Full Text of SB2325 102nd General Assembly
SB2325enr 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,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 9 | | under this Article on or after
January 1, 1993, the Illinois | 10 | | Department shall reimburse ambulance service
providers at | 11 | | rates calculated in accordance with this Section. It is the | 12 | | intent
of the General Assembly to provide adequate | 13 | | reimbursement for ambulance
services so as to ensure adequate | 14 | | access to services for recipients of aid
under this Article | 15 | | and to provide appropriate incentives to ambulance service
| 16 | | providers to provide services in an efficient and | 17 | | cost-effective manner. Thus,
it is the intent of the General | 18 | | Assembly that the Illinois Department implement
a | 19 | | reimbursement system for ambulance services that, to the | 20 | | extent practicable
and subject to the availability of funds | 21 | | appropriated by the General Assembly
for this purpose, is | 22 | | consistent with the payment principles of Medicare. To
ensure | 23 | | uniformity between the payment principles of Medicare and |
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| 1 | | Medicaid, the
Illinois Department shall follow, to the extent | 2 | | necessary and practicable and
subject to the availability of | 3 | | funds appropriated by the General Assembly for
this purpose, | 4 | | the statutes, laws, regulations, policies, procedures,
| 5 | | principles, definitions, guidelines, and manuals used to | 6 | | determine the amounts
paid to ambulance service providers | 7 | | under Title XVIII of the Social Security
Act (Medicare).
| 8 | | (b) For ambulance services provided to a recipient of aid | 9 | | under this Article
on or after January 1, 1996, the Illinois | 10 | | Department shall reimburse ambulance
service providers based | 11 | | upon the actual distance traveled if a natural
disaster, | 12 | | weather conditions, road repairs, or traffic congestion | 13 | | necessitates
the use of a
route other than the most direct | 14 | | route.
| 15 | | (c) For purposes of this Section, "ambulance services" | 16 | | includes medical
transportation services provided by means of | 17 | | an ambulance, medi-car, service
car, or
taxi.
| 18 | | (c-1) For purposes of this Section, "ground ambulance | 19 | | service" means medical transportation services that are | 20 | | described as ground ambulance services by the Centers for | 21 | | Medicare and Medicaid Services and provided in a vehicle that | 22 | | is licensed as an ambulance by the Illinois Department of | 23 | | Public Health pursuant to the Emergency Medical Services (EMS) | 24 | | Systems Act. | 25 | | (c-2) For purposes of this Section, "ground ambulance | 26 | | service provider" means a vehicle service provider as |
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| 1 | | described in the Emergency Medical Services (EMS) Systems Act | 2 | | that operates licensed ambulances for the purpose of providing | 3 | | emergency ambulance services, or non-emergency ambulance | 4 | | services, or both. For purposes of this Section, this includes | 5 | | both ambulance providers and ambulance suppliers as described | 6 | | by the Centers for Medicare and Medicaid Services. | 7 | | (c-3) For purposes of this Section, "medi-car" means | 8 | | transportation services provided to a patient who is confined | 9 | | to a wheelchair and requires the use of a hydraulic or electric | 10 | | lift or ramp and wheelchair lockdown when the patient's | 11 | | condition does not require medical observation, medical | 12 | | supervision, medical equipment, the administration of | 13 | | medications, or the administration of oxygen. | 14 | | (c-4) For purposes of this Section, "service car" means | 15 | | transportation services provided to a patient by a passenger | 16 | | vehicle where that patient does not require the specialized | 17 | | modes described in subsection (c-1) or (c-3). | 18 | | (d) This Section does not prohibit separate billing by | 19 | | ambulance service
providers for oxygen furnished while | 20 | | providing advanced life support
services.
| 21 | | (e) Beginning with services rendered on or after July 1, | 22 | | 2008, all providers of non-emergency medi-car and service car | 23 | | transportation must certify that the driver and employee | 24 | | attendant, as applicable, have completed a safety program | 25 | | approved by the Department to protect both the patient and the | 26 | | driver, prior to transporting a patient.
The provider must |
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| 1 | | maintain this certification in its records. The provider shall | 2 | | produce such documentation upon demand by the Department or | 3 | | its representative. Failure to produce documentation of such | 4 | | training shall result in recovery of any payments made by the | 5 | | Department for services rendered by a non-certified driver or | 6 | | employee attendant. Medi-car and service car providers must | 7 | | maintain legible documentation in their records of the driver | 8 | | and, as applicable, employee attendant that actually | 9 | | transported the patient. Providers must recertify all drivers | 10 | | and employee attendants every 3 years.
| 11 | | Notwithstanding the requirements above, any public | 12 | | transportation provider of medi-car and service car | 13 | | transportation that receives federal funding under 49 U.S.C. | 14 | | 5307 and 5311 need not certify its drivers and employee | 15 | | attendants under this Section, since safety training is | 16 | | already federally mandated.
| 17 | | (f) With respect to any policy or program administered by | 18 | | the Department or its agent regarding approval of | 19 | | non-emergency medical transportation by ground ambulance | 20 | | service providers, including, but not limited to, the | 21 | | Non-Emergency Transportation Services Prior Approval Program | 22 | | (NETSPAP), the Department shall establish by rule a process by | 23 | | which ground ambulance service providers of non-emergency | 24 | | medical transportation may appeal any decision by the | 25 | | Department or its agent for which no denial was received prior | 26 | | to the time of transport that either (i) denies a request for |
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| 1 | | approval for payment of non-emergency transportation by means | 2 | | of ground ambulance service or (ii) grants a request for | 3 | | approval of non-emergency transportation by means of ground | 4 | | ambulance service at a level of service that entitles the | 5 | | ground ambulance service provider to a lower level of | 6 | | compensation from the Department than the ground ambulance | 7 | | service provider would have received as compensation for the | 8 | | level of service requested. The rule shall be filed by | 9 | | December 15, 2012 and shall provide that, for any decision | 10 | | rendered by the Department or its agent on or after the date | 11 | | the rule takes effect, the ground ambulance service provider | 12 | | shall have 60 days from the date the decision is received to | 13 | | file an appeal. The rule established by the Department shall | 14 | | be, insofar as is practical, consistent with the Illinois | 15 | | Administrative Procedure Act. The Director's decision on an | 16 | | appeal under this Section shall be a final administrative | 17 | | decision subject to review under the Administrative Review | 18 | | Law. | 19 | | (f-5) Beginning 90 days after July 20, 2012 (the effective | 20 | | date of Public Act 97-842), (i) no denial of a request for | 21 | | approval for payment of non-emergency transportation by means | 22 | | of ground ambulance service, and (ii) no approval of | 23 | | non-emergency transportation by means of ground ambulance | 24 | | service at a level of service that entitles the ground | 25 | | ambulance service provider to a lower level of compensation | 26 | | from the Department than would have been received at the level |
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| 1 | | of service submitted by the ground ambulance service provider, | 2 | | may be issued by the Department or its agent unless the | 3 | | Department has submitted the criteria for determining the | 4 | | appropriateness of the transport for first notice publication | 5 | | in the Illinois Register pursuant to Section 5-40 of the | 6 | | Illinois Administrative Procedure Act. | 7 | | (f-7) For non-emergency ground ambulance claims properly | 8 | | denied under Department policy at the time the claim is filed | 9 | | due to failure to submit a valid Medical Certification for | 10 | | Non-Emergency Ambulance on and after December 15, 2012 and | 11 | | prior to January 1, 2021, the Department shall allot | 12 | | $2,000,000 to a pool to reimburse such claims if the provider | 13 | | proves medical necessity for the service by other means. | 14 | | Providers must submit any such denied claims for which they | 15 | | seek compensation to the Department no later than December 31, | 16 | | 2021 along with documentation of medical necessity. No later | 17 | | than May 31, 2022, the Department shall determine for which | 18 | | claims medical necessity was established. Such claims for | 19 | | which medical necessity was established shall be paid at the | 20 | | rate in effect at the time of the service, provided the | 21 | | $2,000,000 is sufficient to pay at those rates. If the pool is | 22 | | not sufficient, claims shall be paid at a uniform percentage | 23 | | of the applicable rate such that the pool of $2,000,000 is | 24 | | exhausted. The appeal process described in subsection (f) | 25 | | shall not be applicable to the Department's determinations | 26 | | made in accordance with this subsection. |
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| 1 | | (g) Whenever a patient covered by a medical assistance | 2 | | program under this Code or by another medical program | 3 | | administered by the Department, including a patient covered | 4 | | under the State's Medicaid managed care program, is being | 5 | | transported from a facility and requires non-emergency | 6 | | transportation including ground ambulance, medi-car, or | 7 | | service car transportation, a Physician Certification | 8 | | Statement as described in this Section shall be required for | 9 | | each patient. Facilities shall develop procedures for a | 10 | | licensed medical professional to provide a written and signed | 11 | | Physician Certification Statement. The Physician Certification | 12 | | Statement shall specify the level of transportation services | 13 | | needed and complete a medical certification establishing the | 14 | | criteria for approval of non-emergency ambulance | 15 | | transportation, as published by the Department of Healthcare | 16 | | and Family Services, that is met by the patient. This | 17 | | certification shall be completed prior to ordering the | 18 | | transportation service and prior to patient discharge. The | 19 | | Physician Certification Statement is not required prior to | 20 | | transport if a delay in transport can be expected to | 21 | | negatively affect the patient outcome. If the ground ambulance | 22 | | provider, medi-car provider, or service car provider is unable | 23 | | to obtain the required Physician Certification Statement | 24 | | within 10 calendar days following the date of the service, the | 25 | | ground ambulance provider, medi-car provider, or service car | 26 | | provider must document its attempt to obtain the requested |
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| 1 | | certification and may then submit the claim for payment. | 2 | | Acceptable documentation includes a signed return receipt from | 3 | | the U.S. Postal Service, facsimile receipt, email receipt, or | 4 | | other similar service that evidences that the ground ambulance | 5 | | provider, medi-car provider, or service car provider attempted | 6 | | to obtain the required Physician Certification Statement. | 7 | | The medical certification specifying the level and type of | 8 | | non-emergency transportation needed shall be in the form of | 9 | | the Physician Certification Statement on a standardized form | 10 | | prescribed by the Department of Healthcare and Family | 11 | | Services. Within 75 days after July 27, 2018 (the effective | 12 | | date of Public Act 100-646), the Department of Healthcare and | 13 | | Family Services shall develop a standardized form of the | 14 | | Physician Certification Statement specifying the level and | 15 | | type of transportation services needed in consultation with | 16 | | the Department of Public Health, Medicaid managed care | 17 | | organizations, a statewide association representing ambulance | 18 | | providers, a statewide association representing hospitals, 3 | 19 | | statewide associations representing nursing homes, and other | 20 | | stakeholders. The Physician Certification Statement shall | 21 | | include, but is not limited to, the criteria necessary to | 22 | | demonstrate medical necessity for the level of transport | 23 | | needed as required by (i) the Department of Healthcare and | 24 | | Family Services and (ii) the federal Centers for Medicare and | 25 | | Medicaid Services as outlined in the Centers for Medicare and | 26 | | Medicaid Services' Medicare Benefit Policy Manual, Pub. |
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| 1 | | 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician | 2 | | Certification Statement shall satisfy the obligations of | 3 | | hospitals under Section 6.22 of the Hospital Licensing Act and | 4 | | nursing homes under Section 2-217 of the Nursing Home Care | 5 | | Act. Implementation and acceptance of the Physician | 6 | | Certification Statement shall take place no later than 90 days | 7 | | after the issuance of the Physician Certification Statement by | 8 | | the Department of Healthcare and Family Services. | 9 | | Pursuant to subsection (E) of Section 12-4.25 of this | 10 | | Code, the Department is entitled to recover overpayments paid | 11 | | to a provider or vendor, including, but not limited to, from | 12 | | the discharging physician, the discharging facility, and the | 13 | | ground ambulance service provider, in instances where a | 14 | | non-emergency ground ambulance service is rendered as the | 15 | | result of improper or false certification. | 16 | | Beginning October 1, 2018, the Department of Healthcare | 17 | | and Family Services shall collect data from Medicaid managed | 18 | | care organizations and transportation brokers, including the | 19 | | Department's NETSPAP broker, regarding denials and appeals | 20 | | related to the missing or incomplete Physician Certification | 21 | | Statement forms and overall compliance with this subsection. | 22 | | The Department of Healthcare and Family Services shall publish | 23 | | quarterly results on its website within 15 days following the | 24 | | end of each quarter. | 25 | | (h) On and after July 1, 2012, the Department shall reduce | 26 | | any rate of reimbursement for services or other payments or |
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| 1 | | alter any methodologies authorized by this Code to reduce any | 2 | | rate of reimbursement for services or other payments in | 3 | | accordance with Section 5-5e. | 4 | | (i) On and after July 1, 2018, the Department shall | 5 | | increase the base rate of reimbursement for both base charges | 6 | | and mileage charges for ground ambulance service providers for | 7 | | medical transportation services provided by means of a ground | 8 | | ambulance to a level not lower than 112% of the base rate in | 9 | | effect as of June 30, 2018. | 10 | | (Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18; | 11 | | 101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)
| 12 | | Section 99. Effective date. This Act takes effect upon | 13 | | becoming law. |
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