Illinois 2023-2024 Regular Session

Illinois House Bill HB4079 Compare Versions

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

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1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately. LRB103 32159 SPS 61248 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 820 ILCS 305/8.2 Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately. LRB103 32159 SPS 61248 b LRB103 32159 SPS 61248 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
3	3	820 ILCS 305/8.2 820 ILCS 305/8.2
4	4	820 ILCS 305/8.2
5	5	Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.
6	6	LRB103 32159 SPS 61248 b LRB103 32159 SPS 61248 b
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8	8	A BILL FOR
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11	11	1 AN ACT concerning employment.
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 Workers' Compensation Act is amended by
15	15	5 changing Section 8.2 as follows:
16	16	6 (820 ILCS 305/8.2)
17	17	7 Sec. 8.2. Fee schedule.
18	18	8 (a) Except as provided for in subsection (c), for
19	19	9 procedures, treatments, or services covered under this Act and
20	20	10 rendered or to be rendered on and after February 1, 2006, the
21	21	11 maximum allowable payment shall be 90% of the 80th percentile
22	22	12 of charges and fees as determined by the Commission utilizing
23	23	13 information provided by employers' and insurers' national
24	24	14 databases, with a minimum of 12,000,000 Illinois line item
25	25	15 charges and fees comprised of health care provider and
26	26	16 hospital charges and fees as of August 1, 2004 but not earlier
27	27	17 than August 1, 2002. These charges and fees are provider
28	28	18 billed amounts and shall not include discounted charges. The
29	29	19 80th percentile is the point on an ordered data set from low to
30	30	20 high such that 80% of the cases are below or equal to that
31	31	21 point and at most 20% are above or equal to that point. The
32	32	22 Commission shall adjust these historical charges and fees as
33	33	23 of August 1, 2004 by the Consumer Price Index-U for the period
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
38	38	820 ILCS 305/8.2 820 ILCS 305/8.2
39	39	820 ILCS 305/8.2
40	40	Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.
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43	43	A BILL FOR
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68	68	1 August 1, 2004 through September 30, 2005. The Commission
69	69	2 shall establish fee schedules for procedures, treatments, or
70	70	3 services for hospital inpatient, hospital outpatient,
71	71	4 emergency room and trauma, ambulatory surgical treatment
72	72	5 centers, and professional services. These charges and fees
73	73	6 shall be designated by geozip or any smaller geographic unit.
74	74	7 The data shall in no way identify or tend to identify any
75	75	8 patient, employer, or health care provider. As used in this
76	76	9 Section, "geozip" means a three-digit zip code based on data
77	77	10 similarities, geographical similarities, and frequencies. A
78	78	11 geozip does not cross state boundaries. As used in this
79	79	12 Section, "three-digit zip code" means a geographic area in
80	80	13 which all zip codes have the same first 3 digits. If a geozip
81	81	14 does not have the necessary number of charges and fees to
82	82	15 calculate a valid percentile for a specific procedure,
83	83	16 treatment, or service, the Commission may combine data from
84	84	17 the geozip with up to 4 other geozips that are demographically
85	85	18 and economically similar and exhibit similarities in data and
86	86	19 frequencies until the Commission reaches 9 charges or fees for
87	87	20 that specific procedure, treatment, or service. In cases where
88	88	21 the compiled data contains less than 9 charges or fees for a
89	89	22 procedure, treatment, or service, reimbursement shall occur at
90	90	23 76% of charges and fees as determined by the Commission in a
91	91	24 manner consistent with the provisions of this paragraph.
92	92	25 Providers of out-of-state procedures, treatments, services,
93	93	26 products, or supplies shall be reimbursed at the lesser of
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104	104	1 that state's fee schedule amount or the fee schedule amount
105	105	2 for the region in which the employee resides. If no fee
106	106	3 schedule exists in that state, the provider shall be
107	107	4 reimbursed at the lesser of the actual charge or the fee
108	108	5 schedule amount for the region in which the employee resides.
109	109	6 Not later than September 30 in 2006 and each year thereafter,
110	110	7 the Commission shall automatically increase or decrease the
111	111	8 maximum allowable payment for a procedure, treatment, or
112	112	9 service established and in effect on January 1 of that year by
113	113	10 the percentage change in the Consumer Price Index-U for the 12
114	114	11 month period ending August 31 of that year. The increase or
115	115	12 decrease shall become effective on January 1 of the following
116	116	13 year. As used in this Section, "Consumer Price Index-U" means
117	117	14 the index published by the Bureau of Labor Statistics of the
118	118	15 U.S. Department of Labor, that measures the average change in
119	119	16 prices of all goods and services purchased by all urban
120	120	17 consumers, U.S. city average, all items, 1982-84=100.
121	121	18 (a-1) Notwithstanding the provisions of subsection (a) and
122	122	19 unless otherwise indicated, the following provisions shall
123	123	20 apply to the medical fee schedule starting on September 1,
124	124	21 2011:
125	125	22 (1) The Commission shall establish and maintain fee
126	126	23 schedules for procedures, treatments, products, services,
127	127	24 or supplies for hospital inpatient, hospital outpatient,
128	128	25 emergency room, ambulatory surgical treatment centers,
129	129	26 accredited ambulatory surgical treatment facilities,
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140	140	1 prescriptions filled and dispensed outside of a licensed
141	141	2 pharmacy, dental services, and professional services. This
142	142	3 fee schedule shall be based on the fee schedule amounts
143	143	4 already established by the Commission pursuant to
144	144	5 subsection (a) of this Section. However, starting on
145	145	6 January 1, 2012, these fee schedule amounts shall be
146	146	7 grouped into geographic regions in the following manner:
147	147	8 (A) Four regions for non-hospital fee schedule
148	148	9 amounts shall be utilized:
149	149	10 (i) Cook County;
150	150	11 (ii) DuPage, Kane, Lake, and Will Counties;
151	151	12 (iii) Bond, Calhoun, Clinton, Jersey,
152	152	13 Macoupin, Madison, Monroe, Montgomery, Randolph,
153	153	14 St. Clair, and Washington Counties; and
154	154	15 (iv) All other counties of the State.
155	155	16 (B) Fourteen regions for hospital fee schedule
156	156	17 amounts shall be utilized:
157	157	18 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
158	158	19 Kendall, and Grundy Counties;
159	159	20 (ii) Kankakee County;
160	160	21 (iii) Madison, St. Clair, Macoupin, Clinton,
161	161	22 Monroe, Jersey, Bond, and Calhoun Counties;
162	162	23 (iv) Winnebago and Boone Counties;
163	163	24 (v) Peoria, Tazewell, Woodford, Marshall, and
164	164	25 Stark Counties;
165	165	26 (vi) Champaign, Piatt, and Ford Counties;
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176	176	1 (vii) Rock Island, Henry, and Mercer Counties;
177	177	2 (viii) Sangamon and Menard Counties;
178	178	3 (ix) McLean County;
179	179	4 (x) Lake County;
180	180	5 (xi) Macon County;
181	181	6 (xii) Vermilion County;
182	182	7 (xiii) Alexander County; and
183	183	8 (xiv) All other counties of the State.
184	184	9 (2) If a geozip, as defined in subsection (a) of this
185	185	10 Section, overlaps into one or more of the regions set
186	186	11 forth in this Section, then the Commission shall average
187	187	12 or repeat the charges and fees in a geozip in order to
188	188	13 designate charges and fees for each region.
189	189	14 (3) In cases where the compiled data contains less
190	190	15 than 9 charges or fees for a procedure, treatment,
191	191	16 product, supply, or service or where the fee schedule
192	192	17 amount cannot be determined by the non-discounted charge
193	193	18 data, non-Medicare relative values and conversion factors
194	194	19 derived from established fee schedule amounts, coding
195	195	20 crosswalks, or other data as determined by the Commission,
196	196	21 reimbursement shall occur at 76% of charges and fees until
197	197	22 September 1, 2011 and 53.2% of charges and fees thereafter
198	198	23 as determined by the Commission in a manner consistent
199	199	24 with the provisions of this paragraph.
200	200	25 (4) To establish additional fee schedule amounts, the
201	201	26 Commission shall utilize provider non-discounted charge
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212	212	1 data, non-Medicare relative values and conversion factors
213	213	2 derived from established fee schedule amounts, and coding
214	214	3 crosswalks. The Commission may establish additional fee
215	215	4 schedule amounts based on either the charge or cost of the
216	216	5 procedure, treatment, product, supply, or service.
217	217	6 (5) Implants shall be reimbursed at 25% above the net
218	218	7 manufacturer's invoice price less rebates, plus actual
219	219	8 reasonable and customary shipping charges whether or not
220	220	9 the implant charge is submitted by a provider in
221	221	10 conjunction with a bill for all other services associated
222	222	11 with the implant, submitted by a provider on a separate
223	223	12 claim form, submitted by a distributor, or submitted by
224	224	13 the manufacturer of the implant. "Implants" include the
225	225	14 following codes or any substantially similar updated code
226	226	15 as determined by the Commission: 0274
227	227	16 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
228	228	17 implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
229	229	18 (investigational devices); and 0636 (drugs requiring
230	230	19 detailed coding). Non-implantable devices or supplies
231	231	20 within these codes shall be reimbursed at 65% of actual
232	232	21 charge, which is the provider's normal rates under its
233	233	22 standard chargemaster. A standard chargemaster is the
234	234	23 provider's list of charges for procedures, treatments,
235	235	24 products, supplies, or services used to bill payers in a
236	236	25 consistent manner.
237	237	26 (6) The Commission shall automatically update all
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248	248	1 codes and associated rules with the version of the codes
249	249	2 and rules valid on January 1 of that year.
250	250	3 (a-1.5) The following provisions apply to procedures,
251	251	4 treatments, services, products, and supplies covered under
252	252	5 this Act and rendered or to be rendered on or after September
253	253	6 1, 2024:
254	254	7 (1) In this Section:
255	255	8 "CPT code" means each Current Procedural
256	256	9 Terminology code, for each geographic region specified
257	257	10 in subsection (b) of this Section, included on the
258	258	11 most recent medical fee schedule established by the
259	259	12 Commission pursuant to this Section.
260	260	13 "DRG code" means each current diagnosis related
261	261	14 group code, for each geographic region specified in
262	262	15 subsection (b) of this Section, included on the most
263	263	16 recent medical fee schedule established by the
264	264	17 Commission pursuant to this Section.
265	265	18 "Geozip" means a three-digit zip code based on
266	266	19 data similarities, geographical similarities, and
267	267	20 frequencies.
268	268	21 "Health care services" means those CPT and DRG
269	269	22 codes for procedures, treatments, products, services,
270	270	23 or supplies for hospital inpatient, hospital
271	271	24 outpatient, emergency room, ambulatory surgical
272	272	25 treatment centers, accredited ambulatory surgical
273	273	26 treatment facilities, and professional services.
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284	284	1 "Health care services" does not include codes
285	285	2 classified as healthcare common procedure coding
286	286	3 systems or dental.
287	287	4 "Medicare maximum fee" means, for each CPT and DRG
288	288	5 code, the current maximum fee for that CPT or DRG code
289	289	6 allowed to be charged by the Centers for Medicare and
290	290	7 Medicaid Services for Medicare patients in that
291	291	8 geographic region. The Medicare maximum fee shall be
292	292	9 the greater of (i) the current maximum fee allowed to
293	293	10 be charged by the Centers for Medicare and Medicaid
294	294	11 Services for Medicare patients in the geographic
295	295	12 region or (ii) the maximum fee charged by the Centers
296	296	13 for Medicare and Medicaid Services for Medicare
297	297	14 patients in the geographic region on January 1, 2024.
298	298	15 "Medicare percentage amount" means, for each CPT
299	299	16 and DRG code, the workers' compensation maximum fee as
300	300	17 a percentage of the Medicare maximum fee.
301	301	18 "Workers' compensation maximum fee" means, for
302	302	19 each CPT and DRG code, the current maximum fee allowed
303	303	20 to be charged under the medical fee schedule
304	304	21 established by the Commission for that CPT or DRG code
305	305	22 in that geographic region.
306	306	23 (2) The Commission shall establish and maintain fee
307	307	24 schedules for procedures, treatments, products, services,
308	308	25 or supplies for hospital inpatient, hospital outpatient,
309	309	26 emergency room, ambulatory surgical treatment centers,
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320	320	1 accredited ambulatory surgical treatment facilities,
321	321	2 prescriptions filled and dispensed outside of a licensed
322	322	3 pharmacy, dental services, and professional services.
323	323	4 These fee schedule amounts shall be grouped into
324	324	5 geographic regions in the following manner:
325	325	6 (A) Four regions for non-hospital fee schedule
326	326	7 amounts shall be utilized:
327	327	8 (i) Cook County;
328	328	9 (ii) DuPage, Kane, Lake, and Will Counties;
329	329	10 (iii) Bond, Calhoun, Clinton, Jersey,
330	330	11 Macoupin, Madison, Monroe, Montgomery, Randolph,
331	331	12 St. Clair, and Washington Counties; and
332	332	13 (iv) all other counties of the State.
333	333	14 (B) Fourteen regions for hospital fee schedule
334	334	15 amounts shall be utilized:
335	335	16 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
336	336	17 Kendall, and Grundy Counties;
337	337	18 (ii) Kankakee County;
338	338	19 (iii) Madison, St. Clair, Macoupin, Clinton,
339	339	20 Monroe, Jersey, Bond, and Calhoun Counties;
340	340	21 (iv) Winnebago and Boone Counties;
341	341	22 (v) Peoria, Tazewell, Woodford, Marshall, and
342	342	23 Stark Counties;
343	343	24 (vi) Champaign, Piatt, and Ford Counties;
344	344	25 (vii) Rock Island, Henry, and Mercer Counties;
345	345	26 (viii) Sangamon and Menard Counties;
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356	356	1 (ix) McLean County;
357	357	2 (x) Lake County;
358	358	3 (xi) Macon County;
359	359	4 (xii) Vermilion County;
360	360	5 (xiii) Alexander County; and
361	361	6 (xiv) all other counties of the State.
362	362	7 If a geozip overlaps into one or more of the
363	363	8 regions set forth in this subsection, then the
364	364	9 Commission shall average or repeat the charges and
365	365	10 fees in a geozip in order to designate charges and fees
366	366	11 for each region.
367	367	12 (3) The initial workers' compensation maximum fee for
368	368	13 each CPT and DRG code as of September 1, 2024 shall be
369	369	14 determined as follows:
370	370	15 (A) Within 45 days after the effective date of
371	371	16 this amendatory Act of the 103rd General Assembly, the
372	372	17 Commission shall determine the Medicare percentage
373	373	18 amount for each CPT and DRG code using the most recent
374	374	19 data available.
375	375	20 CPT or DRG codes which have a value, but are not
376	376	21 covered expenses under Medicare, are still compensable
377	377	22 under the medical fee schedule according to the rate
378	378	23 described in subparagraph (B).
379	379	24 (B) Within 30 days after the Commission makes the
380	380	25 determinations required under subparagraph (A), the
381	381	26 Commission shall determine an adjustment to be made to
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392	392	1 the workers' compensation maximum fee for each CPT and
393	393	2 DRG code as follows:
394	394	3 (i) if the Medicare percentage amount for that
395	395	4 CPT or DRG code is equal to or less than 125%, then
396	396	5 the workers' compensation maximum fee for that CPT
397	397	6 or DRG code shall be adjusted so that it equals
398	398	7 125% of the most recent Medicare maximum fee for
399	399	8 that CPT or DRG code;
400	400	9 (ii) if the Medicare percentage amount for
401	401	10 that CPT or DRG code is greater than 125% but less
402	402	11 than 150%, then the workers' compensation maximum
403	403	12 fee for that CPT or DRG code shall not be adjusted;
404	404	13 (iii) if the Medicare percentage amount for
405	405	14 that CPT or DRG code is greater than 150% but less
406	406	15 than or equal to 225%, then the workers'
407	407	16 compensation maximum fee for that CPT or DRG code
408	408	17 shall be adjusted so that it equals the greater of
409	409	18 (I) 150% of the most recent Medicare maximum fee
410	410	19 for that CPT or DRG code or (II) 85% of the most
411	411	20 recent workers' compensation maximum amount for
412	412	21 that CPT or DRG code;
413	413	22 (iv) if the Medicare percentage amount for
414	414	23 that CPT or DRG code is greater than 225% but less
415	415	24 than or equal to 428.57%, then the workers'
416	416	25 compensation maximum fee for that CPT or DRG code
417	417	26 shall be adjusted so that it equals the greater of
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428	428	1 (I) 191.25% of the most recent Medicare maximum
429	429	2 fee for that CPT or DRG code or (II) 70% of the
430	430	3 most recent workers' compensation maximum amount
431	431	4 for that CPT or DRG code; or
432	432	5 (v) if the Medicare percentage amount for that
433	433	6 CPT or DRG code is greater than 428.57%, then the
434	434	7 workers' compensation maximum fee for that CPT or
435	435	8 DRG code shall be adjusted so that it equals 300%
436	436	9 of the most recent Medicare maximum fee for that
437	437	10 CPT or DRG code.
438	438	11 The Commission shall promptly publish on its
439	439	12 website the adjustments determined pursuant to this
440	440	13 subparagraph (B).
441	441	14 (C) The initial workers' compensation maximum fee
442	442	15 for each CPT and DRG code as of September 1, 2024 shall
443	443	16 be equal to the workers' compensation maximum fee for
444	444	17 that code as determined and adjusted pursuant to
445	445	18 subparagraph (B), subject to any further adjustments
446	446	19 under paragraph (5) of this subsection.
447	447	20 (4) The Commission, as of September 1, 2025 and
448	448	21 September 1 of each year thereafter, shall adjust the
449	449	22 workers' compensation maximum fee for each CPT or DRG code
450	450	23 to exactly half of the most recent annual increase in the
451	451	24 Consumer Price Index-U.
452	452	25 (5) A person who believes that the workers'
453	453	26 compensation maximum fee for a CPT or DRG code, as
454	454
455	455
456	456
457	457
458	458
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460	460
461	461
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463	463	HB4079 - 13 - LRB103 32159 SPS 61248 b
464	464	1 otherwise determined pursuant to this subsection, creates
465	465	2 or would create upon implementation a significant
466	466	3 limitation on access to quality health care in either a
467	467	4 specific field of health care services or a specific
468	468	5 geographic limitation on access to health care may
469	469	6 petition the Commission to modify the workers'
470	470	7 compensation maximum fee for that CPT or DRG code so as to
471	471	8 not create that significant limitation.
472	472	9 The petitioner bears the burden of demonstrating, by a
473	473	10 preponderance of the credible evidence, that the workers'
474	474	11 compensation maximum fee that would otherwise apply would
475	475	12 create a significant limitation on access to quality
476	476	13 health care in either a specific field of health care
477	477	14 services or a specific geographic limitation on access to
478	478	15 health care. Petitions shall be made publicly available.
479	479	16 Such credible evidence shall include empirical data
480	480	17 demonstrating a significant limitation on access to
481	481	18 quality health care. Other interested persons may file
482	482	19 comments or responses to a petition within 30 days after
483	483	20 the filing of a petition.
484	484	21 The Commission shall take final action on each
485	485	22 petition within 180 days after filing. The Commission may,
486	486	23 but is not required to, seek the recommendation of the
487	487	24 Medical Fee Advisory Board to assist with this
488	488	25 determination. If the Commission grants the petition, the
489	489	26 Commission shall further increase the workers'
490	490
491	491
492	492
493	493
494	494
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496	496
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500	500	1 compensation maximum fee for that CPT or DRG code by the
501	501	2 amount minimally necessary to avoid creating a significant
502	502	3 limitation on access to quality health care in either a
503	503	4 specific field of health care services or a specific
504	504	5 geographic limitation on access to health care. The
505	505	6 increased workers' compensation maximum fee shall take
506	506	7 effect upon entry of the Commission's final action.
507	507	8 (a-2) For procedures, treatments, services, or supplies
508	508	9 covered under this Act and rendered or to be rendered on or
509	509	10 after September 1, 2011, the maximum allowable payment shall
510	510	11 be 70% of the fee schedule amounts, which shall be adjusted
511	511	12 yearly by the Consumer Price Index-U, as described in
512	512	13 subsection (a) of this Section.
513	513	14 (a-2.5) Subsections (a), (a-1), and (a-2) are inoperative
514	514	15 on and after August 31, 2024.
515	515	16 (a-3) Prescriptions filled and dispensed outside of a
516	516	17 licensed pharmacy shall be subject to a fee schedule that
517	517	18 shall not exceed the Average Wholesale Price (AWP) plus a
518	518	19 dispensing fee of $4.18. AWP or its equivalent as registered
519	519	20 by the National Drug Code shall be set forth for that drug on
520	520	21 that date as published in Medi-Span Medispan.
521	521	22 (a-3.5) By September 1, 2023, the Commission, in
522	522	23 consultation with the Workers' Compensation Medical Fee
523	523	24 Advisory Board, shall adopt by rule an evidence-based drug
524	524	25 formulary and any rules necessary for its administration.
525	525	26 Prescriptions prescribed for workers' compensation cases shall
526	526
527	527
528	528
529	529
530	530
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532	532
533	533
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535	535	HB4079 - 15 - LRB103 32159 SPS 61248 b
536	536	1 be limited to the prescription drugs and doses on the closed
537	537	2 formulary.
538	538	3 A request for a prescription that is not on the closed
539	539	4 formulary shall be reviewed under Section 8.7.
540	540	5 (a-4) As used in this Section, "custom compound
541	541	6 medication" means a customized medication prescribed or
542	542	7 ordered by a duly licensed prescriber for a specific patient
543	543	8 that is prepared in a pharmacy by a licensed pharmacist in
544	544	9 response to a licensed prescriber's prescription or order by
545	545	10 combining, mixing, or altering of ingredients, but not
546	546	11 reconstituting, to meet the unique needs of a specific
547	547	12 patient.
548	548	13 (a-5) A custom compound medication for longer than the
549	549	14 one-time 7-day supply described in subsection (a-6) shall be
550	550	15 approved for payment only if the compound meets all of the
551	551	16 following standards:
552	552	17 (1) there is no readily available commercially
553	553	18 manufactured equivalent product;
554	554	19 (2) no other Food and Drug Administration-approved
555	555	20 alternative drug is appropriate for the patient;
556	556	21 (3) the active ingredients of the compound each have a
557	557	22 National Drug Code number, are components of drugs
558	558	23 approved by the Food and Drug Administration, and the
559	559	24 active ingredients in the custom compound medication are
560	560	25 being used for diagnosis or conditions approved use by the
561	561	26 Food and Drug Administration and not being used for
562	562
563	563
564	564
565	565
566	566
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568	568
569	569
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571	571	HB4079 - 16 - LRB103 32159 SPS 61248 b
572	572	1 off-label use;
573	573	2 (4) the drug has not been withdrawn or removed from
574	574	3 the market for safety reasons; and
575	575	4 (5) the prescriber is able to demonstrate to the payer
576	576	5 that the compound medication is clinically appropriate for
577	577	6 the intended use.
578	578	7 (a-6) Custom compound medications shall be charged using
579	579	8 the specific amount of each component drug and its original
580	580	9 manufacturer's National Drug Code number included in the
581	581	10 compound. Charges shall be based on a maximum charge of the
582	582	11 average wholesale price based upon the original manufacturer's
583	583	12 National Drug Code number, as published by Red Book or
584	584	13 Medi-Span and prorated for each component amount used. If the
585	585	14 National Drug Code for the compound ingredient is a repackaged
586	586	15 drug, the maximum allowable fee for the repackaged drug shall
587	587	16 be determined by the National Drug Code and the average
588	588	17 wholesale price of the underlying original manufacturer.
589	589	18 Components without National Drug Code numbers shall not be
590	590	19 charged. A single dispensing fee for a custom compound
591	591	20 medication as determined by the Commission based on the actual
592	592	21 costs of preparing and dispensing the custom compound
593	593	22 medication shall be paid. The dispensing fee for a compound
594	594	23 prescription shall be billed with code WC 700-C. The provider
595	595	24 may prescribe a one-time 7-day supply. Any custom compound
596	596	25 medication prescriptions for more than 7 days shall be
597	597	26 preauthorized by the employer. Under all circumstances, if the
598	598
599	599
600	600
601	601
602	602
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604	604
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607	607	HB4079 - 17 - LRB103 32159 SPS 61248 b
608	608	1 compound medication meets the requirements in subsection
609	609	2 (a-5), a 7-day supply shall be covered.
610	610	3 (a-7) This Section is subject to the other provisions of
611	611	4 this Act, including, but not limited to, Section 8.7.
612	612	5 (b) Notwithstanding the provisions of subsection (a), if
613	613	6 the Commission finds that there is a significant limitation on
614	614	7 access to quality health care in either a specific field of
615	615	8 health care services or a specific geographic limitation on
616	616	9 access to health care, it may change the Consumer Price
617	617	10 Index-U increase or decrease for that specific field or
618	618	11 specific geographic limitation on access to health care to
619	619	12 address that limitation.
620	620	13 (c) The Commission shall establish by rule a process to
621	621	14 review those medical cases or outliers that involve
622	622	15 extra-ordinary treatment to determine whether to make an
623	623	16 additional adjustment to the maximum payment within a fee
624	624	17 schedule for a procedure, treatment, or service.
625	625	18 (d) When a patient notifies a provider that the treatment,
626	626	19 procedure, or service being sought is for a work-related
627	627	20 illness or injury and furnishes the provider the name and
628	628	21 address of the responsible employer, the provider shall bill
629	629	22 the employer or its designee directly. The employer or its
630	630	23 designee shall make payment for treatment in accordance with
631	631	24 the provisions of this Section directly to the provider,
632	632	25 except that, if a provider has designated a third-party
633	633	26 billing entity to bill on its behalf, payment shall be made
634	634
635	635
636	636
637	637
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640	640
641	641
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643	643	HB4079 - 18 - LRB103 32159 SPS 61248 b
644	644	1 directly to the billing entity. Providers shall submit bills
645	645	2 and records in accordance with the provisions of this Section.
646	646	3 (1) All payments to providers for treatment provided
647	647	4 pursuant to this Act shall be made within 30 days of
648	648	5 receipt of the bills as long as the bill contains
649	649	6 substantially all the required data elements necessary to
650	650	7 adjudicate the bill.
651	651	8 (2) If the bill does not contain substantially all the
652	652	9 required data elements necessary to adjudicate the bill,
653	653	10 or the claim is denied for any other reason, in whole or in
654	654	11 part, the employer or insurer shall provide written
655	655	12 notification to the provider in the form of an explanation
656	656	13 of benefits explaining the basis for the denial and
657	657	14 describing any additional necessary data elements within
658	658	15 30 days of receipt of the bill. The Commission, with
659	659	16 assistance from the Medical Fee Advisory Board, shall
660	660	17 adopt rules detailing the requirements for the explanation
661	661	18 of benefits required under this subsection.
662	662	19 (3) In the case (i) of nonpayment to a provider within
663	663	20 30 days of receipt of the bill which contained
664	664	21 substantially all of the required data elements necessary
665	665	22 to adjudicate the bill, (ii) of nonpayment to a provider
666	666	23 of a portion of such a bill, or (iii) where the provider
667	667	24 has not been issued an explanation of benefits for a bill,
668	668	25 the bill, or portion of the bill up to the lesser of the
669	669	26 actual charge or the payment level set by the Commission
670	670
671	671
672	672
673	673
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680	680	1 in the fee schedule established in this Section, shall
681	681	2 incur interest at a rate of 1% per month payable by the
682	682	3 employer to the provider. Any required interest payments
683	683	4 shall be made by the employer or its insurer to the
684	684	5 provider within 30 days after payment of the bill.
685	685	6 (4) If the employer or its insurer fails to pay
686	686	7 interest within 30 days after payment of the bill as
687	687	8 required pursuant to paragraph (3), the provider may bring
688	688	9 an action in circuit court for the sole purpose of seeking
689	689	10 payment of interest pursuant to paragraph (3) against the
690	690	11 employer or its insurer responsible for insuring the
691	691	12 employer's liability pursuant to item (3) of subsection
692	692	13 (a) of Section 4. The circuit court's jurisdiction shall
693	693	14 be limited to enforcing payment of interest pursuant to
694	694	15 paragraph (3). Interest under paragraph (3) is only
695	695	16 payable to the provider. An employee is not responsible
696	696	17 for the payment of interest under this Section. The right
697	697	18 to interest under paragraph (3) shall not delay, diminish,
698	698	19 restrict, or alter in any way the benefits to which the
699	699	20 employee or his or her dependents are entitled under this
700	700	21 Act.
701	701	22 The changes made to this subsection (d) by this amendatory
702	702	23 Act of the 100th General Assembly apply to procedures,
703	703	24 treatments, and services rendered on and after the effective
704	704	25 date of this amendatory Act of the 100th General Assembly.
705	705	26 (e) Except as provided in subsections (e-5), (e-10), and
706	706
707	707
708	708
709	709
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712	712
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716	716	1 (e-15), a provider shall not hold an employee liable for costs
717	717	2 related to a non-disputed procedure, treatment, or service
718	718	3 rendered in connection with a compensable injury. The
719	719	4 provisions of subsections (e-5), (e-10), (e-15), and (e-20)
720	720	5 shall not apply if an employee provides information to the
721	721	6 provider regarding participation in a group health plan. If
722	722	7 the employee participates in a group health plan, the provider
723	723	8 may submit a claim for services to the group health plan. If
724	724	9 the claim for service is covered by the group health plan, the
725	725	10 employee's responsibility shall be limited to applicable
726	726	11 deductibles, co-payments, or co-insurance. Except as provided
727	727	12 under subsections (e-5), (e-10), (e-15), and (e-20), a
728	728	13 provider shall not bill or otherwise attempt to recover from
729	729	14 the employee the difference between the provider's charge and
730	730	15 the amount paid by the employer or the insurer on a compensable
731	731	16 injury, or for medical services or treatment determined by the
732	732	17 Commission to be excessive or unnecessary.
733	733	18 (e-5) If an employer notifies a provider that the employer
734	734	19 does not consider the illness or injury to be compensable
735	735	20 under this Act, the provider may seek payment of the
736	736	21 provider's actual charges from the employee for any procedure,
737	737	22 treatment, or service rendered. Once an employee informs the
738	738	23 provider that there is an application filed with the
739	739	24 Commission to resolve a dispute over payment of such charges,
740	740	25 the provider shall cease any and all efforts to collect
741	741	26 payment for the services that are the subject of the dispute.
742	742
743	743
744	744
745	745
746	746
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748	748
749	749
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752	752	1 Any statute of limitations or statute of repose applicable to
753	753	2 the provider's efforts to collect payment from the employee
754	754	3 shall be tolled from the date that the employee files the
755	755	4 application with the Commission until the date that the
756	756	5 provider is permitted to resume collection efforts under the
757	757	6 provisions of this Section.
758	758	7 (e-10) If an employer notifies a provider that the
759	759	8 employer will pay only a portion of a bill for any procedure,
760	760	9 treatment, or service rendered in connection with a
761	761	10 compensable illness or disease, the provider may seek payment
762	762	11 from the employee for the remainder of the amount of the bill
763	763	12 up to the lesser of the actual charge, negotiated rate, if
764	764	13 applicable, or the payment level set by the Commission in the
765	765	14 fee schedule established in this Section. Once an employee
766	766	15 informs the provider that there is an application filed with
767	767	16 the Commission to resolve a dispute over payment of such
768	768	17 charges, the provider shall cease any and all efforts to
769	769	18 collect payment for the services that are the subject of the
770	770	19 dispute. Any statute of limitations or statute of repose
771	771	20 applicable to the provider's efforts to collect payment from
772	772	21 the employee shall be tolled from the date that the employee
773	773	22 files the application with the Commission until the date that
774	774	23 the provider is permitted to resume collection efforts under
775	775	24 the provisions of this Section.
776	776	25 (e-15) When there is a dispute over the compensability of
777	777	26 or amount of payment for a procedure, treatment, or service,
778	778
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780	780
781	781
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784	784
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788	788	1 and a case is pending or proceeding before an Arbitrator or the
789	789	2 Commission, the provider may mail the employee reminders that
790	790	3 the employee will be responsible for payment of any procedure,
791	791	4 treatment or service rendered by the provider. The reminders
792	792	5 must state that they are not bills, to the extent practicable
793	793	6 include itemized information, and state that the employee need
794	794	7 not pay until such time as the provider is permitted to resume
795	795	8 collection efforts under this Section. The reminders shall not
796	796	9 be provided to any credit rating agency. The reminders may
797	797	10 request that the employee furnish the provider with
798	798	11 information about the proceeding under this Act, such as the
799	799	12 file number, names of parties, and status of the case. If an
800	800	13 employee fails to respond to such request for information or
801	801	14 fails to furnish the information requested within 90 days of
802	802	15 the date of the reminder, the provider is entitled to resume
803	803	16 any and all efforts to collect payment from the employee for
804	804	17 the services rendered to the employee and the employee shall
805	805	18 be responsible for payment of any outstanding bills for a
806	806	19 procedure, treatment, or service rendered by a provider.
807	807	20 (e-20) Upon a final award or judgment by an Arbitrator or
808	808	21 the Commission, or a settlement agreed to by the employer and
809	809	22 the employee, a provider may resume any and all efforts to
810	810	23 collect payment from the employee for the services rendered to
811	811	24 the employee and the employee shall be responsible for payment
812	812	25 of any outstanding bills for a procedure, treatment, or
813	813	26 service rendered by a provider as well as the interest awarded
814	814
815	815
816	816
817	817
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820	820
821	821
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823	823	HB4079 - 23 - LRB103 32159 SPS 61248 b
824	824	1 under subsection (d) of this Section. In the case of a
825	825	2 procedure, treatment, or service deemed compensable, the
826	826	3 provider shall not require a payment rate, excluding the
827	827	4 interest provisions under subsection (d), greater than the
828	828	5 lesser of the actual charge or the payment level set by the
829	829	6 Commission in the fee schedule established in this Section.
830	830	7 Payment for services deemed not covered or not compensable
831	831	8 under this Act is the responsibility of the employee unless a
832	832	9 provider and employee have agreed otherwise in writing.
833	833	10 Services not covered or not compensable under this Act are not
834	834	11 subject to the fee schedule in this Section.
835	835	12 (f) Nothing in this Act shall prohibit an employer or
836	836	13 insurer from contracting with a health care provider or group
837	837	14 of health care providers for reimbursement levels for benefits
838	838	15 under this Act different from those provided in this Section.
839	839	16 (g) On or before January 1, 2010 the Commission shall
840	840	17 provide to the Governor and General Assembly a report
841	841	18 regarding the implementation of the medical fee schedule and
842	842	19 the index used for annual adjustment to that schedule as
843	843	20 described in this Section.
844	844	21 (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
845	845	22 1-11-19.)
846	846	23 Section 99. Effective date. This Act takes effect upon
847	847	24 becoming law.
848	848
849	849
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