HB2502 98TH GENERAL ASSEMBLY

LRB098 05562 KTG 35599 b

98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB2502

Introduced , by Rep. Esther Golar

SYNOPSIS AS INTRODUCED:

New Act
215 ILCS 5/356z.22 new

Creates the Complex Needs Patient Act. Requires the Department of Healthcare and Family Services to provide separate recognition within the State's Medicaid program for individually configured complex rehabilitation technology products and services for complex needs patients. Defines "complex needs patient" to mean an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities. Provides that the separate recognition for technology products and services for complex needs patients shall take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs. Provides that the Department shall require complex needs patients receiving complex rehabilitation technology to be evaluated by a qualified health care professional and a qualified complex rehabilitation technology professional. Amends the Illinois Insurance Code. Provides that a managed care plan amended, delivered, issued, or renewed in this State after the effective date of the amendatory Act shall adopt the regulations and policies outlined in the Complex Needs Patient Act. Effective immediately.

FISCAL NOTE ACT MAY APPLY

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 1. Short title. This Act may be cited as the Complex Needs Patient Act.

Section 5. Purpose.

It is the intent of the General Assembly to:

(1) protect access for complex needs patients to important technology and supporting services;

(2) establish and improve safeguards relating to the delivery and provision of medically necessary complex rehabilitation technology;

(3) provide supports for complex needs patients to stay in the home or community setting, prevent institutionalization, and prevent hospitalizations and other costly secondary complications; and

(4) establish adequate pricing for complex rehabilitation technology for the purpose of allowing continued access to appropriate products and services.

Section 10. Definitions. As used in this Act:

(a) "Complex needs patient" means an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities. Such term shall include individuals with progressive or degenerative neuromuscular diseases or injuries or trauma which resulted in significant physical or functional needs and capacities, including, but not limited to, individuals with spinal cord injury, traumatic brain injury, cerebral palsy, muscular dystrophy, spina bifida, osteogenesis imperfecta, arthrogryposis, amyotrophic lateral sclerosis, multiple sclerosis, demyelinating disease, myelopathy, myopathy, progressive muscular atrophy, anterior horn cell disease, post-polio syndrome, cerebellar degeneration, dystonia, Huntington's disease, spinocerebellar disease, and certain types of amputation, paralysis, or paresis that result in significant physical or functional needs and capacities.

(b) "Complex rehabilitation technology" means items currently classified by the Centers for Medicare and Medicaid Services as of January 1, 2013 as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary to prevent hospitalization or institutionalization of a complex needs patient. Such items shall include, but not be limited to, complex rehabilitation power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment such as standing frames and gait trainers. The related Healthcare Common Procedure Code System (HCPCS) billing codes include, but are not limited to:

(1) Pure Complex Rehab Technology (CRT) Codes: These HCPCS codes contain 100% CRT products: E0637, E0638, E0641, E0642, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1014, E1037, E1161, E1220, E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E2209, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2351, E2373, E2374, E2376, E2377, E2609, E2610, E2617, E8000, E8001, E8002, K0005, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, and K0898.

(2) Mixed CRT Codes: These HCPCS codes contain a mix of CRT products and standard mobility and accessory products: E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0960, E0967, E0978, E0990, E1015, E1016, E1028, E1029, E1030, E2205, E2208, E2231, E2368, E2369, E2370, E2605, E2606, E2607, E2608, E2613, E2614, E2615, E2616, E2620, E2621, E2624, E2625, K0004, K0009, K0040, K0108, and K0669.

(3) Future codes created to expand on or replace those indicated in paragraphs (1) and (2) of this subsection.

(c) "Individually configured" means a combination of features, adjustments, or modifications a supplier makes to a device that are specific to an individual and that the supplier provides by measuring, fitting, programming, adjusting, or adapting the device as appropriate so that the device is consistent with an assessment or evaluation of the individual by a health care professional and consistent with the individual's medical condition, physical and functional needs, capacities, body size, period of need, and intended use.

(d) "Qualified complex rehabilitation technology supplier" means a company or entity that:

(1) is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology;

(2) is enrolled in the Medicare program and meets the supplier and quality standards established for durable medical equipment suppliers under the Medicare program;

(3) employs at least one complex rehabilitation technology professional for each location to (i) analyze the needs and capacities of qualified individuals with complex medical needs, (ii) assist in selecting appropriate covered complex rehabilitation technology items for such needs and capacities, and (iii) provide training in the use of the selected covered complex rehabilitation technology items; the complex rehabilitation technology professional shall be certified by the Rehabilitation Engineering and Assistive Technology Society of North America as an Assistive Technology Professional (ATP);

(4) has the complex rehabilitation technology professional physically present for the evaluation and determination of the appropriate individually configured complex rehabilitation technologies for the qualified individual with complex medical needs; and

(5) provides service and repair by qualified technicians for all complex rehabilitation technology products it sells.

(e) "Qualified complex rehabilitation technology professional" means an individual who is certified by the Rehabilitation Engineering and Assistive Technology Society of North America as an Assistive Technology Professional (ATP).

Section 15. Creation of a separate recognition for complex rehabilitation technology.

(a) The Department of Healthcare and Family Services shall provide a separate recognition within the State's Medicaid program established under Article V of the Illinois Public Aid Code for complex rehabilitation technology and shall make other required changes to protect access to appropriate products and services. The Department shall provide separate recognition for individually configured complex rehabilitation technology products and services for complex needs patients. Such separate recognition shall take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs by doing all of the following:

(1) By using as a reference those billing codes listed under paragraphs (1) and (2) of subsection (b) of Section 10, designating appropriate current billing codes as complex rehabilitation technology and, as needed, creating new billing codes for services and products covered for complex needs patients.

(2) Establishing specific supplier standards for companies or entities that provide complex rehabilitation technology and restricting the provision of complex rehabilitation technology to only those companies or entities that meet such standards.

(3) Developing pricing policies for complex rehabilitation technology by doing all of the following:

(A) The billing codes referenced under paragraphs (1) and (2) of subsection (b) of Section 10 shall maintain a reimbursement level of no less than 100% of the current Medicare fee schedule amount minus 6%. If the item is not covered by Medicare or is individually considered for reimbursement, then the State's Medicaid plan shall adopt an allowable amount at the Manufacturer's Suggested Retail Price (MSRP) minus 10%.

(B) Adopting the usage of KE billing code modifiers used to help maintain access to complex rehabilitation technology products for those patients who require it.

(C) Modifying the prior approval requirement for wheelchair repairs to apply only when the cost of any one part is greater than or equal to $500 per line item, when the sum of the parts is greater than or equal to a total of $1,500, or when 8 or more units of labor are to be billed. This change shall allow Medicaid beneficiaries to retain access to timely service and repair for routine maintenance while also allowing for a more thorough State review on higher dollar claims. Repair requests shall not require the provider to obtain a physician's prescription. The only exception to this shall be for modifications, which are defined as the addition of a part that was not already on the equipment. Repairs shall also be priced by the Department at the Medicare fee schedule amount minus 6% for set rate items and for those without a Medicare allowable amount at MSRP minus 10%. The Department shall allow for expedited approval of repairs that include wheelchair batteries. Additionally, the Department shall expand its expedited approval process to include circumstances in which the patient's wheelchair will be inoperable without the needed repair, causing the patient to be bed-bound or otherwise confined.

(D) Exempting the billing codes referenced in paragraphs (1) and (2) of subsection (b) of Section 10 from inclusion in any competitive bidding or other such programs.

(4) Making other changes as needed to protect access to complex rehabilitation technology for people with complex medical needs.

(b) The Department of Healthcare and Family Services shall require complex needs patients receiving complex rehabilitation technology to be evaluated by:

(1) a qualified health care professional, including, but not limited to, a physical therapist, occupational therapist, or other health care professional who performs specialty evaluations within his or her scope of practice; and

(2) a qualified complex rehabilitation technology professional.

Section 20. The Illinois Insurance Code is amended by adding Section 356z.22 as follows:

(215 ILCS 5/356z.22 new)

Sec. 356z.22. Coverage for complex rehabilitation technology products and services for complex needs patients. A managed care plan amended, delivered, issued, or renewed in this State after the effective date of this amendatory Act of the 98th General Assembly shall adopt the regulations and policies outlined in the Complex Needs Patient Act.

Section 99. Effective date. This Act takes effect upon becoming law.