HB3570 95TH GENERAL ASSEMBLY

LRB095 03863 LCT 23894 b

95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
HB3570

Introduced 2/28/2007, by Rep. Dan Reitz

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-4.2

from Ch. 23, par. 5-4.2

Amends the Illinois Public Aid Code. Provides a guideline for the repayment of ambulance services for emergency ambulance services, non-emergency ambulance services, mileage, advanced life support services, and specialty care transport services. Provides that the requirement for payment of ground ambulance services by the Illinois Department of Public Aid is met if the services are provided pursuant to a request for evaluation, treatment, and transport for 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. Requires the Department to annually update the ambulance fee schedule rates on July 1 of each year.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

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. Ambulance services payments.

(a) It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to 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 Illinois Department where it concerns ambulance service payments shall be consistent with the payment principals of Medicare to include the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, coding systems, including the ambulance condition coding system, and manuals used to determine the payment system to ambulance service providers under Title XVIII of the Social Security Act.

(b) For ambulance services provided to a recipient of aid under this Article on or after July 1, 2007 January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section.

(1) Payment for non-emergency ambulance services base rates shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 60% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality, except that any non-emergency base rate previously approved by the Illinois Department that exceeds 60% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality shall remain in force.

(2) Payment for emergency ambulance services base rates shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 80% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality, except that any emergency base rate previously approved by the Illinois Department that exceeds 80% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality shall remain in force.

(3) 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 will be based upon the actual distance traveled. For mileage associated to emergency base rates, payment shall be at a rate, which is the lesser of the provider's charge, as reflected on the provider's claim form, or 80% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality, except that any mileage rate previously approved by the Illinois Department that exceeds 80% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality shall remain in force. For mileage associated to non-emergency base rates, payment shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 60% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality, except that any mileage rate previously approved by the Illinois Department that exceeds 60% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality shall remain in force.

(4) For advanced life support services and specialty care transport services provided during transport of a patient between hospitals in an emergency situation for a higher level of care, payments shall be made at the emergency base rate and all other such services shall be paid at the non-emergency base rate.

(c) The requirement for payment of ground ambulance services by the Illinois Department is deemed to be met if the services are provided pursuant to a request for evaluation, treatment, and transport for 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 of knowledge of medicine and health can reasonably expect 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.

(d) The Illinois Department shall update the Medicaid ambulance fee schedule rates annually on July 1 to be in compliance with the Medicare ambulance fee schedule rates in effect at the time of the update. 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.

(e) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of a licensed ambulance and does not include transportation services provided by a an ambulance, medi-car, service car, or taxi, or other form of transportation not defined as an ambulance service by Medicare or the Illinois Emergency Medical Services Systems Act.

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

(Source: P.A. 88-104; 89-43, eff. 1-1-96.)