Illinois General Assembly - Full Text of SB1733
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Full Text of SB1733  98th General Assembly




State of Illinois
2013 and 2014


Introduced 2/15/2013, by Sen. Donne E. Trotter


New Act
215 ILCS 5/356z.22 new

    Creates the Complex Needs Patient Act. Requires the Department of Healthcare and Family Services to provide separate recognition within the State's Medicaid program for individually configured complex rehabilitation technology products and services for complex needs patients. Defines "complex needs patient" to mean an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities. Provides that the separate recognition for technology products and services for complex needs patients shall take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs. Provides that the Department shall require complex needs patients receiving complex rehabilitation technology to be evaluated by a qualified health care professional and a qualified complex rehabilitation technology professional. Amends the Illinois Insurance Code. Provides that a managed care plan amended, delivered, issued, or renewed in this State after the effective date of the amendatory Act shall adopt the regulations and policies outlined in the Complex Needs Patient Act. Effective immediately.

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SB1733LRB098 05561 KTG 40571 b

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 1. Short title. This Act may be cited as the
5Complex Needs Patient Act.
6    Section 5. Purpose.
7    It is the intent of the General Assembly to:
8        (1) protect access for complex needs patients to
9    important technology and supporting services;
10        (2) establish and improve safeguards relating to the
11    delivery and provision of medically necessary complex
12    rehabilitation technology;
13        (3) provide supports for complex needs patients to stay
14    in the home or community setting, prevent
15    institutionalization, and prevent hospitalizations and
16    other costly secondary complications; and
17        (4) establish adequate pricing for complex
18    rehabilitation technology for the purpose of allowing
19    continued access to appropriate products and services.
20    Section 10. Definitions. As used in this Act:
21    (a) "Complex needs patient" means an individual with a
22diagnosis or medical condition that results in significant



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1physical or functional needs and capacities. Such term shall
2include individuals with progressive or degenerative
3neuromuscular diseases or injuries or trauma which resulted in
4significant physical or functional needs and capacities,
5including, but not limited to, individuals with spinal cord
6injury, traumatic brain injury, cerebral palsy, muscular
7dystrophy, spina bifida, osteogenesis imperfecta,
8arthrogryposis, amyotrophic lateral sclerosis, multiple
9sclerosis, demyelinating disease, myelopathy, myopathy,
10progressive muscular atrophy, anterior horn cell disease,
11post-polio syndrome, cerebellar degeneration, dystonia,
12Huntington's disease, spinocerebellar disease, and certain
13types of amputation, paralysis, or paresis that result in
14significant physical or functional needs and capacities.
15    (b) "Complex rehabilitation technology" means items
16currently classified by the Centers for Medicare and Medicaid
17Services as of January 1, 2013 as durable medical equipment
18that are individually configured for individuals to meet their
19specific and unique medical, physical, and functional needs and
20capacities for basic activities of daily living and
21instrumental activities of daily living identified as
22medically necessary to prevent hospitalization or
23institutionalization of a complex needs patient. Such items
24shall include, but not be limited to, complex rehabilitation
25power wheelchairs, highly configurable manual wheelchairs,
26adaptive seating and positioning systems, and other



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1specialized equipment such as standing frames and gait
2trainers. The related Healthcare Common Procedure Code System
3(HCPCS) billing codes include, but are not limited to:
4        (1) Pure Complex Rehab Technology (CRT) Codes: These
5    HCPCS codes contain 100% CRT products: E0637, E0638, E0641,
6    E0642, E0986, E1002, E1003, E1004, E1005, E1006, E1007,
7    E1008, E1009, E1010, E1011, E1014, E1037, E1161, E1220,
8    E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236,
9    E1237, E1238, E1239, E2209, E2291, E2292, E2293, E2294,
10    E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321,
11    E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329,
12    E2330, E2331, E2351, E2373, E2374, E2376, E2377, E2609,
13    E2610, E2617, E8000, E8001, E8002, K0005, K0835, K0836,
14    K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848,
15    K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856,
16    K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864,
17    K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880,
18    K0884, K0885, K0886, K0890, K0891, and K0898.
19        (2) Mixed CRT Codes: These HCPCS codes contain a mix of
20    CRT products and standard mobility and accessory products:
21    E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0960,
22    E0967, E0978, E0990, E1015, E1016, E1028, E1029, E1030,
23    E2205, E2208, E2231, E2368, E2369, E2370, E2605, E2606,
24    E2607, E2608, E2613, E2614, E2615, E2616, E2620, E2621,
25    E2624, E2625, K0004, K0009, K0040, K0108, and K0669.
26        (3) Future codes created to expand on or replace those



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1    indicated in paragraphs (1) and (2) of this subsection.
2    (c) "Individually configured" means a combination of
3features, adjustments, or modifications a supplier makes to a
4device that are specific to an individual and that the supplier
5provides by measuring, fitting, programming, adjusting, or
6adapting the device as appropriate so that the device is
7consistent with an assessment or evaluation of the individual
8by a health care professional and consistent with the
9individual's medical condition, physical and functional needs,
10capacities, body size, period of need, and intended use.
11    (d) "Qualified complex rehabilitation technology supplier"
12means a company or entity that:
13            (1) is accredited by a recognized accrediting
14        organization as a supplier of complex rehabilitation
15        technology;
16            (2) is enrolled in the Medicare program and meets
17        the supplier and quality standards established for
18        durable medical equipment suppliers under the Medicare
19        program;
20            (3) employs at least one complex rehabilitation
21        technology professional for each location to (i)
22        analyze the needs and capacities of qualified
23        individuals with complex medical needs, (ii) assist in
24        selecting appropriate covered complex rehabilitation
25        technology items for such needs and capacities, and
26        (iii) provide training in the use of the selected



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1        covered complex rehabilitation technology items; the
2        complex rehabilitation technology professional shall
3        be certified by the Rehabilitation Engineering and
4        Assistive Technology Society of North America as an
5        Assistive Technology Professional (ATP);
6            (4) has the complex rehabilitation technology
7        professional physically present for the evaluation and
8        determination of the appropriate individually
9        configured complex rehabilitation technologies for the
10        qualified individual with complex medical needs; and
11            (5) provides service and repair by qualified
12        technicians for all complex rehabilitation technology
13        products it sells.
14    (e) "Qualified complex rehabilitation technology
15professional" means an individual who is certified by the
16Rehabilitation Engineering and Assistive Technology Society of
17North America as an Assistive Technology Professional (ATP).
18    Section 15. Creation of a separate recognition for complex
19rehabilitation technology.
20    (a) The Department of Healthcare and Family Services shall
21provide a separate recognition within the State's Medicaid
22program established under Article V of the Illinois Public Aid
23Code for complex rehabilitation technology and shall make other
24required changes to protect access to appropriate products and
25services. The Department shall provide separate recognition



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1for individually configured complex rehabilitation technology
2products and services for complex needs patients. Such separate
3recognition shall take into consideration the customized
4nature of complex rehabilitation technology and the broad range
5of services necessary to meet the unique medical and functional
6needs of people with complex medical needs by doing all of the
8        (1) By using as a reference those billing codes listed
9    under paragraphs (1) and (2) of subsection (b) of Section
10    10, designating appropriate current billing codes as
11    complex rehabilitation technology and, as needed, creating
12    new billing codes for services and products covered for
13    complex needs patients.
14        (2) Establishing specific supplier standards for
15    companies or entities that provide complex rehabilitation
16    technology and restricting the provision of complex
17    rehabilitation technology to only those companies or
18    entities that meet such standards.
19        (3) Developing pricing policies for complex
20    rehabilitation technology by doing all of the following:
21            (A) The billing codes referenced under paragraphs
22        (1) and (2) of subsection (b) of Section 10 shall
23        maintain a reimbursement level of no less than 100% of
24        the current Medicare fee schedule amount minus 6%. If
25        the item is not covered by Medicare or is individually
26        considered for reimbursement, then the State's



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1        Medicaid plan shall adopt an allowable amount at the
2        Manufacturer's Suggested Retail Price (MSRP) minus
3        10%.
4            (B) Adopting the usage of KE billing code modifiers
5        used to help maintain access to complex rehabilitation
6        technology products for those patients who require it.
7            (C) Modifying the prior approval requirement for
8        wheelchair repairs to apply only when the cost of any
9        one part is greater than or equal to $500 per line
10        item, when the sum of the parts is greater than or
11        equal to a total of $1,500, or when 8 or more units of
12        labor are to be billed. This change shall allow
13        Medicaid beneficiaries to retain access to timely
14        service and repair for routine maintenance while also
15        allowing for a more thorough State review on higher
16        dollar claims. Repair requests shall not require the
17        provider to obtain a physician's prescription. The
18        only exception to this shall be for modifications,
19        which are defined as the addition of a part that was
20        not already on the equipment. Repairs shall also be
21        priced by the Department at the Medicare fee schedule
22        amount minus 6% for set rate items and for those
23        without a Medicare allowable amount at MSRP minus 10%.
24        The Department shall allow for expedited approval of
25        repairs that include wheelchair batteries.
26        Additionally, the Department shall expand its



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1        expedited approval process to include circumstances in
2        which the patient's wheelchair will be inoperable
3        without the needed repair, causing the patient to be
4        bed-bound or otherwise confined.
5            (D) Exempting the billing codes referenced in
6        paragraphs (1) and (2) of subsection (b) of Section 10
7        from inclusion in any competitive bidding or other such
8        programs.
9        (4) Making other changes as needed to protect access to
10    complex rehabilitation technology for people with complex
11    medical needs.
12    (b) The Department of Healthcare and Family Services shall
13require complex needs patients receiving complex
14rehabilitation technology to be evaluated by:
15        (1) a qualified health care professional, including,
16    but not limited to, a physical therapist, occupational
17    therapist, or other health care professional who performs
18    specialty evaluations within his or her scope of practice;
19    and
20        (2) a qualified complex rehabilitation technology
21    professional.
22    Section 20. The Illinois Insurance Code is amended by
23adding Section 356z.22 as follows:
24    (215 ILCS 5/356z.22 new)



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1    Sec. 356z.22. Coverage for complex rehabilitation
2technology products and services for complex needs patients. A
3managed care plan amended, delivered, issued, or renewed in
4this State after the effective date of this amendatory Act of
5the 98th General Assembly shall adopt the regulations and
6policies outlined in the Complex Needs Patient Act.
7    Section 99. Effective date. This Act takes effect upon
8becoming law.