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

SB2325ham001 102ND GENERAL ASSEMBLY

Rep. Jay Hoffman

Filed: 5/19/2021

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 2325

2    AMENDMENT NO. ______. Amend Senate Bill 2325 by replacing
3everything after the enacting clause with the following:
 
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

 

 

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1cost-effective manner. Thus, it is the intent of the General
2Assembly that the Illinois Department implement a
3reimbursement system for ambulance services that, to the
4extent practicable and subject to the availability of funds
5appropriated by the General Assembly for this purpose, is
6consistent with the payment principles of Medicare. To ensure
7uniformity between the payment principles of Medicare and
8Medicaid, the Illinois Department shall follow, to the extent
9necessary and practicable and subject to the availability of
10funds appropriated by the General Assembly for this purpose,
11the statutes, laws, regulations, policies, procedures,
12principles, definitions, guidelines, and manuals used to
13determine the amounts paid to ambulance service providers
14under Title XVIII of the Social Security Act (Medicare).
15    (b) For ambulance services provided to a recipient of aid
16under this Article on or after January 1, 1996, the Illinois
17Department shall reimburse ambulance service providers based
18upon the actual distance traveled if a natural disaster,
19weather conditions, road repairs, or traffic congestion
20necessitates the use of a route other than the most direct
21route.
22    (c) For purposes of this Section, "ambulance services"
23includes medical transportation services provided by means of
24an ambulance, medi-car, service car, or taxi.
25    (c-1) For purposes of this Section, "ground ambulance
26service" means medical transportation services that are

 

 

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1described as ground ambulance services by the Centers for
2Medicare and Medicaid Services and provided in a vehicle that
3is licensed as an ambulance by the Illinois Department of
4Public Health pursuant to the Emergency Medical Services (EMS)
5Systems Act.
6    (c-2) For purposes of this Section, "ground ambulance
7service provider" means a vehicle service provider as
8described in the Emergency Medical Services (EMS) Systems Act
9that operates licensed ambulances for the purpose of providing
10emergency ambulance services, or non-emergency ambulance
11services, or both. For purposes of this Section, this includes
12both ambulance providers and ambulance suppliers as described
13by the Centers for Medicare and Medicaid Services.
14    (c-3) For purposes of this Section, "medi-car" means
15transportation services provided to a patient who is confined
16to a wheelchair and requires the use of a hydraulic or electric
17lift or ramp and wheelchair lockdown when the patient's
18condition does not require medical observation, medical
19supervision, medical equipment, the administration of
20medications, or the administration of oxygen.
21    (c-4) For purposes of this Section, "service car" means
22transportation services provided to a patient by a passenger
23vehicle where that patient does not require the specialized
24modes described in subsection (c-1) or (c-3).
25    (d) This Section does not prohibit separate billing by
26ambulance service providers for oxygen furnished while

 

 

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1providing advanced life support services.
2    (e) Beginning with services rendered on or after July 1,
32008, all providers of non-emergency medi-car and service car
4transportation must certify that the driver and employee
5attendant, as applicable, have completed a safety program
6approved by the Department to protect both the patient and the
7driver, prior to transporting a patient. The provider must
8maintain this certification in its records. The provider shall
9produce such documentation upon demand by the Department or
10its representative. Failure to produce documentation of such
11training shall result in recovery of any payments made by the
12Department for services rendered by a non-certified driver or
13employee attendant. Medi-car and service car providers must
14maintain legible documentation in their records of the driver
15and, as applicable, employee attendant that actually
16transported the patient. Providers must recertify all drivers
17and employee attendants every 3 years.
18    Notwithstanding the requirements above, any public
19transportation provider of medi-car and service car
20transportation that receives federal funding under 49 U.S.C.
215307 and 5311 need not certify its drivers and employee
22attendants under this Section, since safety training is
23already federally mandated.
24    (f) With respect to any policy or program administered by
25the Department or its agent regarding approval of
26non-emergency medical transportation by ground ambulance

 

 

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1service providers, including, but not limited to, the
2Non-Emergency Transportation Services Prior Approval Program
3(NETSPAP), the Department shall establish by rule a process by
4which ground ambulance service providers of non-emergency
5medical transportation may appeal any decision by the
6Department or its agent for which no denial was received prior
7to the time of transport that either (i) denies a request for
8approval for payment of non-emergency transportation by means
9of ground ambulance service or (ii) grants a request for
10approval of non-emergency transportation by means of ground
11ambulance service at a level of service that entitles the
12ground ambulance service provider to a lower level of
13compensation from the Department than the ground ambulance
14service provider would have received as compensation for the
15level of service requested. The rule shall be filed by
16December 15, 2012 and shall provide that, for any decision
17rendered by the Department or its agent on or after the date
18the rule takes effect, the ground ambulance service provider
19shall have 60 days from the date the decision is received to
20file an appeal. The rule established by the Department shall
21be, insofar as is practical, consistent with the Illinois
22Administrative Procedure Act. The Director's decision on an
23appeal under this Section shall be a final administrative
24decision subject to review under the Administrative Review
25Law.
26    (f-5) Beginning 90 days after July 20, 2012 (the effective

 

 

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1date of Public Act 97-842), (i) no denial of a request for
2approval for payment of non-emergency transportation by means
3of ground ambulance service, and (ii) no approval of
4non-emergency transportation by means of ground ambulance
5service at a level of service that entitles the ground
6ambulance service provider to a lower level of compensation
7from the Department than would have been received at the level
8of service submitted by the ground ambulance service provider,
9may be issued by the Department or its agent unless the
10Department has submitted the criteria for determining the
11appropriateness of the transport for first notice publication
12in the Illinois Register pursuant to Section 5-40 of the
13Illinois Administrative Procedure Act.
14    (f-7) For non-emergency ground ambulance claims properly
15denied under Department policy at the time the claim is filed
16due to failure to submit a valid Medical Certification for
17Non-Emergency Ambulance on and after December 15, 2012 and
18prior to January 1, 2021, the Department shall allot
19$2,000,000 to a pool to reimburse such claims if the provider
20proves medical necessity for the service by other means.
21Providers must submit any such denied claims for which they
22seek compensation to the Department no later than December 31,
232021 along with documentation of medical necessity. No later
24than May 31, 2022, the Department shall determine for which
25claims medical necessity was established. Such claims for
26which medical necessity was established shall be paid at the

 

 

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1rate in effect at the time of the service, provided the
2$2,000,000 is sufficient to pay at those rates. If the pool is
3not sufficient, claims shall be paid at a uniform percentage
4of the applicable rate such that the pool of $2,000,000 is
5exhausted. The appeal process described in subsection (f)
6shall not be applicable to the Department's determinations
7made in accordance with this subsection.
8    (g) Whenever a patient covered by a medical assistance
9program under this Code or by another medical program
10administered by the Department, including a patient covered
11under the State's Medicaid managed care program, is being
12transported from a facility and requires non-emergency
13transportation including ground ambulance, medi-car, or
14service car transportation, a Physician Certification
15Statement as described in this Section shall be required for
16each patient. Facilities shall develop procedures for a
17licensed medical professional to provide a written and signed
18Physician Certification Statement. The Physician Certification
19Statement shall specify the level of transportation services
20needed and complete a medical certification establishing the
21criteria for approval of non-emergency ambulance
22transportation, as published by the Department of Healthcare
23and Family Services, that is met by the patient. This
24certification shall be completed prior to ordering the
25transportation service and prior to patient discharge. The
26Physician Certification Statement is not required prior to

 

 

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1transport if a delay in transport can be expected to
2negatively affect the patient outcome. If the ground ambulance
3provider, medi-car provider, or service car provider is unable
4to obtain the required Physician Certification Statement
5within 10 calendar days following the date of the service, the
6ground ambulance provider, medi-car provider, or service car
7provider must document its attempt to obtain the requested
8certification and may then submit the claim for payment.
9Acceptable documentation includes a signed return receipt from
10the U.S. Postal Service, facsimile receipt, email receipt, or
11other similar service that evidences that the ground ambulance
12provider, medi-car provider, or service car provider attempted
13to obtain the required Physician Certification Statement.
14    The medical certification specifying the level and type of
15non-emergency transportation needed shall be in the form of
16the Physician Certification Statement on a standardized form
17prescribed by the Department of Healthcare and Family
18Services. Within 75 days after July 27, 2018 (the effective
19date of Public Act 100-646), the Department of Healthcare and
20Family Services shall develop a standardized form of the
21Physician Certification Statement specifying the level and
22type of transportation services needed in consultation with
23the Department of Public Health, Medicaid managed care
24organizations, a statewide association representing ambulance
25providers, a statewide association representing hospitals, 3
26statewide associations representing nursing homes, and other

 

 

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1stakeholders. The Physician Certification Statement shall
2include, but is not limited to, the criteria necessary to
3demonstrate medical necessity for the level of transport
4needed as required by (i) the Department of Healthcare and
5Family Services and (ii) the federal Centers for Medicare and
6Medicaid Services as outlined in the Centers for Medicare and
7Medicaid Services' Medicare Benefit Policy Manual, Pub.
8100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
9Certification Statement shall satisfy the obligations of
10hospitals under Section 6.22 of the Hospital Licensing Act and
11nursing homes under Section 2-217 of the Nursing Home Care
12Act. Implementation and acceptance of the Physician
13Certification Statement shall take place no later than 90 days
14after the issuance of the Physician Certification Statement by
15the Department of Healthcare and Family Services.
16    Pursuant to subsection (E) of Section 12-4.25 of this
17Code, the Department is entitled to recover overpayments paid
18to a provider or vendor, including, but not limited to, from
19the discharging physician, the discharging facility, and the
20ground ambulance service provider, in instances where a
21non-emergency ground ambulance service is rendered as the
22result of improper or false certification.
23    Beginning October 1, 2018, the Department of Healthcare
24and Family Services shall collect data from Medicaid managed
25care organizations and transportation brokers, including the
26Department's NETSPAP broker, regarding denials and appeals

 

 

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1related to the missing or incomplete Physician Certification
2Statement forms and overall compliance with this subsection.
3The Department of Healthcare and Family Services shall publish
4quarterly results on its website within 15 days following the
5end of each quarter.
6    (h) On and after July 1, 2012, the Department shall reduce
7any rate of reimbursement for services or other payments or
8alter any methodologies authorized by this Code to reduce any
9rate of reimbursement for services or other payments in
10accordance with Section 5-5e.
11    (i) On and after July 1, 2018, the Department shall
12increase the base rate of reimbursement for both base charges
13and mileage charges for ground ambulance service providers for
14medical transportation services provided by means of a ground
15ambulance to a level not lower than 112% of the base rate in
16effect as of June 30, 2018.
17(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
18101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)
 
19    Section 99. Effective date. This Act takes effect upon
20becoming law.".