MEDICAID-AIR AMBULANCES RATES

Illinois General Assembly - Full Text of HB2457

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB2457

Introduced 2/4/2025, 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

HB2457
LRB104 08103 KTG 18149 b
1

AN ACT concerning public aid.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The Illinois Public Aid Code is amended by
5
changing Section 5-4.2 as follows:

6

(305 ILCS 5/5-4.2)
7

Sec. 5-4.2.
Ambulance services payments.

8

(a) For ambulance services provided to a recipient of aid
9
under this Article on or after January 1, 1993, the Illinois
10
Department shall reimburse ambulance service providers at
11
rates calculated in accordance with this Section. It is the
12
intent of the General Assembly to provide adequate
13
reimbursement for ambulance services so as to ensure adequate
14
access to services for recipients of aid under this Article
15
and to provide appropriate incentives to ambulance service
16
providers to provide services in an efficient and
17
cost-effective manner. Thus, it is the intent of the General
18
Assembly that the Illinois Department implement a
19
reimbursement system for ambulance services that, to the
20
extent practicable and subject to the availability of funds
21
appropriated by the General Assembly for this purpose, is
22
consistent with the payment principles of Medicare. To ensure
23
uniformity between the payment principles of Medicare and

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LRB104 08103 KTG 18149 b
1
Medicaid, the Illinois Department shall follow, to the extent
2
necessary and practicable and subject to the availability of
3
funds appropriated by the General Assembly for this purpose,
4
the statutes, laws, regulations, policies, procedures,
5
principles, definitions, guidelines, and manuals used to
6
determine the amounts paid to ambulance service providers
7
under Title XVIII of the Social Security Act (Medicare).
8

(b) For ambulance services provided to a recipient of aid
9
under this Article on or after January 1, 1996, the Illinois
10
Department shall reimburse ambulance service providers based
11
upon the actual distance traveled if a natural disaster,
12
weather conditions, road repairs, or traffic congestion
13
necessitates the use of a route other than the most direct
14
route.
15

(c) For purposes of this Section, "ambulance services"
16
includes medical transportation services provided by means of
17
an ambulance, air ambulance, medi-car, service car, or taxi.
18

(c-1) For purposes of this Section, "ground ambulance
19
service" means medical transportation services that are
20
described as ground ambulance services by the Centers for
21
Medicare and Medicaid Services and provided in a vehicle that
22
is licensed as an ambulance by the Illinois Department of
23
Public Health pursuant to the Emergency Medical Services (EMS)
24
Systems Act.
25

(c-2) For purposes of this Section, "ground ambulance
26
service provider" means a vehicle service provider as

HB2457
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LRB104 08103 KTG 18149 b
1
described in the Emergency Medical Services (EMS) Systems Act
2
that operates licensed ambulances for the purpose of providing
3
emergency ambulance services, or non-emergency ambulance
4
services, or both. For purposes of this Section, this includes
5
both ambulance providers and ambulance suppliers as described
6
by the Centers for Medicare and Medicaid Services.
7

(c-3) For purposes of this Section, "medi-car" means
8
transportation services provided to a patient who is confined
9
to a wheelchair and requires the use of a hydraulic or electric
10
lift or ramp and wheelchair lockdown when the patient's
11
condition does not require medical observation, medical
12
supervision, medical equipment, the administration of
13
medications, or the administration of oxygen.
14

(c-4) For purposes of this Section, "service car" means
15
transportation services provided to a patient by a passenger
16
vehicle where that patient does not require the specialized
17
modes described in subsection (c-1) or (c-3).
18

(c-5) For purposes of this Section, "air ambulance
19
service" means medical transport by helicopter or airplane for
20
patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
21
that is described as an air ambulance service by the federal
22
Centers for Medicare and Medicaid Services.
23

(d) This Section does not prohibit separate billing by
24
ambulance service providers for oxygen furnished while
25
providing advanced life support services.
26

(e) Beginning with services rendered on or after July 1,

HB2457
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LRB104 08103 KTG 18149 b
1
2008, all providers of non-emergency medi-car and service car
2
transportation must certify that the driver and employee
3
attendant, as applicable, have completed a safety program
4
approved by the Department to protect both the patient and the
5
driver, prior to transporting a patient. The provider must
6
maintain this certification in its records. The provider shall
7
produce such documentation upon demand by the Department or
8
its representative. Failure to produce documentation of such
9
training shall result in recovery of any payments made by the
10
Department for services rendered by a non-certified driver or
11
employee attendant. Medi-car and service car providers must
12
maintain legible documentation in their records of the driver
13
and, as applicable, employee attendant that actually
14
transported the patient. Providers must recertify all drivers
15
and employee attendants every 3 years. If they meet the
16
established training components set forth by the Department,
17
providers of non-emergency medi-car and service car
18
transportation that are either directly or through an
19
affiliated company licensed by the Department of Public Health
20
shall be approved by the Department to have in-house safety
21
programs for training their own staff.
22

Notwithstanding the requirements above, any public
23
transportation provider of medi-car and service car
24
transportation that receives federal funding under 49 U.S.C.
25
5307 and 5311 need not certify its drivers and employee
26
attendants under this Section, since safety training is

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LRB104 08103 KTG 18149 b
1
already federally mandated.
2

(f) With respect to any policy or program administered by
3
the Department or its agent regarding approval of
4
non-emergency medical transportation by ground ambulance
5
service providers, including, but not limited to, the
6
Non-Emergency Transportation Services Prior Approval Program
7
(NETSPAP), the Department shall establish by rule a process by
8
which ground ambulance service providers of non-emergency
9
medical transportation may appeal any decision by the
10
Department or its agent for which no denial was received prior
11
to the time of transport that either (i) denies a request for
12
approval for payment of non-emergency transportation by means
13
of ground ambulance service or (ii) grants a request for
14
approval of non-emergency transportation by means of ground
15
ambulance service at a level of service that entitles the
16
ground ambulance service provider to a lower level of
17
compensation from the Department than the ground ambulance
18
service provider would have received as compensation for the
19
level of service requested. The rule shall be filed by
20
December 15, 2012 and shall provide that, for any decision
21
rendered by the Department or its agent on or after the date
22
the rule takes effect, the ground ambulance service provider
23
shall have 60 days from the date the decision is received to
24
file an appeal. The rule established by the Department shall
25
be, insofar as is practical, consistent with the Illinois
26
Administrative Procedure Act. The Director's decision on an

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LRB104 08103 KTG 18149 b
1
appeal under this Section shall be a final administrative
2
decision subject to review under the Administrative Review
3
Law.
4

(f-5) Beginning 90 days after July 20, 2012 (the effective
5
date of Public Act 97-842), (i) no denial of a request for
6
approval for payment of non-emergency transportation by means
7
of ground ambulance service, and (ii) no approval of
8
non-emergency transportation by means of ground ambulance
9
service at a level of service that entitles the ground
10
ambulance service provider to a lower level of compensation
11
from the Department than would have been received at the level
12
of service submitted by the ground ambulance service provider,
13
may be issued by the Department or its agent unless the
14
Department has submitted the criteria for determining the
15
appropriateness of the transport for first notice publication
16
in the Illinois Register pursuant to Section 5-40 of the
17
Illinois Administrative Procedure Act.
18

(f-6) Within 90 days after June 2, 2022 (the effective
19
date of Public Act 102-1037) and subject to federal approval,
20
the Department shall file rules to allow for the approval of
21
ground ambulance services when the sole purpose of the
22
transport is for the navigation of stairs or the assisting or
23
lifting of a patient at a medical facility or during a medical
24
appointment in instances where the Department or a contracted
25
Medicaid managed care organization or their transportation
26
broker is unable to secure transportation through any other

HB2457
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LRB104 08103 KTG 18149 b
1
transportation provider.
2

(f-7) For non-emergency ground ambulance claims properly
3
denied under Department policy at the time the claim is filed
4
due to failure to submit a valid Medical Certification for
5
Non-Emergency Ambulance on and after December 15, 2012 and
6
prior to January 1, 2021, the Department shall allot
7
$2,000,000 to a pool to reimburse such claims if the provider
8
proves medical necessity for the service by other means.
9
Providers must submit any such denied claims for which they
10
seek compensation to the Department no later than December 31,
11
2021 along with documentation of medical necessity. No later
12
than May 31, 2022, the Department shall determine for which
13
claims medical necessity was established. Such claims for
14
which medical necessity was established shall be paid at the
15
rate in effect at the time of the service, provided the
16
$2,000,000 is sufficient to pay at those rates. If the pool is
17
not sufficient, claims shall be paid at a uniform percentage
18
of the applicable rate such that the pool of $2,000,000 is
19
exhausted. The appeal process described in subsection (f)
20
shall not be applicable to the Department's determinations
21
made in accordance with this subsection.
22

(g) Whenever a patient covered by a medical assistance
23
program under this Code or by another medical program
24
administered by the Department, including a patient covered
25
under the State's Medicaid managed care program, is being
26
transported from a facility and requires non-emergency

HB2457
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LRB104 08103 KTG 18149 b
1
transportation including ground ambulance, medi-car, or
2
service car transportation, a Physician Certification
3
Statement as described in this Section shall be required for
4
each patient. Facilities shall develop procedures for a
5
licensed medical professional to provide a written and signed
6
Physician Certification Statement. The Physician Certification
7
Statement shall specify the level of transportation services
8
needed and complete a medical certification establishing the
9
criteria for approval of non-emergency ambulance
10
transportation, as published by the Department of Healthcare
11
and Family Services, that is met by the patient. This
12
certification shall be completed prior to ordering the
13
transportation service and prior to patient discharge. The
14
Physician Certification Statement is not required prior to
15
transport if a delay in transport can be expected to
16
negatively affect the patient outcome. If the ground ambulance
17
provider, medi-car provider, or service car provider is unable
18
to obtain the required Physician Certification Statement
19
within 10 calendar days following the date of the service, the
20
ground ambulance provider, medi-car provider, or service car
21
provider must document its attempt to obtain the requested
22
certification and may then submit the claim for payment.
23
Acceptable documentation includes a signed return receipt from
24
the U.S. Postal Service, facsimile receipt, email receipt, or
25
other similar service that evidences that the ground ambulance
26
provider, medi-car provider, or service car provider attempted

HB2457
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LRB104 08103 KTG 18149 b
1
to obtain the required Physician Certification Statement.
2

The medical certification specifying the level and type of
3
non-emergency transportation needed shall be in the form of
4
the Physician Certification Statement on a standardized form
5
prescribed by the Department of Healthcare and Family
6
Services. Within 75 days after July 27, 2018 (the effective
7
date of Public Act 100-646), the Department of Healthcare and
8
Family Services shall develop a standardized form of the
9
Physician Certification Statement specifying the level and
10
type of transportation services needed in consultation with
11
the Department of Public Health, Medicaid managed care
12
organizations, a statewide association representing ambulance
13
providers, a statewide association representing hospitals, 3
14
statewide associations representing nursing homes, and other
15
stakeholders. The Physician Certification Statement shall
16
include, but is not limited to, the criteria necessary to
17
demonstrate medical necessity for the level of transport
18
needed as required by (i) the Department of Healthcare and
19
Family Services and (ii) the federal Centers for Medicare and
20
Medicaid Services as outlined in the Centers for Medicare and
21
Medicaid Services' Medicare Benefit Policy Manual, Pub.
22
100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
23
Certification Statement shall satisfy the obligations of
24
hospitals under Section 6.22 of the Hospital Licensing Act and
25
nursing homes under Section 2-217 of the Nursing Home Care
26
Act. Implementation and acceptance of the Physician

HB2457
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LRB104 08103 KTG 18149 b
1
Certification Statement shall take place no later than 90 days
2
after the issuance of the Physician Certification Statement by
3
the Department of Healthcare and Family Services.
4

Pursuant to subsection (E) of Section 12-4.25 of this
5
Code, the Department is entitled to recover overpayments paid
6
to a provider or vendor, including, but not limited to, from
7
the discharging physician, the discharging facility, and the
8
ground ambulance service provider, in instances where a
9
non-emergency ground ambulance service is rendered as the
10
result of improper or false certification.
11

Beginning October 1, 2018, the Department of Healthcare
12
and Family Services shall collect data from Medicaid managed
13
care organizations and transportation brokers, including the
14
Department's NETSPAP broker, regarding denials and appeals
15
related to the missing or incomplete Physician Certification
16
Statement forms and overall compliance with this subsection.
17
The Department of Healthcare and Family Services shall publish
18
quarterly results on its website within 15 days following the
19
end of each quarter.
20

(h) On and after July 1, 2012, the Department shall reduce
21
any rate of reimbursement for services or other payments or
22
alter any methodologies authorized by this Code to reduce any
23
rate of reimbursement for services or other payments in
24
accordance with Section 5-5e.
25

(i) Subject to federal approval, on and after January 1,
26
2024, the Department shall increase the base rate of

HB2457
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LRB104 08103 KTG 18149 b
1
reimbursement for both base charges and mileage charges for
2
ground ambulance service providers not participating in the
3
Ground Emergency Medical Transportation (GEMT) Program for
4
medical transportation services provided by means of a ground
5
ambulance to a level not lower than 140% of the base rate in
6
effect as of January 1, 2023.
7

(j) For the purpose of understanding ground ambulance
8
transportation services cost structures and their impact on
9
the Medical Assistance Program, the Department shall engage
10
stakeholders, including, but not limited to, a statewide
11
association representing private ground ambulance service
12
providers in Illinois, to develop recommendations for a plan
13
for the regular collection of cost data for all ground
14
ambulance transportation providers reimbursed under the
15
Illinois Title XIX State Plan. Cost data obtained through this
16
process shall be used to inform on and to ensure the
17
effectiveness and efficiency of Illinois Medicaid rates. The
18
Department shall establish a process to limit public
19
availability of portions of the cost report data determined to
20
be proprietary. This process shall be concluded and
21
recommendations shall be provided no later than December 31,
22
2025.
23

(k) Subject to federal approval, beginning on January 1,
24
2024, the Department shall increase the base rate of
25
reimbursement for both base charges and mileage charges for
26
medical transportation services provided by means of an air

HB2457
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LRB104 08103 KTG 18149 b
1
ambulance to a level not lower than 50% of the Medicare
2
ambulance fee schedule rates, by designated Medicare locality,
3
in effect on January 1, 2023.
4

(l) Subject to federal approval, the Department shall
5
increase the base rate of reimbursement for both base charges
6
and mileage charges for medical transportation services
7
provided by means of an air ambulance to a level not lower than
8
75% of the Medicare ambulance fee schedule rates, by
9
designated Medicare locality.

10
(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;
11
102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
12
70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
13
80-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.
14
7-1-24.)

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