HB1363 104TH GENERAL ASSEMBLY

LRB104 03271 KTG 13293 b

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB1363

Introduced 1/28/2025, by Rep. Dagmara Avelar

SYNOPSIS AS INTRODUCED:

210 ILCS 45/2-217
210 ILCS 85/6.22
305 ILCS 5/5-4.2

Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning non-emergency transportation services for medical assistance recipients, removes a requirement that facilities complete a Physician Certification Statement prior to ordering non-emergency transportation services for a patient. Instead, requires the Department of Healthcare and Family Services to develop, subject to federal approval, a Uniform Non-Emergency Transportation Certification Form (form) for non-emergency transportation. Provides that the form shall be the only form used by and required of all facilities, physicians, transportation providers, and transportation brokers whenever a patient or person covered by the medical assistance program is being transported from a facility or personal residence and requires non-emergency transportation. Makes corresponding changes to the Nursing Home Care Act and the Hospital Licensing Act. Further amends the Medical Assistance Article with a provision authorizing transportation brokers to use a network of independent driver providers for the delivery of covered transportation services. Provides that transportation brokers and participating independent driver providers shall be subject to the same driver credentialing and licensing standards and provider registration requirements as transportation network companies (TNC) and TNC drivers enrolled in the Impact Medicaid Program Advanced Cloud Technology system. With respect to the Department's Business Enterprise Program requirements for Medicaid managed care organizations (MCO), requires each MCO to submit only one Letter of Intent that consolidates and sets forth all pending transportation services from all BEP-certified transportation providers contracted with the MCO. Requires the Department to permit a MCO's transportation broker to attest to the accuracy of all claims for services provided by a contracted transportation provider.

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 Nursing Home Care Act is amended by changing Section 2-217 as follows:

(210 ILCS 45/2-217)

Sec. 2-217. Order for transportation of resident by an ambulance service provider. If a facility orders medi-car, service car, or ground ambulance transportation of a resident of the facility by an ambulance service provider, the facility must maintain a written record that shows (i) the name of the person who placed the order for that transportation and (ii) the medical reason for that transportation. Additionally, the facility must provide the ambulance service provider with a completed Uniform Non-Emergency Transportation Certification Form as Physician Certification Statement on a form prescribed by the Department of Healthcare and Family Services in accordance with subsection (g) of Section 5-4.2 of the Illinois Public Aid Code. The facility shall provide a copy of the completed Uniform Non-Emergency Transportation Certification Form Physician Certification Statement to the ambulance service provider prior to or at the time of transport. The Uniform Non-Emergency Transportation Certification Form Physician Certification Statement is not required prior to the transport if a delay in transport can be expected to negatively affect the patient outcome; however, the facility shall provide a copy of the Uniform Non-Emergency Transportation Certification Form Physician Certification Statement to the ambulance service provider at no charge within 10 days after the request. A facility shall, upon request, furnish assistance to the transportation provider in the completion of the form if the form Physician Certification Statement is incomplete. The facility must maintain the record for a period of at least 3 years after the date of the order for transportation by ambulance.

(Source: P.A. 100-646, eff. 7-27-18.)

Section 10. The Hospital Licensing Act is amended by changing Section 6.22 as follows:

(210 ILCS 85/6.22)

Sec. 6.22. Arrangement for transportation of patient by an ambulance service provider.

(a) In this Section:

"Ambulance service provider" means a Vehicle Service Provider as defined in the Emergency Medical Services (EMS) Systems Act who provides non-emergency transportation services by ambulance.

"Patient" means a person who is transported by an ambulance service provider.

(b) If a hospital arranges for medi-car, service car, or ground ambulance transportation of a patient of the hospital, the hospital must provide the ambulance service provider, at or prior to transport, a completed Uniform Non-Emergency Transportation Certification Form as prescribed by the Department of Healthcare and Family Services in subsection (g) of Section 5-4.2 of the Illinois Public Aid Code. Physician Certification Statement formatted and completed in compliance with federal regulations or an equivalent form developed by the hospital. Each hospital shall develop a policy requiring a physician or the physician's designee to complete the Uniform Non-Emergency Transportation Certification Form. The Uniform Non-Emergency Transportation Certification Form Physician Certification Statement. The Physician Certification Statement shall be maintained as part of the patient's medical record. A hospital shall, upon request, furnish assistance to the ambulance service provider in the completion of the form if the Uniform Non-Emergency Transportation Certification Form Physician Certification Statement is incomplete. The Physician Certification Statement or equivalent form is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome; however, a hospital shall provide a copy of the form Physician Certification Statement to the ambulance service provider at no charge within 10 days after the request.

(c) If a hospital is unable to provide a completed Uniform Non-Emergency Transportation Certification Form Physician Certification Statement or equivalent form, then the hospital shall provide to the patient a written notice and a verbal explanation of the written notice, which notice must meet all of the following requirements:

(1) The following caption must appear at the beginning of the notice in at least 14-point type: Notice to Patient Regarding Non-Emergency Ambulance Services.

(2) The notice must contain each of the following statements in at least 14-point type:

(A) The purpose of this notice is to help you make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance.

(B) Your insurance may not cover the charges for ambulance transportation.

(C) You may be responsible for the cost of ambulance transportation.

(D) The estimated cost of ambulance transportation is $(amount).

(3) The notice must be signed by the patient or by the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy.

(d) The notice set forth in subsection (c) of this Section shall not be required if a delay in transport can be expected to negatively affect the patient outcome.

(e) If a patient is physically or mentally unable to sign the notice described in subsection (c) of this Section and no authorized representative of the patient is available to sign the notice on the patient's behalf, the hospital must be able to provide documentation of the patient's inability to sign the notice and the unavailability of an authorized representative. In any case described in this subsection (e), the hospital shall be considered to have met the requirements of subsection (c) of this Section.

(Source: P.A. 100-646, eff. 7-27-18.)

Section 15. The Illinois Public Aid Code is amended by changing Section 5-4.2 as follows:

(305 ILCS 5/5-4.2)

Sec. 5-4.2. Ambulance services payments.

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

(b) 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.

(c) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, air ambulance, medi-car, service car, or taxi.

(c-1) For purposes of this Section, "ground ambulance service" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act.

(c-2) For purposes of this Section, "ground ambulance service provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services.

(c-3) For purposes of this Section, "medi-car" means transportation services provided to a patient who is confined to a wheelchair and requires the use of a hydraulic or electric lift or ramp and wheelchair lockdown when the patient's condition does not require medical observation, medical supervision, medical equipment, the administration of medications, or the administration of oxygen.

(c-4) For purposes of this Section, "service car" means transportation services provided to a patient by a passenger vehicle where that patient does not require the specialized modes described in subsection (c-1) or (c-3).

(c-5) For purposes of this Section, "air ambulance service" means medical transport by helicopter or airplane for patients, as defined in 29 U.S.C. 1185f(c)(1), and any service that is described as an air ambulance service by the federal Centers for Medicare and Medicaid Services.

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

(e) 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. If they meet the established training components set forth by the Department, providers of non-emergency medi-car and service car transportation that are either directly or through an affiliated company licensed by the Department of Public Health shall be approved by the Department to have in-house safety programs for training their own staff.

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.

(f) With respect to any policy or program administered by the Department or its agent regarding approval of non-emergency medical transportation by ground ambulance service providers, including, but not limited to, the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), the Department shall establish by rule a process by which ground ambulance service providers of non-emergency medical transportation may appeal any decision by the Department or its agent for which no denial was received prior to the time of transport that either (i) denies a request for approval for payment of non-emergency transportation by means of ground ambulance service or (ii) grants a request for approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than the ground ambulance service provider would have received as compensation for the level of service requested. The rule shall be filed by December 15, 2012 and shall provide that, for any decision rendered by the Department or its agent on or after the date the rule takes effect, the ground ambulance service provider shall have 60 days from the date the decision is received to file an appeal. The rule established by the Department shall be, insofar as is practical, consistent with the Illinois Administrative Procedure Act. The Director's decision on an appeal under this Section shall be a final administrative decision subject to review under the Administrative Review Law.

(f-5) Beginning 90 days after July 20, 2012 (the effective date of Public Act 97-842), (i) no denial of a request for approval for payment of non-emergency transportation by means of ground ambulance service, and (ii) no approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than would have been received at the level of service submitted by the ground ambulance service provider, may be issued by the Department or its agent unless the Department has submitted the criteria for determining the appropriateness of the transport for first notice publication in the Illinois Register pursuant to Section 5-40 of the Illinois Administrative Procedure Act.

(f-6) Within 90 days after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, the Department shall file rules to allow for the approval of ground ambulance services when the sole purpose of the transport is for the navigation of stairs or the assisting or lifting of a patient at a medical facility or during a medical appointment in instances where the Department or a contracted Medicaid managed care organization or their transportation broker is unable to secure transportation through any other transportation provider.

(f-7) For non-emergency ground ambulance claims properly denied under Department policy 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. Providers must 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. No later than May 31, 2022, the Department shall determine for which claims medical necessity was established. 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. 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. The appeal process described in subsection (f) shall not be applicable to the Department's determinations made in accordance with this subsection.

(g) Subject to federal approval, the Department of Healthcare and Family Services shall develop one Uniform Non-Emergency Transportation Certification Form for non-emergency transportation, including ground ambulance, medi-car, or service car transportation. The Department of Healthcare and Family Services shall develop the form in compliance with all applicable federal regulations and shall work in consultation with the Department of Public Health, Medicaid managed care organizations, a statewide association representing ambulance providers, a statewide association representing hospitals, 3 statewide associations representing nursing homes, and other stakeholders. The form shall be the only form used by and required of all facilities, physicians, transportation providers, and transportation brokers whenever Whenever a patient or person covered by a medical assistance program under this Code or by another medical program administered by the Department, including a patient or person covered under the State's Medicaid managed care program, is being transported from a facility or personal residence and requires non-emergency transportation including ground ambulance, medi-car, or service car transportation. The Uniform Non-Emergency Transportation Certification Form shall include a standard expiration date and shall provide a space for a facility, physician, transportation provider, or transportation broker to specify the level and type of non-emergency transportation needed and the scheduled service date. The Uniform Non-Emergency Transportation Certification Form shall also include, but is not limited to, the criteria necessary for a facility or physician to demonstrate medical necessity for the level of transport needed as required by (i) the Department of Healthcare and Family Services and (ii) the federal Centers for Medicare and Medicaid Services as outlined in the Centers for Medicare and Medicaid Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Uniform Non-Emergency Transportation Certification Form shall satisfy the obligations of hospitals under Section 6.22 of the Hospital Licensing Act and nursing homes under Section 2-217 of the Nursing Home Care Act. The Department of Healthcare and Family Services shall apply for any federal waivers or approvals necessary to develop and implement the Uniform Non-Emergency Transportation Certification Form. Implementation and acceptance of the form shall be contingent on the Department's receipt of all necessary federal waivers or approvals, if required, and shall take place no later than 90 days after the issuance of the form by the Department of Healthcare and Family Services. , a Physician Certification Statement as described in this Section shall be required for each patient.

Facilities shall develop procedures for a licensed medical professional to complete provide a written and signed Uniform Non-Emergency Transportation Certification Form. A written and signed Uniform Non-Emergency Transportation Certification Form shall Physician Certification Statement. The Physician Certification Statement shall specify the level of transportation services needed and complete a medical certification establishing the criteria for approval of non-emergency ambulance transportation, as published by the Department of Healthcare and Family Services, that is met by the patient. This medical certification shall be completed prior to ordering the transportation service and prior to patient discharge. The Uniform Non-Emergency Transportation Certification Form Physician Certification Statement is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome. If the ground ambulance provider, medi-car provider, or service car provider is unable to obtain a completed Uniform Non-Emergency Transportation Certification Form from the discharging facility the required Physician Certification Statement within 10 calendar days following the date of the service, the ground ambulance provider, medi-car provider, or service car provider must document its attempt to obtain the requested certification and may then submit the claim for payment. Acceptable documentation includes a signed return receipt from the U.S. Postal Service, facsimile receipt, email receipt, or other similar service that evidences that the ground ambulance provider, medi-car provider, or service car provider attempted to obtain the required Uniform Non-Emergency Transportation Certification Form from the discharging facility. Physician Certification Statement.

The medical certification specifying the level and type of non-emergency transportation needed shall be in the form of the Physician Certification Statement on a standardized form prescribed by the Department of Healthcare and Family Services. Within 75 days after July 27, 2018 (the effective date of Public Act 100-646), the Department of Healthcare and Family Services shall develop a standardized form of the Physician Certification Statement specifying the level and type of transportation services needed in consultation with the Department of Public Health, Medicaid managed care organizations, a statewide association representing ambulance providers, a statewide association representing hospitals, 3 statewide associations representing nursing homes, and other stakeholders. The Physician Certification Statement shall include, but is not limited to, the criteria necessary to demonstrate medical necessity for the level of transport needed as required by (i) the Department of Healthcare and Family Services and (ii) the federal Centers for Medicare and Medicaid Services as outlined in the Centers for Medicare and Medicaid Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician Certification Statement shall satisfy the obligations of hospitals under Section 6.22 of the Hospital Licensing Act and nursing homes under Section 2-217 of the Nursing Home Care Act. Implementation and acceptance of the Physician Certification Statement shall take place no later than 90 days after the issuance of the Physician Certification Statement by the Department of Healthcare and Family Services.

Pursuant to subsection (E) of Section 12-4.25 of this Code, the Department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification.

Beginning one year after the issuance of the Uniform Non-Emergency Transportation Certification Form, the Beginning October 1, 2018, the Department of Healthcare and Family Services shall collect data from Medicaid managed care organizations and transportation brokers, including the Department's NETSPAP broker, regarding denials and appeals related to the missing or incomplete Uniform Non-Emergency Transportation Certification Form Physician Certification Statement forms and overall compliance with this subsection. The Department of Healthcare and Family Services shall publish quarterly results on its website within 15 days following the end of each quarter.

(h) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

(i) Subject to federal approval, on and after January 1, 2024, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers not participating in the Ground Emergency Medical Transportation (GEMT) Program for medical transportation services provided by means of a ground ambulance to a level not lower than 140% of the base rate in effect as of January 1, 2023.

(j) For the purpose of understanding ground ambulance transportation services cost structures and their impact on the Medical Assistance Program, the Department shall engage stakeholders, including, but not limited to, a statewide association representing private ground ambulance service providers in Illinois, to develop recommendations for a plan for the regular collection of cost data for all ground ambulance transportation providers reimbursed under the Illinois Title XIX State Plan. Cost data obtained through this process shall be used to inform on and to ensure the effectiveness and efficiency of Illinois Medicaid rates. The Department shall establish a process to limit public availability of portions of the cost report data determined to be proprietary. This process shall be concluded and recommendations shall be provided no later than December 31, 2025.

(k) Subject to federal approval, beginning on January 1, 2024, the Department 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 50% of the Medicare ambulance fee schedule rates, by designated Medicare locality, in effect on January 1, 2023.

(l) To ensure the availability of non-emergency transportation services to medical assistance recipients, a transportation broker contracted with a Medicaid managed care organization shall be authorized to use a network of independent driver providers for the delivery of covered transportation services. A transportation broker and its participating independent driver providers shall be subject to the same driver credentialing and licensing standards and provider registration requirements as transportation network companies (TNC) and TNC drivers enrolled in the Impact Medicaid Program Advanced Cloud Technology system. The Department shall apply for any federal waivers or approvals necessary to implement the provisions of this subsection. Implementation shall be contingent upon the Department's receipt of all necessary federal waivers or approvals.

(m) In order to minimize the administrative burden placed on Medicaid managed care organizations and their contracting transportation providers in meeting the Department's Business Enterprise Program requirements, the Department shall require each Medicaid managed care organization to submit only one Letter of Intent that consolidates and sets forth, as prescribed by the Department, all pending transportation services from all BEP-certified transportation providers contracted with the Medicaid managed care organization. In addition, the Department shall permit a Medicaid managed care organization's transportation broker to act on behalf of a transportation provider and attest to the accuracy of all claims for services provided by the transportation provider.

(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article 70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section 80-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff. 7-1-24.)