Full Text of HB1546 103rd General Assembly
HB1546 103RD GENERAL ASSEMBLY |
| | 103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024 HB1546 Introduced 1/31/2023, by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: |
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Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission, upon consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt an evidence-based drug formulary. Requires prescriptions in workers' compensation cases to be limited to the drugs on the formulary. Effective immediately.
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| | A BILL FOR |
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| 1 | | AN ACT concerning employment.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Workers' Compensation Act is amended by | 5 | | changing Section 8.2 as follows: | 6 | | (820 ILCS 305/8.2)
| 7 | | Sec. 8.2. Fee schedule.
| 8 | | (a) Except as provided for in subsection (c), for | 9 | | procedures, treatments, or services covered under this Act and | 10 | | rendered or to be rendered on and after February 1, 2006, the | 11 | | maximum allowable payment shall be 90% of the 80th percentile | 12 | | of charges and fees as determined by the Commission utilizing | 13 | | information provided by employers' and insurers' national | 14 | | databases, with a minimum of 12,000,000 Illinois line item | 15 | | charges and fees comprised of health care provider and | 16 | | hospital charges and fees as of August 1, 2004 but not earlier | 17 | | than August 1, 2002. These charges and fees are provider | 18 | | billed amounts and shall not include discounted charges. The | 19 | | 80th percentile is the point on an ordered data set from low to | 20 | | high such that 80% of the cases are below or equal to that | 21 | | point and at most 20% are above or equal to that point. The | 22 | | Commission shall adjust these historical charges and fees as | 23 | | of August 1, 2004 by the Consumer Price Index-U for the period |
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| 1 | | August 1, 2004 through September 30, 2005. The Commission | 2 | | shall establish fee schedules for procedures, treatments, or | 3 | | services for hospital inpatient, hospital outpatient, | 4 | | emergency room and trauma, ambulatory surgical treatment | 5 | | centers, and professional services. These charges and fees | 6 | | shall be designated by geozip or any smaller geographic unit. | 7 | | The data shall in no way identify or tend to identify any | 8 | | patient, employer, or health care provider. As used in this | 9 | | Section, "geozip" means a three-digit zip code based on data | 10 | | similarities, geographical similarities, and frequencies. A | 11 | | geozip does not cross state boundaries. As used in this | 12 | | Section, "three-digit zip code" means a geographic area in | 13 | | which all zip codes have the same first 3 digits. If a geozip | 14 | | does not have the necessary number of charges and fees to | 15 | | calculate a valid percentile for a specific procedure, | 16 | | treatment, or service, the Commission may combine data from | 17 | | the geozip with up to 4 other geozips that are demographically | 18 | | and economically similar and exhibit similarities in data and | 19 | | frequencies until the Commission reaches 9 charges or fees for | 20 | | that specific procedure, treatment, or service. In cases where | 21 | | the compiled data contains less than 9 charges or fees for a | 22 | | procedure, treatment, or service, reimbursement shall occur at | 23 | | 76% of charges and fees as determined by the Commission in a | 24 | | manner consistent with the provisions of this paragraph. | 25 | | Providers of out-of-state procedures, treatments, services, | 26 | | products, or supplies shall be reimbursed at the lesser of |
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| 1 | | that state's fee schedule amount or the fee schedule amount | 2 | | for the region in which the employee resides. If no fee | 3 | | schedule exists in that state, the provider shall be | 4 | | reimbursed at the lesser of the actual charge or the fee | 5 | | schedule amount for the region in which the employee resides. | 6 | | Not later than September 30 in 2006 and each year thereafter, | 7 | | the Commission shall automatically increase or decrease the | 8 | | maximum allowable payment for a procedure, treatment, or | 9 | | service established and in effect on January 1 of that year by | 10 | | the percentage change in the Consumer Price Index-U for the 12 | 11 | | month period ending August 31 of that year. The increase or | 12 | | decrease shall become effective on January 1 of the following | 13 | | year. As used in this Section, "Consumer Price Index-U" means | 14 | | the index published by the Bureau of Labor Statistics of the | 15 | | U.S. Department of Labor, that measures the average change in | 16 | | prices of all goods and services purchased by all urban | 17 | | consumers, U.S. city average, all items, 1982-84=100. | 18 | | (a-1) Notwithstanding the provisions of subsection (a) and | 19 | | unless otherwise indicated, the following provisions shall | 20 | | apply to the medical fee schedule starting on September 1, | 21 | | 2011: | 22 | | (1) The Commission shall establish and maintain fee | 23 | | schedules for procedures, treatments, products, services, | 24 | | or supplies for hospital inpatient, hospital outpatient, | 25 | | emergency room, ambulatory surgical treatment centers, | 26 | | accredited ambulatory surgical treatment facilities, |
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| 1 | | prescriptions filled and dispensed outside of a licensed | 2 | | pharmacy, dental services, and professional services. This | 3 | | fee schedule shall be based on the fee schedule amounts | 4 | | already established by the Commission pursuant to | 5 | | subsection (a) of this Section. However, starting on | 6 | | January 1, 2012, these fee schedule amounts shall be | 7 | | grouped into geographic regions in the following manner: | 8 | | (A) Four regions for non-hospital fee schedule | 9 | | amounts shall be utilized: | 10 | | (i) Cook County; | 11 | | (ii) DuPage, Kane, Lake, and Will Counties; | 12 | | (iii) Bond, Calhoun, Clinton, Jersey, | 13 | | Macoupin, Madison, Monroe, Montgomery, Randolph, | 14 | | St. Clair, and Washington Counties; and | 15 | | (iv) All other counties of the State. | 16 | | (B) Fourteen regions for hospital fee schedule | 17 | | amounts shall be utilized: | 18 | | (i) Cook, DuPage, Will, Kane, McHenry, DeKalb, | 19 | | Kendall, and Grundy Counties; | 20 | | (ii) Kankakee County; | 21 | | (iii) Madison, St. Clair, Macoupin, Clinton, | 22 | | Monroe, Jersey, Bond, and Calhoun Counties; | 23 | | (iv) Winnebago and Boone Counties; | 24 | | (v) Peoria, Tazewell, Woodford, Marshall, and | 25 | | Stark Counties; | 26 | | (vi) Champaign, Piatt, and Ford Counties; |
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| 1 | | (vii) Rock Island, Henry, and Mercer Counties; | 2 | | (viii) Sangamon and Menard Counties; | 3 | | (ix) McLean County; | 4 | | (x) Lake County; | 5 | | (xi) Macon County; | 6 | | (xii) Vermilion County; | 7 | | (xiii) Alexander County; and | 8 | | (xiv) All other counties of the State. | 9 | | (2) If a geozip, as defined in subsection (a) of this | 10 | | Section, overlaps into one or more of the regions set | 11 | | forth in this Section, then the Commission shall average | 12 | | or repeat the charges and fees in a geozip in order to | 13 | | designate charges and fees for each region. | 14 | | (3) In cases where the compiled data contains less | 15 | | than 9 charges or fees for a procedure, treatment, | 16 | | product, supply, or service or where the fee schedule | 17 | | amount cannot be determined by the non-discounted charge | 18 | | data, non-Medicare relative values and conversion factors | 19 | | derived from established fee schedule amounts, coding | 20 | | crosswalks, or other data as determined by the Commission, | 21 | | reimbursement shall occur at 76% of charges and fees until | 22 | | September 1, 2011 and 53.2% of charges and fees thereafter | 23 | | as determined by the Commission in a manner consistent | 24 | | with the provisions of this paragraph. | 25 | | (4) To establish additional fee schedule amounts, the | 26 | | Commission shall utilize provider non-discounted charge |
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| 1 | | data, non-Medicare relative values and conversion factors | 2 | | derived from established fee schedule amounts, and coding | 3 | | crosswalks. The Commission may establish additional fee | 4 | | schedule amounts based on either the charge or cost of the | 5 | | procedure, treatment, product, supply, or service. | 6 | | (5) Implants shall be reimbursed at 25% above the net | 7 | | manufacturer's invoice price less rebates, plus actual | 8 | | reasonable and customary shipping charges whether or not | 9 | | the implant charge is submitted by a provider in | 10 | | conjunction with a bill for all other services associated | 11 | | with the implant, submitted by a provider on a separate | 12 | | claim form, submitted by a distributor, or submitted by | 13 | | the manufacturer of the implant. "Implants" include the | 14 | | following codes or any substantially similar updated code | 15 | | as determined by the Commission: 0274 | 16 | | (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens | 17 | | implant); 0278 (implants); 0540 and 0545 (ambulance); 0624 | 18 | | (investigational devices); and 0636 (drugs requiring | 19 | | detailed coding). Non-implantable devices or supplies | 20 | | within these codes shall be reimbursed at 65% of actual | 21 | | charge, which is the provider's normal rates under its | 22 | | standard chargemaster. A standard chargemaster is the | 23 | | provider's list of charges for procedures, treatments, | 24 | | products, supplies, or services used to bill payers in a | 25 | | consistent manner. | 26 | | (6) The Commission shall automatically update all |
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| 1 | | codes and associated rules with the version of the codes | 2 | | and rules valid on January 1 of that year. | 3 | | (a-2) For procedures, treatments, services, or supplies | 4 | | covered under this Act and rendered or to be rendered on or | 5 | | after September 1, 2011, the maximum allowable payment shall | 6 | | be 70% of the fee schedule amounts, which shall be adjusted | 7 | | yearly by the Consumer Price Index-U, as described in | 8 | | subsection (a) of this Section. | 9 | | (a-3) Prescriptions filled and dispensed outside of a | 10 | | licensed pharmacy shall be subject to a fee schedule that | 11 | | shall not exceed the Average Wholesale Price (AWP) plus a | 12 | | dispensing fee of $4.18. AWP or its equivalent as registered | 13 | | by the National Drug Code shall be set forth for that drug on | 14 | | that date as published in Medi-Span Medispan . | 15 | | (a-4) By September 1, 2023, the Commission, in | 16 | | consultation with the Workers' Compensation Medical Fee | 17 | | Advisory Board, shall adopt by rule an evidence-based drug | 18 | | formulary and any rules necessary for its administration. | 19 | | Prescriptions prescribed for workers' compensation cases shall | 20 | | be limited to the prescription drugs and doses on the closed | 21 | | formulary. | 22 | | A request for a prescription that is not on the closed | 23 | | formulary shall be reviewed under Section 8.7. | 24 | | (b) Notwithstanding the provisions of subsection (a), if
| 25 | | the Commission finds that there is a significant limitation on
| 26 | | access to quality health care in either a specific field of
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| 1 | | health care services or a specific geographic limitation on
| 2 | | access to health care, it may change the Consumer Price | 3 | | Index-U
increase or decrease for that specific field or | 4 | | specific
geographic limitation on access to health care to | 5 | | address that
limitation. | 6 | | (c) The Commission shall establish by rule a process to | 7 | | review those medical cases or outliers that involve | 8 | | extra-ordinary treatment to determine whether to make an | 9 | | additional adjustment to the maximum payment within a fee | 10 | | schedule for a procedure, treatment, or service. | 11 | | (d) When a patient notifies a provider that the treatment, | 12 | | procedure, or service being sought is for a work-related | 13 | | illness or injury and furnishes the provider the name and | 14 | | address of the responsible employer, the provider shall bill | 15 | | the employer or its designee directly. The employer or its | 16 | | designee shall make payment for treatment in accordance with | 17 | | the provisions of this Section directly to the provider, | 18 | | except that, if a provider has designated a third-party | 19 | | billing entity to bill on its behalf, payment shall be made | 20 | | directly to the billing entity. Providers shall submit bills | 21 | | and records in accordance with the provisions of this Section. | 22 | | (1) All payments to providers for treatment provided | 23 | | pursuant to this Act shall be made within 30 days of | 24 | | receipt of the bills as long as the bill contains | 25 | | substantially all the required data elements necessary to | 26 | | adjudicate the bill. |
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| 1 | | (2) If the bill does not contain substantially all the | 2 | | required data elements necessary to adjudicate the bill, | 3 | | or the claim is denied for any other reason, in whole or in | 4 | | part, the employer or insurer shall provide written | 5 | | notification to the provider in the form of an explanation | 6 | | of benefits explaining the basis for the denial and | 7 | | describing any additional necessary data elements within | 8 | | 30 days of receipt of the bill. The Commission, with | 9 | | assistance from the Medical Fee Advisory Board, shall | 10 | | adopt rules detailing the requirements for the explanation | 11 | | of benefits required under this subsection. | 12 | | (3) In the case (i) of nonpayment to a provider within | 13 | | 30 days of receipt of the bill which contained | 14 | | substantially all of the required data elements necessary | 15 | | to adjudicate the bill, (ii) of nonpayment to a provider | 16 | | of a portion of such a bill, or (iii) where the provider | 17 | | has not been issued an explanation of benefits for a bill, | 18 | | the bill, or portion of the bill up to the lesser of the | 19 | | actual charge or the payment level set by the Commission | 20 | | in the fee schedule established in this Section, shall | 21 | | incur interest at a rate of 1% per month payable by the | 22 | | employer to the provider. Any required interest payments | 23 | | shall be made by the employer or its insurer to the | 24 | | provider within 30 days after payment of the bill. | 25 | | (4) If the employer or its insurer fails to pay | 26 | | interest within 30 days after payment of the bill as |
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| 1 | | required pursuant to paragraph (3), the provider may bring | 2 | | an action in circuit court for the sole purpose of seeking | 3 | | payment of interest pursuant to paragraph (3) against the | 4 | | employer or its insurer responsible for insuring the | 5 | | employer's liability pursuant to item (3) of subsection | 6 | | (a) of Section 4. The circuit court's jurisdiction shall | 7 | | be limited to enforcing payment of interest pursuant to | 8 | | paragraph (3). Interest under paragraph (3) is only | 9 | | payable to the provider. An employee is not responsible | 10 | | for the payment of interest under this Section. The right | 11 | | to interest under paragraph (3) shall not delay, diminish, | 12 | | restrict, or alter in any way the benefits to which the | 13 | | employee or his or her dependents are entitled under this | 14 | | Act. | 15 | | The changes made to this subsection (d) by this amendatory | 16 | | Act of the 100th General Assembly apply to procedures, | 17 | | treatments, and services rendered on and after the effective | 18 | | date of this amendatory Act of the 100th General Assembly. | 19 | | (e) Except as provided in subsections (e-5), (e-10), and | 20 | | (e-15), a provider shall not hold an employee liable for costs | 21 | | related to a non-disputed procedure, treatment, or service | 22 | | rendered in connection with a compensable injury. The | 23 | | provisions of subsections (e-5), (e-10), (e-15), and (e-20) | 24 | | shall not apply if an employee provides information to the | 25 | | provider regarding participation in a group health plan. If | 26 | | the employee participates in a group health plan, the provider |
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| 1 | | may submit a claim for services to the group health plan. If | 2 | | the claim for service is covered by the group health plan, the | 3 | | employee's responsibility shall be limited to applicable | 4 | | deductibles, co-payments, or co-insurance. Except as provided | 5 | | under subsections (e-5), (e-10), (e-15), and (e-20), a | 6 | | provider shall not bill or otherwise attempt to recover from | 7 | | the employee the difference between the provider's charge and | 8 | | the amount paid by the employer or the insurer on a compensable | 9 | | injury, or for medical services or treatment determined by the | 10 | | Commission to be excessive or unnecessary. | 11 | | (e-5) If an employer notifies a provider that the employer | 12 | | does not consider the illness or injury to be compensable | 13 | | under this Act, the provider may seek payment of the | 14 | | provider's actual charges from the employee for any procedure, | 15 | | treatment, or service rendered. Once an employee informs the | 16 | | provider that there is an application filed with the | 17 | | Commission to resolve a dispute over payment of such charges, | 18 | | the provider shall cease any and all efforts to collect | 19 | | payment for the services that are the subject of the dispute. | 20 | | Any statute of limitations or statute of repose applicable to | 21 | | the provider's efforts to collect payment from the employee | 22 | | shall be tolled from the date that the employee files the | 23 | | application with the Commission until the date that the | 24 | | provider is permitted to resume collection efforts under the | 25 | | provisions of this Section. | 26 | | (e-10) If an employer notifies a provider that the |
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| 1 | | employer will pay only a portion of a bill for any procedure, | 2 | | treatment, or service rendered in connection with a | 3 | | compensable illness or disease, the provider may seek payment | 4 | | from the employee for the remainder of the amount of the bill | 5 | | up to the lesser of the actual charge, negotiated rate, if | 6 | | applicable, or the payment level set by the Commission in the | 7 | | fee schedule established in this Section. Once an employee | 8 | | informs the provider that there is an application filed with | 9 | | the Commission to resolve a dispute over payment of such | 10 | | charges, the provider shall cease any and all efforts to | 11 | | collect payment for the services that are the subject of the | 12 | | dispute. Any statute of limitations or statute of repose | 13 | | applicable to the provider's efforts to collect payment from | 14 | | the employee shall be tolled from the date that the employee | 15 | | files the application with the Commission until the date that | 16 | | the provider is permitted to resume collection efforts under | 17 | | the provisions of this Section. | 18 | | (e-15) When there is a dispute over the compensability of | 19 | | or amount of payment for a procedure, treatment, or service, | 20 | | and a case is pending or proceeding before an Arbitrator or the | 21 | | Commission, the provider may mail the employee reminders that | 22 | | the employee will be responsible for payment of any procedure, | 23 | | treatment or service rendered by the provider. The reminders | 24 | | must state that they are not bills, to the extent practicable | 25 | | include itemized information, and state that the employee need | 26 | | not pay until such time as the provider is permitted to resume |
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| 1 | | collection efforts under this Section. The reminders shall not | 2 | | be provided to any credit rating agency. The reminders may | 3 | | request that the employee furnish the provider with | 4 | | information about the proceeding under this Act, such as the | 5 | | file number, names of parties, and status of the case. If an | 6 | | employee fails to respond to such request for information or | 7 | | fails to furnish the information requested within 90 days of | 8 | | the date of the reminder, the provider is entitled to resume | 9 | | any and all efforts to collect payment from the employee for | 10 | | the services rendered to the employee and the employee shall | 11 | | be responsible for payment of any outstanding bills for a | 12 | | procedure, treatment, or service rendered by a provider. | 13 | | (e-20) Upon a final award or judgment by an Arbitrator or | 14 | | the Commission, or a settlement agreed to by the employer and | 15 | | the employee, a provider may resume any and all efforts to | 16 | | collect payment from the employee for the services rendered to | 17 | | the employee and the employee shall be responsible for payment | 18 | | of any outstanding bills for a procedure, treatment, or | 19 | | service rendered by a provider as well as the interest awarded | 20 | | under subsection (d) of this Section. In the case of a | 21 | | procedure, treatment, or service deemed compensable, the | 22 | | provider shall not require a payment rate, excluding the | 23 | | interest provisions under subsection (d), greater than the | 24 | | lesser of the actual charge or the payment level set by the | 25 | | Commission in the fee schedule established in this Section. | 26 | | Payment for services deemed not covered or not compensable |
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| 1 | | under this Act is the responsibility of the employee unless a | 2 | | provider and employee have agreed otherwise in writing. | 3 | | Services not covered or not compensable under this Act are not | 4 | | subject to the fee schedule in this Section. | 5 | | (f) Nothing in this Act shall prohibit an employer or
| 6 | | insurer from contracting with a health care provider or group
| 7 | | of health care providers for reimbursement levels for benefits | 8 | | under this Act different
from those provided in this Section. | 9 | | (g) On or before January 1, 2010 the Commission shall | 10 | | provide to the Governor and General Assembly a report | 11 | | regarding the implementation of the medical fee schedule and | 12 | | the index used for annual adjustment to that schedule as | 13 | | described in this Section.
| 14 | | (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff. | 15 | | 1-11-19.)
| 16 | | Section 99. Effective date. This Act takes effect upon | 17 | | becoming law.
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