Full Text of HB3244 102nd General Assembly
HB3244 102ND GENERAL ASSEMBLY |
| | 102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022 HB3244 Introduced 2/19/2021, by Rep. Natalie A. Manley SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/5-5.12 | from Ch. 23, par. 5-5.12 | 305 ILCS 5/5-36 | |
|
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires all Medicaid managed care organizations to reimburse pharmacy provider dispensing fees and acquisition costs at no less than the amounts established under the fee-for-service program whether the Medicaid managed care organization directly reimburses pharmacy providers or contracts with a pharmacy benefit manager to reimburse pharmacy providers. Provides that the reimbursement requirement applies to all pharmacy services for persons receiving benefits under the Code including pharmacy services. Effective immediately.
|
| |
| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
|
| | | HB3244 | | LRB102 13203 KTG 18547 b |
|
| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Sections 5-5.12 and 5-36 as follows:
| 6 | | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
| 7 | | Sec. 5-5.12. Pharmacy payments.
| 8 | | (a) Every request submitted by a pharmacy for | 9 | | reimbursement under this
Article for prescription drugs | 10 | | provided to a recipient of aid under this
Article shall | 11 | | include the name of the prescriber or an acceptable
| 12 | | identification number as established by the Department.
| 13 | | (b) Pharmacies providing prescription drugs under
this | 14 | | Article shall be reimbursed at a rate which shall include
a | 15 | | professional dispensing fee as determined by the Illinois
| 16 | | Department, plus the current acquisition cost of the | 17 | | prescription
drug dispensed. The Illinois Department shall | 18 | | update its
information on the acquisition costs of all | 19 | | prescription drugs
no less frequently than every 30 days. | 20 | | However, the Illinois
Department may set the rate of | 21 | | reimbursement for the acquisition
cost, by rule, at a | 22 | | percentage of the current average wholesale
acquisition cost.
| 23 | | All Medicaid managed care organizations must reimburse |
| | | HB3244 | - 2 - | LRB102 13203 KTG 18547 b |
|
| 1 | | pharmacy provider dispensing fees and acquisition costs at no | 2 | | less than the amounts established under the fee-for-service | 3 | | program whether the Medicaid managed care organization | 4 | | directly reimburses pharmacy providers or contracts with a | 5 | | pharmacy benefit manager to reimburse pharmacy providers. The | 6 | | reimbursement requirement specified in this paragraph applies | 7 | | to all pharmacy services for persons receiving benefits under | 8 | | this Code including services reimbursed under Section 5-36. | 9 | | (c) (Blank).
| 10 | | (d) The Department shall review utilization of narcotic | 11 | | medications in the medical assistance program and impose | 12 | | utilization controls that protect against abuse.
| 13 | | (e) When making determinations as to which drugs shall be | 14 | | on a prior approval list, the Department shall include as part | 15 | | of the analysis for this determination, the degree to which a | 16 | | drug may affect individuals in different ways based on factors | 17 | | including the gender of the person taking the medication. | 18 | | (f) The Department shall cooperate with the Department of | 19 | | Public Health and the Department of Human Services Division of | 20 | | Mental Health in identifying psychotropic medications that, | 21 | | when given in a particular form, manner, duration, or | 22 | | frequency (including "as needed") in a dosage, or in | 23 | | conjunction with other psychotropic medications to a nursing | 24 | | home resident or to a resident of a facility licensed under the | 25 | | ID/DD Community Care Act or the MC/DD Act, may constitute a | 26 | | chemical restraint or an "unnecessary drug" as defined by the |
| | | HB3244 | - 3 - | LRB102 13203 KTG 18547 b |
|
| 1 | | Nursing Home Care Act or Titles XVIII and XIX of the Social | 2 | | Security Act and the implementing rules and regulations. The | 3 | | Department shall require prior approval for any such | 4 | | medication prescribed for a nursing home resident or to a | 5 | | resident of a facility licensed under the ID/DD Community Care | 6 | | Act or the MC/DD Act, that appears to be a chemical restraint | 7 | | or an unnecessary drug. The Department shall consult with the | 8 | | Department of Human Services Division of Mental Health in | 9 | | developing a protocol and criteria for deciding whether to | 10 | | grant such prior approval. | 11 | | (g) The Department may by rule provide for reimbursement | 12 | | of the dispensing of a 90-day supply of a generic or brand | 13 | | name, non-narcotic maintenance medication in circumstances | 14 | | where it is cost effective. | 15 | | (g-5) On and after July 1, 2012, the Department may | 16 | | require the dispensing of drugs to nursing home residents be | 17 | | in a 7-day supply or other amount less than a 31-day supply. | 18 | | The Department shall pay only one dispensing fee per 31-day | 19 | | supply. | 20 | | (h) Effective July 1, 2011, the Department shall | 21 | | discontinue coverage of select over-the-counter drugs, | 22 | | including analgesics and cough and cold and allergy | 23 | | medications. | 24 | | (h-5) On and after July 1, 2012, the Department shall | 25 | | impose utilization controls, including, but not limited to, | 26 | | prior approval on specialty drugs, oncolytic drugs, drugs for |
| | | HB3244 | - 4 - | LRB102 13203 KTG 18547 b |
|
| 1 | | the treatment of HIV or AIDS, immunosuppressant drugs, and | 2 | | biological products in order to maximize savings on these | 3 | | drugs. The Department may adjust payment methodologies for | 4 | | non-pharmacy billed drugs in order to incentivize the | 5 | | selection of lower-cost drugs. For drugs for the treatment of | 6 | | AIDS, the Department shall take into consideration the | 7 | | potential for non-adherence by certain populations, and shall | 8 | | develop protocols with organizations or providers primarily | 9 | | serving those with HIV/AIDS, as long as such measures intend | 10 | | to maintain cost neutrality with other utilization management | 11 | | controls such as prior approval.
For hemophilia, the | 12 | | Department shall develop a program of utilization review and | 13 | | control which may include, in the discretion of the | 14 | | Department, prior approvals. The Department may impose special | 15 | | standards on providers that dispense blood factors which shall | 16 | | include, in the discretion of the Department, staff training | 17 | | and education; patient outreach and education; case | 18 | | management; in-home patient assessments; assay management; | 19 | | maintenance of stock; emergency dispensing timeframes; data | 20 | | collection and reporting; dispensing of supplies related to | 21 | | blood factor infusions; cold chain management and packaging | 22 | | practices; care coordination; product recalls; and emergency | 23 | | clinical consultation. The Department may require patients to | 24 | | receive a comprehensive examination annually at an appropriate | 25 | | provider in order to be eligible to continue to receive blood | 26 | | factor. |
| | | HB3244 | - 5 - | LRB102 13203 KTG 18547 b |
|
| 1 | | (i) On and after July 1, 2012, the Department shall reduce | 2 | | any rate of reimbursement for services or other payments or | 3 | | alter any methodologies authorized by this Code to reduce any | 4 | | rate of reimbursement for services or other payments in | 5 | | accordance with Section 5-5e. | 6 | | (j) On and after July 1, 2012, the Department shall impose | 7 | | limitations on prescription drugs such that the Department | 8 | | shall not provide reimbursement for more than 4 prescriptions, | 9 | | including 3 brand name prescriptions, for distinct drugs in a | 10 | | 30-day period, unless prior approval is received for all | 11 | | prescriptions in excess of the 4-prescription limit. Drugs in | 12 | | the following therapeutic classes shall not be subject to | 13 | | prior approval as a result of the 4-prescription limit: | 14 | | immunosuppressant drugs, oncolytic drugs, anti-retroviral | 15 | | drugs, and, on or after July 1, 2014, antipsychotic drugs. On | 16 | | or after July 1, 2014, the Department may exempt children with | 17 | | complex medical needs enrolled in a care coordination entity | 18 | | contracted with the Department to solely coordinate care for | 19 | | such children, if the Department determines that the entity | 20 | | has a comprehensive drug reconciliation program. | 21 | | (k) No medication therapy management program implemented | 22 | | by the Department shall be contrary to the provisions of the | 23 | | Pharmacy Practice Act. | 24 | | (l) Any provider enrolled with the Department that bills | 25 | | the Department for outpatient drugs and is eligible to enroll | 26 | | in the federal Drug Pricing Program under Section 340B of the |
| | | HB3244 | - 6 - | LRB102 13203 KTG 18547 b |
|
| 1 | | federal Public Health Service Services Act shall enroll in | 2 | | that program. No entity participating in the federal Drug | 3 | | Pricing Program under Section 340B of the federal Public | 4 | | Health Service Services Act may exclude Medicaid from their | 5 | | participation in that program, although the Department may | 6 | | exclude entities defined in Section 1905(l)(2)(B) of the | 7 | | Social Security Act from this requirement. | 8 | | (Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; | 9 | | 99-180, eff. 7-29-15; revised 9-2-20.)
| 10 | | (305 ILCS 5/5-36) | 11 | | Sec. 5-36. Pharmacy benefits. | 12 | | (a)(1) The Department may enter into a contract with a | 13 | | third party on a fee-for-service reimbursement model for the | 14 | | purpose of administering pharmacy benefits as provided in this | 15 | | Section for members not enrolled in a Medicaid managed care | 16 | | organization; however, these services shall be approved by the | 17 | | Department. The Department shall ensure coordination of care | 18 | | between the third-party administrator and managed care | 19 | | organizations as a consideration in any contracts established | 20 | | in accordance with this Section. Any managed care techniques, | 21 | | principles, or administration of benefits utilized in | 22 | | accordance with this subsection shall comply with State law. | 23 | | (2) The following shall apply to contracts between | 24 | | entities contracting relating to the Department's third-party | 25 | | administrators and pharmacies: |
| | | HB3244 | - 7 - | LRB102 13203 KTG 18547 b |
|
| 1 | | (A) the Department shall approve any contract between | 2 | | a third-party administrator and a pharmacy; | 3 | | (B) the Department's third-party administrator shall | 4 | | not change the terms of a contract between a third-party | 5 | | administrator and a pharmacy without written approval by | 6 | | the Department; and | 7 | | (C) the Department's third-party administrator shall | 8 | | not create, modify, implement, or indirectly establish any | 9 | | fee on a pharmacy, pharmacist, or a recipient of medical | 10 | | assistance without written approval by the Department. | 11 | | (b) The provisions of this Section shall not apply to | 12 | | outpatient pharmacy services provided by a health care | 13 | | facility registered as a covered entity pursuant to 42 U.S.C. | 14 | | 256b or any pharmacy owned by or contracted with the covered | 15 | | entity. A Medicaid managed care organization shall, either | 16 | | directly or through a pharmacy benefit manager, administer and | 17 | | reimburse outpatient pharmacy claims submitted by a health | 18 | | care facility registered as a covered entity pursuant to 42 | 19 | | U.S.C. 256b, its owned pharmacies, and contracted pharmacies | 20 | | in accordance with the contractual agreements the Medicaid | 21 | | managed care organization or its pharmacy benefit manager has | 22 | | with such facilities and pharmacies. Any pharmacy benefit | 23 | | manager that contracts with a Medicaid managed care | 24 | | organization to administer and reimburse pharmacy claims as | 25 | | provided in this Section must be registered with the Director | 26 | | of Insurance in accordance with Section 513b2 of the Illinois |
| | | HB3244 | - 8 - | LRB102 13203 KTG 18547 b |
|
| 1 | | Insurance Code. | 2 | | (c) On at least an annual basis, the Director of the | 3 | | Department of Healthcare and Family Services shall submit a | 4 | | report beginning no later than one year after January 1, 2020 | 5 | | ( the effective date of Public Act 101-452) this amendatory Act | 6 | | of the 101st General Assembly that provides an update on any | 7 | | contract, contract issues, formulary, dispensing fees, and | 8 | | maximum allowable cost concerns regarding a third-party | 9 | | administrator and managed care. The requirement for reporting | 10 | | to the General Assembly shall be satisfied by filing copies of | 11 | | the report with the Speaker, the Minority Leader, and the | 12 | | Clerk of the House of Representatives and with the President, | 13 | | the Minority Leader, and the Secretary of the Senate. The | 14 | | Department shall take care that no proprietary information is | 15 | | included in the report required under this Section. | 16 | | (d) A pharmacy benefit manager shall notify the Department | 17 | | in writing of any activity, policy, or practice of the | 18 | | pharmacy benefit manager that directly or indirectly presents | 19 | | a conflict of interest that interferes with the discharge of | 20 | | the pharmacy benefit manager's duty to a managed care | 21 | | organization to exercise its contractual duties. "Conflict of | 22 | | interest" shall be defined by rule by the Department. | 23 | | (e) A pharmacy benefit manager shall, upon request, | 24 | | disclose to the Department the following information: | 25 | | (1) whether the pharmacy benefit manager has a | 26 | | contract, agreement, or other arrangement with a |
| | | HB3244 | - 9 - | LRB102 13203 KTG 18547 b |
|
| 1 | | pharmaceutical manufacturer to exclusively dispense or | 2 | | provide a drug to a managed care organization's enrollees, | 3 | | and the aggregate amounts of consideration of economic | 4 | | benefits collected or received pursuant to that | 5 | | arrangement; | 6 | | (2) the percentage of claims payments made by the | 7 | | pharmacy benefit manager to pharmacies owned, managed, or | 8 | | controlled by the pharmacy benefit manager or any of the | 9 | | pharmacy benefit manager's management companies, parent | 10 | | companies, subsidiary companies, or jointly held | 11 | | companies; | 12 | | (3) the aggregate amount of the fees or assessments | 13 | | imposed on, or collected from, pharmacy providers; and | 14 | | (4) the average annualized percentage of revenue | 15 | | collected by the pharmacy benefit manager as a result of | 16 | | each contract it has executed with a managed care | 17 | | organization contracted by the Department to provide | 18 | | medical assistance benefits which is not paid by the | 19 | | pharmacy benefit manager to pharmacy providers and | 20 | | pharmaceutical manufacturers or labelers or in order to | 21 | | perform administrative functions pursuant to its contracts | 22 | | with managed care organizations. | 23 | | (f) The information disclosed under subsection (e) shall | 24 | | include all retail, mail order, specialty, and compounded | 25 | | prescription products. All information made
available to the | 26 | | Department under subsection (e) is confidential and not |
| | | HB3244 | - 10 - | LRB102 13203 KTG 18547 b |
|
| 1 | | subject to disclosure under the Freedom of Information Act. | 2 | | All information made available to the Department under | 3 | | subsection (e) shall not be reported or distributed in any way | 4 | | that compromises its competitive, proprietary, or financial | 5 | | value. The information shall only be used by the Department to | 6 | | assess the contract, agreement, or other arrangements made | 7 | | between a pharmacy benefit manager and a pharmacy provider, | 8 | | pharmaceutical manufacturer or labeler, managed care | 9 | | organization, or other entity, as applicable. | 10 | | (g) A pharmacy benefit manager shall disclose directly in | 11 | | writing to a pharmacy provider or pharmacy services | 12 | | administrative organization contracting with the pharmacy | 13 | | benefit manager of any material change to a contract provision | 14 | | that affects the terms of the reimbursement, the process for | 15 | | verifying benefits and eligibility, dispute resolution, | 16 | | procedures for verifying drugs included on the formulary, and | 17 | | contract termination at least 30 days prior to the date of the | 18 | | change to the provision. The terms of this subsection shall be | 19 | | deemed met if the pharmacy benefit manager posts the | 20 | | information on a website, viewable by the public. A pharmacy | 21 | | service administration organization shall notify all contract | 22 | | pharmacies of any material change, as described in this | 23 | | subsection, within 2 days of notification. As used in this | 24 | | Section, "pharmacy services administrative organization" means | 25 | | an entity operating within the State that contracts with | 26 | | independent pharmacies to conduct business on their behalf |
| | | HB3244 | - 11 - | LRB102 13203 KTG 18547 b |
|
| 1 | | with third-party payers. A pharmacy services administrative | 2 | | organization may provide administrative services to pharmacies | 3 | | and negotiate and enter into contracts with third-party payers | 4 | | or pharmacy benefit managers on behalf of pharmacies. | 5 | | (h) A pharmacy benefit manager shall not include the | 6 | | following in a contract with a pharmacy provider: | 7 | | (1) a provision prohibiting the provider from | 8 | | informing a patient of a less costly alternative to a | 9 | | prescribed medication; or | 10 | | (2) a provision that prohibits the provider from | 11 | | dispensing a particular amount of a prescribed medication, | 12 | | if the pharmacy benefit manager allows that amount to be | 13 | | dispensed through a pharmacy owned or controlled by the | 14 | | pharmacy benefit manager, unless the prescription drug is | 15 | | subject to restricted distribution by the United States | 16 | | Food and Drug Administration or requires special handling, | 17 | | provider coordination, or patient education that cannot be | 18 | | provided by a retail pharmacy. | 19 | | (i) Nothing in this Section shall be construed to prohibit | 20 | | a pharmacy benefit manager from requiring the same | 21 | | reimbursement and terms and conditions for a pharmacy provider | 22 | | as for a pharmacy owned, controlled, or otherwise associated | 23 | | with the pharmacy benefit manager. Reimbursement must not be | 24 | | less than the dispensing fees and acquisition costs under the | 25 | | fee-for-service program as required under subsection (b) of | 26 | | Section 5-5.12. |
| | | HB3244 | - 12 - | LRB102 13203 KTG 18547 b |
|
| 1 | | (j) A pharmacy benefit manager shall establish and | 2 | | implement a process for the resolution of disputes arising out | 3 | | of this Section, which shall be approved by the Department. | 4 | | (k) The Department shall adopt rules establishing | 5 | | reasonable dispensing fees for fee-for-service payments in | 6 | | accordance with guidance or guidelines from the federal | 7 | | Centers for Medicare and Medicaid Services.
| 8 | | (Source: P.A. 101-452, eff. 1-1-20; revised 10-22-19.)
| 9 | | Section 99. Effective date. This Act takes effect upon | 10 | | becoming law.
|
|