Illinois General Assembly - Full Text of SB2325
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Full Text of SB2325  102nd General Assembly

SB2325 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB2325

 

Introduced 2/26/2021, by Sen. Sara Feigenholtz

 

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. In a provision requiring the Department of Healthcare and Family Services to establish, by rule, a process by which a provider of ambulance services can appeal a denied request for payment of ambulance services (rather than payment of non-emergency transportation by means of ground ambulance service), provides that for all appeals concerning ambulance services provided on and after December 15, 2012, the provider shall establish the medical necessity of the transport utilizing the patient care report and any other materials available in accordance with specified criteria established under the Code. Provides that a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form is not necessary to establish subject matter jurisdiction for appeal or medical necessity on appeal but may be considered if available. Provides that all Department rules, or parts thereof, in conflict with the provisions of the amendatory Act shall not apply. Provides that nothing in the amendatory Act shall be construed to affect any rights, actions, or causes of action that accrued prior to the effective date of the amendatory Act, except that the non-necessity of a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form as provided in the amendatory Act shall be retroactively applied to the full extent permissible.


LRB102 16957 KTG 22374 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2325LRB102 16957 KTG 22374 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 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
15and to 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
20extent practicable 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
7under Title XVIII of the Social Security Act (Medicare).
8    (b) For ambulance services provided to a recipient of aid
9under this Article on or after January 1, 1996, the Illinois
10Department shall reimburse ambulance service providers based
11upon the actual distance traveled if a natural disaster,
12weather conditions, road repairs, or traffic congestion
13necessitates the use of a route other than the most direct
14route.
15    (c) For purposes of this Section, "ambulance services"
16includes medical transportation services provided by means of
17an ambulance, medi-car, service car, or taxi.
18    (c-1) For purposes of this Section, "ground ambulance
19service" means medical transportation services that are
20described as ground ambulance services by the Centers for
21Medicare and Medicaid Services and provided in a vehicle that
22is licensed as an ambulance by the Illinois Department of
23Public Health pursuant to the Emergency Medical Services (EMS)
24Systems Act.
25    (c-2) For purposes of this Section, "ground ambulance
26service provider" means a vehicle service provider as

 

 

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1described in the Emergency Medical Services (EMS) Systems Act
2that operates licensed ambulances for the purpose of providing
3emergency ambulance services, or non-emergency ambulance
4services, or both. For purposes of this Section, this includes
5both ambulance providers and ambulance suppliers as described
6by the Centers for Medicare and Medicaid Services.
7    (c-3) For purposes of this Section, "medi-car" means
8transportation services provided to a patient who is confined
9to a wheelchair and requires the use of a hydraulic or electric
10lift or ramp and wheelchair lockdown when the patient's
11condition does not require medical observation, medical
12supervision, medical equipment, the administration of
13medications, or the administration of oxygen.
14    (c-4) For purposes of this Section, "service car" means
15transportation services provided to a patient by a passenger
16vehicle where that patient does not require the specialized
17modes described in subsection (c-1) or (c-3).
18    (d) This Section does not prohibit separate billing by
19ambulance service providers for oxygen furnished while
20providing advanced life support services.
21    (e) Beginning with services rendered on or after July 1,
222008, all providers of non-emergency medi-car and service car
23transportation must certify that the driver and employee
24attendant, as applicable, have completed a safety program
25approved by the Department to protect both the patient and the
26driver, prior to transporting a patient. The provider must

 

 

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1maintain this certification in its records. The provider shall
2produce such documentation upon demand by the Department or
3its representative. Failure to produce documentation of such
4training shall result in recovery of any payments made by the
5Department for services rendered by a non-certified driver or
6employee attendant. Medi-car and service car providers must
7maintain legible documentation in their records of the driver
8and, as applicable, employee attendant that actually
9transported the patient. Providers must recertify all drivers
10and employee attendants every 3 years.
11    Notwithstanding the requirements above, any public
12transportation provider of medi-car and service car
13transportation that receives federal funding under 49 U.S.C.
145307 and 5311 need not certify its drivers and employee
15attendants under this Section, since safety training is
16already federally mandated.
17    (f) With respect to any policy or program administered by
18the Department or its agent regarding approval of
19non-emergency medical transportation by ground ambulance
20service providers, including, but not limited to, the
21Non-Emergency Transportation Services Prior Approval Program
22(NETSPAP), the Department shall establish by rule a process by
23which ground ambulance service providers of ambulance
24services, as defined in subsection (c), non-emergency medical
25transportation may appeal any decision by the Department or
26its agent for which no denial was received prior to the time of

 

 

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1transport that either (i) denies a request for approval for
2payment of ambulance services non-emergency transportation by
3means of ground ambulance service or (ii) grants a request for
4approval of ambulance services non-emergency transportation by
5means of ground ambulance service at a level of service that
6entitles the ground ambulance service provider to a lower
7level of compensation from the Department than the ground
8ambulance service provider would have received as compensation
9for the level of service requested. For all appeals under this
10subsection concerning ambulance services provided on and after
11December 15, 2012, the provider shall establish the medical
12necessity of the transport utilizing the patient care report
13and any other materials available in accordance with the
14criteria established in subsection (f-5). A Physician
15Certification Statement, Certificate of Transportation
16Services, or Medical Certification for Non-Emergency Ambulance
17form is not necessary to establish subject matter jurisdiction
18for appeal or medical necessity on appeal but may be
19considered if available. All Department rules, or parts
20thereof, in conflict with the provisions of this subsection
21shall not apply. However, nothing in this amendatory Act of
22the 102nd General Assembly shall be construed to affect any
23rights, actions, or causes of action that existed or accrued
24prior to the effective date of this amendatory Act of the 102nd
25General Assembly, except that the non-necessity of a Physician
26Certification Statement, Certificate of Transportation

 

 

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1Services, or Medical Certification for Non-Emergency Ambulance
2form as provided in this subsection shall be retroactively
3applied to the full extent permissible. The rule shall be
4filed by December 15, 2012 and shall provide that, for any
5decision rendered by the Department or its agent on or after
6the date the rule takes effect, the ground ambulance service
7provider shall have 60 days from the date the decision is
8received to file an appeal. The rule established by the
9Department shall be, insofar as is practical, consistent with
10the Illinois Administrative Procedure Act. The Director's
11decision on an appeal under this Section shall be a final
12administrative decision subject to review under the
13Administrative Review Law.
14    (f-5) Beginning 90 days after July 20, 2012 (the effective
15date of Public Act 97-842), (i) no denial of a request for
16approval for payment of non-emergency transportation by means
17of ground ambulance service, and (ii) no approval of
18non-emergency transportation by means of ground ambulance
19service at a level of service that entitles the ground
20ambulance service provider to a lower level of compensation
21from the Department than would have been received at the level
22of service submitted by the ground ambulance service provider,
23may be issued by the Department or its agent unless the
24Department has submitted the criteria for determining the
25appropriateness of the transport for first notice publication
26in the Illinois Register pursuant to Section 5-40 of the

 

 

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1Illinois Administrative Procedure Act.
2    (g) Whenever a patient covered by a medical assistance
3program under this Code or by another medical program
4administered by the Department, including a patient covered
5under the State's Medicaid managed care program, is being
6transported from a facility and requires non-emergency
7transportation including ground ambulance, medi-car, or
8service car transportation, a Physician Certification
9Statement as described in this Section shall be required for
10each patient. Facilities shall develop procedures for a
11licensed medical professional to provide a written and signed
12Physician Certification Statement. The Physician Certification
13Statement shall specify the level of transportation services
14needed and complete a medical certification establishing the
15criteria for approval of non-emergency ambulance
16transportation, as published by the Department of Healthcare
17and Family Services, that is met by the patient. This
18certification shall be completed prior to ordering the
19transportation service and prior to patient discharge. The
20Physician Certification Statement is not required prior to
21transport if a delay in transport can be expected to
22negatively affect the patient outcome. If the ground ambulance
23provider, medi-car provider, or service car provider is unable
24to obtain the required Physician Certification Statement
25within 10 calendar days following the date of the service, the
26ground ambulance provider, medi-car provider, or service car

 

 

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1provider must document its attempt to obtain the requested
2certification and may then submit the claim for payment.
3Acceptable documentation includes a signed return receipt from
4the U.S. Postal Service, facsimile receipt, email receipt, or
5other similar service that evidences that the ground ambulance
6provider, medi-car provider, or service car provider attempted
7to obtain the required Physician Certification Statement.
8    The medical certification specifying the level and type of
9non-emergency transportation needed shall be in the form of
10the Physician Certification Statement on a standardized form
11prescribed by the Department of Healthcare and Family
12Services. Within 75 days after July 27, 2018 (the effective
13date of Public Act 100-646), the Department of Healthcare and
14Family Services shall develop a standardized form of the
15Physician Certification Statement specifying the level and
16type of transportation services needed in consultation with
17the Department of Public Health, Medicaid managed care
18organizations, a statewide association representing ambulance
19providers, a statewide association representing hospitals, 3
20statewide associations representing nursing homes, and other
21stakeholders. The Physician Certification Statement shall
22include, but is not limited to, the criteria necessary to
23demonstrate medical necessity for the level of transport
24needed as required by (i) the Department of Healthcare and
25Family Services and (ii) the federal Centers for Medicare and
26Medicaid Services as outlined in the Centers for Medicare and

 

 

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1Medicaid Services' Medicare Benefit Policy Manual, Pub.
2100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
3Certification Statement shall satisfy the obligations of
4hospitals under Section 6.22 of the Hospital Licensing Act and
5nursing homes under Section 2-217 of the Nursing Home Care
6Act. Implementation and acceptance of the Physician
7Certification Statement shall take place no later than 90 days
8after the issuance of the Physician Certification Statement by
9the Department of Healthcare and Family Services.
10    Pursuant to subsection (E) of Section 12-4.25 of this
11Code, the Department is entitled to recover overpayments paid
12to a provider or vendor, including, but not limited to, from
13the discharging physician, the discharging facility, and the
14ground ambulance service provider, in instances where a
15non-emergency ground ambulance service is rendered as the
16result of improper or false certification.
17    Beginning October 1, 2018, the Department of Healthcare
18and Family Services shall collect data from Medicaid managed
19care organizations and transportation brokers, including the
20Department's NETSPAP broker, regarding denials and appeals
21related to the missing or incomplete Physician Certification
22Statement forms and overall compliance with this subsection.
23The Department of Healthcare and Family Services shall publish
24quarterly results on its website within 15 days following the
25end of each quarter.
26    (h) On and after July 1, 2012, the Department shall reduce

 

 

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1any rate of reimbursement for services or other payments or
2alter any methodologies authorized by this Code to reduce any
3rate of reimbursement for services or other payments in
4accordance with Section 5-5e.
5    (i) On and after July 1, 2018, the Department shall
6increase the base rate of reimbursement for both base charges
7and mileage charges for ground ambulance service providers for
8medical transportation services provided by means of a ground
9ambulance to a level not lower than 112% of the base rate in
10effect as of June 30, 2018.
11(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
12101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)