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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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. The State Finance Act is amended by adding 
5Section 5.1015 as follows:

6 (30 ILCS 105/5.1015 new)
7 Sec. 5.1015. The Safety-Net Ambulance Sustainability Fund.

8 Section 5. The Illinois Public Aid Code is amended by 
9changing Section 5-4.2 as follows:

10 (305 ILCS 5/5-4.2)
11 Sec. 5-4.2. Ambulance services payments. 
12 (a) For ambulance services provided to a recipient of aid 
13under this Article on or after January 1, 1993, the Illinois 
14Department shall reimburse ambulance service providers at 
15rates calculated in accordance with this Section. It is the 
16intent of the General Assembly to provide adequate 
17reimbursement for ambulance services so as to ensure adequate 
18access to services for recipients of aid under this Article 
19and to provide appropriate incentives to ambulance service 
20providers to provide services in an efficient and 
21cost-effective manner. Thus, it is the intent of the General 
 
 
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1Assembly that the Illinois Department implement a 
2reimbursement system for ambulance services that, to the 
3extent practicable and subject to the availability of funds 
4appropriated by the General Assembly for this purpose, is 
5consistent with the payment principles of Medicare. To ensure 
6uniformity between the payment principles of Medicare and 
7Medicaid, the Illinois Department shall follow, to the extent 
8necessary and practicable and subject to the availability of 
9funds appropriated by the General Assembly for this purpose, 
10the statutes, laws, regulations, policies, procedures, 
11principles, definitions, guidelines, and manuals used to 
12determine the amounts paid to ambulance service providers 
13under Title XVIII of the Social Security Act (Medicare).
14 (b) For ambulance services provided to a recipient of aid 
15under this Article on or after January 1, 1996, the Illinois 
16Department shall reimburse ambulance service providers based 
17upon the actual distance traveled if a natural disaster, 
18weather conditions, road repairs, or traffic congestion 
19necessitates the use of a route other than the most direct 
20route.
21 (c) For purposes of this Section, "ambulance services" 
22includes medical transportation services provided by means of 
23an ambulance, air ambulance, medi-car, service car, or taxi.
24 (c-1) For purposes of this Section, "ground ambulance 
25service" means medical transportation services that are 
26described as ground ambulance services by the Centers for 
 
 
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1Medicare and Medicaid Services and provided in a vehicle that 
2is licensed as an ambulance by the Illinois Department of 
3Public Health pursuant to the Emergency Medical Services (EMS) 
4Systems Act.
5 (c-2) For purposes of this Section, "ground ambulance 
6service provider" means a vehicle service provider as 
7described in the Emergency Medical Services (EMS) Systems Act 
8that operates licensed ambulances for the purpose of providing 
9emergency ambulance services, or non-emergency ambulance 
10services, or both. For purposes of this Section, this includes 
11both ambulance providers and ambulance suppliers as described 
12by the Centers for Medicare and Medicaid Services.
13 (c-3) For purposes of this Section, "medi-car" means 
14transportation services provided to a patient who is confined 
15to a wheelchair and requires the use of a hydraulic or electric 
16lift or ramp and wheelchair lockdown when the patient's 
17condition does not require medical observation, medical 
18supervision, medical equipment, the administration of 
19medications, or the administration of oxygen. 
20 (c-4) For purposes of this Section, "service car" means 
21transportation services provided to a patient by a passenger 
22vehicle where that patient does not require the specialized 
23modes described in subsection (c-1) or (c-3). 
24 (c-5) For purposes of this Section, "air ambulance 
25service" means medical transport by helicopter or airplane for 
26patients, as defined in 29 U.S.C. 1185f(c)(1), and any service 
 
 
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1that is described as an air ambulance service by the federal 
2Centers for Medicare and Medicaid Services. 
3 (d) This Section does not prohibit separate billing by 
4ambulance service providers for oxygen furnished while 
5providing advanced life support services.
6 (e) Beginning with services rendered on or after July 1, 
72008, all providers of non-emergency medi-car and service car 
8transportation must certify that the driver and employee 
9attendant, as applicable, have completed a safety program 
10approved by the Department to protect both the patient and the 
11driver, prior to transporting a patient. The provider must 
12maintain this certification in its records. The provider shall 
13produce such documentation upon demand by the Department or 
14its representative. Failure to produce documentation of such 
15training shall result in recovery of any payments made by the 
16Department for services rendered by a non-certified driver or 
17employee attendant. Medi-car and service car providers must 
18maintain legible documentation in their records of the driver 
19and, as applicable, employee attendant that actually 
20transported the patient. Providers must recertify all drivers 
21and employee attendants every 3 years. If they meet the 
22established training components set forth by the Department, 
23providers of non-emergency medi-car and service car 
24transportation that are either directly or through an 
25affiliated company licensed by the Department of Public Health 
26shall be approved by the Department to have in-house safety 
 
 
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1programs for training their own staff. 
2 Notwithstanding the requirements above, any public 
3transportation provider of medi-car and service car 
4transportation that receives federal funding under 49 U.S.C. 
55307 and 5311 need not certify its drivers and employee 
6attendants under this Section, since safety training is 
7already federally mandated. 
8 (f) With respect to any policy or program administered by 
9the Department or its agent regarding approval of 
10non-emergency medical transportation by ground ambulance 
11service providers, including, but not limited to, the 
12Non-Emergency Transportation Services Prior Approval Program 
13(NETSPAP), the Department shall establish by rule a process by 
14which ground ambulance service providers of non-emergency 
15medical transportation may appeal any decision by the 
16Department or its agent for which no denial was received prior 
17to the time of transport that either (i) denies a request for 
18approval for payment of non-emergency transportation by means 
19of ground ambulance service or (ii) grants a request for 
20approval of non-emergency transportation by means of ground 
21ambulance service at a level of service that entitles the 
22ground ambulance service provider to a lower level of 
23compensation from the Department than the ground ambulance 
24service provider would have received as compensation for the 
25level of service requested. The rule shall be filed by 
26December 15, 2012 and shall provide that, for any decision 
 
 
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1rendered by the Department or its agent on or after the date 
2the rule takes effect, the ground ambulance service provider 
3shall have 60 days from the date the decision is received to 
4file an appeal. The rule established by the Department shall 
5be, insofar as is practical, consistent with the Illinois 
6Administrative Procedure Act. The Director's decision on an 
7appeal under this Section shall be a final administrative 
8decision subject to review under the Administrative Review 
9Law. 
10 (f-5) Beginning 90 days after July 20, 2012 (the effective 
11date of Public Act 97-842), (i) no denial of a request for 
12approval for payment of non-emergency transportation by means 
13of ground ambulance service, and (ii) no approval of 
14non-emergency transportation by means of ground ambulance 
15service at a level of service that entitles the ground 
16ambulance service provider to a lower level of compensation 
17from the Department than would have been received at the level 
18of service submitted by the ground ambulance service provider, 
19may be issued by the Department or its agent unless the 
20Department has submitted the criteria for determining the 
21appropriateness of the transport for first notice publication 
22in the Illinois Register pursuant to Section 5-40 of the 
23Illinois Administrative Procedure Act. 
24 (f-6) Within 90 days after June 2, 2022 (the effective 
25date of Public Act 102-1037) this amendatory Act of the 102nd 
26General Assembly and subject to federal approval, the 
 
 
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1Department shall file rules to allow for the approval of 
2ground ambulance services when the sole purpose of the 
3transport is for the navigation of stairs or the assisting or 
4lifting of a patient at a medical facility or during a medical 
5appointment in instances where the Department or a contracted 
6Medicaid managed care organization or their transportation 
7broker is unable to secure transportation through any other 
8transportation provider. 
9 (f-7) For non-emergency ground ambulance claims properly 
10denied under Department policy at the time the claim is filed 
11due to failure to submit a valid Medical Certification for 
12Non-Emergency Ambulance on and after December 15, 2012 and 
13prior to January 1, 2021, the Department shall allot 
14$2,000,000 to a pool to reimburse such claims if the provider 
15proves medical necessity for the service by other means. 
16Providers must submit any such denied claims for which they 
17seek compensation to the Department no later than December 31, 
182021 along with documentation of medical necessity. No later 
19than May 31, 2022, the Department shall determine for which 
20claims medical necessity was established. Such claims for 
21which medical necessity was established shall be paid at the 
22rate in effect at the time of the service, provided the 
23$2,000,000 is sufficient to pay at those rates. If the pool is 
24not sufficient, claims shall be paid at a uniform percentage 
25of the applicable rate such that the pool of $2,000,000 is 
26exhausted. The appeal process described in subsection (f) 
 
 
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1shall not be applicable to the Department's determinations 
2made in accordance with this subsection. 
3 (g) Whenever a patient covered by a medical assistance 
4program under this Code or by another medical program 
5administered by the Department, including a patient covered 
6under the State's Medicaid managed care program, is being 
7transported from a facility and requires non-emergency 
8transportation including ground ambulance, medi-car, or 
9service car transportation, a Physician Certification 
10Statement as described in this Section shall be required for 
11each patient. Facilities shall develop procedures for a 
12licensed medical professional to provide a written and signed 
13Physician Certification Statement. The Physician Certification 
14Statement shall specify the level of transportation services 
15needed and complete a medical certification establishing the 
16criteria for approval of non-emergency ambulance 
17transportation, as published by the Department of Healthcare 
18and Family Services, that is met by the patient. This 
19certification shall be completed prior to ordering the 
20transportation service and prior to patient discharge. The 
21Physician Certification Statement is not required prior to 
22transport if a delay in transport can be expected to 
23negatively affect the patient outcome. If the ground ambulance 
24provider, medi-car provider, or service car provider is unable 
25to obtain the required Physician Certification Statement 
26within 10 calendar days following the date of the service, the 
 
 
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1ground ambulance provider, medi-car provider, or service car 
2provider must document its attempt to obtain the requested 
3certification and may then submit the claim for payment. 
4Acceptable documentation includes a signed return receipt from 
5the U.S. Postal Service, facsimile receipt, email receipt, or 
6other similar service that evidences that the ground ambulance 
7provider, medi-car provider, or service car provider attempted 
8to obtain the required Physician Certification Statement. 
9 The medical certification specifying the level and type of 
10non-emergency transportation needed shall be in the form of 
11the Physician Certification Statement on a standardized form 
12prescribed by the Department of Healthcare and Family 
13Services. Within 75 days after July 27, 2018 (the effective 
14date of Public Act 100-646), the Department of Healthcare and 
15Family Services shall develop a standardized form of the 
16Physician Certification Statement specifying the level and 
17type of transportation services needed in consultation with 
18the Department of Public Health, Medicaid managed care 
19organizations, a statewide association representing ambulance 
20providers, a statewide association representing hospitals, 3 
21statewide associations representing nursing homes, and other 
22stakeholders. The Physician Certification Statement shall 
23include, but is not limited to, the criteria necessary to 
24demonstrate medical necessity for the level of transport 
25needed as required by (i) the Department of Healthcare and 
26Family Services and (ii) the federal Centers for Medicare and 
 
 
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1Medicaid Services as outlined in the Centers for Medicare and 
2Medicaid Services' Medicare Benefit Policy Manual, Pub. 
3100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician 
4Certification Statement shall satisfy the obligations of 
5hospitals under Section 6.22 of the Hospital Licensing Act and 
6nursing homes under Section 2-217 of the Nursing Home Care 
7Act. Implementation and acceptance of the Physician 
8Certification Statement shall take place no later than 90 days 
9after the issuance of the Physician Certification Statement by 
10the Department of Healthcare and Family Services. 
11 Pursuant to subsection (E) of Section 12-4.25 of this 
12Code, the Department is entitled to recover overpayments paid 
13to a provider or vendor, including, but not limited to, from 
14the discharging physician, the discharging facility, and the 
15ground ambulance service provider, in instances where a 
16non-emergency ground ambulance service is rendered as the 
17result of improper or false certification. 
18 Beginning October 1, 2018, the Department of Healthcare 
19and Family Services shall collect data from Medicaid managed 
20care organizations and transportation brokers, including the 
21Department's NETSPAP broker, regarding denials and appeals 
22related to the missing or incomplete Physician Certification 
23Statement forms and overall compliance with this subsection. 
24The Department of Healthcare and Family Services shall publish 
25quarterly results on its website within 15 days following the 
26end of each quarter. 
 
 
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1 (h) On and after July 1, 2012, the Department shall reduce 
2any rate of reimbursement for services or other payments or 
3alter any methodologies authorized by this Code to reduce any 
4rate of reimbursement for services or other payments in 
5accordance with Section 5-5e. 
6 (i) Subject to federal approval, on and after January 1, 
72024 through June 30, 2026, the Department shall increase the 
8base rate of reimbursement for both base charges and mileage 
9charges for ground ambulance service providers not 
10participating in the Ground Emergency Medical Transportation 
11(GEMT) Program for medical transportation services provided by 
12means of a ground ambulance to a level not lower than 140% of 
13the base rate in effect as of January 1, 2023.
14 (j) For the purpose of understanding ground ambulance 
15transportation services cost structures and their impact on 
16the Medical Assistance Program, the Department shall engage 
17stakeholders, including, but not limited to, a statewide 
18association representing private ground ambulance service 
19providers in Illinois, to develop recommendations for a plan 
20for the regular collection of cost data for all ground 
21ambulance transportation providers reimbursed under the 
22Illinois Title XIX State Plan. Cost data obtained through this 
23process shall be used to inform on and to ensure the 
24effectiveness and efficiency of Illinois Medicaid rates. The 
25Department shall establish a process to limit public 
26availability of portions of the cost report data determined to 
 
 
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1be proprietary. This process shall be concluded and 
2recommendations shall be provided no later than April 1, 2024. 
3 (k) (j) Subject to federal approval, beginning on January 
41, 2024, the Department shall increase the base rate of 
5reimbursement for both base charges and mileage charges for 
6medical transportation services provided by means of an air 
7ambulance to a level not lower than 50% of the Medicare 
8ambulance fee schedule rates, by designated Medicare locality, 
9in effect on January 1, 2023. 
10 (l) The General Assembly finds that access to ground 
11ambulance services improves health equity, increases access to 
12quality care, and reduces health disparities in underserved 
13communities. Due to the underfunding of these critical 
14services by the federal Medicare and Medicaid programs, there 
15is a growing scarcity of non-emergency ground ambulance 
16services in underserved, minority communities in this State, 
17including and particularly in those communities with 
18safety-net hospitals. To address this scarcity, the General 
19Assembly finds that the State has an interest in providing 
20funding to nongovernmental ground ambulance providers in 
21affected communities. The Safety-Net Ambulance Sustainability 
22Fund is created as a special fund in the State treasury. The 
23purpose of the Fund is to receive and disburse funds in 
24accordance with this subsection and for no other purpose. The 
25Fund shall consist of any federal, State, or private moneys 
26designated for deposit into the Fund and all interest earned 
 
 
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