101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2795
 
Introduced , by Rep. Dan Ugaste
 
SYNOPSIS AS INTRODUCED:



820 ILCS 305/8.2

 Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission, upon consultation with the Workers' Compensation Medical Fee Advisory Board, shall promulgate an evidenced-based drug formulary. Requires prescriptions in workers' compensation cases to be limited to the drugs on the formulary. Effective immediately.



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A BILL FOR
 


HB2795LRB101 08362 JLS 53431 b



1 AN ACT concerning employment.


2 Be it enacted by the People of the State of Illinois,

3represented in the General Assembly:



4 Section 5. The Workers' Compensation Act is amended by 
5changing Section 8.2 as follows:

6 (820 ILCS 305/8.2)

7 Sec. 8.2. Fee schedule.

8 (a) Except as provided for in subsection (c), for 
9procedures, treatments, or services covered under this Act and 
10rendered or to be rendered on and after February 1, 2006, the 
11maximum allowable payment shall be 90% of the 80th percentile 
12of charges and fees as determined by the Commission utilizing 
13information provided by employers' and insurers' national 
14databases, with a minimum of 12,000,000 Illinois line item 
15charges and fees comprised of health care provider and hospital 
16charges and fees as of August 1, 2004 but not earlier than 
17August 1, 2002. These charges and fees are provider billed 
18amounts and shall not include discounted charges. The 80th 
19percentile is the point on an ordered data set from low to high 
20such that 80% of the cases are below or equal to that point and 
21at most 20% are above or equal to that point. The Commission 
22shall adjust these historical charges and fees as of August 1, 
232004 by the Consumer Price Index-U for the period August 1, 
 
 
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12004 through September 30, 2005. The Commission shall establish 
2fee schedules for procedures, treatments, or services for 
3hospital inpatient, hospital outpatient, emergency room and 
4trauma, ambulatory surgical treatment centers, and 
5professional services. These charges and fees shall be 
6designated by geozip or any smaller geographic unit. The data 
7shall in no way identify or tend to identify any patient, 
8employer, or health care provider. As used in this Section, 
9"geozip" means a three-digit zip code based on data 
10similarities, geographical similarities, and frequencies. A 
11geozip does not cross state boundaries. As used in this 
12Section, "three-digit zip code" means a geographic area in 
13which all zip codes have the same first 3 digits. If a geozip 
14does not have the necessary number of charges and fees to 
15calculate a valid percentile for a specific procedure, 
16treatment, or service, the Commission may combine data from the 
17geozip with up to 4 other geozips that are demographically and 
18economically similar and exhibit similarities in data and 
19frequencies until the Commission reaches 9 charges or fees for 
20that specific procedure, treatment, or service. In cases where 
21the compiled data contains less than 9 charges or fees for a 
22procedure, treatment, or service, reimbursement shall occur at 
2376% of charges and fees as determined by the Commission in a 
24manner consistent with the provisions of this paragraph. 
25Providers of out-of-state procedures, treatments, services, 
26products, or supplies shall be reimbursed at the lesser of that 
 
 
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1state's fee schedule amount or the fee schedule amount for the 
2region in which the employee resides. If no fee schedule exists 
3in that state, the provider shall be reimbursed at the lesser 
4of the actual charge or the fee schedule amount for the region 
5in which the employee resides. Not later than September 30 in 
62006 and each year thereafter, the Commission shall 
7automatically increase or decrease the maximum allowable 
8payment for a procedure, treatment, or service established and 
9in effect on January 1 of that year by the percentage change in 
10the Consumer Price Index-U for the 12 month period ending 
11August 31 of that year. The increase or decrease shall become 
12effective on January 1 of the following year. As used in this 
13Section, "Consumer Price Index-U" means the index published by 
14the Bureau of Labor Statistics of the U.S. Department of Labor, 
15that measures the average change in prices of all goods and 
16services purchased by all urban consumers, U.S. city average, 
17all items, 1982-84=100.
18 (a-1) Notwithstanding the provisions of subsection (a) and 
19unless otherwise indicated, the following provisions shall 
20apply to the medical fee schedule starting on September 1, 
212011:
22  (1) The Commission shall establish and maintain fee 
23 schedules for procedures, treatments, products, services, 
24 or supplies for hospital inpatient, hospital outpatient, 
25 emergency room, ambulatory surgical treatment centers, 
26 accredited ambulatory surgical treatment facilities, 
 
 
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1 prescriptions filled and dispensed outside of a licensed 
2 pharmacy, dental services, and professional services. This 
3 fee schedule shall be based on the fee schedule amounts 
4 already established by the Commission pursuant to 
5 subsection (a) of this Section. However, starting on 
6 January 1, 2012, these fee schedule amounts shall be 
7 grouped into geographic regions in the following manner:
8   (A) Four regions for non-hospital fee schedule 
9 amounts shall be utilized:
10    (i) Cook County;
11    (ii) DuPage, Kane, Lake, and Will Counties;
12    (iii) Bond, Calhoun, Clinton, Jersey, 
13 Macoupin, Madison, Monroe, Montgomery, Randolph, 
14 St. Clair, and Washington Counties; and
15    (iv) All other counties of the State.
16   (B) Fourteen regions for hospital fee schedule 
17 amounts shall be utilized:
18    (i) Cook, DuPage, Will, Kane, McHenry, DeKalb, 
19 Kendall, and Grundy Counties;
20    (ii) Kankakee County;
21    (iii) Madison, St. Clair, Macoupin, Clinton, 
22 Monroe, Jersey, Bond, and Calhoun Counties;
23    (iv) Winnebago and Boone Counties;
24    (v) Peoria, Tazewell, Woodford, Marshall, and 
25 Stark Counties;
26    (vi) Champaign, Piatt, and Ford Counties;
 
 
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1    (vii) Rock Island, Henry, and Mercer Counties;
2    (viii) Sangamon and Menard Counties;
3    (ix) McLean County;
4    (x) Lake County;
5    (xi) Macon County;
6    (xii) Vermilion County;
7    (xiii) Alexander County; and
8    (xiv) All other counties of the State.
9  (2) If a geozip, as defined in subsection (a) of this 
10 Section, overlaps into one or more of the regions set forth 
11 in this Section, then the Commission shall average or 
12 repeat the charges and fees in a geozip in order to 
13 designate charges and fees for each region.
14  (3) In cases where the compiled data contains less than 
15 9 charges or fees for a procedure, treatment, product, 
16 supply, or service or where the fee schedule amount cannot 
17 be determined by the non-discounted charge data, 
18 non-Medicare relative values and conversion factors 
19 derived from established fee schedule amounts, coding 
20 crosswalks, or other data as determined by the Commission, 
21 reimbursement shall occur at 76% of charges and fees until 
22 September 1, 2011 and 53.2% of charges and fees thereafter 
23 as determined by the Commission in a manner consistent with 
24 the provisions of this paragraph.
25  (4) To establish additional fee schedule amounts, the 
26 Commission shall utilize provider non-discounted charge 
 
 
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1 data, non-Medicare relative values and conversion factors 
2 derived from established fee schedule amounts, and coding 
3 crosswalks. The Commission may establish additional fee 
4 schedule amounts based on either the charge or cost of the 
5 procedure, treatment, product, supply, or service.
6  (5) Implants shall be reimbursed at 25% above the net 
7 manufacturer's invoice price less rebates, plus actual 
8 reasonable and customary shipping charges whether or not 
9 the implant charge is submitted by a provider in 
10 conjunction with a bill for all other services associated 
11 with the implant, submitted by a provider on a separate 
12 claim form, submitted by a distributor, or submitted by the 
13 manufacturer of the implant. "Implants" include the 
14 following codes or any substantially similar updated code 
15 as determined by the Commission: 0274 
16 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens 
17 implant); 0278 (implants); 0540 and 0545 (ambulance); 0624 
18 (investigational devices); and 0636 (drugs requiring 
19 detailed coding). Non-implantable devices or supplies 
20 within these codes shall be reimbursed at 65% of actual 
21 charge, which is the provider's normal rates under its 
22 standard chargemaster. A standard chargemaster is the 
23 provider's list of charges for procedures, treatments, 
24 products, supplies, or services used to bill payers in a 
25 consistent manner.
26  (6) The Commission shall automatically update all 
 
 
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1 codes and associated rules with the version of the codes 
2 and rules valid on January 1 of that year.
3 (a-2) For procedures, treatments, services, or supplies 
4covered under this Act and rendered or to be rendered on or 
5after September 1, 2011, the maximum allowable payment shall be 
670% of the fee schedule amounts, which shall be adjusted yearly 
7by the Consumer Price Index-U, as described in subsection (a) 
8of this Section.
9 (a-3) Prescriptions filled and dispensed outside of a 
10licensed pharmacy shall be subject to a fee schedule that shall 
11not exceed the Average Wholesale Price (AWP) plus a dispensing 
12fee of $4.18. AWP or its equivalent as registered by the 
13National Drug Code shall be set forth for that drug on that 
14date as published in Medi-Span Medispan. 
15 (a-4) By September 1, 2020, the Commission, in consultation 
16with the Workers' Compensation Medical Fee Advisory Board, 
17shall promulgate by rule an evidence-based drug formulary and 
18any rules necessary for its administration. Prescriptions 
19prescribed for workers' compensation cases shall be limited to 
20the prescription drugs and doses on the closed formulary.
21 A request for a prescription that is not on the closed 
22formulary shall be reviewed under Section 8.7. 
23 (b) Notwithstanding the provisions of subsection (a), if

24the Commission finds that there is a significant limitation on

25access to quality health care in either a specific field of

26health care services or a specific geographic limitation on

 
 
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1access to health care, it may change the Consumer Price Index-U

2increase or decrease for that specific field or specific

3geographic limitation on access to health care to address that

4limitation.
5 (c) The Commission shall establish by rule a process to 
6review those medical cases or outliers that involve 
7extra-ordinary treatment to determine whether to make an 
8additional adjustment to the maximum payment within a fee 
9schedule for a procedure, treatment, or service.
10 (d) When a patient notifies a provider that the treatment, 
11procedure, or service being sought is for a work-related 
12illness or injury and furnishes the provider the name and 
13address of the responsible employer, the provider shall bill 
14the employer or its designee directly. The employer or its 
15designee shall make payment for treatment in accordance with 
16the provisions of this Section directly to the provider, except 
17that, if a provider has designated a third-party billing entity 
18to bill on its behalf, payment shall be made directly to the 
19billing entity. Providers shall submit bills and records in 
20accordance with the provisions of this Section. 
21  (1) All payments to providers for treatment provided 
22 pursuant to this Act shall be made within 30 days of 
23 receipt of the bills as long as the bill contains 
24 substantially all the required data elements necessary to 
25 adjudicate the bill. 
26  (2) If the bill does not contain substantially all the 
 
 
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1 required data elements necessary to adjudicate the bill, or 
2 the claim is denied for any other reason, in whole or in 
3 part, the employer or insurer shall provide written 
4 notification to the provider in the form of an explanation 
5 of benefits explaining the basis for the denial and 
6 describing any additional necessary data elements within 
7 30 days of receipt of the bill. The Commission, with 
8 assistance from the Medical Fee Advisory Board, shall adopt 
9 rules detailing the requirements for the explanation of 
10 benefits required under this subsection. 
11  (3) In the case (i) of nonpayment to a provider within 
12 30 days of receipt of the bill which contained 
13 substantially all of the required data elements necessary 
14 to adjudicate the bill, (ii) of nonpayment to a provider of 
15 a portion of such a bill, or (iii) where the provider has 
16 not been issued an explanation of benefits for a bill, the 
17 bill, or portion of the bill up to the lesser of the actual 
18 charge or the payment level set by the Commission in the 
19 fee schedule established in this Section, shall incur 
20 interest at a rate of 1% per month payable by the employer 
21 to the provider. Any required interest payments shall be 
22 made by the employer or its insurer to the provider within 
23 30 days after payment of the bill. 
24  (4) If the employer or its insurer fails to pay 
25 interest within 30 days after payment of the bill as 
26 required pursuant to paragraph (3), the provider may bring 
 
 
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1 an action in circuit court for the sole purpose of seeking 
2 payment of interest pursuant to paragraph (3) against the 
3 employer or its insurer responsible for insuring the 
4 employer's liability pursuant to item (3) of subsection (a) 
5 of Section 4. The circuit court's jurisdiction shall be 
6 limited to enforcing payment of interest pursuant to 
7 paragraph (3). Interest under paragraph (3) is only payable 
8 to the provider. An employee is not responsible for the 
9 payment of interest under this Section. The right to 
10 interest under paragraph (3) shall not delay, diminish, 
11 restrict, or alter in any way the benefits to which the 
12 employee or his or her dependents are entitled under this 
13 Act. 
14 The changes made to this subsection (d) by this amendatory 
15Act of the 100th General Assembly apply to procedures, 
16treatments, and services rendered on and after the effective 
17date of this amendatory Act of the 100th General Assembly. 
18 (e) Except as provided in subsections (e-5), (e-10), and 
19(e-15), a provider shall not hold an employee liable for costs 
20related to a non-disputed procedure, treatment, or service 
21rendered in connection with a compensable injury. The 
22provisions of subsections (e-5), (e-10), (e-15), and (e-20) 
23shall not apply if an employee provides information to the 
24provider regarding participation in a group health plan. If the 
25employee participates in a group health plan, the provider may 
26submit a claim for services to the group health plan. If the 
 
 
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1claim for service is covered by the group health plan, the 
2employee's responsibility shall be limited to applicable 
3deductibles, co-payments, or co-insurance. Except as provided 
4under subsections (e-5), (e-10), (e-15), and (e-20), a provider 
5shall not bill or otherwise attempt to recover from the 
6employee the difference between the provider's charge and the 
7amount paid by the employer or the insurer on a compensable 
8injury, or for medical services or treatment determined by the 
9Commission to be excessive or unnecessary.
10 (e-5) If an employer notifies a provider that the employer 
11does not consider the illness or injury to be compensable under 
12this Act, the provider may seek payment of the provider's 
13actual charges from the employee for any procedure, treatment, 
14or service rendered. Once an employee informs the provider that 
15there is an application filed with the Commission to resolve a 
16dispute over payment of such charges, the provider shall cease 
17any and all efforts to collect payment for the services that 
18are the subject of the dispute. Any statute of limitations or 
19statute of repose applicable to the provider's efforts to 
20collect payment from the employee shall be tolled from the date 
21that the employee files the application with the Commission 
22until the date that the provider is permitted to resume 
23collection efforts under the provisions of this Section.
24 (e-10) If an employer notifies a provider that the employer 
25will pay only a portion of a bill for any procedure, treatment, 
26or service rendered in connection with a compensable illness or 
 
 
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1disease, the provider may seek payment from the employee for 
2the remainder of the amount of the bill up to the lesser of the 
3actual charge, negotiated rate, if applicable, or the payment 
4level set by the Commission in the fee schedule established in 
5this Section. Once an employee informs the provider that there 
6is an application filed with the Commission to resolve a 
7dispute over payment of such charges, the provider shall cease 
8any and all efforts to collect payment for the services that 
9are the subject of the dispute. Any statute of limitations or 
10statute of repose applicable to the provider's efforts to 
11collect payment from the employee shall be tolled from the date 
12that the employee files the application with the Commission 
13until the date that the provider is permitted to resume 
14collection efforts under the provisions of this Section.
15 (e-15) When there is a dispute over the compensability of 
16or amount of payment for a procedure, treatment, or service, 
17and a case is pending or proceeding before an Arbitrator or the 
18Commission, the provider may mail the employee reminders that 
19the employee will be responsible for payment of any procedure, 
20treatment or service rendered by the provider. The reminders 
21must state that they are not bills, to the extent practicable 
22include itemized information, and state that the employee need 
23not pay until such time as the provider is permitted to resume 
24collection efforts under this Section. The reminders shall not 
25be provided to any credit rating agency. The reminders may 
26request that the employee furnish the provider with information 
 
 
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1about the proceeding under this Act, such as the file number, 
2names of parties, and status of the case. If an employee fails 
3to respond to such request for information or fails to furnish 
4the information requested within 90 days of the date of the 
5reminder, the provider is entitled to resume any and all 
6efforts to collect payment from the employee for the services 
7rendered to the employee and the employee shall be responsible 
8for payment of any outstanding bills for a procedure, 
9treatment, or service rendered by a provider.
10 (e-20) Upon a final award or judgment by an Arbitrator or 
11the Commission, or a settlement agreed to by the employer and 
12the employee, a provider may resume any and all efforts to 
13collect payment from the employee for the services rendered to 
14the employee and the employee shall be responsible for payment 
15of any outstanding bills for a procedure, treatment, or service 
16rendered by a provider as well as the interest awarded under 
17subsection (d) of this Section. In the case of a procedure, 
18treatment, or service deemed compensable, the provider shall 
19not require a payment rate, excluding the interest provisions 
20under subsection (d), greater than the lesser of the actual 
21charge or the payment level set by the Commission in the fee 
22schedule established in this Section. Payment for services 
23deemed not covered or not compensable under this Act is the 
24responsibility of the employee unless a provider and employee 
25have agreed otherwise in writing. Services not covered or not 
26compensable under this Act are not subject to the fee schedule 
 
 
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1in this Section.
2 (f) Nothing in this Act shall prohibit an employer or

3insurer from contracting with a health care provider or group

4of health care providers for reimbursement levels for benefits 
5under this Act different
from those provided in this Section.
6 (g) On or before January 1, 2010 the Commission shall 
7provide to the Governor and General Assembly a report regarding 
8the implementation of the medical fee schedule and the index 
9used for annual adjustment to that schedule as described in 
10this Section.

11(Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff. 
121-11-19.)


13 Section 99. Effective date. This Act takes effect upon 
14becoming law.