly or through an affiliated company licensed by the Department of Public Health shall be approved by the Department to have in-house safety programs for training their own staff.

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.

(f) With respect to any policy or program administered by the Department or its agent regarding approval of non-emergency medical transportation by ground ambulance service providers, including, but not limited to, the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), the Department shall establish by rule a process by which ground ambulance service providers of non-emergency medical transportation may appeal any decision by the Department or its agent for which no denial was received prior to the time of transport that either (i) denies a request for approval for payment of non-emergency transportation by means of ground ambulance service or (ii) grants a request for approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than the ground ambulance service provider would have received as compensation for the level of service requested. The rule shall be filed by December 15, 2012 and shall provide that, for any decision rendered by the Department or its agent on or after the date the rule takes effect, the ground ambulance service provider shall have 60 days from the date the decision is received to file an appeal. The rule established by the Department shall be, insofar as is practical, consistent with the Illinois Administrative Procedure Act. The Director's decision on an appeal under this Section shall be a final administrative decision subject to review under the Administrative Review Law.

(f-5) Beginning 90 days after July 20, 2012 (the effective date of Public Act 97-842), (i) no denial of a request for approval for payment of non-emergency transportation by means of ground ambulance service, and (ii) no approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than would have been received at the level of service submitted by the ground ambulance service provider, may be issued by the Department or its agent unless the Department has submitted the criteria for determining the appropriateness of the transport for first notice publication in the Illinois Register pursuant to Section 5-40 of the Illinois Administrative Procedure Act.

(f-6) Within 90 days after the effective date of this amendatory Act of the 102nd General Assembly, the Department shall adjust the criteria established under subsection (f-5) by striking any reference to prohibiting approval of ground ambulance services when the sole purpose of the transport is for the navigation of stairs or the assisting or lifting of a patient at a medical facility or during a medical appointment. It is the intent of the General Assembly to permit ground ambulance reimbursement for lifting, moving, or navigating stairs in instances when a recipient exhibits extenuating circumstances related to the social determinants of health which would make an otherwise non-eligible ground ambulance transport eligible for reimbursement. Such extenuating circumstances may include a condition which would present an unreasonable risk for the patient to navigate the stairs without the assistance of medically trained ground ambulance personnel. Such extenuating circumstances may be established through the completion of a Physician Certification Statement as set forth in subsection (g).

(f-7) For non-emergency ground ambulance claims properly denied under Department policy at the time the claim is filed due to failure to submit a valid Medical Certification for Non-Emergency Ambulance on and after December 15, 2012 and prior to January 1, 2021, the Department shall allot $2,000,000 to a pool to reimburse such claims if the provider proves medical necessity for the service by other means. Providers must submit any such denied claims for which they seek compensation to the Department no later than December 31, 2021 along with documentation of medical necessity. No later than May 31, 2022, the Department shall determine for which claims medical necessity was established. Such claims for which medical necessity was established shall be paid at the rate in effect at the time of the service, provided the $2,000,000 is sufficient to pay at those rates. If the pool is not sufficient, claims shall be paid at a uniform percentage of the applicable rate such that the pool of $2,000,000 is exhausted. The appeal process described in subsection (f) shall not be applicable to the Department's determinations made in accordance with this subsection.

(g) Whenever a patient covered by a medical assistance program under this Code or by another medical program administered by the Department, including a patient covered under the State's Medicaid managed care program, is being transported from a facility and requires non-emergency transportation including ground ambulance, medi-car, or service car transportation, a Physician Certification Statement as described in this Section shall be required for each patient. Facilities shall develop procedures for a licensed medical professional to provide a written and signed Physician Certification Statement. The Physician Certification Statement shall specify the level of transportation services needed and complete a medical certification establishing the criteria for approval of non-emergency ambulance transportation, as published by the Department of Healthcare and Family Services, that is met by the patient. This certification shall be completed prior to ordering the transportation service and prior to patient discharge. The Physician Certification Statement is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome. If the ground ambulance provider, medi-car provider, or service car provider is unable to obtain the required Physician Certification Statement within 10 calendar days following the date of the service, the ground ambulance provider, medi-car provider, or service car provider must document its attempt to obtain the requested certification and may then submit the claim for payment. Acceptable documentation includes a signed return receipt from the U.S. Postal Service, facsimile receipt, email receipt, or other similar service that evidences that the ground ambulance provider, medi-car provider, or service car provider attempted to obtain the required Physician Certification Statement.

The medical certification specifying the level and type of non-emergency transportation needed shall be in the form of the Physician Certification Statement on a standardized form prescribed by the Department of Healthcare and Family Services. Within 75 days after July 27, 2018 (the effective date of Public Act 100-646), the Department of Healthcare and Family Services shall develop a standardized form of the Physician Certification Statement specifying the level and type of transportation services needed in consultation with the Department of Public Health, Medicaid managed care organizations, a statewide association representing ambulance providers, a statewide association representing hospitals, 3 statewide associations representing nursing homes, and other stakeholders. The Physician Certification Statement shall include, but is not limited to, the criteria necessary to demonstrate medical necessity for the level of transport needed as required by (i) the Department of Healthcare and Family Services and (ii) the federal Centers for Medicare and Medicaid Services as outlined in the Centers for Medicare and Medicaid Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician Certification Statement shall satisfy the obligations of hospitals under Section 6.22 of the Hospital Licensing Act and nursing homes under Section 2-217 of the Nursing Home Care Act. Implementation and acceptance of the Physician Certification Statement shall take place no later than 90 days after the issuance of the Physician Certification Statement by the Department of Healthcare and Family Services.

Pursuant to subsection (E) of Section 12-4.25 of this Code, the Department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification.

Beginning October 1, 2018, the Department of Healthcare and Family Services shall collect data from Medicaid managed care organizations and transportation brokers, including the Department's NETSPAP broker, regarding denials and appeals related to the missing or incomplete Physician Certification Statement forms and overall compliance with this subsection. The Department of Healthcare and Family Services shall publish quarterly results on its website within 15 days following the end of each quarter.

(h) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(i) On and after July 1, 2018, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers for medical transportation services provided by means of a ground ambulance to a level not lower than rates 112% of the base rate in effect as of July 1, 2021 June 30, 2018.

(k) Within 90 days after the effective date of this amendatory Act of the 102nd General Assembly, the Department shall establish a methodology for providing reimbursement for: (i) bariatric transports at an amount of one additional base rate for each additional 2 personnel necessary to safely move the patient; and (ii) specialty care transports to include transports originating or terminating at a residence and for intra-facility transports.

(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20; 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; revised 11-8-21.)

(305 ILCS 5/5-30c new)

Sec. 5-30c. Medi-car and stretcher van services; rate increase. To ensure access to medical appointments and covered services and realize the objectives of the medical assistance program, the General Assembly must address the inadequate supply of non-emergency medical transportation providers across the State. To increase access to non-emergency transportation services, the Department shall increase the base rate for medi-car and stretcher van services to at least $50, and the rate of each attendant for medi-car and stretcher van services to at least $50. This reimbursement rate shall only apply to stretcher van providers licensed by the Department of Public Health in accordance with Section 3.86 of the Emergency Medical Services (EMS) Systems Act. The Department shall establish a grant program for the purpose of building capacity among IMPACT-enrolled and BEP-certified providers of medi-car and stretcher van transportation services.

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