Sen. Sara Feigenholtz

Filed: 4/16/2021





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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
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 ambulance
5services, as defined in subsection (c), non-emergency medical
6transportation may appeal any decision by the Department or
7its agent for which no denial was received prior to the time of
8transport that either (i) denies a request for approval for
9payment of ambulance services non-emergency transportation by
10means of ground ambulance service or (ii) grants a request for
11approval of ambulance services non-emergency transportation by
12means of ground ambulance service at a level of service that
13entitles the ground ambulance service provider to a lower
14level of compensation from the Department than the ground
15ambulance service provider would have received as compensation
16for the level of service requested. For all claims under this
17subsection concerning ambulance services provided to
18fee-for-service Medicaid beneficiaries denied for failure of
19submittal of a valid Physician Certification Statement,
20Certificate of Transportation Services, or Medical
21Certification for Non-Emergency Ambulance on and after
22December 15, 2012, the provider shall be able to appeal such
23denial and establish the medical necessity of the transport
24utilizing the patient care report and any other materials
25available in accordance with the criteria established in
26subsection (f-5). A Physician Certification Statement,



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1Certificate of Transportation Services, or Medical
2Certification for Non-Emergency Ambulance form is not
3necessary to establish subject matter jurisdiction for appeal
4or medical necessity on appeal but may be considered if
5available. All Department rules, or parts thereof, in conflict
6with the provisions of this subsection shall not apply.
7However, nothing in this amendatory Act of the 102nd General
8Assembly shall be construed to affect any rights, actions, or
9causes of action that existed or accrued prior to the
10effective date of this amendatory Act of the 102nd General
11Assembly, except that the non-necessity of a Physician
12Certification Statement, Certificate of Transportation
13Services, or Medical Certification for Non-Emergency Ambulance
14form as provided in this subsection shall be retroactively
15applied to the full extent permissible, including allowing any
16claims denied for failure to procure such form which were not
17appealed at the time of denial to have an opportunity for
18proper appeal. The rule shall be filed by December 15, 2012 and
19shall provide that, for any decision rendered by the
20Department or its agent on or after the date the rule takes
21effect, the ground ambulance service provider shall have 60
22days from the date the decision is received to file an appeal
23with the exception of claims for ambulance transports provided
24to fee-for-service Medicaid beneficiaries which were denied
25prior to January 1, 2020 for failure of submittal of a valid
26Physician Certification Statement, Certificate of



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1Transportation Services, or Medical Certification for
2Non-Emergency Ambulance which can be appealed at any time. The
3rule established by the Department shall be, insofar as is
4practical, consistent with the Illinois Administrative
5Procedure Act. The Director's decision on an appeal under this
6Section shall be a final administrative decision subject to
7review under the Administrative Review Law.
8    (f-5) Beginning 90 days after July 20, 2012 (the effective
9date of Public Act 97-842), (i) no denial of a request for
10approval for payment of non-emergency transportation by means
11of ground ambulance service, and (ii) no approval of
12non-emergency transportation by means of ground ambulance
13service at a level of service that entitles the ground
14ambulance service provider to a lower level of compensation
15from the Department than would have been received at the level
16of service submitted by the ground ambulance service provider,
17may be issued by the Department or its agent unless the
18Department has submitted the criteria for determining the
19appropriateness of the transport for first notice publication
20in the Illinois Register pursuant to Section 5-40 of the
21Illinois Administrative Procedure Act.
22    (g) Whenever a patient covered by a medical assistance
23program under this Code or by another medical program
24administered by the Department, including a patient covered
25under the State's Medicaid managed care program, is being
26transported from a facility and requires non-emergency



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1transportation including ground ambulance, medi-car, or
2service car transportation, a Physician Certification
3Statement as described in this Section shall be required for
4each patient. Facilities shall develop procedures for a
5licensed medical professional to provide a written and signed
6Physician Certification Statement. The Physician Certification
7Statement shall specify the level of transportation services
8needed and complete a medical certification establishing the
9criteria for approval of non-emergency ambulance
10transportation, as published by the Department of Healthcare
11and Family Services, that is met by the patient. This
12certification shall be completed prior to ordering the
13transportation service and prior to patient discharge. The
14Physician Certification Statement is not required prior to
15transport if a delay in transport can be expected to
16negatively affect the patient outcome. If the ground ambulance
17provider, medi-car provider, or service car provider is unable
18to obtain the required Physician Certification Statement
19within 10 calendar days following the date of the service, the
20ground ambulance provider, medi-car provider, or service car
21provider must document its attempt to obtain the requested
22certification and may then submit the claim for payment.
23Acceptable documentation includes a signed return receipt from
24the U.S. Postal Service, facsimile receipt, email receipt, or
25other similar service that evidences that the ground ambulance
26provider, medi-car provider, or service car provider attempted



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1to obtain the required Physician Certification Statement.
2    The medical certification specifying the level and type of
3non-emergency transportation needed shall be in the form of
4the Physician Certification Statement on a standardized form
5prescribed by the Department of Healthcare and Family
6Services. Within 75 days after July 27, 2018 (the effective
7date of Public Act 100-646), the Department of Healthcare and
8Family Services shall develop a standardized form of the
9Physician Certification Statement specifying the level and
10type of transportation services needed in consultation with
11the Department of Public Health, Medicaid managed care
12organizations, a statewide association representing ambulance
13providers, a statewide association representing hospitals, 3
14statewide associations representing nursing homes, and other
15stakeholders. The Physician Certification Statement shall
16include, but is not limited to, the criteria necessary to
17demonstrate medical necessity for the level of transport
18needed as required by (i) the Department of Healthcare and
19Family Services and (ii) the federal Centers for Medicare and
20Medicaid Services as outlined in the Centers for Medicare and
21Medicaid Services' Medicare Benefit Policy Manual, Pub.
22100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
23Certification Statement shall satisfy the obligations of
24hospitals under Section 6.22 of the Hospital Licensing Act and
25nursing homes under Section 2-217 of the Nursing Home Care
26Act. Implementation and acceptance of the Physician



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1Certification Statement shall take place no later than 90 days
2after the issuance of the Physician Certification Statement by
3the Department of Healthcare and Family Services.
4    Pursuant to subsection (E) of Section 12-4.25 of this
5Code, the Department is entitled to recover overpayments paid
6to a provider or vendor, including, but not limited to, from
7the discharging physician, the discharging facility, and the
8ground ambulance service provider, in instances where a
9non-emergency ground ambulance service is rendered as the
10result of improper or false certification.
11    Beginning October 1, 2018, the Department of Healthcare
12and Family Services shall collect data from Medicaid managed
13care organizations and transportation brokers, including the
14Department's NETSPAP broker, regarding denials and appeals
15related to the missing or incomplete Physician Certification
16Statement forms and overall compliance with this subsection.
17The Department of Healthcare and Family Services shall publish
18quarterly results on its website within 15 days following the
19end of each quarter.
20    (h) On and after July 1, 2012, the Department shall reduce
21any rate of reimbursement for services or other payments or
22alter any methodologies authorized by this Code to reduce any
23rate of reimbursement for services or other payments in
24accordance with Section 5-5e.
25    (i) On and after July 1, 2018, the Department shall
26increase the base rate of reimbursement for both base charges



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1and mileage charges for ground ambulance service providers for
2medical transportation services provided by means of a ground
3ambulance to a level not lower than 112% of the base rate in
4effect as of June 30, 2018.
5(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
6101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)".