Ill. Admin. Code tit. 89 § 140.492

Current through Register Vol. 48, No. 45, November 8, 2024

Section 140.492 - Payment for Medical Transportation

Notwithstanding the provisions set forth in subsections (a) through (h), beginning July 1, 2002, the reimbursement rates paid for medical transportation services shall be the lesser of the provider's usual and customary charge to the general public or 94 percent of the fiscal year 2002 rate otherwise determined by the Department under this Section. Notwithstanding Section 140.405, beginning with date of service July 1, 2013 and thereafter, the Department's established maximum rate for ambulance services shall be equivalent to 100% of the rate in effect on June 30, 2012, as reflected on the Department's Fee Schedule, except when a rate that is higher than the rate in effect on June 30, 2012 is specified in subsection (h). Payment for medical transportation services shall be made in accordance with the methodologies outlined in this Section. Base rate reimbursement is determined by the county in which the vehicle is, or the vehicles are, based. In no case shall rates exceed the Medicare allowable, where applicable, or the rates charged to the general public.

a) For dates of service prior to July 1, 2006, medicar providers shall be paid a base rate, which includes the first ten miles (20 miles round trip), a mileage rate and a fixed amount for an employee or non-employee attendant. Loaded miles, i.e., those miles for which the provider is actually transporting an individual, after ten miles (20 miles round trip) shall be reimbursed.

b) For dates of service prior to July 1, 2006, service car providers shall be paid a base rate, which includes the first ten miles (20 miles round trip), a mileage rate and a fixed amount for a non-employee attendant. Loaded miles, i.e., those miles for which the provider is actually transporting an individual, after ten miles (20 miles round trip) shall be reimbursed.

c) For dates of service on or after July 1, 2006, medicar providers and service car providers shall be paid at a base rate, a mileage rate and a fixed amount for an attendant. Payment for an attendant is subject to the requirements in Section 140.490(e)(5). Mileage reimbursement is made for loaded miles, i.e., those miles for which the provider is actually transporting an individual. Mileage for multiple passengers is reimbursed pursuant to Section 140.490(d).

d) Private auto providers shall be paid for loaded miles at a mileage rate.

e) Payment for transportation services provided by common carrier, such as commercial airplanes, buses and trains, shall be at the usual community rate.

f) Taxicabs in an area regulated by a municipality or township shall be reimbursed at the community rate and a fixed amount for an attendant. Payment for an attendant is subject to the requirements in Section 140.490(e).

g) Taxicabs in non-regulated areas shall be reimbursed at a rate as determined by the Department and a fixed amount for an attendant. Payment for an attendant is subject to the requirements in Section 140.490(e). The Department rate shall be reviewed on an annual basis each July.

h) The Department shall pay for medically necessary ambulance services provided in accordance with Section 140.490 at a base, mileage rate (loaded miles) and a rate for oxygen, as appropriate. Payment shall also be made for Advanced Life Support (ALS) at an all inclusive rate, which includes the base rate, supplies, and all other services, excluding mileage. However, for ALS services provided on or after July 1, 1993, separate reimbursement shall be made for oxygen when used and appropriately billed. Loaded miles for ALS trips shall be reimbursed at the per mile rate. Payment shall also be made for Specialty Care Transport (SCT). Rates shall be reviewed beginning November 1, 1986, and each November thereafter, according to the methodology set forth in subsections (h)(1) through (5). Revised rates pursuant to this methodology shall be effective with services provided on or after July 1 of the succeeding year.

1) Payment shall be made at a basic rate for Basic Life Support (BLS) services that is provider specific. The basic rate shall be the lesser of the provider's usual and customary charge to the general public, as reflected on the provider's claim form, or 80 percent of the 50^th percentile of the Medicare prevailing charge for Basic Life Support for the designated Medicare Locality, except that any basic rate previously approved by the Department that exceeds these parameters shall remain in force. The rate of annual increase shall not exceed five percent. Beginning with dates of service July 1, 2018 and thereafter, the Department's established maximum rate for BLS services shall be equivalent to 112% of the rate in effect on June 30, 2018, as reflected on the Department's Fee Schedule.

2) Payment for loaded miles shall be at a rate per mile. If a natural disaster, weather or other conditions necessitate the use of a route other than the most direct route, reimbursement will be based on the actual distance traveled. The rate per mile shall be 50 percent of the 50^th percentile of the Medicare prevailing mileage charge for Medicare Locality 16. The annual rate of increase shall not exceed five percent. Beginning with dates of service July 1, 2018 and thereafter, regardless of the county in which the vehicle is based, loaded miles shall be paid at the lesser of the provider's usual and customary charge to the general public, as reflected on the provider's claim, or the Department's established rate of $5.60 per mile, as reflected on the Department's Fee Schedule.

3) Payment for oxygen shall be made at a flat rate statewide. The rate shall be 50 percent of the 50^th percentile of the Medicare prevailing charge for Medicare Locality 16. The annual rate of increase shall not exceed five percent.

4) Payment for Advanced Life Support (ALS) services shall be at the lesser of the provider's usual charge, or a maximum allowable rate statewide. The maximum rate shall be 80 percent of the difference between the Medicare 50^th percentile prevailing charge for Basic Life Support services and Advanced Life Support services for Medicare Locality 16. The annual rate of increase shall not exceed five percent. Beginning with dates of service July 1, 2018 and thereafter, the Department's established maximum rate for ALS services shall be equivalent to 112% of the rate in effect on June 30, 2018, as reflected on the Department's Fee Schedule.

5) Beginning with dates of service July 1, 2018 and thereafter, payment for SCT shall be made at the lesser of the provider's usual and customary charge to the general public, as reflected on the provider's claim, or the Department's established rate, which is equivalent to 112% of the ALS rate in effect on June 30, 2018, as reflected on the Department's Fee Schedule.

i) Payment for medical transportation services provided by individuals, including those currently receiving public assistance, legally responsible relatives or household members, will be made at a loaded mileage rate.

j) The Department may adjust reimbursement for medical transportation services in a county when such adjustment is necessary to ensure the availability of transportation to medical services.

Ill. Admin. Code tit. 89, § 140.492

Amended at 37 Ill. Reg. 20339, effective December 9, 2013

Amended at 43 Ill. Reg. 1014, effective 12/31/2018