Bill Text: IL HB5857 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Sets forth the following findings of the General Assembly: (i) access to ground ambulance services improves health equity, increases access to quality care, and reduces health disparities in underserved communities; (ii) due to the underfunding of these critical services by the federal Medicare and Medicaid programs, there is a growing scarcity of non-emergency ground ambulance services in underserved, minority communities in this State; and (iii) the State has an interest in providing funding to nonemergency ground ambulance service providers in affected communities. Creates the Safety-Net Ambulance Sustainability Fund as a special fund in the State treasury. Provides that the Fund shall consist of any federal, State, or private moneys designated for deposit into the Fund and all interest earned on moneys in the Fund. Provides that moneys in the Fund, including all accrued interest thereon, shall only be used and disbursed by the Department of Healthcare and Family Services to support the operating expenses of nongovernmental ground ambulance providers in high-Medicaid communities. Provides that any amounts expended from the Fund that are later recouped by the Department following an audit or otherwise shall be returned to the Fund. Amends the State Finance Act. Adds the Safety-Net Ambulance Sustainability Fund to the list of special funds under the Act.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-05-24 - Referred to Rules Committee [HB5857 Detail]

Download: Illinois-2023-HB5857-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5857 Introduced , by Rep. Robert "Bob" Rita SYNOPSIS AS INTRODUCED:
30 ILCS 105/5.1015 new
305 ILCS 5/5-4.2
Amends the Medical Assistance Article of the Illinois Public Aid Code. Sets forth the following findings of the General Assembly: (i) access to ground ambulance services improves health equity, increases access to quality care, and reduces health disparities in underserved communities; (ii) due to the underfunding of these critical services by the federal Medicare and Medicaid programs, there is a growing scarcity of non-emergency ground ambulance services in underserved, minority communities in this State; and (iii) the State has an interest in providing funding to nonemergency ground ambulance service providers in affected communities. Creates the Safety-Net Ambulance Sustainability Fund as a special fund in the State treasury. Provides that the Fund shall consist of any federal, State, or private moneys designated for deposit into the Fund and all interest earned on moneys in the Fund. Provides that moneys in the Fund, including all accrued interest thereon, shall only be used and disbursed by the Department of Healthcare and Family Services to support the operating expenses of nongovernmental ground ambulance providers in high-Medicaid communities. Provides that any amounts expended from the Fund that are later recouped by the Department following an audit or otherwise shall be returned to the Fund. Amends the State Finance Act. Adds the Safety-Net Ambulance Sustainability Fund to the list of special funds under the Act.
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A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. The State Finance Act is amended by adding
Section 5.1015 as follows:
(30 ILCS 105/5.1015 new)
Sec. 5.1015. The Safety-Net Ambulance Sustainability Fund.
Section 5. The Illinois Public Aid Code is amended by
changing Section 5-4.2 as follows:
(305 ILCS 5/5-4.2)
Sec. 5-4.2. Ambulance services payments.
(a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article
and to provide appropriate incentives to ambulance service
providers to provide services in an efficient and
cost-effective manner. Thus, it is the intent of the General

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Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the
extent practicable and subject to the availability of funds
appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to
determine the amounts paid to ambulance service providers
under Title XVIII of the Social Security Act (Medicare).
(b) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
(c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, air ambulance, medi-car, service car, or taxi.
(c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are
described as ground ambulance services by the Centers for

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Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)
Systems Act.
(c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as
described in the Emergency Medical Services (EMS) Systems Act
that operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described
by the Centers for Medicare and Medicaid Services.
(c-3) For purposes of this Section, "medi-car" means
transportation services provided to a patient who is confined
to a wheelchair and requires the use of a hydraulic or electric
lift or ramp and wheelchair lockdown when the patient's
condition does not require medical observation, medical
supervision, medical equipment, the administration of
medications, or the administration of oxygen.
(c-4) For purposes of this Section, "service car" means
transportation services provided to a patient by a passenger
vehicle where that patient does not require the specialized
modes described in subsection (c-1) or (c-3).
(c-5) For purposes of this Section, "air ambulance
service" means medical transport by helicopter or airplane for
patients, as defined in 29 U.S.C. 1185f(c)(1), and any service

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that is described as an air ambulance service by the federal
Centers for Medicare and Medicaid Services.
(d) This Section does not prohibit separate billing by
ambulance service providers for oxygen furnished while
providing advanced life support services.
(e) Beginning with services rendered on or after July 1,
2008, all providers of non-emergency medi-car and service car
transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must
maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or
its representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the
Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually
transported the patient. Providers must recertify all drivers
and employee attendants every 3 years. If they meet the
established training components set forth by the Department,
providers of non-emergency medi-car and service car
transportation that are either directly or through an
affiliated company licensed by the Department of Public Health
shall be approved by the Department to have in-house safety

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programs for training their own staff.
Notwithstanding the requirements above, any public
transportation provider of medi-car and service car
transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is
already federally mandated.
(f) With respect to any policy or program administered by
the Department or its agent regarding approval of
non-emergency medical transportation by ground ambulance
service providers, including, but not limited to, the
Non-Emergency Transportation Services Prior Approval Program
(NETSPAP), the Department shall establish by rule a process by
which ground ambulance service providers of non-emergency
medical transportation may appeal any decision by the
Department or its agent for which no denial was received prior
to the time of transport that either (i) denies a request for
approval for payment of non-emergency transportation by means
of ground ambulance service or (ii) grants a request for
approval of non-emergency transportation by means of ground
ambulance service at a level of service that entitles the
ground ambulance service provider to a lower level of
compensation from the Department than the ground ambulance
service provider would have received as compensation for the
level of service requested. The rule shall be filed by
December 15, 2012 and shall provide that, for any decision

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rendered by the Department or its agent on or after the date
the rule takes effect, the ground ambulance service provider
shall have 60 days from the date the decision is received to
file an appeal. The rule established by the Department shall
be, insofar as is practical, consistent with the Illinois
Administrative Procedure Act. The Director's decision on an
appeal under this Section shall be a final administrative
decision subject to review under the Administrative Review
Law.
(f-5) Beginning 90 days after July 20, 2012 (the effective
date of Public Act 97-842), (i) no denial of a request for
approval for payment of non-emergency transportation by means
of ground ambulance service, and (ii) no approval of
non-emergency transportation by means of ground ambulance
service at a level of service that entitles the ground
ambulance service provider to a lower level of compensation
from the Department than would have been received at the level
of service submitted by the ground ambulance service provider,
may be issued by the Department or its agent unless the
Department has submitted the criteria for determining the
appropriateness of the transport for first notice publication
in the Illinois Register pursuant to Section 5-40 of the
Illinois Administrative Procedure Act.
(f-6) Within 90 days after June 2, 2022 (the effective
date of Public Act 102-1037) this amendatory Act of the 102nd
General Assembly and subject to federal approval, the

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Department shall file rules to allow for the approval of
ground ambulance services when the sole purpose of the
transport is for the navigation of stairs or the assisting or
lifting of a patient at a medical facility or during a medical
appointment in instances where the Department or a contracted
Medicaid managed care organization or their transportation
broker is unable to secure transportation through any other
transportation provider.
(f-7) For non-emergency ground ambulance claims properly
denied under Department policy at the time the claim is filed
due to failure to submit a valid Medical Certification for
Non-Emergency Ambulance on and after December 15, 2012 and
prior to January 1, 2021, the Department shall allot
$2,000,000 to a pool to reimburse such claims if the provider
proves medical necessity for the service by other means.
Providers must submit any such denied claims for which they
seek compensation to the Department no later than December 31,
2021 along with documentation of medical necessity. No later
than May 31, 2022, the Department shall determine for which
claims medical necessity was established. Such claims for
which medical necessity was established shall be paid at the
rate in effect at the time of the service, provided the
$2,000,000 is sufficient to pay at those rates. If the pool is
not sufficient, claims shall be paid at a uniform percentage
of the applicable rate such that the pool of $2,000,000 is
exhausted. The appeal process described in subsection (f)

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shall not be applicable to the Department's determinations
made in accordance with this subsection.
(g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program
administered by the Department, including a patient covered
under the State's Medicaid managed care program, is being
transported from a facility and requires non-emergency
transportation including ground ambulance, medi-car, or
service car transportation, a Physician Certification
Statement as described in this Section shall be required for
each patient. Facilities shall develop procedures for a
licensed medical professional to provide a written and signed
Physician Certification Statement. The Physician Certification
Statement shall specify the level of transportation services
needed and complete a medical certification establishing the
criteria for approval of non-emergency ambulance
transportation, as published by the Department of Healthcare
and Family Services, that is met by the patient. This
certification shall be completed prior to ordering the
transportation service and prior to patient discharge. The
Physician Certification Statement is not required prior to
transport if a delay in transport can be expected to
negatively affect the patient outcome. If the ground ambulance
provider, medi-car provider, or service car provider is unable
to obtain the required Physician Certification Statement
within 10 calendar days following the date of the service, the

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ground ambulance provider, medi-car provider, or service car
provider must document its attempt to obtain the requested
certification and may then submit the claim for payment.
Acceptable documentation includes a signed return receipt from
the U.S. Postal Service, facsimile receipt, email receipt, or
other similar service that evidences that the ground ambulance
provider, medi-car provider, or service car provider attempted
to obtain the required Physician Certification Statement.
The medical certification specifying the level and type of
non-emergency transportation needed shall be in the form of
the Physician Certification Statement on a standardized form
prescribed by the Department of Healthcare and Family
Services. Within 75 days after July 27, 2018 (the effective
date of Public Act 100-646), the Department of Healthcare and
Family Services shall develop a standardized form of the
Physician Certification Statement specifying the level and
type of transportation services needed in consultation with
the Department of Public Health, Medicaid managed care
organizations, a statewide association representing ambulance
providers, a statewide association representing hospitals, 3
statewide associations representing nursing homes, and other
stakeholders. The Physician Certification Statement shall
include, but is not limited to, the criteria necessary to
demonstrate medical necessity for the level of transport
needed as required by (i) the Department of Healthcare and
Family Services and (ii) the federal Centers for Medicare and

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Medicaid Services as outlined in the Centers for Medicare and
Medicaid Services' Medicare Benefit Policy Manual, Pub.
100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
Certification Statement shall satisfy the obligations of
hospitals under Section 6.22 of the Hospital Licensing Act and
nursing homes under Section 2-217 of the Nursing Home Care
Act. Implementation and acceptance of the Physician
Certification Statement shall take place no later than 90 days
after the issuance of the Physician Certification Statement by
the Department of Healthcare and Family Services.
Pursuant to subsection (E) of Section 12-4.25 of this
Code, the Department is entitled to recover overpayments paid
to a provider or vendor, including, but not limited to, from
the discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
Beginning October 1, 2018, the Department of Healthcare
and Family Services shall collect data from Medicaid managed
care organizations and transportation brokers, including the
Department's NETSPAP broker, regarding denials and appeals
related to the missing or incomplete Physician Certification
Statement forms and overall compliance with this subsection.
The Department of Healthcare and Family Services shall publish
quarterly results on its website within 15 days following the
end of each quarter.

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(h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(i) Subject to federal approval, on and after January 1,
2024 through June 30, 2026, the Department shall increase the
base rate of reimbursement for both base charges and mileage
charges for ground ambulance service providers not
participating in the Ground Emergency Medical Transportation
(GEMT) Program for medical transportation services provided by
means of a ground ambulance to a level not lower than 140% of
the base rate in effect as of January 1, 2023.
(j) For the purpose of understanding ground ambulance
transportation services cost structures and their impact on
the Medical Assistance Program, the Department shall engage
stakeholders, including, but not limited to, a statewide
association representing private ground ambulance service
providers in Illinois, to develop recommendations for a plan
for the regular collection of cost data for all ground
ambulance transportation providers reimbursed under the
Illinois Title XIX State Plan. Cost data obtained through this
process shall be used to inform on and to ensure the
effectiveness and efficiency of Illinois Medicaid rates. The
Department shall establish a process to limit public
availability of portions of the cost report data determined to

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be proprietary. This process shall be concluded and
recommendations shall be provided no later than April 1, 2024.
(k) (j) Subject to federal approval, beginning on January
1, 2024, the Department shall increase the base rate of
reimbursement for both base charges and mileage charges for
medical transportation services provided by means of an air
ambulance to a level not lower than 50% of the Medicare
ambulance fee schedule rates, by designated Medicare locality,
in effect on January 1, 2023.
(l) The General Assembly finds that access to ground
ambulance services improves health equity, increases access to
quality care, and reduces health disparities in underserved
communities. Due to the underfunding of these critical
services by the federal Medicare and Medicaid programs, there
is a growing scarcity of non-emergency ground ambulance
services in underserved, minority communities in this State,
including and particularly in those communities with
safety-net hospitals. To address this scarcity, the General
Assembly finds that the State has an interest in providing
funding to nongovernmental ground ambulance providers in
affected communities. The Safety-Net Ambulance Sustainability
Fund is created as a special fund in the State treasury. The
purpose of the Fund is to receive and disburse funds in
accordance with this subsection and for no other purpose. The
Fund shall consist of any federal, State, or private moneys
designated for deposit into the Fund and all interest earned

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