95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
HB5613

 

Introduced , by Rep. John E. Bradley

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-4.2   from Ch. 23, par. 5-4.2

    Amends the Illinois Public Aid Code. Replaces the provisions concerning medical assistance payments for ambulance services. Provides that for ambulance services provided to a recipient of medical assistance on or after July 1, 2008, the Department of Healthcare and Family Services shall reimburse ambulance service providers for base charges and mileage charges based upon the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule rate calculated in accordance with the provisions set forth in the bill. Provides that the requirement of payment by the Department for ground ambulance services is deemed to be met if the services are provided pursuant to a request for evaluation, treatment, and transport from an individual with a condition of such a nature that a prudent layperson would have reasonably expected that a delay in seeking immediate medical attention would have been hazardous to life or health. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

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,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-4.2 as follows:
 
6     (305 ILCS 5/5-4.2)  (from Ch. 23, par. 5-4.2)
7     Sec. 5-4.2. Ambulance services payments.
8     (a) For purposes of this Section, "ambulance services"
9 includes medical transportation services provided by means of a
10 licensed ambulance and does not include transportation
11 services provided by a medi-car, service car, taxi, or other
12 form of transportation not defined as an ambulance service by
13 Medicare or the Illinois Emergency Medical Services (EMS)
14 Systems Act.
15     (b) It is the intent of the General Assembly to provide
16 adequate reimbursement for ambulance services so as to ensure
17 adequate access to services for both recipients of aid under
18 this Article and for the general population of Illinois. Unless
19 otherwise indicated in this Section, the practices of the
20 Department of Healthcare and Family Services in connection with
21 ambulance service payments shall be consistent with the payment
22 principles of Medicare to include the statutes, laws,
23 regulations, policies, procedures, principles, definitions,

 

 

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1 guidelines, coding systems, including the ambulance condition
2 coding system, and manuals used to determine the payment system
3 to ambulance service providers under Title XVIII of the Social
4 Security Act.
5     (c) For ambulance services provided to a recipient of aid
6 under this Article on or after July 1, 2008, the Department
7 shall reimburse ambulance service providers for base charges
8 and mileage charges based upon the lesser of the provider's
9 charge, as reflected on the provider's claim form, or the
10 Illinois Medicaid Ambulance Fee Schedule rate calculated in
11 accordance with this Section.
12         (1) Effective July 1, 2008 through June 30, 2009, for
13     each individual base rate and mileage rate, the Illinois
14     Medicaid Ambulance Fee Schedule rate shall be based on 75%
15     of the Medicaid rate for ambulance services in effect as of
16     January 1, 2008 and 25% of the Medicare Ambulance Fee
17     Schedule amount in effect on January 1, 2008 for the
18     designated Medicare Locality, except that any rate that was
19     previously approved by the Department that exceeds this
20     amount shall remain in force.
21         (2) Effective July 1, 2009 through June 30, 2010, for
22     each individual base rate and mileage rate, the Illinois
23     Medicaid Ambulance Fee Schedule rate shall be based on 50%
24     of the Medicaid rate for ambulance services that was in
25     effect as of January 1, 2008 and 50% of the Medicare
26     Ambulance Fee Schedule amount in effect on January 1, 2009

 

 

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1     for the designated Medicare Locality, except that any rate
2     that was previously approved by the Department that exceeds
3     this amount shall remain in force.
4         (3) Effective July 1, 2010 through June 30, 2011, for
5     each individual base rate and mileage rate, the Illinois
6     Medicaid Ambulance Fee Schedule rate shall be based on 25%
7     of the Medicaid rate for ambulance services that was in
8     effect as of January 1, 2008 and 75% of the Medicare
9     Ambulance Fee Schedule amount in effect on January 1, 2010
10     for the designated Medicare Locality, except that any rate
11     that was previously approved by the Department that exceeds
12     this amount shall remain in force.
13         (4) On July 1, 2011, and on each July 1 thereafter, the
14     Department shall update the Illinois Medicaid Ambulance
15     Fee Schedule rates annually so that they are the same as
16     the Medicare Ambulance Fee Schedule rate in effect at the
17     time of the update for the designated Medicare Locality.
18     (d) Payment for mileage shall be per loaded mile with no
19 loaded mileage included in the base rate. If a natural
20 disaster, weather, or other conditions necessitate a route
21 other than the most direct route, reimbursement shall be based
22 on the actual distance traveled.
23     (e) The requirement of payment by the Department for ground
24 ambulance services is deemed to be met if the services are
25 provided pursuant to a request for evaluation, treatment, and
26 transport from an individual with a condition of such a nature

 

 

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1 that a prudent layperson would have reasonably expected that a
2 delay in seeking immediate medical attention would have been
3 hazardous to life or health. This standard will be deemed to be
4 met if there is an emergency medical condition manifesting
5 itself by acute symptoms of sufficient severity, including but
6 not limited to severe pain, such that a prudent layperson who
7 possesses an average of knowledge of medicine and health can
8 reasonably that expect the absence of immediate medical
9 attention could result in placing the health of the individual
10 or, with respect to a pregnant woman, the health of the woman
11 or her unborn child, in serious jeopardy, serious impairment to
12 bodily functions, or serious dysfunction of any bodily organ or
13 part.
14 For ambulance services provided to a recipient of aid under
15 this Article on or after January 1, 1993, the Illinois
16 Department shall reimburse ambulance service providers at
17 rates calculated in accordance with this Section. It is the
18 intent of the General Assembly to provide adequate
19 reimbursement for ambulance services so as to ensure adequate
20 access to services for recipients of aid under this Article and
21 to provide appropriate incentives to ambulance service
22 providers to provide services in an efficient and
23 cost-effective manner. Thus, it is the intent of the General
24 Assembly that the Illinois Department implement a
25 reimbursement system for ambulance services that, to the extent
26 practicable and subject to the availability of funds

 

 

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1 appropriated by the General Assembly for this purpose, is
2 consistent with the payment principles of Medicare. To ensure
3 uniformity between the payment principles of Medicare and
4 Medicaid, the Illinois Department shall follow, to the extent
5 necessary and practicable and subject to the availability of
6 funds appropriated by the General Assembly for this purpose,
7 the statutes, laws, regulations, policies, procedures,
8 principles, definitions, guidelines, and manuals used to
9 determine the amounts paid to ambulance service providers under
10 Title XVIII of the Social Security Act (Medicare).
11     For ambulance services provided to a recipient of aid under
12 this Article on or after January 1, 1996, the Illinois
13 Department shall reimburse ambulance service providers based
14 upon the actual distance traveled if a natural disaster,
15 weather conditions, road repairs, or traffic congestion
16 necessitates the use of a route other than the most direct
17 route.
18     For purposes of this Section, "ambulance services"
19 includes medical transportation services provided by means of
20 an ambulance, medi-car, service car, or taxi.
21     This Section does not prohibit separate billing by
22 ambulance service providers for oxygen furnished while
23 providing advanced life support services.
24     Beginning with services rendered on or after July 1, 2008,
25 all providers of non-emergency medi-car and service car
26 transportation must certify that the driver and employee

 

 

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1 attendant, as applicable, have completed a safety program
2 approved by the Department to protect both the patient and the
3 driver, prior to transporting a patient. The provider must
4 maintain this certification in its records. The provider shall
5 produce such documentation upon demand by the Department or its
6 representative. Failure to produce documentation of such
7 training shall result in recovery of any payments made by the
8 Department for services rendered by a non-certified driver or
9 employee attendant. Medi-car and service car providers must
10 maintain legible documentation in their records of the driver
11 and, as applicable, employee attendant that actually
12 transported the patient. Providers must recertify all drivers
13 and employee attendants every 3 years.
14     Notwithstanding the requirements above, any public
15 transportation provider of medi-car and service car
16 transportation that receives federal funding under 49 U.S.C.
17 5307 and 5311 need not certify its drivers and employee
18 attendants under this Section, since safety training is already
19 federally mandated.
20 (Source: P.A. 95-501, eff. 8-28-07.)
 
21     Section 99. Effective date. This Act takes effect upon
22 becoming law.