103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5857

 

Introduced 5/24/2024, 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.


LRB103 40887 KTG 73847 b

 

 

A BILL FOR

 

HB5857LRB103 40887 KTG 73847 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 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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1on moneys in the Fund. Moneys in the Fund, including all
2accrued interest thereon, shall only be used and disbursed by
3the Department to support the operating expenses of
4nongovernmental ground ambulance providers in high-Medicaid
5communities. Any amounts expended from the Fund that are later
6recouped by the Department following an audit or otherwise
7shall be returned to the Fund.
8(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;
9102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
1070, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
1180-5, eff. 1-1-24; revised 12-15-23.)