Illinois 2023-2024 Regular Session

Illinois House Bill HB1546 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1546 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 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. LRB103 05095 SPS 50109 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1546 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 820 ILCS 305/8.2 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. LRB103 05095 SPS 50109 b LRB103 05095 SPS 50109 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1546 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
3	3	820 ILCS 305/8.2 820 ILCS 305/8.2
4	4	820 ILCS 305/8.2
5	5	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.
6	6	LRB103 05095 SPS 50109 b LRB103 05095 SPS 50109 b
7	7	LRB103 05095 SPS 50109 b
8	8	A BILL FOR
9	9	HB1546LRB103 05095 SPS 50109 b HB1546 LRB103 05095 SPS 50109 b
10	10	HB1546 LRB103 05095 SPS 50109 b
11	11	1 AN ACT concerning employment.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Workers' Compensation Act is amended by
15	15	5 changing Section 8.2 as follows:
16	16	6 (820 ILCS 305/8.2)
17	17	7 Sec. 8.2. Fee schedule.
18	18	8 (a) Except as provided for in subsection (c), for
19	19	9 procedures, treatments, or services covered under this Act and
20	20	10 rendered or to be rendered on and after February 1, 2006, the
21	21	11 maximum allowable payment shall be 90% of the 80th percentile
22	22	12 of charges and fees as determined by the Commission utilizing
23	23	13 information provided by employers' and insurers' national
24	24	14 databases, with a minimum of 12,000,000 Illinois line item
25	25	15 charges and fees comprised of health care provider and
26	26	16 hospital charges and fees as of August 1, 2004 but not earlier
27	27	17 than August 1, 2002. These charges and fees are provider
28	28	18 billed amounts and shall not include discounted charges. The
29	29	19 80th percentile is the point on an ordered data set from low to
30	30	20 high such that 80% of the cases are below or equal to that
31	31	21 point and at most 20% are above or equal to that point. The
32	32	22 Commission shall adjust these historical charges and fees as
33	33	23 of August 1, 2004 by the Consumer Price Index-U for the period
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1546 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
38	38	820 ILCS 305/8.2 820 ILCS 305/8.2
39	39	820 ILCS 305/8.2
40	40	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.
41	41	LRB103 05095 SPS 50109 b LRB103 05095 SPS 50109 b
42	42	LRB103 05095 SPS 50109 b
43	43	A BILL FOR
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49	49	820 ILCS 305/8.2
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68	68	1 August 1, 2004 through September 30, 2005. The Commission
69	69	2 shall establish fee schedules for procedures, treatments, or
70	70	3 services for hospital inpatient, hospital outpatient,
71	71	4 emergency room and trauma, ambulatory surgical treatment
72	72	5 centers, and professional services. These charges and fees
73	73	6 shall be designated by geozip or any smaller geographic unit.
74	74	7 The data shall in no way identify or tend to identify any
75	75	8 patient, employer, or health care provider. As used in this
76	76	9 Section, "geozip" means a three-digit zip code based on data
77	77	10 similarities, geographical similarities, and frequencies. A
78	78	11 geozip does not cross state boundaries. As used in this
79	79	12 Section, "three-digit zip code" means a geographic area in
80	80	13 which all zip codes have the same first 3 digits. If a geozip
81	81	14 does not have the necessary number of charges and fees to
82	82	15 calculate a valid percentile for a specific procedure,
83	83	16 treatment, or service, the Commission may combine data from
84	84	17 the geozip with up to 4 other geozips that are demographically
85	85	18 and economically similar and exhibit similarities in data and
86	86	19 frequencies until the Commission reaches 9 charges or fees for
87	87	20 that specific procedure, treatment, or service. In cases where
88	88	21 the compiled data contains less than 9 charges or fees for a
89	89	22 procedure, treatment, or service, reimbursement shall occur at
90	90	23 76% of charges and fees as determined by the Commission in a
91	91	24 manner consistent with the provisions of this paragraph.
92	92	25 Providers of out-of-state procedures, treatments, services,
93	93	26 products, or supplies shall be reimbursed at the lesser of
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104	104	1 that state's fee schedule amount or the fee schedule amount
105	105	2 for the region in which the employee resides. If no fee
106	106	3 schedule exists in that state, the provider shall be
107	107	4 reimbursed at the lesser of the actual charge or the fee
108	108	5 schedule amount for the region in which the employee resides.
109	109	6 Not later than September 30 in 2006 and each year thereafter,
110	110	7 the Commission shall automatically increase or decrease the
111	111	8 maximum allowable payment for a procedure, treatment, or
112	112	9 service established and in effect on January 1 of that year by
113	113	10 the percentage change in the Consumer Price Index-U for the 12
114	114	11 month period ending August 31 of that year. The increase or
115	115	12 decrease shall become effective on January 1 of the following
116	116	13 year. As used in this Section, "Consumer Price Index-U" means
117	117	14 the index published by the Bureau of Labor Statistics of the
118	118	15 U.S. Department of Labor, that measures the average change in
119	119	16 prices of all goods and services purchased by all urban
120	120	17 consumers, U.S. city average, all items, 1982-84=100.
121	121	18 (a-1) Notwithstanding the provisions of subsection (a) and
122	122	19 unless otherwise indicated, the following provisions shall
123	123	20 apply to the medical fee schedule starting on September 1,
124	124	21 2011:
125	125	22 (1) The Commission shall establish and maintain fee
126	126	23 schedules for procedures, treatments, products, services,
127	127	24 or supplies for hospital inpatient, hospital outpatient,
128	128	25 emergency room, ambulatory surgical treatment centers,
129	129	26 accredited ambulatory surgical treatment facilities,
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140	140	1 prescriptions filled and dispensed outside of a licensed
141	141	2 pharmacy, dental services, and professional services. This
142	142	3 fee schedule shall be based on the fee schedule amounts
143	143	4 already established by the Commission pursuant to
144	144	5 subsection (a) of this Section. However, starting on
145	145	6 January 1, 2012, these fee schedule amounts shall be
146	146	7 grouped into geographic regions in the following manner:
147	147	8 (A) Four regions for non-hospital fee schedule
148	148	9 amounts shall be utilized:
149	149	10 (i) Cook County;
150	150	11 (ii) DuPage, Kane, Lake, and Will Counties;
151	151	12 (iii) Bond, Calhoun, Clinton, Jersey,
152	152	13 Macoupin, Madison, Monroe, Montgomery, Randolph,
153	153	14 St. Clair, and Washington Counties; and
154	154	15 (iv) All other counties of the State.
155	155	16 (B) Fourteen regions for hospital fee schedule
156	156	17 amounts shall be utilized:
157	157	18 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
158	158	19 Kendall, and Grundy Counties;
159	159	20 (ii) Kankakee County;
160	160	21 (iii) Madison, St. Clair, Macoupin, Clinton,
161	161	22 Monroe, Jersey, Bond, and Calhoun Counties;
162	162	23 (iv) Winnebago and Boone Counties;
163	163	24 (v) Peoria, Tazewell, Woodford, Marshall, and
164	164	25 Stark Counties;
165	165	26 (vi) Champaign, Piatt, and Ford Counties;
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176	176	1 (vii) Rock Island, Henry, and Mercer Counties;
177	177	2 (viii) Sangamon and Menard Counties;
178	178	3 (ix) McLean County;
179	179	4 (x) Lake County;
180	180	5 (xi) Macon County;
181	181	6 (xii) Vermilion County;
182	182	7 (xiii) Alexander County; and
183	183	8 (xiv) All other counties of the State.
184	184	9 (2) If a geozip, as defined in subsection (a) of this
185	185	10 Section, overlaps into one or more of the regions set
186	186	11 forth in this Section, then the Commission shall average
187	187	12 or repeat the charges and fees in a geozip in order to
188	188	13 designate charges and fees for each region.
189	189	14 (3) In cases where the compiled data contains less
190	190	15 than 9 charges or fees for a procedure, treatment,
191	191	16 product, supply, or service or where the fee schedule
192	192	17 amount cannot be determined by the non-discounted charge
193	193	18 data, non-Medicare relative values and conversion factors
194	194	19 derived from established fee schedule amounts, coding
195	195	20 crosswalks, or other data as determined by the Commission,
196	196	21 reimbursement shall occur at 76% of charges and fees until
197	197	22 September 1, 2011 and 53.2% of charges and fees thereafter
198	198	23 as determined by the Commission in a manner consistent
199	199	24 with the provisions of this paragraph.
200	200	25 (4) To establish additional fee schedule amounts, the
201	201	26 Commission shall utilize provider non-discounted charge
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212	212	1 data, non-Medicare relative values and conversion factors
213	213	2 derived from established fee schedule amounts, and coding
214	214	3 crosswalks. The Commission may establish additional fee
215	215	4 schedule amounts based on either the charge or cost of the
216	216	5 procedure, treatment, product, supply, or service.
217	217	6 (5) Implants shall be reimbursed at 25% above the net
218	218	7 manufacturer's invoice price less rebates, plus actual
219	219	8 reasonable and customary shipping charges whether or not
220	220	9 the implant charge is submitted by a provider in
221	221	10 conjunction with a bill for all other services associated
222	222	11 with the implant, submitted by a provider on a separate
223	223	12 claim form, submitted by a distributor, or submitted by
224	224	13 the manufacturer of the implant. "Implants" include the
225	225	14 following codes or any substantially similar updated code
226	226	15 as determined by the Commission: 0274
227	227	16 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
228	228	17 implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
229	229	18 (investigational devices); and 0636 (drugs requiring
230	230	19 detailed coding). Non-implantable devices or supplies
231	231	20 within these codes shall be reimbursed at 65% of actual
232	232	21 charge, which is the provider's normal rates under its
233	233	22 standard chargemaster. A standard chargemaster is the
234	234	23 provider's list of charges for procedures, treatments,
235	235	24 products, supplies, or services used to bill payers in a
236	236	25 consistent manner.
237	237	26 (6) The Commission shall automatically update all
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248	248	1 codes and associated rules with the version of the codes
249	249	2 and rules valid on January 1 of that year.
250	250	3 (a-2) For procedures, treatments, services, or supplies
251	251	4 covered under this Act and rendered or to be rendered on or
252	252	5 after September 1, 2011, the maximum allowable payment shall
253	253	6 be 70% of the fee schedule amounts, which shall be adjusted
254	254	7 yearly by the Consumer Price Index-U, as described in
255	255	8 subsection (a) of this Section.
256	256	9 (a-3) Prescriptions filled and dispensed outside of a
257	257	10 licensed pharmacy shall be subject to a fee schedule that
258	258	11 shall not exceed the Average Wholesale Price (AWP) plus a
259	259	12 dispensing fee of $4.18. AWP or its equivalent as registered
260	260	13 by the National Drug Code shall be set forth for that drug on
261	261	14 that date as published in Medi-Span Medispan.
262	262	15 (a-4) By September 1, 2023, the Commission, in
263	263	16 consultation with the Workers' Compensation Medical Fee
264	264	17 Advisory Board, shall adopt by rule an evidence-based drug
265	265	18 formulary and any rules necessary for its administration.
266	266	19 Prescriptions prescribed for workers' compensation cases shall
267	267	20 be limited to the prescription drugs and doses on the closed
268	268	21 formulary.
269	269	22 A request for a prescription that is not on the closed
270	270	23 formulary shall be reviewed under Section 8.7.
271	271	24 (b) Notwithstanding the provisions of subsection (a), if
272	272	25 the Commission finds that there is a significant limitation on
273	273	26 access to quality health care in either a specific field of
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284	284	1 health care services or a specific geographic limitation on
285	285	2 access to health care, it may change the Consumer Price
286	286	3 Index-U increase or decrease for that specific field or
287	287	4 specific geographic limitation on access to health care to
288	288	5 address that limitation.
289	289	6 (c) The Commission shall establish by rule a process to
290	290	7 review those medical cases or outliers that involve
291	291	8 extra-ordinary treatment to determine whether to make an
292	292	9 additional adjustment to the maximum payment within a fee
293	293	10 schedule for a procedure, treatment, or service.
294	294	11 (d) When a patient notifies a provider that the treatment,
295	295	12 procedure, or service being sought is for a work-related
296	296	13 illness or injury and furnishes the provider the name and
297	297	14 address of the responsible employer, the provider shall bill
298	298	15 the employer or its designee directly. The employer or its
299	299	16 designee shall make payment for treatment in accordance with
300	300	17 the provisions of this Section directly to the provider,
301	301	18 except that, if a provider has designated a third-party
302	302	19 billing entity to bill on its behalf, payment shall be made
303	303	20 directly to the billing entity. Providers shall submit bills
304	304	21 and records in accordance with the provisions of this Section.
305	305	22 (1) All payments to providers for treatment provided
306	306	23 pursuant to this Act shall be made within 30 days of
307	307	24 receipt of the bills as long as the bill contains
308	308	25 substantially all the required data elements necessary to
309	309	26 adjudicate the bill.
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320	320	1 (2) If the bill does not contain substantially all the
321	321	2 required data elements necessary to adjudicate the bill,
322	322	3 or the claim is denied for any other reason, in whole or in
323	323	4 part, the employer or insurer shall provide written
324	324	5 notification to the provider in the form of an explanation
325	325	6 of benefits explaining the basis for the denial and
326	326	7 describing any additional necessary data elements within
327	327	8 30 days of receipt of the bill. The Commission, with
328	328	9 assistance from the Medical Fee Advisory Board, shall
329	329	10 adopt rules detailing the requirements for the explanation
330	330	11 of benefits required under this subsection.
331	331	12 (3) In the case (i) of nonpayment to a provider within
332	332	13 30 days of receipt of the bill which contained
333	333	14 substantially all of the required data elements necessary
334	334	15 to adjudicate the bill, (ii) of nonpayment to a provider
335	335	16 of a portion of such a bill, or (iii) where the provider
336	336	17 has not been issued an explanation of benefits for a bill,
337	337	18 the bill, or portion of the bill up to the lesser of the
338	338	19 actual charge or the payment level set by the Commission
339	339	20 in the fee schedule established in this Section, shall
340	340	21 incur interest at a rate of 1% per month payable by the
341	341	22 employer to the provider. Any required interest payments
342	342	23 shall be made by the employer or its insurer to the
343	343	24 provider within 30 days after payment of the bill.
344	344	25 (4) If the employer or its insurer fails to pay
345	345	26 interest within 30 days after payment of the bill as
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356	356	1 required pursuant to paragraph (3), the provider may bring
357	357	2 an action in circuit court for the sole purpose of seeking
358	358	3 payment of interest pursuant to paragraph (3) against the
359	359	4 employer or its insurer responsible for insuring the
360	360	5 employer's liability pursuant to item (3) of subsection
361	361	6 (a) of Section 4. The circuit court's jurisdiction shall
362	362	7 be limited to enforcing payment of interest pursuant to
363	363	8 paragraph (3). Interest under paragraph (3) is only
364	364	9 payable to the provider. An employee is not responsible
365	365	10 for the payment of interest under this Section. The right
366	366	11 to interest under paragraph (3) shall not delay, diminish,
367	367	12 restrict, or alter in any way the benefits to which the
368	368	13 employee or his or her dependents are entitled under this
369	369	14 Act.
370	370	15 The changes made to this subsection (d) by this amendatory
371	371	16 Act of the 100th General Assembly apply to procedures,
372	372	17 treatments, and services rendered on and after the effective
373	373	18 date of this amendatory Act of the 100th General Assembly.
374	374	19 (e) Except as provided in subsections (e-5), (e-10), and
375	375	20 (e-15), a provider shall not hold an employee liable for costs
376	376	21 related to a non-disputed procedure, treatment, or service
377	377	22 rendered in connection with a compensable injury. The
378	378	23 provisions of subsections (e-5), (e-10), (e-15), and (e-20)
379	379	24 shall not apply if an employee provides information to the
380	380	25 provider regarding participation in a group health plan. If
381	381	26 the employee participates in a group health plan, the provider
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392	392	1 may submit a claim for services to the group health plan. If
393	393	2 the claim for service is covered by the group health plan, the
394	394	3 employee's responsibility shall be limited to applicable
395	395	4 deductibles, co-payments, or co-insurance. Except as provided
396	396	5 under subsections (e-5), (e-10), (e-15), and (e-20), a
397	397	6 provider shall not bill or otherwise attempt to recover from
398	398	7 the employee the difference between the provider's charge and
399	399	8 the amount paid by the employer or the insurer on a compensable
400	400	9 injury, or for medical services or treatment determined by the
401	401	10 Commission to be excessive or unnecessary.
402	402	11 (e-5) If an employer notifies a provider that the employer
403	403	12 does not consider the illness or injury to be compensable
404	404	13 under this Act, the provider may seek payment of the
405	405	14 provider's actual charges from the employee for any procedure,
406	406	15 treatment, or service rendered. Once an employee informs the
407	407	16 provider that there is an application filed with the
408	408	17 Commission to resolve a dispute over payment of such charges,
409	409	18 the provider shall cease any and all efforts to collect
410	410	19 payment for the services that are the subject of the dispute.
411	411	20 Any statute of limitations or statute of repose applicable to
412	412	21 the provider's efforts to collect payment from the employee
413	413	22 shall be tolled from the date that the employee files the
414	414	23 application with the Commission until the date that the
415	415	24 provider is permitted to resume collection efforts under the
416	416	25 provisions of this Section.
417	417	26 (e-10) If an employer notifies a provider that the
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428	428	1 employer will pay only a portion of a bill for any procedure,
429	429	2 treatment, or service rendered in connection with a
430	430	3 compensable illness or disease, the provider may seek payment
431	431	4 from the employee for the remainder of the amount of the bill
432	432	5 up to the lesser of the actual charge, negotiated rate, if
433	433	6 applicable, or the payment level set by the Commission in the
434	434	7 fee schedule established in this Section. Once an employee
435	435	8 informs the provider that there is an application filed with
436	436	9 the Commission to resolve a dispute over payment of such
437	437	10 charges, the provider shall cease any and all efforts to
438	438	11 collect payment for the services that are the subject of the
439	439	12 dispute. Any statute of limitations or statute of repose
440	440	13 applicable to the provider's efforts to collect payment from
441	441	14 the employee shall be tolled from the date that the employee
442	442	15 files the application with the Commission until the date that
443	443	16 the provider is permitted to resume collection efforts under
444	444	17 the provisions of this Section.
445	445	18 (e-15) When there is a dispute over the compensability of
446	446	19 or amount of payment for a procedure, treatment, or service,
447	447	20 and a case is pending or proceeding before an Arbitrator or the
448	448	21 Commission, the provider may mail the employee reminders that
449	449	22 the employee will be responsible for payment of any procedure,
450	450	23 treatment or service rendered by the provider. The reminders
451	451	24 must state that they are not bills, to the extent practicable
452	452	25 include itemized information, and state that the employee need
453	453	26 not pay until such time as the provider is permitted to resume
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464	464	1 collection efforts under this Section. The reminders shall not
465	465	2 be provided to any credit rating agency. The reminders may
466	466	3 request that the employee furnish the provider with
467	467	4 information about the proceeding under this Act, such as the
468	468	5 file number, names of parties, and status of the case. If an
469	469	6 employee fails to respond to such request for information or
470	470	7 fails to furnish the information requested within 90 days of
471	471	8 the date of the reminder, the provider is entitled to resume
472	472	9 any and all efforts to collect payment from the employee for
473	473	10 the services rendered to the employee and the employee shall
474	474	11 be responsible for payment of any outstanding bills for a
475	475	12 procedure, treatment, or service rendered by a provider.
476	476	13 (e-20) Upon a final award or judgment by an Arbitrator or
477	477	14 the Commission, or a settlement agreed to by the employer and
478	478	15 the employee, a provider may resume any and all efforts to
479	479	16 collect payment from the employee for the services rendered to
480	480	17 the employee and the employee shall be responsible for payment
481	481	18 of any outstanding bills for a procedure, treatment, or
482	482	19 service rendered by a provider as well as the interest awarded
483	483	20 under subsection (d) of this Section. In the case of a
484	484	21 procedure, treatment, or service deemed compensable, the
485	485	22 provider shall not require a payment rate, excluding the
486	486	23 interest provisions under subsection (d), greater than the
487	487	24 lesser of the actual charge or the payment level set by the
488	488	25 Commission in the fee schedule established in this Section.
489	489	26 Payment for services deemed not covered or not compensable
490	490
491	491
492	492
493	493
494	494
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497	497
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500	500	1 under this Act is the responsibility of the employee unless a
501	501	2 provider and employee have agreed otherwise in writing.
502	502	3 Services not covered or not compensable under this Act are not
503	503	4 subject to the fee schedule in this Section.
504	504	5 (f) Nothing in this Act shall prohibit an employer or
505	505	6 insurer from contracting with a health care provider or group
506	506	7 of health care providers for reimbursement levels for benefits
507	507	8 under this Act different from those provided in this Section.
508	508	9 (g) On or before January 1, 2010 the Commission shall
509	509	10 provide to the Governor and General Assembly a report
510	510	11 regarding the implementation of the medical fee schedule and
511	511	12 the index used for annual adjustment to that schedule as
512	512	13 described in this Section.
513	513	14 (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
514	514	15 1-11-19.)
515	515	16 Section 99. Effective date. This Act takes effect upon
516	516	17 becoming law.
517	517
518	518
519	519
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