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| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2912 Introduced , by Rep. Gregory Harris SYNOPSIS AS INTRODUCED:
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| 305 ILCS 5/5-4.2 | from Ch. 23, par. 5-4.2 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services must implement an average commercial rate supplemental payment program for ground ambulance services providers for dates of service beginning no later than January 1, 2020. Provides that no later than July 1, 2019, the Department must submit to the Centers for Medicare and Medicaid Services an Illinois Title XIX State Plan amendment to implement an average commercial rate supplemental payment program for ground ambulance services providers; and that the Department must require Medicaid managed care organizations, including managed care community networks, to pay the approved average commercial rates in coordination with the Department. Effective immediately.
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1 | | AN ACT concerning public aid.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 10. The Illinois Public Aid Code is amended by |
5 | | changing Section 5-4.2 as follows:
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6 | | (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
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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
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16 | | providers to provide services in an efficient and |
17 | | cost-effective manner. Thus,
it is the intent of the General |
18 | | Assembly that the Illinois Department implement
a |
19 | | reimbursement system for ambulance services that, to the extent |
20 | | practicable
and subject to the availability of funds |
21 | | appropriated by the General Assembly
for this purpose, is |
22 | | consistent with the payment principles of Medicare. To
ensure |
23 | | uniformity between the payment principles of Medicare and |
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1 | | Medicaid, the
Illinois Department shall follow, to the extent |
2 | | necessary and practicable and
subject to the availability of |
3 | | funds appropriated by the General Assembly for
this purpose, |
4 | | the statutes, laws, regulations, policies, procedures,
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5 | | principles, definitions, guidelines, and manuals used to |
6 | | determine the amounts
paid to ambulance service providers under |
7 | | Title XVIII of the Social Security
Act (Medicare).
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8 | | (b) For ambulance services provided to a recipient of aid |
9 | | under this Article
on or after January 1, 1996, the Illinois |
10 | | Department shall reimburse ambulance
service providers based |
11 | | upon the actual distance traveled if a natural
disaster, |
12 | | weather conditions, road repairs, or traffic congestion |
13 | | necessitates
the use of a
route other than the most direct |
14 | | route.
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15 | | (c) For purposes of this Section, "ambulance services" |
16 | | includes medical
transportation services provided by means of |
17 | | an ambulance, medi-car, service
car, or
taxi.
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18 | | (c-1) For purposes of this Section, "ground ambulance |
19 | | service" means medical transportation services that are |
20 | | described as ground ambulance services by the Centers for |
21 | | Medicare and Medicaid Services and provided in a vehicle that |
22 | | is licensed as an ambulance by the Illinois Department of |
23 | | Public Health pursuant to the Emergency Medical Services (EMS) |
24 | | Systems Act. |
25 | | (c-2) For purposes of this Section, "ground ambulance |
26 | | service provider" means a vehicle service provider as described |
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1 | | in the Emergency Medical Services (EMS) Systems Act that |
2 | | operates licensed ambulances for the purpose of providing |
3 | | emergency ambulance services, or non-emergency ambulance |
4 | | services, or both. For purposes of this Section, this includes |
5 | | both ambulance providers and ambulance suppliers as described |
6 | | by the Centers for Medicare and Medicaid Services. |
7 | | (c-3) For purposes of this Section, "medi-car" means |
8 | | transportation services provided to a patient who is confined |
9 | | to a wheelchair and requires the use of a hydraulic or electric |
10 | | lift or ramp and wheelchair lockdown when the patient's |
11 | | condition does not require medical observation, medical |
12 | | supervision, medical equipment, the administration of |
13 | | medications, or the administration of oxygen. |
14 | | (c-4) For purposes of this Section, "service car" means |
15 | | transportation services provided to a patient by a passenger |
16 | | vehicle where that patient does not require the specialized |
17 | | modes described in subsection (c-1) or (c-3). |
18 | | (d) This Section does not prohibit separate billing by |
19 | | ambulance service
providers for oxygen furnished while |
20 | | providing advanced life support
services.
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21 | | (e) Beginning with services rendered on or after July 1, |
22 | | 2008, all providers of non-emergency medi-car and service car |
23 | | transportation must certify that the driver and employee |
24 | | attendant, as applicable, have completed a safety program |
25 | | approved by the Department to protect both the patient and the |
26 | | driver, prior to transporting a patient.
The provider must |
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1 | | maintain this certification in its records. The provider shall |
2 | | produce such documentation upon demand by the Department or its |
3 | | representative. Failure to produce documentation of such |
4 | | training shall result in recovery of any payments made by the |
5 | | Department for services rendered by a non-certified driver or |
6 | | employee attendant. Medi-car and service car providers must |
7 | | maintain legible documentation in their records of the driver |
8 | | and, as applicable, employee attendant that actually |
9 | | transported the patient. Providers must recertify all drivers |
10 | | and employee attendants every 3 years.
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11 | | Notwithstanding the requirements above, any public |
12 | | transportation provider of medi-car and service car |
13 | | transportation that receives federal funding under 49 U.S.C. |
14 | | 5307 and 5311 need not certify its drivers and employee |
15 | | attendants under this Section, since safety training is already |
16 | | federally mandated.
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17 | | (f) With respect to any policy or program administered by |
18 | | the Department or its agent regarding approval of non-emergency |
19 | | medical transportation by ground ambulance service providers, |
20 | | including, but not limited to, the Non-Emergency |
21 | | Transportation Services Prior Approval Program (NETSPAP), the |
22 | | Department shall establish by rule a process by which ground |
23 | | ambulance service providers of non-emergency medical |
24 | | transportation may appeal any decision by the Department or its |
25 | | agent for which no denial was received prior to the time of |
26 | | transport that either (i) denies a request for approval for |
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1 | | payment of non-emergency transportation by means of ground |
2 | | ambulance service or (ii) grants a request for 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 the ground ambulance service provider |
7 | | would have received as compensation for the level of service |
8 | | requested. The rule shall be filed by December 15, 2012 and |
9 | | shall provide that, for any decision rendered by the Department |
10 | | or its agent on or after the date the rule takes effect, the |
11 | | ground ambulance service provider shall have 60 days from the |
12 | | date the decision is received to file an appeal. The rule |
13 | | established by the Department shall be, insofar as is |
14 | | practical, consistent with the Illinois Administrative |
15 | | Procedure Act. The Director's decision on an appeal under this |
16 | | Section shall be a final administrative decision subject to |
17 | | review under the Administrative Review Law. |
18 | | (f-5) Beginning 90 days after July 20, 2012 (the effective |
19 | | date of Public Act 97-842), (i) no denial of a request for |
20 | | approval for payment of non-emergency transportation by means |
21 | | of ground ambulance service, and (ii) no approval of |
22 | | non-emergency transportation by means of ground ambulance |
23 | | service at a level of service that entitles the ground |
24 | | ambulance service provider to a lower level of compensation |
25 | | from the Department than would have been received at the level |
26 | | of service submitted by the ground ambulance service provider, |
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1 | | may be issued by the Department or its agent unless the |
2 | | Department has submitted the criteria for determining the |
3 | | appropriateness of the transport for first notice publication |
4 | | in the Illinois Register pursuant to Section 5-40 of the |
5 | | Illinois Administrative Procedure Act. |
6 | | (g) Whenever a patient covered by a medical assistance |
7 | | program under this Code or by another medical program |
8 | | administered by the Department, including a patient covered |
9 | | under the State's Medicaid managed care program, is being |
10 | | transported from a facility and requires non-emergency |
11 | | transportation including ground ambulance, medi-car, or |
12 | | service car transportation, a Physician Certification |
13 | | Statement as described in this Section shall be required for |
14 | | each patient. Facilities shall develop procedures for a |
15 | | licensed medical professional to provide a written and signed |
16 | | Physician Certification Statement. The Physician Certification |
17 | | Statement shall specify the level of transportation services |
18 | | needed and complete a medical certification establishing the |
19 | | criteria for approval of non-emergency ambulance |
20 | | transportation, as published by the Department of Healthcare |
21 | | and Family Services, that is met by the patient. This |
22 | | certification shall be completed prior to ordering the |
23 | | transportation service and prior to patient discharge. The |
24 | | Physician Certification Statement is not required prior to |
25 | | transport if a delay in transport can be expected to negatively |
26 | | affect the patient outcome. |
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1 | | The medical certification specifying the level and type of |
2 | | non-emergency transportation needed shall be in the form of the |
3 | | Physician Certification Statement on a standardized form |
4 | | prescribed by the Department of Healthcare and Family Services. |
5 | | Within 75 days after July 27, 2018 ( the effective date of |
6 | | Public Act 100-646) this amendatory Act of the 100th General |
7 | | Assembly , the Department of Healthcare and Family Services |
8 | | shall develop a standardized form of the Physician |
9 | | Certification Statement specifying the level and type of |
10 | | transportation services needed in consultation with the |
11 | | Department of Public Health, Medicaid managed care |
12 | | organizations, a statewide association representing ambulance |
13 | | providers, a statewide association representing hospitals, 3 |
14 | | statewide associations representing nursing homes, and other |
15 | | stakeholders. The Physician Certification Statement shall |
16 | | include, but is not limited to, the criteria necessary to |
17 | | demonstrate medical necessity for the level of transport needed |
18 | | as required by (i) the Department of Healthcare and Family |
19 | | Services and (ii) the federal Centers for Medicare and Medicaid |
20 | | Services as outlined in the Centers for Medicare and Medicaid |
21 | | Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. |
22 | | 10, Sec. 10.2.1, et seq. The use of the Physician Certification |
23 | | Statement shall satisfy the obligations of hospitals under |
24 | | Section 6.22 of the Hospital Licensing Act and nursing homes |
25 | | under Section 2-217 of the Nursing Home Care Act. |
26 | | Implementation and acceptance of the Physician Certification |
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1 | | Statement shall take place no later than 90 days after the |
2 | | issuance of the Physician Certification Statement by the |
3 | | Department of Healthcare and Family Services. |
4 | | Pursuant to subsection (E) of Section 12-4.25 of this Code, |
5 | | the Department is entitled to recover overpayments paid to a |
6 | | provider or vendor, including, but not limited to, from the |
7 | | discharging physician, the discharging facility, and the |
8 | | ground ambulance service provider, in instances where a |
9 | | non-emergency ground ambulance service is rendered as the |
10 | | result of improper or false certification. |
11 | | Beginning October 1, 2018, the Department of Healthcare and |
12 | | Family Services shall collect data from Medicaid managed care |
13 | | organizations and transportation brokers, including the |
14 | | Department's NETSPAP broker, regarding denials and appeals |
15 | | related to the missing or incomplete Physician Certification |
16 | | Statement forms and overall compliance with this subsection. |
17 | | The Department of Healthcare and Family Services shall publish |
18 | | quarterly results on its website within 15 days following the |
19 | | end of each quarter. |
20 | | (h) On and after July 1, 2012, the Department shall reduce |
21 | | any rate of reimbursement for services or other payments or |
22 | | alter any methodologies authorized by this Code to reduce any |
23 | | rate of reimbursement for services or other payments in |
24 | | accordance with Section 5-5e. |
25 | | (i) On and after July 1, 2018, the Department shall |
26 | | increase the base rate of reimbursement for both base charges |
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1 | | and mileage charges for ground ambulance service providers for |
2 | | medical transportation services provided by means of a ground |
3 | | ambulance to a level not lower than 112% of the base rate in |
4 | | effect as of June 30, 2018. |
5 | | (m) The Department must implement an average commercial |
6 | | rate supplemental payment program for ground ambulance |
7 | | services providers for dates of service beginning no later than |
8 | | January 1, 2020. No later than July 1, 2019, the Department |
9 | | must submit to the Centers for Medicare and Medicaid Services |
10 | | an Illinois Title XIX State Plan amendment to implement an |
11 | | average commercial rate supplemental payment program for |
12 | | ground ambulance services providers. The Department must |
13 | | require Medicaid managed care organizations as defined in |
14 | | Section 5-30.1 of this Article, including managed care |
15 | | community networks as defined in Section 5-11 of this Article, |
16 | | to pay the approved average commercial rates in coordination |
17 | | with the Department. |
18 | | (Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18; |
19 | | revised 8-27-18.)
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20 | | Section 99. Effective date. This Act takes effect upon |
21 | | becoming law.
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