Full Text of HB2795 101st General Assembly
HB2795 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB2795 Introduced , 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 promulgate an evidenced-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 hospital | 16 | | charges and fees as of August 1, 2004 but not earlier than | 17 | | August 1, 2002. These charges and fees are provider billed | 18 | | amounts and shall not include discounted charges. The 80th | 19 | | percentile is the point on an ordered data set from low to high | 20 | | such that 80% of the cases are below or equal to that point and | 21 | | at most 20% are above or equal to that point. The Commission | 22 | | shall adjust these historical charges and fees as of August 1, | 23 | | 2004 by the Consumer Price Index-U for the period August 1, |
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| 1 | | 2004 through September 30, 2005. The Commission shall establish | 2 | | fee schedules for procedures, treatments, or services for | 3 | | hospital inpatient, hospital outpatient, emergency room and | 4 | | trauma, ambulatory surgical treatment centers, and | 5 | | professional services. These charges and fees shall be | 6 | | designated by geozip or any smaller geographic unit. The data | 7 | | shall in no way identify or tend to identify any patient, | 8 | | employer, or health care provider. As used in this Section, | 9 | | "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 the | 17 | | geozip with up to 4 other geozips that are demographically and | 18 | | 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 that |
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| 1 | | state's fee schedule amount or the fee schedule amount for the | 2 | | region in which the employee resides. If no fee schedule exists | 3 | | in that state, the provider shall be reimbursed at the lesser | 4 | | of the actual charge or the fee schedule amount for the region | 5 | | in which the employee resides. Not later than September 30 in | 6 | | 2006 and each year thereafter, the Commission shall | 7 | | automatically increase or decrease the maximum allowable | 8 | | payment for a procedure, treatment, or service established and | 9 | | in effect on January 1 of that year by the percentage change in | 10 | | the Consumer Price Index-U for the 12 month period ending | 11 | | August 31 of that year. The increase or decrease shall become | 12 | | effective on January 1 of the following year. As used in this | 13 | | Section, "Consumer Price Index-U" means the index published by | 14 | | the Bureau of Labor Statistics of the U.S. Department of Labor, | 15 | | that measures the average change in prices of all goods and | 16 | | services purchased by all urban consumers, U.S. city average, | 17 | | 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 forth | 11 | | in this Section, then the Commission shall average or | 12 | | 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 than | 15 | | 9 charges or fees for a procedure, treatment, product, | 16 | | supply, or service or where the fee schedule amount cannot | 17 | | be determined by the non-discounted charge data, | 18 | | 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 with | 24 | | 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 the | 13 | | 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 be | 6 | | 70% of the fee schedule amounts, which shall be adjusted yearly | 7 | | by the Consumer Price Index-U, as described in subsection (a) | 8 | | of this Section. | 9 | | (a-3) Prescriptions filled and dispensed outside of a | 10 | | licensed pharmacy shall be subject to a fee schedule that shall | 11 | | not exceed the Average Wholesale Price (AWP) plus a dispensing | 12 | | fee of $4.18. AWP or its equivalent as registered by the | 13 | | National Drug Code shall be set forth for that drug on that | 14 | | date as published in Medi-Span Medispan . | 15 | | (a-4) By September 1, 2020, the Commission, in consultation | 16 | | with the Workers' Compensation Medical Fee Advisory Board, | 17 | | shall promulgate by rule an evidence-based drug formulary and | 18 | | any rules necessary for its administration. Prescriptions | 19 | | prescribed for workers' compensation cases shall be limited to | 20 | | the prescription drugs and doses on the closed formulary. | 21 | | A request for a prescription that is not on the closed | 22 | | formulary shall be reviewed under Section 8.7. | 23 | | (b) Notwithstanding the provisions of subsection (a), if
| 24 | | the Commission finds that there is a significant limitation on
| 25 | | access to quality health care in either a specific field of
| 26 | | health care services or a specific geographic limitation on
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| 1 | | access to health care, it may change the Consumer Price Index-U
| 2 | | increase or decrease for that specific field or specific
| 3 | | geographic limitation on access to health care to address that
| 4 | | limitation. | 5 | | (c) The Commission shall establish by rule a process to | 6 | | review those medical cases or outliers that involve | 7 | | extra-ordinary treatment to determine whether to make an | 8 | | additional adjustment to the maximum payment within a fee | 9 | | schedule for a procedure, treatment, or service. | 10 | | (d) When a patient notifies a provider that the treatment, | 11 | | procedure, or service being sought is for a work-related | 12 | | illness or injury and furnishes the provider the name and | 13 | | address of the responsible employer, the provider shall bill | 14 | | the employer or its designee directly. The employer or its | 15 | | designee shall make payment for treatment in accordance with | 16 | | the provisions of this Section directly to the provider, except | 17 | | that, if a provider has designated a third-party billing entity | 18 | | to bill on its behalf, payment shall be made directly to the | 19 | | billing entity. Providers shall submit bills and records in | 20 | | accordance with the provisions of this Section. | 21 | | (1) All payments to providers for treatment provided | 22 | | pursuant to this Act shall be made within 30 days of | 23 | | receipt of the bills as long as the bill contains | 24 | | substantially all the required data elements necessary to | 25 | | adjudicate the bill. | 26 | | (2) If the bill does not contain substantially all the |
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| 1 | | required data elements necessary to adjudicate the bill, or | 2 | | the claim is denied for any other reason, in whole or in | 3 | | part, the employer or insurer shall provide written | 4 | | notification to the provider in the form of an explanation | 5 | | of benefits explaining the basis for the denial and | 6 | | describing any additional necessary data elements within | 7 | | 30 days of receipt of the bill. The Commission, with | 8 | | assistance from the Medical Fee Advisory Board, shall adopt | 9 | | rules detailing the requirements for the explanation of | 10 | | benefits required under this subsection. | 11 | | (3) In the case (i) of nonpayment to a provider within | 12 | | 30 days of receipt of the bill which contained | 13 | | substantially all of the required data elements necessary | 14 | | to adjudicate the bill, (ii) of nonpayment to a provider of | 15 | | a portion of such a bill, or (iii) where the provider has | 16 | | not been issued an explanation of benefits for a bill, the | 17 | | bill, or portion of the bill up to the lesser of the actual | 18 | | charge or the payment level set by the Commission in the | 19 | | fee schedule established in this Section, shall incur | 20 | | interest at a rate of 1% per month payable by the employer | 21 | | to the provider. Any required interest payments shall be | 22 | | made by the employer or its insurer to the provider within | 23 | | 30 days after payment of the bill. | 24 | | (4) If the employer or its insurer fails to pay | 25 | | interest within 30 days after payment of the bill as | 26 | | required pursuant to paragraph (3), the provider may bring |
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| 1 | | an action in circuit court for the sole purpose of seeking | 2 | | payment of interest pursuant to paragraph (3) against the | 3 | | employer or its insurer responsible for insuring the | 4 | | employer's liability pursuant to item (3) of subsection (a) | 5 | | of Section 4. The circuit court's jurisdiction shall be | 6 | | limited to enforcing payment of interest pursuant to | 7 | | paragraph (3). Interest under paragraph (3) is only payable | 8 | | to the provider. An employee is not responsible for the | 9 | | payment of interest under this Section. The right to | 10 | | interest under paragraph (3) shall not delay, diminish, | 11 | | restrict, or alter in any way the benefits to which the | 12 | | employee or his or her dependents are entitled under this | 13 | | Act. | 14 | | The changes made to this subsection (d) by this amendatory | 15 | | Act of the 100th General Assembly apply to procedures, | 16 | | treatments, and services rendered on and after the effective | 17 | | date of this amendatory Act of the 100th General Assembly. | 18 | | (e) Except as provided in subsections (e-5), (e-10), and | 19 | | (e-15), a provider shall not hold an employee liable for costs | 20 | | related to a non-disputed procedure, treatment, or service | 21 | | rendered in connection with a compensable injury. The | 22 | | provisions of subsections (e-5), (e-10), (e-15), and (e-20) | 23 | | shall not apply if an employee provides information to the | 24 | | provider regarding participation in a group health plan. If the | 25 | | employee participates in a group health plan, the provider may | 26 | | submit a claim for services to the group health plan. If the |
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| 1 | | claim for service is covered by the group health plan, the | 2 | | employee's responsibility shall be limited to applicable | 3 | | deductibles, co-payments, or co-insurance. Except as provided | 4 | | under subsections (e-5), (e-10), (e-15), and (e-20), a provider | 5 | | shall not bill or otherwise attempt to recover from the | 6 | | employee the difference between the provider's charge and the | 7 | | amount paid by the employer or the insurer on a compensable | 8 | | injury, or for medical services or treatment determined by the | 9 | | Commission to be excessive or unnecessary. | 10 | | (e-5) If an employer notifies a provider that the employer | 11 | | does not consider the illness or injury to be compensable under | 12 | | this Act, the provider may seek payment of the provider's | 13 | | actual charges from the employee for any procedure, treatment, | 14 | | or service rendered. Once an employee informs the provider that | 15 | | there is an application filed with the Commission to resolve a | 16 | | dispute over payment of such charges, the provider shall cease | 17 | | any and all efforts to collect payment for the services that | 18 | | are the subject of the dispute. Any statute of limitations or | 19 | | statute of repose applicable to the provider's efforts to | 20 | | collect payment from the employee shall be tolled from the date | 21 | | that the employee files the application with the Commission | 22 | | until the date that the provider is permitted to resume | 23 | | collection efforts under the provisions of this Section. | 24 | | (e-10) If an employer notifies a provider that the employer | 25 | | will pay only a portion of a bill for any procedure, treatment, | 26 | | or service rendered in connection with a compensable illness or |
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| 1 | | disease, the provider may seek payment from the employee for | 2 | | the remainder of the amount of the bill up to the lesser of the | 3 | | actual charge, negotiated rate, if applicable, or the payment | 4 | | level set by the Commission in the fee schedule established in | 5 | | this Section. Once an employee informs the provider that there | 6 | | is an application filed with the Commission to resolve a | 7 | | dispute over payment of such charges, the provider shall cease | 8 | | any and all efforts to collect payment for the services that | 9 | | are the subject of the dispute. Any statute of limitations or | 10 | | statute of repose applicable to the provider's efforts to | 11 | | collect payment from the employee shall be tolled from the date | 12 | | that the employee files the application with the Commission | 13 | | until the date that the provider is permitted to resume | 14 | | collection efforts under the provisions of this Section. | 15 | | (e-15) When there is a dispute over the compensability of | 16 | | or amount of payment for a procedure, treatment, or service, | 17 | | and a case is pending or proceeding before an Arbitrator or the | 18 | | Commission, the provider may mail the employee reminders that | 19 | | the employee will be responsible for payment of any procedure, | 20 | | treatment or service rendered by the provider. The reminders | 21 | | must state that they are not bills, to the extent practicable | 22 | | include itemized information, and state that the employee need | 23 | | not pay until such time as the provider is permitted to resume | 24 | | collection efforts under this Section. The reminders shall not | 25 | | be provided to any credit rating agency. The reminders may | 26 | | request that the employee furnish the provider with information |
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| 1 | | about the proceeding under this Act, such as the file number, | 2 | | names of parties, and status of the case. If an employee fails | 3 | | to respond to such request for information or fails to furnish | 4 | | the information requested within 90 days of the date of the | 5 | | reminder, the provider is entitled to resume any and all | 6 | | efforts to collect payment from the employee for the services | 7 | | rendered to the employee and the employee shall be responsible | 8 | | for payment of any outstanding bills for a procedure, | 9 | | treatment, or service rendered by a provider. | 10 | | (e-20) Upon a final award or judgment by an Arbitrator or | 11 | | the Commission, or a settlement agreed to by the employer and | 12 | | the employee, a provider may resume any and all efforts to | 13 | | collect payment from the employee for the services rendered to | 14 | | the employee and the employee shall be responsible for payment | 15 | | of any outstanding bills for a procedure, treatment, or service | 16 | | rendered by a provider as well as the interest awarded under | 17 | | subsection (d) of this Section. In the case of a procedure, | 18 | | treatment, or service deemed compensable, the provider shall | 19 | | not require a payment rate, excluding the interest provisions | 20 | | under subsection (d), greater than the lesser of the actual | 21 | | charge or the payment level set by the Commission in the fee | 22 | | schedule established in this Section. Payment for services | 23 | | deemed not covered or not compensable under this Act is the | 24 | | responsibility of the employee unless a provider and employee | 25 | | have agreed otherwise in writing. Services not covered or not | 26 | | compensable under this Act are not subject to the fee schedule |
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| 1 | | in this Section. | 2 | | (f) Nothing in this Act shall prohibit an employer or
| 3 | | insurer from contracting with a health care provider or group
| 4 | | of health care providers for reimbursement levels for benefits | 5 | | under this Act different
from those provided in this Section. | 6 | | (g) On or before January 1, 2010 the Commission shall | 7 | | provide to the Governor and General Assembly a report regarding | 8 | | the implementation of the medical fee schedule and the index | 9 | | used for annual adjustment to that schedule as described in | 10 | | this Section.
| 11 | | (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff. | 12 | | 1-11-19.)
| 13 | | Section 99. Effective date. This Act takes effect upon | 14 | | becoming law.
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