Illinois General Assembly - Full Text of SB0636
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Full Text of SB0636  98th General Assembly



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1    AN ACT concerning regulation.
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 and
15to provide appropriate incentives to ambulance service
16providers to provide services in an efficient and
17cost-effective manner. It is also the intent of the General
18Assembly to ensure that ambulance service providers are
19appropriately reimbursed for medically necessary ambulance
20services by requiring the Illinois Department to adopt, by
21rule, criteria establishing medical necessity and appropriate
22procedures for the processing of claims for reimbursement.
23Thus, it is the intent of the General Assembly that the



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1Illinois Department implement a reimbursement system for
2ambulance services that, to the extent practicable and subject
3to the availability of funds appropriated by the General
4Assembly for this purpose, is consistent with the payment
5principles of Medicare. To ensure uniformity between the
6payment principles of Medicare and Medicaid, the Illinois
7Department shall follow, to the extent necessary and
8practicable and subject to the availability of funds
9appropriated by the General Assembly for this purpose, the
10statutes, laws, regulations, policies, procedures, principles,
11definitions, guidelines, and manuals used to determine the
12amounts paid to ambulance service providers under Title XVIII
13of 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
21    (c) For purposes of this Section, "ambulance services"
22includes medical transportation services provided by means of
23an 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 described
7in the Emergency Medical Services (EMS) Systems Act that
8operates 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    (d) This Section does not prohibit separate billing by
14ambulance service providers for oxygen furnished while
15providing advanced life support services.
16    (e) Beginning with services rendered on or after July 1,
172008, all providers of non-emergency medi-car and service car
18transportation must certify that the driver and employee
19attendant, as applicable, have completed a safety program
20approved by the Department to protect both the patient and the
21driver, prior to transporting a patient. The provider must
22maintain this certification in its records. The provider shall
23produce such documentation upon demand by the Department or its
24representative. Failure to produce documentation of such
25training shall result in recovery of any payments made by the
26Department for services rendered by a non-certified driver or



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1employee attendant. Medi-car and service car providers must
2maintain legible documentation in their records of the driver
3and, as applicable, employee attendant that actually
4transported the patient. Providers must recertify all drivers
5and employee attendants every 3 years.
6    Notwithstanding the requirements above, any public
7transportation provider of medi-car and service car
8transportation that receives federal funding under 49 U.S.C.
95307 and 5311 need not certify its drivers and employee
10attendants under this Section, since safety training is already
11federally mandated.
12    (f) With respect to any policy or program administered by
13the Department or its agent regarding approval of non-emergency
14medical transportation by ground ambulance service providers,
15including, but not limited to, the Non-Emergency
16Transportation Services Prior Approval Program (NETSPAP), the
17Department shall establish by rule a process by which ground
18ambulance service providers of non-emergency medical
19transportation may appeal any decision by the Department or its
20agent in for which a claim is not approved for payment, but the
21patient meets the criteria for medical necessity and the
22appropriate level of ambulance service was provided. The
23Department shall consider appeals filed for reimbursement
24denials based upon the lack of availability of a physician
25discharge order occurring on or after July 1, 2013 if such
26appeal is filed within 90 days of the effective date of this



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1amendatory Act of the 98th General Assembly. The Department
2shall apply the medical criteria established by rule in
3determining all appeals and shall take into account all
4relevant documentation substantiating the patient's condition
5as it relates to the criteria for medical necessity and may
6accept a provider's run report or equivalent. no denial was
7received prior to the time of transport that either (i) denies
8a request for approval for payment of non-emergency
9transportation by means of ground ambulance service or (ii)
10grants a request for approval of non-emergency transportation
11by means of ground ambulance service at a level of service that
12entitles the ground ambulance service provider to a lower level
13of compensation from the Department than the ground ambulance
14service provider would have received as compensation for the
15level of service requested. The rule shall be filed by December
1615, 2012 and shall provide that, for any decision rendered by
17the Department or its agent on or after the date the rule takes
18effect, the ground ambulance service provider shall have 60
19days from the date the decision is received to file an appeal.
20The rule established by the Department shall be, insofar as is
21practical, consistent with the Illinois Administrative
22Procedure Act. The Director's decision on an appeal under this
23Section shall be a final administrative decision subject to
24review under the Administrative Review Law.
25    (f-5) Beginning 90 days after July 20, 2012 (the effective
26date of Public Act 97-842), (i) no denial of a request for



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1approval for payment of non-emergency transportation by means
2of ground ambulance service, and (ii) no approval of
3non-emergency transportation by means of ground ambulance
4service at a level of service that entitles the ground
5ambulance service provider to a lower level of compensation
6from the Department than would have been received at the level
7of service submitted by the ground ambulance service provider,
8may be issued by the Department or its agent unless the
9Department has submitted the criteria for determining the
10appropriateness of the transport for first notice publication
11in the Illinois Register pursuant to Section 5-40 of the
12Illinois Administrative Procedure Act.
13    (g) Whenever a patient covered by a medical assistance
14program under this Code or by another medical program
15administered by the Department is being discharged from a
16facility, a physician discharge order as described in this
17Section shall be required for each patient whose discharge
18requires medically supervised ground ambulance services.
19Facilities shall develop procedures for a physician with
20medical staff privileges to provide a written and signed
21physician discharge order. The physician discharge order shall
22specify the level of ground ambulance services needed and
23complete a medical certification establishing the criteria for
24approval of non-emergency ambulance transportation, as
25published by the Department of Healthcare and Family Services,
26that is met by the patient. This order and the medical



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1certification shall be completed prior to ordering an ambulance
2service and prior to patient discharge.
3    Pursuant to subsection (E) of Section 12-4.25 of this Code,
4the Department is entitled to recover overpayments paid to a
5provider or vendor, including, but not limited to, from the
6discharging physician, the discharging facility, and the
7ground ambulance service provider, in instances where a
8non-emergency ground ambulance service is rendered as the
9result of improper or false certification.
10    (h) On and after July 1, 2012, the Department shall reduce
11any rate of reimbursement for services or other payments or
12alter any methodologies authorized by this Code to reduce any
13rate of reimbursement for services or other payments in
14accordance with Section 5-5e.
15(Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12;
1697-842, eff. 7-20-12; 98-463, eff. 8-16-13.)
17    Section 99. Effective date. This Act takes effect upon
18becoming law.