Bill Text: IL SB2325 | 2021-2022 | 102nd General Assembly | Enrolled


Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that for non-emergency ground ambulance claims properly denied under the policy of the Department of Healthcare and Family Services 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. Requires providers to 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. Provides that no later than May 31, 2022, the Department shall determine for which claims medical necessity was established. Provides that 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. Provides that 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. Provides that the appeal process described in a specified provision of the Code shall not be applicable to the Department's determinations. Effective immediately.

Spectrum: Slight Partisan Bill (Democrat 3-1)

Status: (Enrolled) 2021-06-29 - Sent to the Governor [SB2325 Detail]

Download: Illinois-2021-SB2325-Enrolled.html



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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 5. The Illinois Public Aid Code is amended by
5changing 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 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, 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 (d) This Section does not prohibit separate billing by
19ambulance service providers for oxygen furnished while
20providing advanced life support services.
21 (e) Beginning with services rendered on or after July 1,
222008, all providers of non-emergency medi-car and service car
23transportation must certify that the driver and employee
24attendant, as applicable, have completed a safety program
25approved by the Department to protect both the patient and the
26driver, prior to transporting a patient. The provider must

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1maintain this certification in its records. The provider shall
2produce such documentation upon demand by the Department or
3its representative. Failure to produce documentation of such
4training shall result in recovery of any payments made by the
5Department for services rendered by a non-certified driver or
6employee attendant. Medi-car and service car providers must
7maintain legible documentation in their records of the driver
8and, as applicable, employee attendant that actually
9transported the patient. Providers must recertify all drivers
10and employee attendants every 3 years.
11 Notwithstanding the requirements above, any public
12transportation provider of medi-car and service car
13transportation that receives federal funding under 49 U.S.C.
145307 and 5311 need not certify its drivers and employee
15attendants under this Section, since safety training is
16already federally mandated.
17 (f) With respect to any policy or program administered by
18the Department or its agent regarding approval of
19non-emergency medical transportation by ground ambulance
20service providers, including, but not limited to, the
21Non-Emergency Transportation Services Prior Approval Program
22(NETSPAP), the Department shall establish by rule a process by
23which ground ambulance service providers of non-emergency
24medical transportation may appeal any decision by the
25Department or its agent for which no denial was received prior
26to the time of transport that either (i) denies a request for

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1approval for payment of non-emergency transportation by means
2of ground ambulance service or (ii) grants a request for
3approval of non-emergency transportation by means of ground
4ambulance service at a level of service that entitles the
5ground ambulance service provider to a lower level of
6compensation from the Department than the ground ambulance
7service provider would have received as compensation for the
8level of service requested. The rule shall be filed by
9December 15, 2012 and shall provide that, for any decision
10rendered by the Department or its agent on or after the date
11the rule takes effect, the ground ambulance service provider
12shall have 60 days from the date the decision is received to
13file an appeal. The rule established by the Department shall
14be, insofar as is practical, consistent with the Illinois
15Administrative Procedure Act. The Director's decision on an
16appeal under this Section shall be a final administrative
17decision subject to review under the Administrative Review
18Law.
19 (f-5) Beginning 90 days after July 20, 2012 (the effective
20date of Public Act 97-842), (i) no denial of a request for
21approval for payment of non-emergency transportation by means
22of ground ambulance service, and (ii) no approval of
23non-emergency transportation by means of ground ambulance
24service at a level of service that entitles the ground
25ambulance service provider to a lower level of compensation
26from the Department than would have been received at the level

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1of service submitted by the ground ambulance service provider,
2may be issued by the Department or its agent unless the
3Department has submitted the criteria for determining the
4appropriateness of the transport for first notice publication
5in the Illinois Register pursuant to Section 5-40 of the
6Illinois Administrative Procedure Act.
7 (f-7) For non-emergency ground ambulance claims properly
8denied under Department policy at the time the claim is filed
9due to failure to submit a valid Medical Certification for
10Non-Emergency Ambulance on and after December 15, 2012 and
11prior to January 1, 2021, the Department shall allot
12$2,000,000 to a pool to reimburse such claims if the provider
13proves medical necessity for the service by other means.
14Providers must submit any such denied claims for which they
15seek compensation to the Department no later than December 31,
162021 along with documentation of medical necessity. No later
17than May 31, 2022, the Department shall determine for which
18claims medical necessity was established. Such claims for
19which medical necessity was established shall be paid at the
20rate in effect at the time of the service, provided the
21$2,000,000 is sufficient to pay at those rates. If the pool is
22not sufficient, claims shall be paid at a uniform percentage
23of the applicable rate such that the pool of $2,000,000 is
24exhausted. The appeal process described in subsection (f)
25shall not be applicable to the Department's determinations
26made in accordance with this subsection.

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1 (g) Whenever a patient covered by a medical assistance
2program under this Code or by another medical program
3administered by the Department, including a patient covered
4under the State's Medicaid managed care program, is being
5transported from a facility and requires non-emergency
6transportation including ground ambulance, medi-car, or
7service car transportation, a Physician Certification
8Statement as described in this Section shall be required for
9each patient. Facilities shall develop procedures for a
10licensed medical professional to provide a written and signed
11Physician Certification Statement. The Physician Certification
12Statement shall specify the level of transportation services
13needed and complete a medical certification establishing the
14criteria for approval of non-emergency ambulance
15transportation, as published by the Department of Healthcare
16and Family Services, that is met by the patient. This
17certification shall be completed prior to ordering the
18transportation service and prior to patient discharge. The
19Physician Certification Statement is not required prior to
20transport if a delay in transport can be expected to
21negatively affect the patient outcome. If the ground ambulance
22provider, medi-car provider, or service car provider is unable
23to obtain the required Physician Certification Statement
24within 10 calendar days following the date of the service, the
25ground ambulance provider, medi-car provider, or service car
26provider must document its attempt to obtain the requested

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1certification and may then submit the claim for payment.
2Acceptable documentation includes a signed return receipt from
3the U.S. Postal Service, facsimile receipt, email receipt, or
4other similar service that evidences that the ground ambulance
5provider, medi-car provider, or service car provider attempted
6to obtain the required Physician Certification Statement.
7 The medical certification specifying the level and type of
8non-emergency transportation needed shall be in the form of
9the Physician Certification Statement on a standardized form
10prescribed by the Department of Healthcare and Family
11Services. Within 75 days after July 27, 2018 (the effective
12date of Public Act 100-646), the Department of Healthcare and
13Family Services shall develop a standardized form of the
14Physician Certification Statement specifying the level and
15type of transportation services needed in consultation with
16the Department of Public Health, Medicaid managed care
17organizations, a statewide association representing ambulance
18providers, a statewide association representing hospitals, 3
19statewide associations representing nursing homes, and other
20stakeholders. The Physician Certification Statement shall
21include, but is not limited to, the criteria necessary to
22demonstrate medical necessity for the level of transport
23needed as required by (i) the Department of Healthcare and
24Family Services and (ii) the federal Centers for Medicare and
25Medicaid Services as outlined in the Centers for Medicare and
26Medicaid Services' Medicare Benefit Policy Manual, Pub.

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1100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
2Certification Statement shall satisfy the obligations of
3hospitals under Section 6.22 of the Hospital Licensing Act and
4nursing homes under Section 2-217 of the Nursing Home Care
5Act. Implementation and acceptance of the Physician
6Certification Statement shall take place no later than 90 days
7after the issuance of the Physician Certification Statement by
8the Department of Healthcare and Family Services.
9 Pursuant to subsection (E) of Section 12-4.25 of this
10Code, the Department is entitled to recover overpayments paid
11to a provider or vendor, including, but not limited to, from
12the discharging physician, the discharging facility, and the
13ground ambulance service provider, in instances where a
14non-emergency ground ambulance service is rendered as the
15result of improper or false certification.
16 Beginning October 1, 2018, the Department of Healthcare
17and Family Services shall collect data from Medicaid managed
18care organizations and transportation brokers, including the
19Department's NETSPAP broker, regarding denials and appeals
20related to the missing or incomplete Physician Certification
21Statement forms and overall compliance with this subsection.
22The Department of Healthcare and Family Services shall publish
23quarterly results on its website within 15 days following the
24end of each quarter.
25 (h) On and after July 1, 2012, the Department shall reduce
26any rate of reimbursement for services or other payments or

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1alter any methodologies authorized by this Code to reduce any
2rate of reimbursement for services or other payments in
3accordance with Section 5-5e.
4 (i) On and after July 1, 2018, the Department shall
5increase the base rate of reimbursement for both base charges
6and mileage charges for ground ambulance service providers for
7medical transportation services provided by means of a ground
8ambulance to a level not lower than 112% of the base rate in
9effect as of June 30, 2018.
10(Source: P.A. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18;
11101-81, eff. 7-12-19; 101-649, eff. 7-7-20.)
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