103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 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 shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately. LRB103 32159 SPS 61248 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 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 shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately. LRB103 32159 SPS 61248 b LRB103 32159 SPS 61248 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
820 ILCS 305/8.2 820 ILCS 305/8.2
820 ILCS 305/8.2
Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.
LRB103 32159 SPS 61248 b LRB103 32159 SPS 61248 b
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A BILL FOR
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HB4079 LRB103 32159 SPS 61248 b
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
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
820 ILCS 305/8.2 820 ILCS 305/8.2
820 ILCS 305/8.2
Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.
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A BILL FOR
820 ILCS 305/8.2
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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-1.5) The following provisions apply to procedures,
4 treatments, services, products, and supplies covered under
5 this Act and rendered or to be rendered on or after September
6 1, 2024:
7 (1) In this Section:
8 "CPT code" means each Current Procedural
9 Terminology code, for each geographic region specified
10 in subsection (b) of this Section, included on the
11 most recent medical fee schedule established by the
12 Commission pursuant to this Section.
13 "DRG code" means each current diagnosis related
14 group code, for each geographic region specified in
15 subsection (b) of this Section, included on the most
16 recent medical fee schedule established by the
17 Commission pursuant to this Section.
18 "Geozip" means a three-digit zip code based on
19 data similarities, geographical similarities, and
20 frequencies.
21 "Health care services" means those CPT and DRG
22 codes for procedures, treatments, products, services,
23 or supplies for hospital inpatient, hospital
24 outpatient, emergency room, ambulatory surgical
25 treatment centers, accredited ambulatory surgical
26 treatment facilities, and professional services.
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1 "Health care services" does not include codes
2 classified as healthcare common procedure coding
3 systems or dental.
4 "Medicare maximum fee" means, for each CPT and DRG
5 code, the current maximum fee for that CPT or DRG code
6 allowed to be charged by the Centers for Medicare and
7 Medicaid Services for Medicare patients in that
8 geographic region. The Medicare maximum fee shall be
9 the greater of (i) the current maximum fee allowed to
10 be charged by the Centers for Medicare and Medicaid
11 Services for Medicare patients in the geographic
12 region or (ii) the maximum fee charged by the Centers
13 for Medicare and Medicaid Services for Medicare
14 patients in the geographic region on January 1, 2024.
15 "Medicare percentage amount" means, for each CPT
16 and DRG code, the workers' compensation maximum fee as
17 a percentage of the Medicare maximum fee.
18 "Workers' compensation maximum fee" means, for
19 each CPT and DRG code, the current maximum fee allowed
20 to be charged under the medical fee schedule
21 established by the Commission for that CPT or DRG code
22 in that geographic region.
23 (2) The Commission shall establish and maintain fee
24 schedules for procedures, treatments, products, services,
25 or supplies for hospital inpatient, hospital outpatient,
26 emergency room, ambulatory surgical treatment centers,
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1 accredited ambulatory surgical treatment facilities,
2 prescriptions filled and dispensed outside of a licensed
3 pharmacy, dental services, and professional services.
4 These fee schedule amounts shall be grouped into
5 geographic regions in the following manner:
6 (A) Four regions for non-hospital fee schedule
7 amounts shall be utilized:
8 (i) Cook County;
9 (ii) DuPage, Kane, Lake, and Will Counties;
10 (iii) Bond, Calhoun, Clinton, Jersey,
11 Macoupin, Madison, Monroe, Montgomery, Randolph,
12 St. Clair, and Washington Counties; and
13 (iv) all other counties of the State.
14 (B) Fourteen regions for hospital fee schedule
15 amounts shall be utilized:
16 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
17 Kendall, and Grundy Counties;
18 (ii) Kankakee County;
19 (iii) Madison, St. Clair, Macoupin, Clinton,
20 Monroe, Jersey, Bond, and Calhoun Counties;
21 (iv) Winnebago and Boone Counties;
22 (v) Peoria, Tazewell, Woodford, Marshall, and
23 Stark Counties;
24 (vi) Champaign, Piatt, and Ford Counties;
25 (vii) Rock Island, Henry, and Mercer Counties;
26 (viii) Sangamon and Menard Counties;
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1 (ix) McLean County;
2 (x) Lake County;
3 (xi) Macon County;
4 (xii) Vermilion County;
5 (xiii) Alexander County; and
6 (xiv) all other counties of the State.
7 If a geozip overlaps into one or more of the
8 regions set forth in this subsection, then the
9 Commission shall average or repeat the charges and
10 fees in a geozip in order to designate charges and fees
11 for each region.
12 (3) The initial workers' compensation maximum fee for
13 each CPT and DRG code as of September 1, 2024 shall be
14 determined as follows:
15 (A) Within 45 days after the effective date of
16 this amendatory Act of the 103rd General Assembly, the
17 Commission shall determine the Medicare percentage
18 amount for each CPT and DRG code using the most recent
19 data available.
20 CPT or DRG codes which have a value, but are not
21 covered expenses under Medicare, are still compensable
22 under the medical fee schedule according to the rate
23 described in subparagraph (B).
24 (B) Within 30 days after the Commission makes the
25 determinations required under subparagraph (A), the
26 Commission shall determine an adjustment to be made to
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1 the workers' compensation maximum fee for each CPT and
2 DRG code as follows:
3 (i) if the Medicare percentage amount for that
4 CPT or DRG code is equal to or less than 125%, then
5 the workers' compensation maximum fee for that CPT
6 or DRG code shall be adjusted so that it equals
7 125% of the most recent Medicare maximum fee for
8 that CPT or DRG code;
9 (ii) if the Medicare percentage amount for
10 that CPT or DRG code is greater than 125% but less
11 than 150%, then the workers' compensation maximum
12 fee for that CPT or DRG code shall not be adjusted;
13 (iii) if the Medicare percentage amount for
14 that CPT or DRG code is greater than 150% but less
15 than or equal to 225%, then the workers'
16 compensation maximum fee for that CPT or DRG code
17 shall be adjusted so that it equals the greater of
18 (I) 150% of the most recent Medicare maximum fee
19 for that CPT or DRG code or (II) 85% of the most
20 recent workers' compensation maximum amount for
21 that CPT or DRG code;
22 (iv) if the Medicare percentage amount for
23 that CPT or DRG code is greater than 225% but less
24 than or equal to 428.57%, then the workers'
25 compensation maximum fee for that CPT or DRG code
26 shall be adjusted so that it equals the greater of
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1 (I) 191.25% of the most recent Medicare maximum
2 fee for that CPT or DRG code or (II) 70% of the
3 most recent workers' compensation maximum amount
4 for that CPT or DRG code; or
5 (v) if the Medicare percentage amount for that
6 CPT or DRG code is greater than 428.57%, then the
7 workers' compensation maximum fee for that CPT or
8 DRG code shall be adjusted so that it equals 300%
9 of the most recent Medicare maximum fee for that
10 CPT or DRG code.
11 The Commission shall promptly publish on its
12 website the adjustments determined pursuant to this
13 subparagraph (B).
14 (C) The initial workers' compensation maximum fee
15 for each CPT and DRG code as of September 1, 2024 shall
16 be equal to the workers' compensation maximum fee for
17 that code as determined and adjusted pursuant to
18 subparagraph (B), subject to any further adjustments
19 under paragraph (5) of this subsection.
20 (4) The Commission, as of September 1, 2025 and
21 September 1 of each year thereafter, shall adjust the
22 workers' compensation maximum fee for each CPT or DRG code
23 to exactly half of the most recent annual increase in the
24 Consumer Price Index-U.
25 (5) A person who believes that the workers'
26 compensation maximum fee for a CPT or DRG code, as
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1 otherwise determined pursuant to this subsection, creates
2 or would create upon implementation a significant
3 limitation on access to quality health care in either a
4 specific field of health care services or a specific
5 geographic limitation on access to health care may
6 petition the Commission to modify the workers'
7 compensation maximum fee for that CPT or DRG code so as to
8 not create that significant limitation.
9 The petitioner bears the burden of demonstrating, by a
10 preponderance of the credible evidence, that the workers'
11 compensation maximum fee that would otherwise apply would
12 create a significant limitation on access to quality
13 health care in either a specific field of health care
14 services or a specific geographic limitation on access to
15 health care. Petitions shall be made publicly available.
16 Such credible evidence shall include empirical data
17 demonstrating a significant limitation on access to
18 quality health care. Other interested persons may file
19 comments or responses to a petition within 30 days after
20 the filing of a petition.
21 The Commission shall take final action on each
22 petition within 180 days after filing. The Commission may,
23 but is not required to, seek the recommendation of the
24 Medical Fee Advisory Board to assist with this
25 determination. If the Commission grants the petition, the
26 Commission shall further increase the workers'
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1 compensation maximum fee for that CPT or DRG code by the
2 amount minimally necessary to avoid creating a significant
3 limitation on access to quality health care in either a
4 specific field of health care services or a specific
5 geographic limitation on access to health care. The
6 increased workers' compensation maximum fee shall take
7 effect upon entry of the Commission's final action.
8 (a-2) For procedures, treatments, services, or supplies
9 covered under this Act and rendered or to be rendered on or
10 after September 1, 2011, the maximum allowable payment shall
11 be 70% of the fee schedule amounts, which shall be adjusted
12 yearly by the Consumer Price Index-U, as described in
13 subsection (a) of this Section.
14 (a-2.5) Subsections (a), (a-1), and (a-2) are inoperative
15 on and after August 31, 2024.
16 (a-3) Prescriptions filled and dispensed outside of a
17 licensed pharmacy shall be subject to a fee schedule that
18 shall not exceed the Average Wholesale Price (AWP) plus a
19 dispensing fee of $4.18. AWP or its equivalent as registered
20 by the National Drug Code shall be set forth for that drug on
21 that date as published in Medi-Span Medispan.
22 (a-3.5) By September 1, 2023, the Commission, in
23 consultation with the Workers' Compensation Medical Fee
24 Advisory Board, shall adopt by rule an evidence-based drug
25 formulary and any rules necessary for its administration.
26 Prescriptions prescribed for workers' compensation cases shall
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1 be limited to the prescription drugs and doses on the closed
2 formulary.
3 A request for a prescription that is not on the closed
4 formulary shall be reviewed under Section 8.7.
5 (a-4) As used in this Section, "custom compound
6 medication" means a customized medication prescribed or
7 ordered by a duly licensed prescriber for a specific patient
8 that is prepared in a pharmacy by a licensed pharmacist in
9 response to a licensed prescriber's prescription or order by
10 combining, mixing, or altering of ingredients, but not
11 reconstituting, to meet the unique needs of a specific
12 patient.
13 (a-5) A custom compound medication for longer than the
14 one-time 7-day supply described in subsection (a-6) shall be
15 approved for payment only if the compound meets all of the
16 following standards:
17 (1) there is no readily available commercially
18 manufactured equivalent product;
19 (2) no other Food and Drug Administration-approved
20 alternative drug is appropriate for the patient;
21 (3) the active ingredients of the compound each have a
22 National Drug Code number, are components of drugs
23 approved by the Food and Drug Administration, and the
24 active ingredients in the custom compound medication are
25 being used for diagnosis or conditions approved use by the
26 Food and Drug Administration and not being used for
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1 off-label use;
2 (4) the drug has not been withdrawn or removed from
3 the market for safety reasons; and
4 (5) the prescriber is able to demonstrate to the payer
5 that the compound medication is clinically appropriate for
6 the intended use.
7 (a-6) Custom compound medications shall be charged using
8 the specific amount of each component drug and its original
9 manufacturer's National Drug Code number included in the
10 compound. Charges shall be based on a maximum charge of the
11 average wholesale price based upon the original manufacturer's
12 National Drug Code number, as published by Red Book or
13 Medi-Span and prorated for each component amount used. If the
14 National Drug Code for the compound ingredient is a repackaged
15 drug, the maximum allowable fee for the repackaged drug shall
16 be determined by the National Drug Code and the average
17 wholesale price of the underlying original manufacturer.
18 Components without National Drug Code numbers shall not be
19 charged. A single dispensing fee for a custom compound
20 medication as determined by the Commission based on the actual
21 costs of preparing and dispensing the custom compound
22 medication shall be paid. The dispensing fee for a compound
23 prescription shall be billed with code WC 700-C. The provider
24 may prescribe a one-time 7-day supply. Any custom compound
25 medication prescriptions for more than 7 days shall be
26 preauthorized by the employer. Under all circumstances, if the
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1 compound medication meets the requirements in subsection
2 (a-5), a 7-day supply shall be covered.
3 (a-7) This Section is subject to the other provisions of
4 this Act, including, but not limited to, Section 8.7.
5 (b) Notwithstanding the provisions of subsection (a), if
6 the Commission finds that there is a significant limitation on
7 access to quality health care in either a specific field of
8 health care services or a specific geographic limitation on
9 access to health care, it may change the Consumer Price
10 Index-U increase or decrease for that specific field or
11 specific geographic limitation on access to health care to
12 address that limitation.
13 (c) The Commission shall establish by rule a process to
14 review those medical cases or outliers that involve
15 extra-ordinary treatment to determine whether to make an
16 additional adjustment to the maximum payment within a fee
17 schedule for a procedure, treatment, or service.
18 (d) When a patient notifies a provider that the treatment,
19 procedure, or service being sought is for a work-related
20 illness or injury and furnishes the provider the name and
21 address of the responsible employer, the provider shall bill
22 the employer or its designee directly. The employer or its
23 designee shall make payment for treatment in accordance with
24 the provisions of this Section directly to the provider,
25 except that, if a provider has designated a third-party
26 billing entity to bill on its behalf, payment shall be made
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1 directly to the billing entity. Providers shall submit bills
2 and records in accordance with the provisions of this Section.
3 (1) All payments to providers for treatment provided
4 pursuant to this Act shall be made within 30 days of
5 receipt of the bills as long as the bill contains
6 substantially all the required data elements necessary to
7 adjudicate the bill.
8 (2) If the bill does not contain substantially all the
9 required data elements necessary to adjudicate the bill,
10 or the claim is denied for any other reason, in whole or in
11 part, the employer or insurer shall provide written
12 notification to the provider in the form of an explanation
13 of benefits explaining the basis for the denial and
14 describing any additional necessary data elements within
15 30 days of receipt of the bill. The Commission, with
16 assistance from the Medical Fee Advisory Board, shall
17 adopt rules detailing the requirements for the explanation
18 of benefits required under this subsection.
19 (3) In the case (i) of nonpayment to a provider within
20 30 days of receipt of the bill which contained
21 substantially all of the required data elements necessary
22 to adjudicate the bill, (ii) of nonpayment to a provider
23 of a portion of such a bill, or (iii) where the provider
24 has not been issued an explanation of benefits for a bill,
25 the bill, or portion of the bill up to the lesser of the
26 actual charge or the payment level set by the Commission
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1 in the fee schedule established in this Section, shall
2 incur interest at a rate of 1% per month payable by the
3 employer to the provider. Any required interest payments
4 shall be made by the employer or its insurer to the
5 provider within 30 days after payment of the bill.
6 (4) If the employer or its insurer fails to pay
7 interest within 30 days after payment of the bill as
8 required pursuant to paragraph (3), the provider may bring
9 an action in circuit court for the sole purpose of seeking
10 payment of interest pursuant to paragraph (3) against the
11 employer or its insurer responsible for insuring the
12 employer's liability pursuant to item (3) of subsection
13 (a) of Section 4. The circuit court's jurisdiction shall
14 be limited to enforcing payment of interest pursuant to
15 paragraph (3). Interest under paragraph (3) is only
16 payable to the provider. An employee is not responsible
17 for the payment of interest under this Section. The right
18 to interest under paragraph (3) shall not delay, diminish,
19 restrict, or alter in any way the benefits to which the
20 employee or his or her dependents are entitled under this
21 Act.
22 The changes made to this subsection (d) by this amendatory
23 Act of the 100th General Assembly apply to procedures,
24 treatments, and services rendered on and after the effective
25 date of this amendatory Act of the 100th General Assembly.
26 (e) Except as provided in subsections (e-5), (e-10), and
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1 (e-15), a provider shall not hold an employee liable for costs
2 related to a non-disputed procedure, treatment, or service
3 rendered in connection with a compensable injury. The
4 provisions of subsections (e-5), (e-10), (e-15), and (e-20)
5 shall not apply if an employee provides information to the
6 provider regarding participation in a group health plan. If
7 the employee participates in a group health plan, the provider
8 may submit a claim for services to the group health plan. If
9 the claim for service is covered by the group health plan, the
10 employee's responsibility shall be limited to applicable
11 deductibles, co-payments, or co-insurance. Except as provided
12 under subsections (e-5), (e-10), (e-15), and (e-20), a
13 provider shall not bill or otherwise attempt to recover from
14 the employee the difference between the provider's charge and
15 the amount paid by the employer or the insurer on a compensable
16 injury, or for medical services or treatment determined by the
17 Commission to be excessive or unnecessary.
18 (e-5) If an employer notifies a provider that the employer
19 does not consider the illness or injury to be compensable
20 under this Act, the provider may seek payment of the
21 provider's actual charges from the employee for any procedure,
22 treatment, or service rendered. Once an employee informs the
23 provider that there is an application filed with the
24 Commission to resolve a dispute over payment of such charges,
25 the provider shall cease any and all efforts to collect
26 payment for the services that are the subject of the dispute.
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1 Any statute of limitations or statute of repose applicable to
2 the provider's efforts to collect payment from the employee
3 shall be tolled from the date that the employee files the
4 application with the Commission until the date that the
5 provider is permitted to resume collection efforts under the
6 provisions of this Section.
7 (e-10) If an employer notifies a provider that the
8 employer will pay only a portion of a bill for any procedure,
9 treatment, or service rendered in connection with a
10 compensable illness or disease, the provider may seek payment
11 from the employee for the remainder of the amount of the bill
12 up to the lesser of the actual charge, negotiated rate, if
13 applicable, or the payment level set by the Commission in the
14 fee schedule established in this Section. Once an employee
15 informs the provider that there is an application filed with
16 the Commission to resolve a dispute over payment of such
17 charges, the provider shall cease any and all efforts to
18 collect payment for the services that are the subject of the
19 dispute. Any statute of limitations or statute of repose
20 applicable to the provider's efforts to collect payment from
21 the employee shall be tolled from the date that the employee
22 files the application with the Commission until the date that
23 the provider is permitted to resume collection efforts under
24 the provisions of this Section.
25 (e-15) When there is a dispute over the compensability of
26 or amount of payment for a procedure, treatment, or service,
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1 and a case is pending or proceeding before an Arbitrator or the
2 Commission, the provider may mail the employee reminders that
3 the employee will be responsible for payment of any procedure,
4 treatment or service rendered by the provider. The reminders
5 must state that they are not bills, to the extent practicable
6 include itemized information, and state that the employee need
7 not pay until such time as the provider is permitted to resume
8 collection efforts under this Section. The reminders shall not
9 be provided to any credit rating agency. The reminders may
10 request that the employee furnish the provider with
11 information about the proceeding under this Act, such as the
12 file number, names of parties, and status of the case. If an
13 employee fails to respond to such request for information or
14 fails to furnish the information requested within 90 days of
15 the date of the reminder, the provider is entitled to resume
16 any and all efforts to collect payment from the employee for
17 the services rendered to the employee and the employee shall
18 be responsible for payment of any outstanding bills for a
19 procedure, treatment, or service rendered by a provider.
20 (e-20) Upon a final award or judgment by an Arbitrator or
21 the Commission, or a settlement agreed to by the employer and
22 the employee, a provider may resume any and all efforts to
23 collect payment from the employee for the services rendered to
24 the employee and the employee shall be responsible for payment
25 of any outstanding bills for a procedure, treatment, or
26 service rendered by a provider as well as the interest awarded
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1 under subsection (d) of this Section. In the case of a
2 procedure, treatment, or service deemed compensable, the
3 provider shall not require a payment rate, excluding the
4 interest provisions under subsection (d), greater than the
5 lesser of the actual charge or the payment level set by the
6 Commission in the fee schedule established in this Section.
7 Payment for services deemed not covered or not compensable
8 under this Act is the responsibility of the employee unless a
9 provider and employee have agreed otherwise in writing.
10 Services not covered or not compensable under this Act are not
11 subject to the fee schedule in this Section.
12 (f) Nothing in this Act shall prohibit an employer or
13 insurer from contracting with a health care provider or group
14 of health care providers for reimbursement levels for benefits
15 under this Act different from those provided in this Section.
16 (g) On or before January 1, 2010 the Commission shall
17 provide to the Governor and General Assembly a report
18 regarding the implementation of the medical fee schedule and
19 the index used for annual adjustment to that schedule as
20 described in this Section.
21 (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
22 1-11-19.)
23 Section 99. Effective date. This Act takes effect upon
24 becoming law.
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