Illinois House Bill HB1536

Illinois 2023-2024 Regular Session

• Introduced: 1/30/23
• Refer: 1/31/23

Caption

MEDICAID-PHARMACY PAYMENTS

Impact

The implementation of HB1536 is set to enhance access to specialty pharmacy services for Medicaid recipients, ensuring that a wider array of providers can offer specialized medication for complex health conditions. By mandating that these specialty pharmacies are certified and accredited, the bill aims to uphold standards in the prescription of essential drugs for patients with serious health issues. This change is expected to positively affect patients with conditions such as cancer, HIV/AIDS, and multiple sclerosis by potentially allowing them to access necessary medications in a timelier manner.

Summary

House Bill 1536 amends the Medical Assistance Article of the Illinois Public Aid Code, particularly concerning how prescription drug benefits are provided under managed care arrangements. The bill mandates that no appropriations can be made to any managed care organization contracted with the Department of Healthcare and Family Services unless their pharmacy benefits manager permits the provision of prescription drug benefits through specialty pharmacies certified in the Business Enterprise Program. It specifies that these specialty pharmacies must be accredited by at least two different accreditation entities and must provide their services under the same terms and conditions as any other willing provider recognized as qualified for network participation.

Contention

One notable point of contention surrounding HB1536 lies in its implications for managed care organizations and their pharmacy benefits managers. Some factions are concerned that the extensive requirements for specialty pharmacies could lead to operational challenges and increased costs for managed care organizations. Opponents may argue that these stipulations could create barriers rather than improve access, as not all managed care entities may have the capacity to comply with the dual accreditation requirement. Consequently, this could limit choices for beneficiaries or lead to disruptions in their ongoing treatments.