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Illinois House Bill HB2457

Illinois 2025-2026 Regular Session

Illinois House Bill HB2457 Compare Versions

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11 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2457 Introduced , by Rep. Jay Hoffman SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-4.2 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that subject to federal approval, the Department of Healthcare and Family Services shall increase the base rate of reimbursement for both base charges and mileage charges for medical transportation services provided by means of an air ambulance to a level not lower than 75% of the Medicare ambulance fee schedule rates, by designated Medicare locality. LRB104 08103 KTG 18149 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2457 Introduced , by Rep. Jay Hoffman SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-4.2 305 ILCS 5/5-4.2 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that subject to federal approval, the Department of Healthcare and Family Services shall increase the base rate of reimbursement for both base charges and mileage charges for medical transportation services provided by means of an air ambulance to a level not lower than 75% of the Medicare ambulance fee schedule rates, by designated Medicare locality. LRB104 08103 KTG 18149 b LRB104 08103 KTG 18149 b A BILL FOR
22 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2457 Introduced , by Rep. Jay Hoffman SYNOPSIS AS INTRODUCED:
33 305 ILCS 5/5-4.2 305 ILCS 5/5-4.2
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55 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that subject to federal approval, the Department of Healthcare and Family Services shall increase the base rate of reimbursement for both base charges and mileage charges for medical transportation services provided by means of an air ambulance to a level not lower than 75% of the Medicare ambulance fee schedule rates, by designated Medicare locality.
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1111 1 AN ACT concerning public aid.
1212 2 Be it enacted by the People of the State of Illinois,
1313 3 represented in the General Assembly:
1414 4 Section 5. The Illinois Public Aid Code is amended by
1515 5 changing Section 5-4.2 as follows:
1616 6 (305 ILCS 5/5-4.2)
1717 7 Sec. 5-4.2. Ambulance services payments.
1818 8 (a) For ambulance services provided to a recipient of aid
1919 9 under this Article on or after January 1, 1993, the Illinois
2020 10 Department shall reimburse ambulance service providers at
2121 11 rates calculated in accordance with this Section. It is the
2222 12 intent of the General Assembly to provide adequate
2323 13 reimbursement for ambulance services so as to ensure adequate
2424 14 access to services for recipients of aid under this Article
2525 15 and to provide appropriate incentives to ambulance service
2626 16 providers to provide services in an efficient and
2727 17 cost-effective manner. Thus, it is the intent of the General
2828 18 Assembly that the Illinois Department implement a
2929 19 reimbursement system for ambulance services that, to the
3030 20 extent practicable and subject to the availability of funds
3131 21 appropriated by the General Assembly for this purpose, is
3232 22 consistent with the payment principles of Medicare. To ensure
3333 23 uniformity between the payment principles of Medicare and
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3838 305 ILCS 5/5-4.2 305 ILCS 5/5-4.2
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4040 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that subject to federal approval, the Department of Healthcare and Family Services shall increase the base rate of reimbursement for both base charges and mileage charges for medical transportation services provided by means of an air ambulance to a level not lower than 75% of the Medicare ambulance fee schedule rates, by designated Medicare locality.
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6868 1 Medicaid, the Illinois Department shall follow, to the extent
6969 2 necessary and practicable and subject to the availability of
7070 3 funds appropriated by the General Assembly for this purpose,
7171 4 the statutes, laws, regulations, policies, procedures,
7272 5 principles, definitions, guidelines, and manuals used to
7373 6 determine the amounts paid to ambulance service providers
7474 7 under Title XVIII of the Social Security Act (Medicare).
7575 8 (b) For ambulance services provided to a recipient of aid
7676 9 under this Article on or after January 1, 1996, the Illinois
7777 10 Department shall reimburse ambulance service providers based
7878 11 upon the actual distance traveled if a natural disaster,
7979 12 weather conditions, road repairs, or traffic congestion
8080 13 necessitates the use of a route other than the most direct
8181 14 route.
8282 15 (c) For purposes of this Section, "ambulance services"
8383 16 includes medical transportation services provided by means of
8484 17 an ambulance, air ambulance, medi-car, service car, or taxi.
8585 18 (c-1) For purposes of this Section, "ground ambulance
8686 19 service" means medical transportation services that are
8787 20 described as ground ambulance services by the Centers for
8888 21 Medicare and Medicaid Services and provided in a vehicle that
8989 22 is licensed as an ambulance by the Illinois Department of
9090 23 Public Health pursuant to the Emergency Medical Services (EMS)
9191 24 Systems Act.
9292 25 (c-2) For purposes of this Section, "ground ambulance
9393 26 service provider" means a vehicle service provider as
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104104 1 described in the Emergency Medical Services (EMS) Systems Act
105105 2 that operates licensed ambulances for the purpose of providing
106106 3 emergency ambulance services, or non-emergency ambulance
107107 4 services, or both. For purposes of this Section, this includes
108108 5 both ambulance providers and ambulance suppliers as described
109109 6 by the Centers for Medicare and Medicaid Services.
110110 7 (c-3) For purposes of this Section, "medi-car" means
111111 8 transportation services provided to a patient who is confined
112112 9 to a wheelchair and requires the use of a hydraulic or electric
113113 10 lift or ramp and wheelchair lockdown when the patient's
114114 11 condition does not require medical observation, medical
115115 12 supervision, medical equipment, the administration of
116116 13 medications, or the administration of oxygen.
117117 14 (c-4) For purposes of this Section, "service car" means
118118 15 transportation services provided to a patient by a passenger
119119 16 vehicle where that patient does not require the specialized
120120 17 modes described in subsection (c-1) or (c-3).
121121 18 (c-5) For purposes of this Section, "air ambulance
122122 19 service" means medical transport by helicopter or airplane for
123123 20 patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
124124 21 that is described as an air ambulance service by the federal
125125 22 Centers for Medicare and Medicaid Services.
126126 23 (d) This Section does not prohibit separate billing by
127127 24 ambulance service providers for oxygen furnished while
128128 25 providing advanced life support services.
129129 26 (e) Beginning with services rendered on or after July 1,
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140140 1 2008, all providers of non-emergency medi-car and service car
141141 2 transportation must certify that the driver and employee
142142 3 attendant, as applicable, have completed a safety program
143143 4 approved by the Department to protect both the patient and the
144144 5 driver, prior to transporting a patient. The provider must
145145 6 maintain this certification in its records. The provider shall
146146 7 produce such documentation upon demand by the Department or
147147 8 its representative. Failure to produce documentation of such
148148 9 training shall result in recovery of any payments made by the
149149 10 Department for services rendered by a non-certified driver or
150150 11 employee attendant. Medi-car and service car providers must
151151 12 maintain legible documentation in their records of the driver
152152 13 and, as applicable, employee attendant that actually
153153 14 transported the patient. Providers must recertify all drivers
154154 15 and employee attendants every 3 years. If they meet the
155155 16 established training components set forth by the Department,
156156 17 providers of non-emergency medi-car and service car
157157 18 transportation that are either directly or through an
158158 19 affiliated company licensed by the Department of Public Health
159159 20 shall be approved by the Department to have in-house safety
160160 21 programs for training their own staff.
161161 22 Notwithstanding the requirements above, any public
162162 23 transportation provider of medi-car and service car
163163 24 transportation that receives federal funding under 49 U.S.C.
164164 25 5307 and 5311 need not certify its drivers and employee
165165 26 attendants under this Section, since safety training is
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176176 1 already federally mandated.
177177 2 (f) With respect to any policy or program administered by
178178 3 the Department or its agent regarding approval of
179179 4 non-emergency medical transportation by ground ambulance
180180 5 service providers, including, but not limited to, the
181181 6 Non-Emergency Transportation Services Prior Approval Program
182182 7 (NETSPAP), the Department shall establish by rule a process by
183183 8 which ground ambulance service providers of non-emergency
184184 9 medical transportation may appeal any decision by the
185185 10 Department or its agent for which no denial was received prior
186186 11 to the time of transport that either (i) denies a request for
187187 12 approval for payment of non-emergency transportation by means
188188 13 of ground ambulance service or (ii) grants a request for
189189 14 approval of non-emergency transportation by means of ground
190190 15 ambulance service at a level of service that entitles the
191191 16 ground ambulance service provider to a lower level of
192192 17 compensation from the Department than the ground ambulance
193193 18 service provider would have received as compensation for the
194194 19 level of service requested. The rule shall be filed by
195195 20 December 15, 2012 and shall provide that, for any decision
196196 21 rendered by the Department or its agent on or after the date
197197 22 the rule takes effect, the ground ambulance service provider
198198 23 shall have 60 days from the date the decision is received to
199199 24 file an appeal. The rule established by the Department shall
200200 25 be, insofar as is practical, consistent with the Illinois
201201 26 Administrative Procedure Act. The Director's decision on an
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212212 1 appeal under this Section shall be a final administrative
213213 2 decision subject to review under the Administrative Review
214214 3 Law.
215215 4 (f-5) Beginning 90 days after July 20, 2012 (the effective
216216 5 date of Public Act 97-842), (i) no denial of a request for
217217 6 approval for payment of non-emergency transportation by means
218218 7 of ground ambulance service, and (ii) no approval of
219219 8 non-emergency transportation by means of ground ambulance
220220 9 service at a level of service that entitles the ground
221221 10 ambulance service provider to a lower level of compensation
222222 11 from the Department than would have been received at the level
223223 12 of service submitted by the ground ambulance service provider,
224224 13 may be issued by the Department or its agent unless the
225225 14 Department has submitted the criteria for determining the
226226 15 appropriateness of the transport for first notice publication
227227 16 in the Illinois Register pursuant to Section 5-40 of the
228228 17 Illinois Administrative Procedure Act.
229229 18 (f-6) Within 90 days after June 2, 2022 (the effective
230230 19 date of Public Act 102-1037) and subject to federal approval,
231231 20 the Department shall file rules to allow for the approval of
232232 21 ground ambulance services when the sole purpose of the
233233 22 transport is for the navigation of stairs or the assisting or
234234 23 lifting of a patient at a medical facility or during a medical
235235 24 appointment in instances where the Department or a contracted
236236 25 Medicaid managed care organization or their transportation
237237 26 broker is unable to secure transportation through any other
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248248 1 transportation provider.
249249 2 (f-7) For non-emergency ground ambulance claims properly
250250 3 denied under Department policy at the time the claim is filed
251251 4 due to failure to submit a valid Medical Certification for
252252 5 Non-Emergency Ambulance on and after December 15, 2012 and
253253 6 prior to January 1, 2021, the Department shall allot
254254 7 $2,000,000 to a pool to reimburse such claims if the provider
255255 8 proves medical necessity for the service by other means.
256256 9 Providers must submit any such denied claims for which they
257257 10 seek compensation to the Department no later than December 31,
258258 11 2021 along with documentation of medical necessity. No later
259259 12 than May 31, 2022, the Department shall determine for which
260260 13 claims medical necessity was established. Such claims for
261261 14 which medical necessity was established shall be paid at the
262262 15 rate in effect at the time of the service, provided the
263263 16 $2,000,000 is sufficient to pay at those rates. If the pool is
264264 17 not sufficient, claims shall be paid at a uniform percentage
265265 18 of the applicable rate such that the pool of $2,000,000 is
266266 19 exhausted. The appeal process described in subsection (f)
267267 20 shall not be applicable to the Department's determinations
268268 21 made in accordance with this subsection.
269269 22 (g) Whenever a patient covered by a medical assistance
270270 23 program under this Code or by another medical program
271271 24 administered by the Department, including a patient covered
272272 25 under the State's Medicaid managed care program, is being
273273 26 transported from a facility and requires non-emergency
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284284 1 transportation including ground ambulance, medi-car, or
285285 2 service car transportation, a Physician Certification
286286 3 Statement as described in this Section shall be required for
287287 4 each patient. Facilities shall develop procedures for a
288288 5 licensed medical professional to provide a written and signed
289289 6 Physician Certification Statement. The Physician Certification
290290 7 Statement shall specify the level of transportation services
291291 8 needed and complete a medical certification establishing the
292292 9 criteria for approval of non-emergency ambulance
293293 10 transportation, as published by the Department of Healthcare
294294 11 and Family Services, that is met by the patient. This
295295 12 certification shall be completed prior to ordering the
296296 13 transportation service and prior to patient discharge. The
297297 14 Physician Certification Statement is not required prior to
298298 15 transport if a delay in transport can be expected to
299299 16 negatively affect the patient outcome. If the ground ambulance
300300 17 provider, medi-car provider, or service car provider is unable
301301 18 to obtain the required Physician Certification Statement
302302 19 within 10 calendar days following the date of the service, the
303303 20 ground ambulance provider, medi-car provider, or service car
304304 21 provider must document its attempt to obtain the requested
305305 22 certification and may then submit the claim for payment.
306306 23 Acceptable documentation includes a signed return receipt from
307307 24 the U.S. Postal Service, facsimile receipt, email receipt, or
308308 25 other similar service that evidences that the ground ambulance
309309 26 provider, medi-car provider, or service car provider attempted
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320320 1 to obtain the required Physician Certification Statement.
321321 2 The medical certification specifying the level and type of
322322 3 non-emergency transportation needed shall be in the form of
323323 4 the Physician Certification Statement on a standardized form
324324 5 prescribed by the Department of Healthcare and Family
325325 6 Services. Within 75 days after July 27, 2018 (the effective
326326 7 date of Public Act 100-646), the Department of Healthcare and
327327 8 Family Services shall develop a standardized form of the
328328 9 Physician Certification Statement specifying the level and
329329 10 type of transportation services needed in consultation with
330330 11 the Department of Public Health, Medicaid managed care
331331 12 organizations, a statewide association representing ambulance
332332 13 providers, a statewide association representing hospitals, 3
333333 14 statewide associations representing nursing homes, and other
334334 15 stakeholders. The Physician Certification Statement shall
335335 16 include, but is not limited to, the criteria necessary to
336336 17 demonstrate medical necessity for the level of transport
337337 18 needed as required by (i) the Department of Healthcare and
338338 19 Family Services and (ii) the federal Centers for Medicare and
339339 20 Medicaid Services as outlined in the Centers for Medicare and
340340 21 Medicaid Services' Medicare Benefit Policy Manual, Pub.
341341 22 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
342342 23 Certification Statement shall satisfy the obligations of
343343 24 hospitals under Section 6.22 of the Hospital Licensing Act and
344344 25 nursing homes under Section 2-217 of the Nursing Home Care
345345 26 Act. Implementation and acceptance of the Physician
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356356 1 Certification Statement shall take place no later than 90 days
357357 2 after the issuance of the Physician Certification Statement by
358358 3 the Department of Healthcare and Family Services.
359359 4 Pursuant to subsection (E) of Section 12-4.25 of this
360360 5 Code, the Department is entitled to recover overpayments paid
361361 6 to a provider or vendor, including, but not limited to, from
362362 7 the discharging physician, the discharging facility, and the
363363 8 ground ambulance service provider, in instances where a
364364 9 non-emergency ground ambulance service is rendered as the
365365 10 result of improper or false certification.
366366 11 Beginning October 1, 2018, the Department of Healthcare
367367 12 and Family Services shall collect data from Medicaid managed
368368 13 care organizations and transportation brokers, including the
369369 14 Department's NETSPAP broker, regarding denials and appeals
370370 15 related to the missing or incomplete Physician Certification
371371 16 Statement forms and overall compliance with this subsection.
372372 17 The Department of Healthcare and Family Services shall publish
373373 18 quarterly results on its website within 15 days following the
374374 19 end of each quarter.
375375 20 (h) On and after July 1, 2012, the Department shall reduce
376376 21 any rate of reimbursement for services or other payments or
377377 22 alter any methodologies authorized by this Code to reduce any
378378 23 rate of reimbursement for services or other payments in
379379 24 accordance with Section 5-5e.
380380 25 (i) Subject to federal approval, on and after January 1,
381381 26 2024, the Department shall increase the base rate of
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392392 1 reimbursement for both base charges and mileage charges for
393393 2 ground ambulance service providers not participating in the
394394 3 Ground Emergency Medical Transportation (GEMT) Program for
395395 4 medical transportation services provided by means of a ground
396396 5 ambulance to a level not lower than 140% of the base rate in
397397 6 effect as of January 1, 2023.
398398 7 (j) For the purpose of understanding ground ambulance
399399 8 transportation services cost structures and their impact on
400400 9 the Medical Assistance Program, the Department shall engage
401401 10 stakeholders, including, but not limited to, a statewide
402402 11 association representing private ground ambulance service
403403 12 providers in Illinois, to develop recommendations for a plan
404404 13 for the regular collection of cost data for all ground
405405 14 ambulance transportation providers reimbursed under the
406406 15 Illinois Title XIX State Plan. Cost data obtained through this
407407 16 process shall be used to inform on and to ensure the
408408 17 effectiveness and efficiency of Illinois Medicaid rates. The
409409 18 Department shall establish a process to limit public
410410 19 availability of portions of the cost report data determined to
411411 20 be proprietary. This process shall be concluded and
412412 21 recommendations shall be provided no later than December 31,
413413 22 2025.
414414 23 (k) Subject to federal approval, beginning on January 1,
415415 24 2024, the Department shall increase the base rate of
416416 25 reimbursement for both base charges and mileage charges for
417417 26 medical transportation services provided by means of an air
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