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




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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
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 claims under this
10subsection concerning ambulance services provided to
11fee-for-service Medicaid beneficiaries denied for failure of
12submittal of a valid Physician Certification Statement,
13Certificate of Transportation Services, or Medical
14Certification for Non-Emergency Ambulance on and after
15December 15, 2012, the provider shall be able to appeal such
16denial and establish the medical necessity of the transport
17utilizing the patient care report and any other materials
18available in accordance with the criteria established in
19subsection (f-5). A Physician Certification Statement,
20Certificate of Transportation Services, or Medical
21Certification for Non-Emergency Ambulance form is not
22necessary to establish subject matter jurisdiction for appeal
23or medical necessity on appeal but may be considered if
24available. All Department rules, or parts thereof, in conflict
25with the provisions of this subsection shall not apply.
26However, nothing in this amendatory Act of the 102nd General



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1Assembly shall be construed to affect any rights, actions, or
2causes of action that existed or accrued prior to the
3effective date of this amendatory Act of the 102nd General
4Assembly, except that the non-necessity of a Physician
5Certification Statement, Certificate of Transportation
6Services, or Medical Certification for Non-Emergency Ambulance
7form as provided in this subsection shall be retroactively
8applied to the full extent permissible, including allowing any
9claims denied for failure to procure such form which were not
10appealed at the time of denial to have an opportunity for
11proper appeal. The rule shall be filed by December 15, 2012 and
12shall provide that, for any decision rendered by the
13Department or its agent on or after the date the rule takes
14effect, the ground ambulance service provider shall have 60
15days from the date the decision is received to file an appeal
16with the exception of claims for ambulance transports provided
17to fee-for-service Medicaid beneficiaries which were denied
18prior to January 1, 2020 for failure of submittal of a valid
19Physician Certification Statement, Certificate of
20Transportation Services, or Medical Certification for
21Non-Emergency Ambulance which can be appealed at any time. The
22rule established by the Department shall be, insofar as is
23practical, consistent with the Illinois Administrative
24Procedure Act. The Director's decision on an appeal under this
25Section shall be a final administrative decision subject to
26review under the Administrative Review Law.



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1    (f-5) Beginning 90 days after July 20, 2012 (the effective
2date of Public Act 97-842), (i) no denial of a request for
3approval for payment of non-emergency transportation by means
4of ground ambulance service, and (ii) no approval of
5non-emergency transportation by means of ground ambulance
6service at a level of service that entitles the ground
7ambulance service provider to a lower level of compensation
8from the Department than would have been received at the level
9of service submitted by the ground ambulance service provider,
10may be issued by the Department or its agent unless the
11Department has submitted the criteria for determining the
12appropriateness of the transport for first notice publication
13in the Illinois Register pursuant to Section 5-40 of the
14Illinois Administrative Procedure Act.
15    (g) Whenever a patient covered by a medical assistance
16program under this Code or by another medical program
17administered by the Department, including a patient covered
18under the State's Medicaid managed care program, is being
19transported from a facility and requires non-emergency
20transportation including ground ambulance, medi-car, or
21service car transportation, a Physician Certification
22Statement as described in this Section shall be required for
23each patient. Facilities shall develop procedures for a
24licensed medical professional to provide a written and signed
25Physician Certification Statement. The Physician Certification
26Statement shall specify the level of transportation services



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1needed and complete a medical certification establishing the
2criteria for approval of non-emergency ambulance
3transportation, as published by the Department of Healthcare
4and Family Services, that is met by the patient. This
5certification shall be completed prior to ordering the
6transportation service and prior to patient discharge. The
7Physician Certification Statement is not required prior to
8transport if a delay in transport can be expected to
9negatively affect the patient outcome. If the ground ambulance
10provider, medi-car provider, or service car provider is unable
11to obtain the required Physician Certification Statement
12within 10 calendar days following the date of the service, the
13ground ambulance provider, medi-car provider, or service car
14provider must document its attempt to obtain the requested
15certification and may then submit the claim for payment.
16Acceptable documentation includes a signed return receipt from
17the U.S. Postal Service, facsimile receipt, email receipt, or
18other similar service that evidences that the ground ambulance
19provider, medi-car provider, or service car provider attempted
20to obtain the required Physician Certification Statement.
21    The medical certification specifying the level and type of
22non-emergency transportation needed shall be in the form of
23the Physician Certification Statement on a standardized form
24prescribed by the Department of Healthcare and Family
25Services. Within 75 days after July 27, 2018 (the effective
26date of Public Act 100-646), the Department of Healthcare and



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1Family Services shall develop a standardized form of the
2Physician Certification Statement specifying the level and
3type of transportation services needed in consultation with
4the Department of Public Health, Medicaid managed care
5organizations, a statewide association representing ambulance
6providers, a statewide association representing hospitals, 3
7statewide associations representing nursing homes, and other
8stakeholders. The Physician Certification Statement shall
9include, but is not limited to, the criteria necessary to
10demonstrate medical necessity for the level of transport
11needed as required by (i) the Department of Healthcare and
12Family Services and (ii) the federal Centers for Medicare and
13Medicaid Services as outlined in the Centers for Medicare and
14Medicaid Services' Medicare Benefit Policy Manual, Pub.
15100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
16Certification Statement shall satisfy the obligations of
17hospitals under Section 6.22 of the Hospital Licensing Act and
18nursing homes under Section 2-217 of the Nursing Home Care
19Act. Implementation and acceptance of the Physician
20Certification Statement shall take place no later than 90 days
21after the issuance of the Physician Certification Statement by
22the Department of Healthcare and Family Services.
23    Pursuant to subsection (E) of Section 12-4.25 of this
24Code, the Department is entitled to recover overpayments paid
25to a provider or vendor, including, but not limited to, from
26the discharging physician, the discharging facility, and the



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1ground ambulance service provider, in instances where a
2non-emergency ground ambulance service is rendered as the
3result of improper or false certification.
4    Beginning October 1, 2018, the Department of Healthcare
5and Family Services shall collect data from Medicaid managed
6care organizations and transportation brokers, including the
7Department's NETSPAP broker, regarding denials and appeals
8related to the missing or incomplete Physician Certification
9Statement forms and overall compliance with this subsection.
10The Department of Healthcare and Family Services shall publish
11quarterly results on its website within 15 days following the
12end of each quarter.
13    (h) On and after July 1, 2012, the Department shall reduce
14any rate of reimbursement for services or other payments or
15alter any methodologies authorized by this Code to reduce any
16rate of reimbursement for services or other payments in
17accordance with Section 5-5e.
18    (i) On and after July 1, 2018, the Department shall
19increase the base rate of reimbursement for both base charges
20and mileage charges for ground ambulance service providers for
21medical transportation services provided by means of a ground
22ambulance to a level not lower than 112% of the base rate in
23effect as of June 30, 2018.
24(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
25101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)