96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB0542

 

Introduced 2/4/2009, 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.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1     AN ACT concerning public aid.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Public Aid Code is amended by
5 changing 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) It is the intent of the General Assembly to provide
9 adequate reimbursement for ambulance services so as to ensure
10 adequate access to services for both recipients of aid under
11 this Article and for the general population of Illinois. Unless
12 otherwise indicated in this Section, the practices of the
13 Illinois Department where it concerns ambulance service
14 payments shall be consistent with the payment principles of
15 Medicare to include the statutes, laws, regulations, policies,
16 procedures, principles, definitions, guidelines, coding
17 systems, including the ambulance condition coding system, and
18 manuals used to determine the payment system to ambulance
19 service providers under Title XVIII of the Social Security Act.
20     (b) For ambulance services provided to a recipient of aid
21 under this Article on or after July 1, 2009 January 1, 1993,
22 the Illinois Department shall reimburse ambulance service
23 providers at rates calculated in accordance with this Section.

 

 

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1         (1) Payment for non-emergency ambulance services base
2     rates shall be at a rate that is the lesser of the
3     provider's charge, as reflected on the provider's claim
4     form, or 60% of the Medicare Ambulance Fee Schedule amount
5     for the designated Medicare Locality, except that any
6     non-emergency base rate previously approved by the
7     Illinois Department that exceeds 60% of the Medicare
8     Ambulance Fee Schedule amount for the designated Medicare
9     Locality shall remain in force.
10         (2) Payment for emergency ambulance services base
11     rates shall be at a rate that is the lesser of the
12     provider's charge, as reflected on the provider's claim
13     form, or 80% of the Medicare Ambulance Fee Schedule amount
14     for the designated Medicare Locality, except that any
15     emergency base rate previously approved by the Illinois
16     Department that exceeds 80% of the Medicare Ambulance Fee
17     Schedule amount for the designated Medicare Locality shall
18     remain in force.
19         (3) Payment for mileage shall be per loaded mile with
20     no loaded mileage included in the base rate. If a natural
21     disaster, weather, or other conditions necessitate a route
22     other than the most direct route, reimbursement shall be
23     based upon the actual distance traveled. For mileage
24     associated to emergency base rates, payment shall be at a
25     rate that is the lesser of the provider's charge, as
26     reflected on the provider's claim form, or 80% of the

 

 

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1     Medicare Ambulance Fee Schedule rate for the designated
2     Medicare Locality, except that any mileage rate previously
3     approved by the Illinois Department that exceeds 80% of the
4     Medicare Ambulance Fee Schedule rate for the designated
5     Medicare Locality shall remain in force. For mileage
6     associated with non-emergency base rates, payment shall be
7     at a rate that is the lesser of the provider's charge, as
8     reflected on the provider's claim form, or 60% of the
9     Medicare Ambulance Fee Schedule rate for the designated
10     Medicare Locality, except that any mileage rate previously
11     approved by the Illinois Department that exceeds 60% of the
12     Medicare Ambulance Fee Schedule rate for the designated
13     Medicare Locality shall remain in force.
14         (4) For advanced life support services and specialty
15     care transport services provided during transport of a
16     patient between hospitals in an emergency situation for a
17     higher level of care, payments shall be made at the
18     emergency base rate and all other such services shall be
19     paid at the non-emergency base rate.
20     (c) The requirement for payment of ground ambulance
21 services by the Illinois Department is deemed to be met if the
22 services are provided pursuant to a request for evaluation,
23 treatment, and transport for an individual with a condition of
24 such a nature that a prudent layperson would have reasonably
25 expected that a delay in seeking immediate medical attention
26 would have been hazardous to life or health. This standard is

 

 

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1 deemed to be met if there is an emergency medical condition
2 manifesting itself by acute symptoms of sufficient severity,
3 including but not limited to severe pain, such that a prudent
4 layperson who possesses an average of knowledge of medicine and
5 health can reasonably expect the absence of immediate medical
6 attention could result in placing the health of the individual
7 or, with respect to a pregnant woman, the health of the woman
8 or her unborn child, in serious jeopardy, cause serious
9 impairment to bodily functions, or cause serious dysfunction of
10 any bodily organ or part.
11     (d) The Illinois Department shall update the Medicaid
12 ambulance fee schedule rates annually on July 1 to be in
13 compliance with the Medicare ambulance fee schedule rates in
14 effect at the time of the update. It is the intent of the
15 General Assembly to provide adequate reimbursement for
16 ambulance services so as to ensure adequate access to services
17 for recipients of aid under this Article and to provide
18 appropriate incentives to ambulance service providers to
19 provide services in an efficient and cost-effective manner.
20 Thus, it is the intent of the General Assembly that the
21 Illinois Department implement a reimbursement system for
22 ambulance services that, to the extent practicable and subject
23 to the availability of funds appropriated by the General
24 Assembly for this purpose, is consistent with the payment
25 principles of Medicare. To ensure uniformity between the
26 payment principles of Medicare and Medicaid, the Illinois

 

 

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1 Department shall follow, to the extent necessary and
2 practicable and subject to the availability of funds
3 appropriated by the General Assembly for this purpose, the
4 statutes, laws, regulations, policies, procedures, principles,
5 definitions, guidelines, and manuals used to determine the
6 amounts paid to ambulance service providers under Title XVIII
7 of the Social Security Act (Medicare).
8     For ambulance services provided to a recipient of aid under
9 this Article on or after January 1, 1996, the Illinois
10 Department shall reimburse ambulance service providers based
11 upon the actual distance traveled if a natural disaster,
12 weather conditions, road repairs, or traffic congestion
13 necessitates the use of a route other than the most direct
14 route.
15     (e) For purposes of this Section, "ambulance services"
16 includes medical transportation services provided by means of a
17 licensed ambulance and does not include transportation
18 services provided by a an ambulance, medi-car, service car, or
19 taxi, or other form of transportation not defined as an
20 ambulance service by Medicare or the Emergency Medical Services
21 (EMS) Systems Act.
22     This Section does not prohibit separate billing by
23 ambulance service providers for oxygen furnished while
24 providing advanced life support services.
25     Beginning with services rendered on or after July 1, 2008,
26 all providers of non-emergency medi-car and service car

 

 

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1 transportation must certify that the driver and employee
2 attendant, as applicable, have completed a safety program
3 approved by the Department to protect both the patient and the
4 driver, prior to transporting a patient. The provider must
5 maintain this certification in its records. The provider shall
6 produce such documentation upon demand by the Department or its
7 representative. Failure to produce documentation of such
8 training shall result in recovery of any payments made by the
9 Department for services rendered by a non-certified driver or
10 employee attendant. Medi-car and service car providers must
11 maintain legible documentation in their records of the driver
12 and, as applicable, employee attendant that actually
13 transported the patient. Providers must recertify all drivers
14 and employee attendants every 3 years.
15     Notwithstanding the requirements above, any public
16 transportation provider of medi-car and service car
17 transportation that receives federal funding under 49 U.S.C.
18 5307 and 5311 need not certify its drivers and employee
19 attendants under this Section, since safety training is already
20 federally mandated.
21 (Source: P.A. 95-501, eff. 8-28-07.)