Illinois 2023-2024 Regular Session

Illinois House Bill HB1536 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1536 Introduced , by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides the no appropriation may be expended to a managed care organization under contract with the Department of Healthcare and Family Services unless the managed care organization, and its pharmacy benefits manager, allows prescription drug benefits to be provided by specialty pharmacies that are certified in the Business Enterprise Program and accredited by at least 2 different accreditation entities for specialty pharmacy services on the same terms and conditions by any willing provider that is qualified for network participation and authorized to dispense prescription drugs. Prescription drug benefits include those that are managed both as a part of the overall healthcare benefits package, medical and pharmacy benefits that are integrated into one package through a managed care organization, and pharmacy benefits that are separately administered or subcontracted through a pharmacy benefits manager. Defines "specialty pharmacy". Effective July 1, 2023. LRB103 04823 KTG 49833 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1536 Introduced , by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12 305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides the no appropriation may be expended to a managed care organization under contract with the Department of Healthcare and Family Services unless the managed care organization, and its pharmacy benefits manager, allows prescription drug benefits to be provided by specialty pharmacies that are certified in the Business Enterprise Program and accredited by at least 2 different accreditation entities for specialty pharmacy services on the same terms and conditions by any willing provider that is qualified for network participation and authorized to dispense prescription drugs. Prescription drug benefits include those that are managed both as a part of the overall healthcare benefits package, medical and pharmacy benefits that are integrated into one package through a managed care organization, and pharmacy benefits that are separately administered or subcontracted through a pharmacy benefits manager. Defines "specialty pharmacy". Effective July 1, 2023. LRB103 04823 KTG 49833 b LRB103 04823 KTG 49833 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1536 Introduced , by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12 305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
4	4	305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides the no appropriation may be expended to a managed care organization under contract with the Department of Healthcare and Family Services unless the managed care organization, and its pharmacy benefits manager, allows prescription drug benefits to be provided by specialty pharmacies that are certified in the Business Enterprise Program and accredited by at least 2 different accreditation entities for specialty pharmacy services on the same terms and conditions by any willing provider that is qualified for network participation and authorized to dispense prescription drugs. Prescription drug benefits include those that are managed both as a part of the overall healthcare benefits package, medical and pharmacy benefits that are integrated into one package through a managed care organization, and pharmacy benefits that are separately administered or subcontracted through a pharmacy benefits manager. Defines "specialty pharmacy". Effective July 1, 2023.
6	6	LRB103 04823 KTG 49833 b LRB103 04823 KTG 49833 b
7	7	LRB103 04823 KTG 49833 b
8	8	A BILL FOR
9	9	HB1536LRB103 04823 KTG 49833 b HB1536 LRB103 04823 KTG 49833 b
10	10	HB1536 LRB103 04823 KTG 49833 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5.12 as follows:
16	16	6 (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
17	17	7 Sec. 5-5.12. Pharmacy payments.
18	18	8 (a) Every request submitted by a pharmacy for
19	19	9 reimbursement under this Article for prescription drugs
20	20	10 provided to a recipient of aid under this Article shall
21	21	11 include the name of the prescriber or an acceptable
22	22	12 identification number as established by the Department.
23	23	13 (b) Pharmacies providing prescription drugs under this
24	24	14 Article shall be reimbursed at a rate which shall include a
25	25	15 professional dispensing fee as determined by the Illinois
26	26	16 Department, plus the current acquisition cost of the
27	27	17 prescription drug dispensed. The Illinois Department shall
28	28	18 update its information on the acquisition costs of all
29	29	19 prescription drugs no less frequently than every 30 days.
30	30	20 However, the Illinois Department may set the rate of
31	31	21 reimbursement for the acquisition cost, by rule, at a
32	32	22 percentage of the current average wholesale acquisition cost.
33	33	23 (c) (Blank).
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1536 Introduced , by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12 305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
39	39	305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides the no appropriation may be expended to a managed care organization under contract with the Department of Healthcare and Family Services unless the managed care organization, and its pharmacy benefits manager, allows prescription drug benefits to be provided by specialty pharmacies that are certified in the Business Enterprise Program and accredited by at least 2 different accreditation entities for specialty pharmacy services on the same terms and conditions by any willing provider that is qualified for network participation and authorized to dispense prescription drugs. Prescription drug benefits include those that are managed both as a part of the overall healthcare benefits package, medical and pharmacy benefits that are integrated into one package through a managed care organization, and pharmacy benefits that are separately administered or subcontracted through a pharmacy benefits manager. Defines "specialty pharmacy". Effective July 1, 2023.
41	41	LRB103 04823 KTG 49833 b LRB103 04823 KTG 49833 b
42	42	LRB103 04823 KTG 49833 b
43	43	A BILL FOR
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49	49	305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
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68	68	1 (d) The Department shall review utilization of narcotic
69	69	2 medications in the medical assistance program and impose
70	70	3 utilization controls that protect against abuse.
71	71	4 (e) When making determinations as to which drugs shall be
72	72	5 on a prior approval list, the Department shall include as part
73	73	6 of the analysis for this determination, the degree to which a
74	74	7 drug may affect individuals in different ways based on factors
75	75	8 including the gender of the person taking the medication.
76	76	9 (f) The Department shall cooperate with the Department of
77	77	10 Public Health and the Department of Human Services Division of
78	78	11 Mental Health in identifying psychotropic medications that,
79	79	12 when given in a particular form, manner, duration, or
80	80	13 frequency (including "as needed") in a dosage, or in
81	81	14 conjunction with other psychotropic medications to a nursing
82	82	15 home resident or to a resident of a facility licensed under the
83	83	16 ID/DD Community Care Act or the MC/DD Act, may constitute a
84	84	17 chemical restraint or an "unnecessary drug" as defined by the
85	85	18 Nursing Home Care Act or Titles XVIII and XIX of the Social
86	86	19 Security Act and the implementing rules and regulations. The
87	87	20 Department shall require prior approval for any such
88	88	21 medication prescribed for a nursing home resident or to a
89	89	22 resident of a facility licensed under the ID/DD Community Care
90	90	23 Act or the MC/DD Act, that appears to be a chemical restraint
91	91	24 or an unnecessary drug. The Department shall consult with the
92	92	25 Department of Human Services Division of Mental Health in
93	93	26 developing a protocol and criteria for deciding whether to
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104	104	1 grant such prior approval.
105	105	2 (g) The Department may by rule provide for reimbursement
106	106	3 of the dispensing of a 90-day supply of a generic or brand
107	107	4 name, non-narcotic maintenance medication in circumstances
108	108	5 where it is cost effective.
109	109	6 (g-5) On and after July 1, 2012, the Department may
110	110	7 require the dispensing of drugs to nursing home residents be
111	111	8 in a 7-day supply or other amount less than a 31-day supply.
112	112	9 The Department shall pay only one dispensing fee per 31-day
113	113	10 supply.
114	114	11 (h) Effective July 1, 2011, the Department shall
115	115	12 discontinue coverage of select over-the-counter drugs,
116	116	13 including analgesics and cough and cold and allergy
117	117	14 medications.
118	118	15 (h-5) On and after July 1, 2012, the Department shall
119	119	16 impose utilization controls, including, but not limited to,
120	120	17 prior approval on specialty drugs, oncolytic drugs, drugs for
121	121	18 the treatment of HIV or AIDS, immunosuppressant drugs, and
122	122	19 biological products in order to maximize savings on these
123	123	20 drugs. The Department may adjust payment methodologies for
124	124	21 non-pharmacy billed drugs in order to incentivize the
125	125	22 selection of lower-cost drugs. For drugs for the treatment of
126	126	23 AIDS, the Department shall take into consideration the
127	127	24 potential for non-adherence by certain populations, and shall
128	128	25 develop protocols with organizations or providers primarily
129	129	26 serving those with HIV/AIDS, as long as such measures intend
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140	140	1 to maintain cost neutrality with other utilization management
141	141	2 controls such as prior approval. For hemophilia, the
142	142	3 Department shall develop a program of utilization review and
143	143	4 control which may include, in the discretion of the
144	144	5 Department, prior approvals. The Department may impose special
145	145	6 standards on providers that dispense blood factors which shall
146	146	7 include, in the discretion of the Department, staff training
147	147	8 and education; patient outreach and education; case
148	148	9 management; in-home patient assessments; assay management;
149	149	10 maintenance of stock; emergency dispensing timeframes; data
150	150	11 collection and reporting; dispensing of supplies related to
151	151	12 blood factor infusions; cold chain management and packaging
152	152	13 practices; care coordination; product recalls; and emergency
153	153	14 clinical consultation. The Department may require patients to
154	154	15 receive a comprehensive examination annually at an appropriate
155	155	16 provider in order to be eligible to continue to receive blood
156	156	17 factor.
157	157	18 (i) On and after July 1, 2012, the Department shall reduce
158	158	19 any rate of reimbursement for services or other payments or
159	159	20 alter any methodologies authorized by this Code to reduce any
160	160	21 rate of reimbursement for services or other payments in
161	161	22 accordance with Section 5-5e.
162	162	23 (j) On and after July 1, 2012, the Department shall impose
163	163	24 limitations on prescription drugs such that the Department
164	164	25 shall not provide reimbursement for more than 4 prescriptions,
165	165	26 including 3 brand name prescriptions, for distinct drugs in a
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176	176	1 30-day period, unless prior approval is received for all
177	177	2 prescriptions in excess of the 4-prescription limit. Drugs in
178	178	3 the following therapeutic classes shall not be subject to
179	179	4 prior approval as a result of the 4-prescription limit:
180	180	5 immunosuppressant drugs, oncolytic drugs, anti-retroviral
181	181	6 drugs, and, on or after July 1, 2014, antipsychotic drugs. On
182	182	7 or after July 1, 2014, the Department may exempt children with
183	183	8 complex medical needs enrolled in a care coordination entity
184	184	9 contracted with the Department to solely coordinate care for
185	185	10 such children, if the Department determines that the entity
186	186	11 has a comprehensive drug reconciliation program.
187	187	12 (k) No medication therapy management program implemented
188	188	13 by the Department shall be contrary to the provisions of the
189	189	14 Pharmacy Practice Act.
190	190	15 (l) Any provider enrolled with the Department that bills
191	191	16 the Department for outpatient drugs and is eligible to enroll
192	192	17 in the federal Drug Pricing Program under Section 340B of the
193	193	18 federal Public Health Service Act shall enroll in that
194	194	19 program. No entity participating in the federal Drug Pricing
195	195	20 Program under Section 340B of the federal Public Health
196	196	21 Service Act may exclude fee-for-service Medicaid from their
197	197	22 participation in that program, however, entities defined in
198	198	23 Section 1905(l)(2)(B) of the Social Security Act are excluded
199	199	24 from this requirement. This subsection does not apply to
200	200	25 outpatient drugs billed to Medicaid managed care
201	201	26 organizations.
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212	212	1 (m) No appropriation may be expended to a managed care
213	213	2 organization under contract with the Department unless the
214	214	3 managed care organization, and its pharmacy benefits manager,
215	215	4 allows prescription drug benefits to be provided by specialty
216	216	5 pharmacies that are:
217	217	6 (1) certified in the Business Enterprise Program as
218	218	7 defined in the Business Enterprise for Minorities, Women,
219	219	8 and Persons with Disabilities Act; and
220	220	9 (2) accredited by at least 2 different accreditation
221	221	10 entities for specialty pharmacy services,
222	222	11 on the same terms and conditions by any willing provider
223	223	12 that is qualified for network participation and authorized to
224	224	13 dispense prescription drugs. Prescription drug benefits
225	225	14 include those that are managed both as a part of the overall
226	226	15 healthcare benefits package, medical and pharmacy benefits
227	227	16 that are integrated into one package through a managed care
228	228	17 organization, and pharmacy benefits that are separately
229	229	18 administered or subcontracted through a pharmacy benefits
230	230	19 manager. As used in this subsection, "specialty pharmacy"
231	231	20 means a licensed pharmacy in Illinois that solely or largely
232	232	21 provides only medications that are oral, infusion, or
233	233	22 injectable for individuals with serious health conditions
234	234	23 requiring complex therapies that include, but are not limited
235	235	24 to, the following: cancer, hepatitis C, rheumatoid arthritis,
236	236	25 HIV/Aids, multiple sclerosis, cystic fibrosis, organ
237	237	26 transplantation, human growth hormone deficiencies, and
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248	248	1 bleeding disorders.
249	249	2 (Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
250	250	3 Section 99. Effective date. This Act takes effect July 1,
251	251	4 2023.
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