103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB2577

 

Introduced 2/15/2023, by Rep. Jay Hoffman

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-4.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning reimbursement rates for ambulance services, provides that ambulance services includes medical transportation services provided by means of air ambulance. Provides that on and after July 1, 2023, the Department of Healthcare and Family Services 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 75% of the Medicare ambulance fee schedule rates, by designated Medicare locality, in effect on January 1, 2023. Effective July 1, 2023.


LRB103 29817 KTG 56225 b

 

 

A BILL FOR

 

HB2577LRB103 29817 KTG 56225 b

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 5. The Illinois Public Aid Code is amended by
5changing Section 5-4.2 as follows:
 
6    (305 ILCS 5/5-4.2)
7    Sec. 5-4.2. Ambulance services payments.
8    (a) For ambulance services provided to a recipient of aid
9under this Article on or after January 1, 1993, the Illinois
10Department shall reimburse ambulance service providers at
11rates calculated in accordance with this Section. It is the
12intent of the General Assembly to provide adequate
13reimbursement for ambulance services so as to ensure adequate
14access to services for recipients of aid under this Article
15and to provide appropriate incentives to ambulance service
16providers to provide services in an efficient and
17cost-effective manner. Thus, it is the intent of the General
18Assembly that the Illinois Department implement a
19reimbursement system for ambulance services that, to the
20extent practicable and subject to the availability of funds
21appropriated by the General Assembly for this purpose, is
22consistent with the payment principles of Medicare. To ensure
23uniformity between the payment principles of Medicare and

 

 

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1Medicaid, the Illinois Department shall follow, to the extent
2necessary and practicable and subject to the availability of
3funds appropriated by the General Assembly for this purpose,
4the statutes, laws, regulations, policies, procedures,
5principles, definitions, guidelines, and manuals used to
6determine the amounts paid to ambulance service providers
7under Title XVIII of the Social Security Act (Medicare).
8    (b) For ambulance services provided to a recipient of aid
9under this Article on or after January 1, 1996, the Illinois
10Department shall reimburse ambulance service providers based
11upon the actual distance traveled if a natural disaster,
12weather conditions, road repairs, or traffic congestion
13necessitates the use of a route other than the most direct
14route.
15    (c) For purposes of this Section, "ambulance services"
16includes medical transportation services provided by means of
17an ambulance, air ambulance, medi-car, service car, or taxi.
18    (c-1) For purposes of this Section, "ground ambulance
19service" means medical transportation services that are
20described as ground ambulance services by the Centers for
21Medicare and Medicaid Services and provided in a vehicle that
22is licensed as an ambulance by the Illinois Department of
23Public Health pursuant to the Emergency Medical Services (EMS)
24Systems Act.
25    (c-2) For purposes of this Section, "ground ambulance
26service provider" means a vehicle service provider as

 

 

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1described in the Emergency Medical Services (EMS) Systems Act
2that operates licensed ambulances for the purpose of providing
3emergency ambulance services, or non-emergency ambulance
4services, or both. For purposes of this Section, this includes
5both ambulance providers and ambulance suppliers as described
6by the Centers for Medicare and Medicaid Services.
7    (c-3) For purposes of this Section, "medi-car" means
8transportation services provided to a patient who is confined
9to a wheelchair and requires the use of a hydraulic or electric
10lift or ramp and wheelchair lockdown when the patient's
11condition does not require medical observation, medical
12supervision, medical equipment, the administration of
13medications, or the administration of oxygen.
14    (c-4) For purposes of this Section, "service car" means
15transportation services provided to a patient by a passenger
16vehicle where that patient does not require the specialized
17modes described in subsection (c-1) or (c-3).
18    (c-5) For purposes of this Section, "air ambulance
19service" means medical transport by helicopter or airplane for
20patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
21that is described as an air ambulance service by the federal
22Centers for Medicare and Medicaid Services.
23    (d) This Section does not prohibit separate billing by
24ambulance service providers for oxygen furnished while
25providing advanced life support services.
26    (e) Beginning with services rendered on or after July 1,

 

 

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12008, all providers of non-emergency medi-car and service car
2transportation must certify that the driver and employee
3attendant, as applicable, have completed a safety program
4approved by the Department to protect both the patient and the
5driver, prior to transporting a patient. The provider must
6maintain this certification in its records. The provider shall
7produce such documentation upon demand by the Department or
8its representative. Failure to produce documentation of such
9training shall result in recovery of any payments made by the
10Department for services rendered by a non-certified driver or
11employee attendant. Medi-car and service car providers must
12maintain legible documentation in their records of the driver
13and, as applicable, employee attendant that actually
14transported the patient. Providers must recertify all drivers
15and employee attendants every 3 years. If they meet the
16established training components set forth by the Department,
17providers of non-emergency medi-car and service car
18transportation that are either directly or through an
19affiliated company licensed by the Department of Public Health
20shall be approved by the Department to have in-house safety
21programs for training their own staff.
22    Notwithstanding the requirements above, any public
23transportation provider of medi-car and service car
24transportation that receives federal funding under 49 U.S.C.
255307 and 5311 need not certify its drivers and employee
26attendants under this Section, since safety training is

 

 

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1already federally mandated.
2    (f) With respect to any policy or program administered by
3the Department or its agent regarding approval of
4non-emergency medical transportation by ground ambulance
5service providers, including, but not limited to, the
6Non-Emergency Transportation Services Prior Approval Program
7(NETSPAP), the Department shall establish by rule a process by
8which ground ambulance service providers of non-emergency
9medical transportation may appeal any decision by the
10Department or its agent for which no denial was received prior
11to the time of transport that either (i) denies a request for
12approval for payment of non-emergency transportation by means
13of ground ambulance service or (ii) grants a request for
14approval of non-emergency transportation by means of ground
15ambulance service at a level of service that entitles the
16ground ambulance service provider to a lower level of
17compensation from the Department than the ground ambulance
18service provider would have received as compensation for the
19level of service requested. The rule shall be filed by
20December 15, 2012 and shall provide that, for any decision
21rendered by the Department or its agent on or after the date
22the rule takes effect, the ground ambulance service provider
23shall have 60 days from the date the decision is received to
24file an appeal. The rule established by the Department shall
25be, insofar as is practical, consistent with the Illinois
26Administrative Procedure Act. The Director's decision on an

 

 

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1appeal under this Section shall be a final administrative
2decision subject to review under the Administrative Review
3Law.
4    (f-5) Beginning 90 days after July 20, 2012 (the effective
5date of Public Act 97-842), (i) no denial of a request for
6approval for payment of non-emergency transportation by means
7of ground ambulance service, and (ii) no approval of
8non-emergency transportation by means of ground ambulance
9service at a level of service that entitles the ground
10ambulance service provider to a lower level of compensation
11from the Department than would have been received at the level
12of service submitted by the ground ambulance service provider,
13may be issued by the Department or its agent unless the
14Department has submitted the criteria for determining the
15appropriateness of the transport for first notice publication
16in the Illinois Register pursuant to Section 5-40 of the
17Illinois Administrative Procedure Act.
18    (f-6) Within 90 days after the effective date of this
19amendatory Act of the 102nd General Assembly and subject to
20federal approval, the Department shall file rules to allow for
21the approval of ground ambulance services when the sole
22purpose of the transport is for the navigation of stairs or the
23assisting or lifting of a patient at a medical facility or
24during a medical appointment in instances where the Department
25or a contracted Medicaid managed care organization or their
26transportation broker is unable to secure transportation

 

 

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1through any other transportation provider.
2    (f-7) For non-emergency ground ambulance claims properly
3denied under Department policy at the time the claim is filed
4due to failure to submit a valid Medical Certification for
5Non-Emergency Ambulance on and after December 15, 2012 and
6prior to January 1, 2021, the Department shall allot
7$2,000,000 to a pool to reimburse such claims if the provider
8proves medical necessity for the service by other means.
9Providers must submit any such denied claims for which they
10seek compensation to the Department no later than December 31,
112021 along with documentation of medical necessity. No later
12than May 31, 2022, the Department shall determine for which
13claims medical necessity was established. Such claims for
14which medical necessity was established shall be paid at the
15rate in effect at the time of the service, provided the
16$2,000,000 is sufficient to pay at those rates. If the pool is
17not sufficient, claims shall be paid at a uniform percentage
18of the applicable rate such that the pool of $2,000,000 is
19exhausted. The appeal process described in subsection (f)
20shall not be applicable to the Department's determinations
21made in accordance with this subsection.
22    (g) Whenever a patient covered by a medical assistance
23program under this Code or by another medical program
24administered by the Department, including a patient covered
25under the State's Medicaid managed care program, is being
26transported from a facility and requires non-emergency

 

 

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1transportation including ground ambulance, medi-car, or
2service car transportation, a Physician Certification
3Statement as described in this Section shall be required for
4each patient. Facilities shall develop procedures for a
5licensed medical professional to provide a written and signed
6Physician Certification Statement. The Physician Certification
7Statement shall specify the level of transportation services
8needed and complete a medical certification establishing the
9criteria for approval of non-emergency ambulance
10transportation, as published by the Department of Healthcare
11and Family Services, that is met by the patient. This
12certification shall be completed prior to ordering the
13transportation service and prior to patient discharge. The
14Physician Certification Statement is not required prior to
15transport if a delay in transport can be expected to
16negatively affect the patient outcome. If the ground ambulance
17provider, medi-car provider, or service car provider is unable
18to obtain the required Physician Certification Statement
19within 10 calendar days following the date of the service, the
20ground ambulance provider, medi-car provider, or service car
21provider must document its attempt to obtain the requested
22certification and may then submit the claim for payment.
23Acceptable documentation includes a signed return receipt from
24the U.S. Postal Service, facsimile receipt, email receipt, or
25other similar service that evidences that the ground ambulance
26provider, medi-car provider, or service car provider attempted

 

 

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1to obtain the required Physician Certification Statement.
2    The medical certification specifying the level and type of
3non-emergency transportation needed shall be in the form of
4the Physician Certification Statement on a standardized form
5prescribed by the Department of Healthcare and Family
6Services. Within 75 days after July 27, 2018 (the effective
7date of Public Act 100-646), the Department of Healthcare and
8Family Services shall develop a standardized form of the
9Physician Certification Statement specifying the level and
10type of transportation services needed in consultation with
11the Department of Public Health, Medicaid managed care
12organizations, a statewide association representing ambulance
13providers, a statewide association representing hospitals, 3
14statewide associations representing nursing homes, and other
15stakeholders. The Physician Certification Statement shall
16include, but is not limited to, the criteria necessary to
17demonstrate medical necessity for the level of transport
18needed as required by (i) the Department of Healthcare and
19Family Services and (ii) the federal Centers for Medicare and
20Medicaid Services as outlined in the Centers for Medicare and
21Medicaid Services' Medicare Benefit Policy Manual, Pub.
22100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
23Certification Statement shall satisfy the obligations of
24hospitals under Section 6.22 of the Hospital Licensing Act and
25nursing homes under Section 2-217 of the Nursing Home Care
26Act. Implementation and acceptance of the Physician

 

 

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1Certification Statement shall take place no later than 90 days
2after the issuance of the Physician Certification Statement by
3the Department of Healthcare and Family Services.
4    Pursuant to subsection (E) of Section 12-4.25 of this
5Code, the Department is entitled to recover overpayments paid
6to a provider or vendor, including, but not limited to, from
7the discharging physician, the discharging facility, and the
8ground ambulance service provider, in instances where a
9non-emergency ground ambulance service is rendered as the
10result of improper or false certification.
11    Beginning October 1, 2018, the Department of Healthcare
12and Family Services shall collect data from Medicaid managed
13care organizations and transportation brokers, including the
14Department's NETSPAP broker, regarding denials and appeals
15related to the missing or incomplete Physician Certification
16Statement forms and overall compliance with this subsection.
17The Department of Healthcare and Family Services shall publish
18quarterly results on its website within 15 days following the
19end of each quarter.
20    (h) On and after July 1, 2012, the Department shall reduce
21any rate of reimbursement for services or other payments or
22alter any methodologies authorized by this Code to reduce any
23rate of reimbursement for services or other payments in
24accordance with Section 5-5e.
25    (i) On and after July 1, 2018, the Department shall
26increase the base rate of reimbursement for both base charges

 

 

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1and mileage charges for ground ambulance service providers for
2medical transportation services provided by means of a ground
3ambulance to a level not lower than 112% of the base rate in
4effect as of June 30, 2018.
5    (j) On and after July 1, 2023, the Department shall
6increase the base rate of reimbursement for both base charges
7and mileage charges for medical transportation services
8provided by means of an air ambulance to a level not lower than
975% of the Medicare ambulance fee schedule rates, by
10designated Medicare locality, in effect on January 1, 2023.
11(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
12102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
135-13-22; 102-1037, eff. 6-2-22.)
 
14    Section 99. Effective date. This Act takes effect July 1,
152023.