99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB3136

 

Introduced 2/19/2016, by Sen. Wm. Sam McCann

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6  from Ch. 127, par. 526
305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12

    Amends the State Employees Group Insurance Act of 1971. Makes a technical change in a Section concerning the program of health benefits provided under the Act. Amends the Medical Assistance Article of the Illinois Public Aid Code. Makes a technical change in a Section concerning pharmacy payments.


LRB099 19984 KTG 44383 b

 

 

A BILL FOR

 

SB3136LRB099 19984 KTG 44383 b

1    AN ACT concerning health benefits.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6 as follows:
 
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the the financial costs of health care
10expenses incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit, on
18or after July 1, 1980, the non-contributory portion of any such
19program to include the expenses of obtaining an abortion,
20induced miscarriage or induced premature birth unless, in the
21opinion of a physician, such procedures are necessary for the
22preservation of the life of the woman seeking such treatment,
23or except an induced premature birth intended to produce a live

 

 

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1viable child and such procedure is necessary for the health of
2the mother or the unborn child. The program may also include
3coverage for those who rely on treatment by prayer or spiritual
4means alone for healing in accordance with the tenets and
5practice of a recognized religious denomination.
6    The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits and
11as optional benefits, the medical services of practitioners in
12all categories licensed under the Medical Practice Act of 1987,
13(3) to include reasonable controls, which may include
14deductible and co-insurance provisions, applicable to some or
15all of the benefits, or a coordination of benefits provision,
16to prevent or minimize unnecessary utilization of the various
17hospital, surgical and medical expenses to be provided and to
18provide reasonable assurance of stability of the program, and
19(4) to provide benefits to the extent possible to members
20throughout the State, wherever located, on an equitable basis.
21Notwithstanding any other provision of this Section or Act, for
22all members or dependents who are eligible for benefits under
23Social Security or the Railroad Retirement system or who had
24sufficient Medicare-covered government employment, the
25Department shall reduce benefits which would otherwise be paid
26by Medicare, by the amount of benefits for which the member or

 

 

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1dependents are eligible under Medicare, except that such
2reduction in benefits shall apply only to those members or
3dependents who (1) first become eligible for such medicare
4coverage on or after the effective date of this amendatory Act
5of 1992; or (2) are Medicare-eligible members or dependents of
6a local government unit which began participation in the
7program on or after July 1, 1992; or (3) remain eligible for
8but no longer receive Medicare coverage which they had been
9receiving on or after the effective date of this amendatory Act
10of 1992.
11    Notwithstanding any other provisions of this Act, where a
12covered member or dependents are eligible for benefits under
13the federal Medicare health insurance program (Title XVIII of
14the Social Security Act as added by Public Law 89-97, 89th
15Congress), benefits paid under the State of Illinois program or
16plan will be reduced by the amount of benefits paid by
17Medicare. For members or dependents who are eligible for
18benefits under Social Security or the Railroad Retirement
19system or who had sufficient Medicare-covered government
20employment, benefits shall be reduced by the amount for which
21the member or dependent is eligible under Medicare, except that
22such reduction in benefits shall apply only to those members or
23dependents who (1) first become eligible for such Medicare
24coverage on or after the effective date of this amendatory Act
25of 1992; or (2) are Medicare-eligible members or dependents of
26a local government unit which began participation in the

 

 

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1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 93-47, eff. 7-1-03.)
 
17    Section 10. The Illinois Public Aid Code is amended by
18changing Section 5-5.12 as follows:
 
19    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
20    Sec. 5-5.12. Pharmacy payments.
21    (a) Every request submitted by a pharmacy for for
22reimbursement under this Article for prescription drugs
23provided to a recipient of aid under this Article shall include
24the name of the prescriber or an acceptable identification

 

 

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1number as established by the Department.
2    (b) Pharmacies providing prescription drugs under this
3Article shall be reimbursed at a rate which shall include a
4professional dispensing fee as determined by the Illinois
5Department, plus the current acquisition cost of the
6prescription drug dispensed. The Illinois Department shall
7update its information on the acquisition costs of all
8prescription drugs no less frequently than every 30 days.
9However, the Illinois Department may set the rate of
10reimbursement for the acquisition cost, by rule, at a
11percentage of the current average wholesale acquisition cost.
12    (c) (Blank).
13    (d) The Department shall review utilization of narcotic
14medications in the medical assistance program and impose
15utilization controls that protect against abuse.
16    (e) When making determinations as to which drugs shall be
17on a prior approval list, the Department shall include as part
18of the analysis for this determination, the degree to which a
19drug may affect individuals in different ways based on factors
20including the gender of the person taking the medication.
21    (f) The Department shall cooperate with the Department of
22Public Health and the Department of Human Services Division of
23Mental Health in identifying psychotropic medications that,
24when given in a particular form, manner, duration, or frequency
25(including "as needed") in a dosage, or in conjunction with
26other psychotropic medications to a nursing home resident or to

 

 

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1a resident of a facility licensed under the ID/DD Community
2Care Act or the MC/DD Act, may constitute a chemical restraint
3or an "unnecessary drug" as defined by the Nursing Home Care
4Act or Titles XVIII and XIX of the Social Security Act and the
5implementing rules and regulations. The Department shall
6require prior approval for any such medication prescribed for a
7nursing home resident or to a resident of a facility licensed
8under the ID/DD Community Care Act or the MC/DD Act, that
9appears to be a chemical restraint or an unnecessary drug. The
10Department shall consult with the Department of Human Services
11Division of Mental Health in developing a protocol and criteria
12for deciding whether to grant such prior approval.
13    (g) The Department may by rule provide for reimbursement of
14the dispensing of a 90-day supply of a generic or brand name,
15non-narcotic maintenance medication in circumstances where it
16is cost effective.
17    (g-5) On and after July 1, 2012, the Department may require
18the dispensing of drugs to nursing home residents be in a 7-day
19supply or other amount less than a 31-day supply. The
20Department shall pay only one dispensing fee per 31-day supply.
21    (h) Effective July 1, 2011, the Department shall
22discontinue coverage of select over-the-counter drugs,
23including analgesics and cough and cold and allergy
24medications.
25    (h-5) On and after July 1, 2012, the Department shall
26impose utilization controls, including, but not limited to,

 

 

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1prior approval on specialty drugs, oncolytic drugs, drugs for
2the treatment of HIV or AIDS, immunosuppressant drugs, and
3biological products in order to maximize savings on these
4drugs. The Department may adjust payment methodologies for
5non-pharmacy billed drugs in order to incentivize the selection
6of lower-cost drugs. For drugs for the treatment of AIDS, the
7Department shall take into consideration the potential for
8non-adherence by certain populations, and shall develop
9protocols with organizations or providers primarily serving
10those with HIV/AIDS, as long as such measures intend to
11maintain cost neutrality with other utilization management
12controls such as prior approval. For hemophilia, the Department
13shall develop a program of utilization review and control which
14may include, in the discretion of the Department, prior
15approvals. The Department may impose special standards on
16providers that dispense blood factors which shall include, in
17the discretion of the Department, staff training and education;
18patient outreach and education; case management; in-home
19patient assessments; assay management; maintenance of stock;
20emergency dispensing timeframes; data collection and
21reporting; dispensing of supplies related to blood factor
22infusions; cold chain management and packaging practices; care
23coordination; product recalls; and emergency clinical
24consultation. The Department may require patients to receive a
25comprehensive examination annually at an appropriate provider
26in order to be eligible to continue to receive blood factor.

 

 

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1    (i) On and after July 1, 2012, the Department shall reduce
2any rate of reimbursement for services or other payments or
3alter any methodologies authorized by this Code to reduce any
4rate of reimbursement for services or other payments in
5accordance with Section 5-5e.
6    (j) On and after July 1, 2012, the Department shall impose
7limitations on prescription drugs such that the Department
8shall not provide reimbursement for more than 4 prescriptions,
9including 3 brand name prescriptions, for distinct drugs in a
1030-day period, unless prior approval is received for all
11prescriptions in excess of the 4-prescription limit. Drugs in
12the following therapeutic classes shall not be subject to prior
13approval as a result of the 4-prescription limit:
14immunosuppressant drugs, oncolytic drugs, anti-retroviral
15drugs, and, on or after July 1, 2014, antipsychotic drugs. On
16or after July 1, 2014, the Department may exempt children with
17complex medical needs enrolled in a care coordination entity
18contracted with the Department to solely coordinate care for
19such children, if the Department determines that the entity has
20a comprehensive drug reconciliation program.
21    (k) No medication therapy management program implemented
22by the Department shall be contrary to the provisions of the
23Pharmacy Practice Act.
24    (l) Any provider enrolled with the Department that bills
25the Department for outpatient drugs and is eligible to enroll
26in the federal Drug Pricing Program under Section 340B of the

 

 

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1federal Public Health Services Act shall enroll in that
2program. No entity participating in the federal Drug Pricing
3Program under Section 340B of the federal Public Health
4Services Act may exclude Medicaid from their participation in
5that program, although the Department may exclude entities
6defined in Section 1905(l)(2)(B) of the Social Security Act
7from this requirement.
8(Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14;
999-180, eff. 7-29-15.)