Full Text of SB0636 98th General Assembly
SB0636eng 98TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 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 and | 15 | | to provide appropriate incentives to ambulance service
| 16 | | providers to provide services in an efficient and | 17 | | cost-effective manner. It is also the intent of the General | 18 | | Assembly to ensure that ambulance service providers are | 19 | | appropriately reimbursed for medically necessary ambulance | 20 | | services by requiring the Illinois Department to adopt, by | 21 | | rule, criteria establishing medical necessity and appropriate | 22 | | procedures for the processing of claims for reimbursement. | 23 | | Thus,
it is the intent of the General Assembly that the |
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| 1 | | Illinois Department implement
a reimbursement system for | 2 | | ambulance services that, to the extent practicable
and subject | 3 | | to the availability of funds appropriated by the General | 4 | | Assembly
for this purpose, is consistent with the payment | 5 | | principles of Medicare. To
ensure uniformity between the | 6 | | payment principles of Medicare and Medicaid, the
Illinois | 7 | | Department shall follow, to the extent necessary and | 8 | | practicable and
subject to the availability of funds | 9 | | appropriated by the General Assembly for
this purpose, the | 10 | | statutes, laws, regulations, policies, procedures,
principles, | 11 | | definitions, guidelines, and manuals used to determine the | 12 | | amounts
paid to ambulance service providers under Title XVIII | 13 | | of the Social Security
Act (Medicare).
| 14 | | (b) For ambulance services provided to a recipient of aid | 15 | | under this Article
on or after January 1, 1996, the Illinois | 16 | | Department shall reimburse ambulance
service providers based | 17 | | upon the actual distance traveled if a natural
disaster, | 18 | | weather conditions, road repairs, or traffic congestion | 19 | | necessitates
the use of a
route other than the most direct | 20 | | route.
| 21 | | (c) For purposes of this Section, "ambulance services" | 22 | | includes medical
transportation services provided by means of | 23 | | an ambulance, medi-car, service
car, or
taxi.
| 24 | | (c-1) For purposes of this Section, "ground ambulance | 25 | | service" means medical transportation services that are | 26 | | described as ground ambulance services by the Centers for |
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| 1 | | Medicare and Medicaid Services and provided in a vehicle that | 2 | | is licensed as an ambulance by the Illinois Department of | 3 | | Public Health pursuant to the Emergency Medical Services (EMS) | 4 | | Systems Act. | 5 | | (c-2) For purposes of this Section, "ground ambulance | 6 | | service provider" means a vehicle service provider as described | 7 | | in the Emergency Medical Services (EMS) Systems Act that | 8 | | operates licensed ambulances for the purpose of providing | 9 | | emergency ambulance services, or non-emergency ambulance | 10 | | services, or both. For purposes of this Section, this includes | 11 | | both ambulance providers and ambulance suppliers as described | 12 | | by the Centers for Medicare and Medicaid Services. | 13 | | (d) This Section does not prohibit separate billing by | 14 | | ambulance service
providers for oxygen furnished while | 15 | | providing advanced life support
services.
| 16 | | (e) Beginning with services rendered on or after July 1, | 17 | | 2008, all providers of non-emergency medi-car and service car | 18 | | transportation must certify that the driver and employee | 19 | | attendant, as applicable, have completed a safety program | 20 | | approved by the Department to protect both the patient and the | 21 | | driver, prior to transporting a patient.
The provider must | 22 | | maintain this certification in its records. The provider shall | 23 | | produce such documentation upon demand by the Department or its | 24 | | representative. Failure to produce documentation of such | 25 | | training shall result in recovery of any payments made by the | 26 | | Department for services rendered by a non-certified driver or |
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| 1 | | employee attendant. Medi-car and service car providers must | 2 | | maintain legible documentation in their records of the driver | 3 | | and, as applicable, employee attendant that actually | 4 | | transported the patient. Providers must recertify all drivers | 5 | | and employee attendants every 3 years.
| 6 | | Notwithstanding the requirements above, any public | 7 | | transportation provider of medi-car and service car | 8 | | transportation that receives federal funding under 49 U.S.C. | 9 | | 5307 and 5311 need not certify its drivers and employee | 10 | | attendants under this Section, since safety training is already | 11 | | federally mandated.
| 12 | | (f) With respect to any policy or program administered by | 13 | | the Department or its agent regarding approval of non-emergency | 14 | | medical transportation by ground ambulance service providers, | 15 | | including, but not limited to, the Non-Emergency | 16 | | Transportation Services Prior Approval Program (NETSPAP), the | 17 | | Department shall establish by rule a process by which ground | 18 | | ambulance service providers of non-emergency medical | 19 | | transportation may appeal any decision by the Department or its | 20 | | agent in for which a claim is not approved for payment, but the | 21 | | patient meets the criteria for medical necessity and the | 22 | | appropriate level of ambulance service was provided. The | 23 | | Department shall consider appeals filed for reimbursement | 24 | | denials based upon the lack of availability of a physician | 25 | | discharge order occurring on or after July 1, 2013 if such | 26 | | appeal is filed within 90 days of the effective date of this |
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| 1 | | amendatory Act of the 98th General Assembly. The Department | 2 | | shall apply the medical criteria established by rule in | 3 | | determining all appeals and shall take into account all | 4 | | relevant documentation substantiating the patient's condition | 5 | | as it relates to the criteria for medical necessity and may | 6 | | accept a provider's run report or equivalent. no denial was | 7 | | received prior to the time of transport that either (i) denies | 8 | | a request for approval for payment of non-emergency | 9 | | transportation by means of ground ambulance service or (ii) | 10 | | grants a request for approval of non-emergency transportation | 11 | | by means of ground ambulance service at a level of service that | 12 | | entitles the ground ambulance service provider to a lower level | 13 | | of compensation from the Department than the ground ambulance | 14 | | service provider would have received as compensation for the | 15 | | level of service requested. The rule shall be filed by December | 16 | | 15, 2012 and shall provide that, for any decision rendered by | 17 | | the Department or its agent on or after the date the rule takes | 18 | | effect, the ground ambulance service provider shall have 60 | 19 | | days from the date the decision is received to file an appeal. | 20 | | The rule established by the Department shall be, insofar as is | 21 | | practical, consistent with the Illinois Administrative | 22 | | Procedure Act. The Director's decision on an appeal under this | 23 | | Section shall be a final administrative decision subject to | 24 | | review under the Administrative Review Law. | 25 | | (f-5) Beginning 90 days after July 20, 2012 (the effective | 26 | | date of Public Act 97-842), (i) no denial of a request for |
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| 1 | | approval for payment of non-emergency transportation by means | 2 | | of ground ambulance service, and (ii) no approval of | 3 | | non-emergency transportation by means of ground ambulance | 4 | | service at a level of service that entitles the ground | 5 | | ambulance service provider to a lower level of compensation | 6 | | from the Department than would have been received at the level | 7 | | of service submitted by the ground ambulance service provider, | 8 | | may be issued by the Department or its agent unless the | 9 | | Department has submitted the criteria for determining the | 10 | | appropriateness of the transport for first notice publication | 11 | | in the Illinois Register pursuant to Section 5-40 of the | 12 | | Illinois Administrative Procedure Act. | 13 | | (g) Whenever a patient covered by a medical assistance | 14 | | program under this Code or by another medical program | 15 | | administered by the Department is being discharged from a | 16 | | facility, a physician discharge order as described in this | 17 | | Section shall be required for each patient whose discharge | 18 | | requires medically supervised ground ambulance services. | 19 | | Facilities shall develop procedures for a physician with | 20 | | medical staff privileges to provide a written and signed | 21 | | physician discharge order. The physician discharge order shall | 22 | | specify the level of ground ambulance services needed and | 23 | | complete a medical certification establishing the criteria for | 24 | | approval of non-emergency ambulance transportation, as | 25 | | published by the Department of Healthcare and Family Services, | 26 | | that is met by the patient. This order and the medical |
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| 1 | | certification shall be completed prior to ordering an ambulance | 2 | | service and prior to patient discharge. | 3 | | Pursuant to subsection (E) of Section 12-4.25 of this Code, | 4 | | the Department is entitled to recover overpayments paid to a | 5 | | provider or vendor, including, but not limited to, from the | 6 | | discharging physician, the discharging facility, and the | 7 | | ground ambulance service provider, in instances where a | 8 | | non-emergency ground ambulance service is rendered as the | 9 | | result of improper or false certification. | 10 | | (h) On and after July 1, 2012, the Department shall reduce | 11 | | any rate of reimbursement for services or other payments or | 12 | | alter any methodologies authorized by this Code to reduce any | 13 | | rate of reimbursement for services or other payments in | 14 | | accordance with Section 5-5e. | 15 | | (Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12; | 16 | | 97-842, eff. 7-20-12; 98-463, eff. 8-16-13.)
| 17 | | Section 99. Effective date. This Act takes effect upon | 18 | | becoming law.
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