98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB2502
 
Introduced , by Rep. Esther Golar
 
SYNOPSIS AS INTRODUCED:



New Act
215 ILCS 5/356z.22 new

 Creates the Complex Needs Patient Act. Requires the Department of Healthcare and Family Services to provide separate recognition within the State's Medicaid program for individually configured complex rehabilitation technology products and services for complex needs patients. Defines "complex needs patient" to mean an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities. Provides that the separate recognition for technology products and services for complex needs patients shall take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs. Provides that the Department shall require complex needs patients receiving complex rehabilitation technology to be evaluated by a qualified health care professional and a qualified complex rehabilitation technology professional. Amends the Illinois Insurance Code. Provides that a managed care plan amended, delivered, issued, or renewed in this State after the effective date of the amendatory Act shall adopt the regulations and policies outlined in the Complex Needs Patient Act. Effective immediately.



LRB098 05562 KTG 35599 b


FISCAL NOTE ACT MAY APPLY
 
 
A BILL FOR
 


HB2502LRB098 05562 KTG 35599 b



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 1. Short title. This Act may be cited as the 
5Complex Needs Patient Act.

6 Section 5. Purpose. 
7 It is the intent of the General Assembly to:

8  (1) protect access for complex needs patients to 
9 important technology and supporting services;

10  (2) establish and improve safeguards relating to the 
11 delivery and provision of medically necessary complex 
12 rehabilitation technology;
13  (3) provide supports for complex needs patients to stay 
14 in the home or community setting, prevent 
15 institutionalization, and prevent hospitalizations and 
16 other costly secondary complications; and

17  (4) establish adequate pricing for complex 
18 rehabilitation technology for the purpose of allowing 
19 continued access to appropriate products and services.

20 Section 10. Definitions.
As used in this Act:

21 (a) "Complex needs patient" means an individual with a 
22diagnosis or medical condition that results in significant 
 
 
HB2502- 2 -LRB098 05562 KTG 35599 b


1physical or functional needs and capacities. Such term shall 
2include individuals with progressive or degenerative 
3neuromuscular diseases or injuries or trauma which resulted in 
4significant physical or functional needs and capacities, 
5including, but not limited to, individuals with spinal cord 
6injury, traumatic brain injury, cerebral palsy, muscular 
7dystrophy, spina bifida, osteogenesis imperfecta, 
8arthrogryposis, amyotrophic lateral sclerosis, multiple 
9sclerosis, demyelinating disease, myelopathy, myopathy, 
10progressive muscular atrophy, anterior horn cell disease, 
11post-polio syndrome, cerebellar degeneration, dystonia, 
12Huntington's disease, spinocerebellar disease, and certain 
13types of amputation, paralysis, or paresis that result in 
14significant physical or functional needs and capacities.

15 (b) "Complex rehabilitation technology" means items 
16currently classified by the Centers for Medicare and Medicaid 
17Services as of January 1, 2013 as durable medical equipment 
18that are individually configured for individuals to meet their 
19specific and unique medical, physical, and functional needs and 
20capacities for basic activities of daily living and 
21instrumental activities of daily living identified as 
22medically necessary to prevent hospitalization or 
23institutionalization of a complex needs patient. Such items 
24shall include, but not be limited to, complex rehabilitation 
25power wheelchairs, highly configurable manual wheelchairs, 
26adaptive seating and positioning systems, and other 
 
 
HB2502- 3 -LRB098 05562 KTG 35599 b


1specialized equipment such as standing frames and gait 
2trainers. The related Healthcare Common Procedure Code System 
3(HCPCS) billing codes include, but are not limited to:
4  (1) Pure Complex Rehab Technology (CRT) Codes: These 
5 HCPCS codes contain 100% CRT products: E0637, E0638, E0641, 
6 E0642, E0986, E1002, E1003, E1004, E1005, E1006, E1007, 
7 E1008, E1009, E1010, E1011, E1014, E1037, E1161, E1220, 
8 E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236, 
9 E1237, E1238, E1239, E2209, E2291, E2292, E2293, E2294, 
10 E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, 
11 E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, 
12 E2330, E2331, E2351, E2373, E2374, E2376, E2377, E2609, 
13 E2610, E2617, E8000, E8001, E8002, K0005, K0835, K0836, 
14 K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, 
15 K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, 
16 K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, 
17 K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, 
18 K0884, K0885, K0886, K0890, K0891, and K0898.
19  (2) Mixed CRT Codes: These HCPCS codes contain a mix of 
20 CRT products and standard mobility and accessory products: 
21 E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0960, 
22 E0967, E0978, E0990, E1015, E1016, E1028, E1029, E1030, 
23 E2205, E2208, E2231, E2368, E2369, E2370, E2605, E2606, 
24 E2607, E2608, E2613, E2614, E2615, E2616, E2620, E2621, 
25 E2624, E2625, K0004, K0009, K0040, K0108, and K0669.
26  (3) Future codes created to expand on or replace those 
 
 
HB2502- 4 -LRB098 05562 KTG 35599 b


1 indicated in paragraphs (1) and (2) of this subsection.
2 (c) "Individually configured" means a combination of 
3features, adjustments, or modifications a supplier makes to a 
4device that are specific to an individual and that the supplier 
5provides by measuring, fitting, programming, adjusting, or 
6adapting the device as appropriate so that the device is 
7consistent with an assessment or evaluation of the individual 
8by a health care professional and consistent with the 
9individual's medical condition, physical and functional needs, 
10capacities, body size, period of need, and intended use.
11 (d) "Qualified complex rehabilitation technology supplier" 
12means a company or entity that:
13   (1) is accredited by a recognized accrediting 
14 organization as a supplier of complex rehabilitation 
15 technology;

16   (2) is enrolled in the Medicare program and meets 
17 the supplier and quality standards established for 
18 durable medical equipment suppliers under the Medicare 
19 program;
20   (3) employs at least one complex rehabilitation 
21 technology professional for each
location to (i) 
22 analyze the needs and capacities of qualified 
23 individuals with complex medical needs, (ii) assist in 
24 selecting appropriate covered complex rehabilitation 
25 technology items for such needs and capacities, and 
26 (iii) provide training in the use of the selected 
 
 
HB2502- 5 -LRB098 05562 KTG 35599 b


1 covered complex rehabilitation technology items; the 
2 complex rehabilitation technology professional shall 
3 be certified by the Rehabilitation Engineering and 
4 Assistive Technology Society of North America as an 
5 Assistive Technology Professional (ATP);
6   (4) has the complex rehabilitation technology 
7 professional physically present for the evaluation and 
8 determination of the appropriate individually 
9 configured complex rehabilitation technologies for the 
10 qualified individual with complex medical needs; and

11   (5) provides service and repair by qualified 
12 technicians for all complex rehabilitation technology 
13 products it sells.
14 (e) "Qualified complex rehabilitation technology 
15professional" means an individual who is certified by the 
16Rehabilitation Engineering and Assistive Technology Society of 
17North America as an Assistive Technology Professional (ATP).


18 Section 15. Creation of a separate recognition for complex 
19rehabilitation technology.
20 (a) The Department of Healthcare and Family Services shall 
21provide a separate recognition within the State's Medicaid 
22program established under Article V of the Illinois Public Aid 
23Code for complex rehabilitation technology and shall make other 
24required changes to protect access to appropriate products and 
25services. The Department shall provide separate recognition 
 
 
HB2502- 6 -LRB098 05562 KTG 35599 b


1for individually configured complex rehabilitation technology 
2products and services for complex needs patients. Such separate 
3recognition shall take into consideration the customized 
4nature of complex rehabilitation technology and the broad range 
5of services necessary to meet the unique medical and functional 
6needs of people with complex medical needs by doing all of the 
7following:

8  (1) By using as a reference those billing codes listed 
9 under paragraphs (1) and (2) of subsection (b) of Section 
10 10, designating appropriate current billing codes as 
11 complex rehabilitation technology and, as needed, creating 
12 new billing codes for services and products covered for 
13 complex needs patients.

14  (2) Establishing specific supplier standards for 
15 companies or entities that provide complex rehabilitation 
16 technology and restricting the provision of complex 
17 rehabilitation technology to only those companies or 
18 entities that meet such standards.

19  (3) Developing pricing policies for complex 
20 rehabilitation technology by doing all of the following:

21   (A) The billing codes referenced under paragraphs 
22 (1) and (2) of subsection (b) of Section 10 shall 
23 maintain a reimbursement level of no less than 100% of 
24 the current Medicare fee schedule amount minus 6%. If 
25 the item is not covered by Medicare or is individually 
26 considered for reimbursement, then the State's 
 
 
HB2502- 7 -LRB098 05562 KTG 35599 b


1 Medicaid plan shall adopt an allowable amount at the 
2 Manufacturer's Suggested Retail Price (MSRP) minus 
3 10%.

4   (B) Adopting the usage of KE billing code modifiers 
5 used to help maintain access to complex rehabilitation 
6 technology products for those patients who require it.
7   (C) Modifying the prior approval requirement for 
8 wheelchair repairs to apply only when the cost of any 
9 one part is greater than or equal to $500 per line 
10 item, when the sum of the parts is greater than or 
11 equal to a total of $1,500, or when 8 or more units of 
12 labor are to be billed. This change shall allow 
13 Medicaid beneficiaries to retain access to timely 
14 service and repair for routine maintenance while also 
15 allowing for a more thorough State review on higher 
16 dollar claims. Repair requests shall not require the 
17 provider to obtain a physician's prescription. The 
18 only exception to this shall be for modifications, 
19 which are defined as the addition of a part that was 
20 not already on the equipment. Repairs shall also be 
21 priced by the Department at the Medicare fee schedule 
22 amount minus 6% for set rate items and for those 
23 without a Medicare allowable amount at MSRP minus 10%. 
24 The Department shall allow for expedited approval of 
25 repairs that include wheelchair batteries. 
26 Additionally, the Department shall expand its 
 
 
HB2502- 8 -LRB098 05562 KTG 35599 b


1 expedited approval process to include circumstances in 
2 which the patient's wheelchair will be inoperable 
3 without the needed repair, causing the patient to be 
4 bed-bound or otherwise confined.

5   (D) Exempting the billing codes referenced in 
6 paragraphs (1) and (2) of subsection (b) of Section 10 
7 from inclusion in any competitive bidding or other such 
8 programs.

9  (4) Making other changes as needed to protect access to 
10 complex rehabilitation technology for people with complex 
11 medical needs.

12 (b) The Department of Healthcare and Family Services shall 
13require complex needs patients receiving complex 
14rehabilitation technology to be evaluated by:
15  (1) a qualified health care professional, including, 
16 but not limited to, a physical therapist, occupational 
17 therapist, or other health care professional who performs 
18 specialty evaluations within his or her scope of practice; 
19 and
20  (2) a qualified complex rehabilitation technology 
21 professional.
 

22 Section 20. The Illinois Insurance Code is amended by 
23adding Section 356z.22 as follows:

24 (215 ILCS 5/356z.22 new)
 
 
HB2502- 9 -LRB098 05562 KTG 35599 b


1 Sec. 356z.22. Coverage for complex rehabilitation 
2technology products and services for complex needs patients. A 
3managed care plan amended, delivered, issued, or renewed in 
4this State after the effective date of this amendatory Act of 
5the 98th General Assembly shall adopt the regulations and 
6policies outlined in the Complex Needs Patient Act.

7 Section 99. Effective date. This Act takes effect upon 
8becoming law.