HB5331 96TH GENERAL ASSEMBLY

LRB096 18929 KTG 34317 b

96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB5331

Introduced 2/5/2010, by Rep. Dan Reitz

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-4.2

from Ch. 23, par. 5-4.2

Amends the Illinois Public Aid Code. Provides formulas for Medicaid reimbursement of ambulance service providers for emergency ambulance services, non-emergency ambulance services, mileage, advanced life support services, and specialty care transport services. Provides that the requirement for payment of ground ambulance services by the Illinois Department of Healthcare and Family Services is met if the services are provided pursuant to a request for evaluation, treatment, and transport for 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. Requires the Department to annually update the ambulance fee schedule rates on July 1 of each year. Makes other changes.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

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

(305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)

Sec. 5-4.2. Ambulance services payments.

(a) It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for both recipients of aid under this Article and for the general population of Illinois. Unless otherwise indicated in this Section, the practices of the Illinois Department where it concerns ambulance service payments shall be consistent with the payment principles of Medicare to include the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, coding systems, including the ambulance condition coding system, and manuals used to determine the payment system to ambulance service providers under Title XVIII of the Social Security Act.

(b) For ambulance services provided to a recipient of aid under this Article on or after July 1, 2010 January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section.

(1) Payment for non-emergency ambulance services base rates shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 60% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality, except that any non-emergency base rate previously approved by the Illinois Department that exceeds 60% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality shall remain in force.

(2) Payment for emergency ambulance services base rates shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 80% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality, except that any emergency base rate previously approved by the Illinois Department that exceeds 80% of the Medicare Ambulance Fee Schedule amount for the designated Medicare Locality shall remain in force.

(3) Payment for mileage shall be per loaded mile with no loaded mileage included in the base rate. If a natural disaster, weather, or other conditions necessitate a route other than the most direct route, reimbursement shall be based upon the actual distance traveled. For mileage associated to emergency base rates, payment shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 80% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality, except that any mileage rate previously approved by the Illinois Department that exceeds 80% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality shall remain in force. For mileage associated with non-emergency base rates, payment shall be at a rate that is the lesser of the provider's charge, as reflected on the provider's claim form, or 60% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality, except that any mileage rate previously approved by the Illinois Department that exceeds 60% of the Medicare Ambulance Fee Schedule rate for the designated Medicare Locality shall remain in force.

(4) For advanced life support services and specialty care transport services provided during transport of a patient between hospitals in an emergency situation for a higher level of care, payments shall be made at the emergency base rate and all other such services shall be paid at the non-emergency base rate.

(c) The requirement for payment of ground ambulance services by the Illinois Department is deemed to be met if the services are provided pursuant to a request for evaluation, treatment, and transport for 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. This standard is deemed to be met if there is an emergency medical condition manifesting itself by acute symptoms of sufficient severity, including but not limited to severe pain, such that a prudent layperson who possesses an average of knowledge of medicine and health can reasonably expect the absence of immediate medical attention could result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part.

(d) The Illinois Department shall update the Medicaid ambulance fee schedule rates annually on July 1 to be in compliance with the Medicare ambulance fee schedule rates in effect at the time of the update. 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 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).

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.

(e) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of a licensed ambulance and does not include transportation services provided by a an ambulance, medi-car, service car, or taxi, or other form of transportation not defined as an ambulance service by Medicare or the Emergency Medical Services (EMS) Systems Act.

This Section does not prohibit separate billing by ambulance service providers for oxygen furnished while providing advanced life support services.

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.

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.

(Source: P.A. 95-501, eff. 8-28-07.)