Illinois General Assembly - Full Text of SB0636
Illinois General Assembly

Previous General Assemblies

Full Text of SB0636  98th General Assembly


Sen. Antonio Muñoz

Filed: 10/23/2013





09800SB0636sam001LRB098 04421 KTG 49241 a


2    AMENDMENT NO. ______. Amend Senate Bill 636 by replacing
3everything after the enacting clause with the following:
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



09800SB0636sam001- 2 -LRB098 04421 KTG 49241 a

1cost-effective manner. It is also the intent of the General
2Assembly to ensure that ambulance service providers are
3appropriately reimbursed for medically necessary ambulance
4services by requiring the Illinois Department to adopt, by
5rule, criteria establishing medical necessity and appropriate
6procedures for the processing of claims for reimbursement.
7Thus, it is the intent of the General Assembly that the
8Illinois Department implement a reimbursement system for
9ambulance services that, to the extent practicable and subject
10to the availability of funds appropriated by the General
11Assembly for this purpose, is consistent with the payment
12principles of Medicare. To ensure uniformity between the
13payment principles of Medicare and Medicaid, the Illinois
14Department shall follow, to the extent necessary and
15practicable and subject to the availability of funds
16appropriated by the General Assembly for this purpose, the
17statutes, laws, regulations, policies, procedures, principles,
18definitions, guidelines, and manuals used to determine the
19amounts paid to ambulance service providers under Title XVIII
20of the Social Security Act (Medicare).
21    (b) For ambulance services provided to a recipient of aid
22under this Article on or after January 1, 1996, the Illinois
23Department shall reimburse ambulance service providers based
24upon the actual distance traveled if a natural disaster,
25weather conditions, road repairs, or traffic congestion
26necessitates the use of a route other than the most direct



09800SB0636sam001- 3 -LRB098 04421 KTG 49241 a

2    (c) For purposes of this Section, "ambulance services"
3includes medical transportation services provided by means of
4an ambulance, medi-car, service car, or taxi.
5    (c-1) For purposes of this Section, "ground ambulance
6service" means medical transportation services that are
7described as ground ambulance services by the Centers for
8Medicare and Medicaid Services and provided in a vehicle that
9is licensed as an ambulance by the Illinois Department of
10Public Health pursuant to the Emergency Medical Services (EMS)
11Systems Act.
12    (c-2) For purposes of this Section, "ground ambulance
13service provider" means a vehicle service provider as described
14in the Emergency Medical Services (EMS) Systems Act that
15operates licensed ambulances for the purpose of providing
16emergency ambulance services, or non-emergency ambulance
17services, or both. For purposes of this Section, this includes
18both ambulance providers and ambulance suppliers as described
19by the Centers for Medicare and Medicaid Services.
20    (d) This Section does not prohibit separate billing by
21ambulance service providers for oxygen furnished while
22providing advanced life support services.
23    (e) Beginning with services rendered on or after July 1,
242008, all providers of non-emergency medi-car and service car
25transportation must certify that the driver and employee
26attendant, as applicable, have completed a safety program



09800SB0636sam001- 4 -LRB098 04421 KTG 49241 a

1approved by the Department to protect both the patient and the
2driver, prior to transporting a patient. The provider must
3maintain this certification in its records. The provider shall
4produce such documentation upon demand by the Department or its
5representative. Failure to produce documentation of such
6training shall result in recovery of any payments made by the
7Department for services rendered by a non-certified driver or
8employee attendant. Medi-car and service car providers must
9maintain legible documentation in their records of the driver
10and, as applicable, employee attendant that actually
11transported the patient. Providers must recertify all drivers
12and employee attendants every 3 years.
13    Notwithstanding the requirements above, any public
14transportation provider of medi-car and service car
15transportation that receives federal funding under 49 U.S.C.
165307 and 5311 need not certify its drivers and employee
17attendants under this Section, since safety training is already
18federally mandated.
19    (f) With respect to any policy or program administered by
20the Department or its agent regarding approval of non-emergency
21medical transportation by ground ambulance service providers,
22including, but not limited to, the Non-Emergency
23Transportation Services Prior Approval Program (NETSPAP), the
24Department shall establish by rule a process by which ground
25ambulance service providers of non-emergency medical
26transportation may appeal any decision by the Department or its



09800SB0636sam001- 5 -LRB098 04421 KTG 49241 a

1agent in for which a claim is not approved for payment, but the
2patient meets the criteria for medical necessity and the
3appropriate level of ambulance service was provided. The
4Department shall consider appeals filed for reimbursement
5denials based upon the lack of availability of a physician
6discharge order occurring on or after July 1, 2013 if such
7appeal is filed within 90 days of the effective date of this
8amendatory Act of the 98th General Assembly. The Department
9shall apply the medical criteria established by rule in
10determining all appeals and shall take into account all
11relevant documentation substantiating the patient's condition
12as it relates to the criteria for medical necessity and may
13accept a provider's run report or equivalent. no denial was
14received prior to the time of transport that either (i) denies
15a request for approval for payment of non-emergency
16transportation by means of ground ambulance service or (ii)
17grants a request for approval of non-emergency transportation
18by means of ground ambulance service at a level of service that
19entitles the ground ambulance service provider to a lower level
20of compensation from the Department than the ground ambulance
21service provider would have received as compensation for the
22level of service requested. The rule shall be filed by December
2315, 2012 and shall provide that, for any decision rendered by
24the Department or its agent on or after the date the rule takes
25effect, the ground ambulance service provider shall have 60
26days from the date the decision is received to file an appeal.



09800SB0636sam001- 6 -LRB098 04421 KTG 49241 a

1The rule established by the Department shall be, insofar as is
2practical, consistent with the Illinois Administrative
3Procedure Act. The Director's decision on an appeal under this
4Section shall be a final administrative decision subject to
5review under the Administrative Review Law.
6    (f-5) Beginning 90 days after July 20, 2012 (the effective
7date of Public Act 97-842), (i) no denial of a request for
8approval for payment of non-emergency transportation by means
9of ground ambulance service, and (ii) no approval of
10non-emergency transportation by means of ground ambulance
11service at a level of service that entitles the ground
12ambulance service provider to a lower level of compensation
13from the Department than would have been received at the level
14of service submitted by the ground ambulance service provider,
15may be issued by the Department or its agent unless the
16Department has submitted the criteria for determining the
17appropriateness of the transport for first notice publication
18in the Illinois Register pursuant to Section 5-40 of the
19Illinois Administrative Procedure Act.
20    (g) Whenever a patient covered by a medical assistance
21program under this Code or by another medical program
22administered by the Department is being discharged from a
23facility, a physician discharge order as described in this
24Section shall be required for each patient whose discharge
25requires medically supervised ground ambulance services.
26Facilities shall develop procedures for a physician with



09800SB0636sam001- 7 -LRB098 04421 KTG 49241 a

1medical staff privileges to provide a written and signed
2physician discharge order. The physician discharge order shall
3specify the level of ground ambulance services needed and
4complete a medical certification establishing the criteria for
5approval of non-emergency ambulance transportation, as
6published by the Department of Healthcare and Family Services,
7that is met by the patient. This order and the medical
8certification shall be completed prior to ordering an ambulance
9service and prior to patient discharge.
10    Pursuant to subsection (E) of Section 12-4.25 of this Code,
11the Department is entitled to recover overpayments paid to a
12provider or vendor, including, but not limited to, from the
13discharging physician, the discharging facility, and the
14ground ambulance service provider, in instances where a
15non-emergency ground ambulance service is rendered as the
16result of improper or false certification.
17    (h) On and after July 1, 2012, the Department shall reduce
18any rate of reimbursement for services or other payments or
19alter any methodologies authorized by this Code to reduce any
20rate of reimbursement for services or other payments in
21accordance with Section 5-5e.
22(Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12;
2397-842, eff. 7-20-12; 98-463, eff. 8-16-13.)
24    Section 99. Effective date. This Act takes effect upon
25becoming law.".