Full Text of SB3136 99th General Assembly
SB3136 99TH GENERAL ASSEMBLY |
| | 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 |
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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.
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| | A BILL FOR |
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| 1 | | AN ACT concerning health benefits.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The State Employees Group Insurance Act of 1971 | 5 | | is 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 | 9 | | protection
against the the financial costs of health care | 10 | | expenses incurred in and out
of hospital including basic | 11 | | hospital-surgical-medical coverages. The program
may include, | 12 | | but shall not be limited to, such supplemental coverages as
| 13 | | out-patient diagnostic X-ray and laboratory expenses, | 14 | | prescription drugs,
dental services, hearing evaluations, | 15 | | hearing aids, the dispensing and
fitting
of hearing aids, and | 16 | | similar group benefits
as are now or may become available. | 17 | | However, nothing in this Act shall
be construed to permit, on | 18 | | or after July 1, 1980, the non-contributory portion
of any such | 19 | | program to include the expenses of obtaining an abortion, | 20 | | induced
miscarriage or induced premature birth unless, in the | 21 | | opinion of a physician,
such procedures are necessary for the | 22 | | preservation of the life of the woman
seeking such treatment, | 23 | | or except an induced premature birth intended to
produce a live |
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| 1 | | viable child and such procedure is necessary for the health
of | 2 | | the mother or the unborn child. The program may also include
| 3 | | coverage for those who rely on treatment by prayer or spiritual | 4 | | means
alone for healing in accordance with the tenets and | 5 | | practice of a
recognized religious denomination.
| 6 | | The program of health benefits shall be designed by the | 7 | | Director
(1) to provide a reasonable relationship between the | 8 | | benefits to be
included and the expected distribution of | 9 | | expenses of each such type to
be incurred by the covered | 10 | | members and dependents,
(2) to specify, as covered benefits and | 11 | | as optional benefits, the
medical services of practitioners in | 12 | | all categories licensed under the
Medical Practice Act of 1987, | 13 | | (3) to include
reasonable controls, which may include | 14 | | deductible and co-insurance
provisions, applicable to some or | 15 | | all of the benefits, or a coordination
of benefits provision, | 16 | | to prevent or minimize unnecessary utilization of
the various | 17 | | hospital, surgical and medical expenses to be provided and
to | 18 | | provide reasonable assurance of stability of the program, and | 19 | | (4) to
provide benefits to the extent possible to members | 20 | | throughout the
State, wherever located, on an equitable basis.
| 21 | | Notwithstanding any other provision of this Section or Act,
for | 22 | | all members or dependents who are eligible for benefits under | 23 | | Social
Security or the
Railroad Retirement system or who had | 24 | | sufficient Medicare-covered government
employment,
the
| 25 | | Department shall reduce benefits
which would otherwise be paid | 26 | | by Medicare, by the amount of benefits for
which the member or |
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| 1 | | dependents are eligible
under Medicare, except that such | 2 | | reduction in benefits shall apply only to
those members or | 3 | | dependents who (1) first become
eligible for such medicare | 4 | | coverage on or after the effective date of this
amendatory Act | 5 | | of 1992; or (2) are Medicare-eligible members or dependents of
| 6 | | a local government unit which began participation in the | 7 | | program on or after
July 1, 1992; or (3) remain eligible for | 8 | | but no longer receive
Medicare coverage which they had been | 9 | | receiving on or after the effective date
of this amendatory Act | 10 | | of 1992.
| 11 | | Notwithstanding any other provisions of this Act, where a | 12 | | covered member or
dependents are eligible for benefits under | 13 | | the federal Medicare health
insurance program (Title XVIII of | 14 | | the Social Security Act as added by
Public Law 89-97, 89th | 15 | | Congress), benefits paid under the State of Illinois
program or | 16 | | plan will be reduced by the amount of benefits paid by | 17 | | Medicare.
For members or dependents
who are eligible for | 18 | | benefits under Social Security
or the Railroad Retirement | 19 | | system or who had sufficient Medicare-covered
government | 20 | | employment, benefits shall be reduced by the amount for which
| 21 | | the member or dependent is eligible under Medicare,
except that | 22 | | such reduction in benefits shall apply only to those
members or | 23 | | dependents who (1) first become eligible for such
Medicare | 24 | | coverage on or after the effective date of this amendatory Act
| 25 | | of 1992; or (2) are Medicare-eligible members or dependents of | 26 | | a local
government unit which began participation in the |
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| 1 | | program on or after July 1,
1992; or (3) remain eligible for, | 2 | | but no longer receive Medicare
coverage which they had been | 3 | | receiving on or after the effective date of this
amendatory Act | 4 | | of 1992. Premiums may be adjusted, where applicable, to an
| 5 | | amount deemed by the Director to be reasonably consistent with | 6 | | any reduction
of benefits.
| 7 | | (b) A member, not otherwise covered by this Act, who has | 8 | | retired as a
participating member under Article 2 of the | 9 | | Illinois Pension Code
but is ineligible for the retirement | 10 | | annuity under Section 2-119 of the
Illinois
Pension Code, shall | 11 | | pay the premiums for coverage, not
exceeding the amount paid by | 12 | | the State for the non-contributory coverage for
other members, | 13 | | under the group health benefits program under this Act. The
| 14 | | Director shall determine the premiums to be paid
by a member | 15 | | under this subsection (b).
| 16 | | (Source: P.A. 93-47, eff. 7-1-03.)
| 17 | | Section 10. The Illinois Public Aid Code is amended by | 18 | | changing 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 | 22 | | reimbursement under this
Article for prescription drugs | 23 | | provided to a recipient of aid under this
Article shall include | 24 | | the name of the prescriber or an acceptable
identification |
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| 1 | | number as established by the Department.
| 2 | | (b) Pharmacies providing prescription drugs under
this | 3 | | Article shall be reimbursed at a rate which shall include
a | 4 | | professional dispensing fee as determined by the Illinois
| 5 | | Department, plus the current acquisition cost of the | 6 | | prescription
drug dispensed. The Illinois Department shall | 7 | | update its
information on the acquisition costs of all | 8 | | prescription drugs
no less frequently than every 30 days. | 9 | | However, the Illinois
Department may set the rate of | 10 | | reimbursement for the acquisition
cost, by rule, at a | 11 | | percentage of the current average wholesale
acquisition cost.
| 12 | | (c) (Blank).
| 13 | | (d) The Department shall review utilization of narcotic | 14 | | medications in the medical assistance program and impose | 15 | | utilization controls that protect against abuse.
| 16 | | (e) When making determinations as to which drugs shall be | 17 | | on a prior approval list, the Department shall include as part | 18 | | of the analysis for this determination, the degree to which a | 19 | | drug may affect individuals in different ways based on factors | 20 | | including the gender of the person taking the medication. | 21 | | (f) The Department shall cooperate with the Department of | 22 | | Public Health and the Department of Human Services Division of | 23 | | Mental Health in identifying psychotropic medications that, | 24 | | when given in a particular form, manner, duration, or frequency | 25 | | (including "as needed") in a dosage, or in conjunction with | 26 | | other psychotropic medications to a nursing home resident or to |
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| 1 | | a resident of a facility licensed under the ID/DD Community | 2 | | Care Act or the MC/DD Act, may constitute a chemical restraint | 3 | | or an "unnecessary drug" as defined by the Nursing Home Care | 4 | | Act or Titles XVIII and XIX of the Social Security Act and the | 5 | | implementing rules and regulations. The Department shall | 6 | | require prior approval for any such medication prescribed for a | 7 | | nursing home resident or to a resident of a facility licensed | 8 | | under the ID/DD Community Care Act or the MC/DD Act, that | 9 | | appears to be a chemical restraint or an unnecessary drug. The | 10 | | Department shall consult with the Department of Human Services | 11 | | Division of Mental Health in developing a protocol and criteria | 12 | | for deciding whether to grant such prior approval. | 13 | | (g) The Department may by rule provide for reimbursement of | 14 | | the dispensing of a 90-day supply of a generic or brand name, | 15 | | non-narcotic maintenance medication in circumstances where it | 16 | | is cost effective. | 17 | | (g-5) On and after July 1, 2012, the Department may require | 18 | | the dispensing of drugs to nursing home residents be in a 7-day | 19 | | supply or other amount less than a 31-day supply. The | 20 | | Department shall pay only one dispensing fee per 31-day supply. | 21 | | (h) Effective July 1, 2011, the Department shall | 22 | | discontinue coverage of select over-the-counter drugs, | 23 | | including analgesics and cough and cold and allergy | 24 | | medications. | 25 | | (h-5) On and after July 1, 2012, the Department shall | 26 | | impose utilization controls, including, but not limited to, |
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| 1 | | prior approval on specialty drugs, oncolytic drugs, drugs for | 2 | | the treatment of HIV or AIDS, immunosuppressant drugs, and | 3 | | biological products in order to maximize savings on these | 4 | | drugs. The Department may adjust payment methodologies for | 5 | | non-pharmacy billed drugs in order to incentivize the selection | 6 | | of lower-cost drugs. For drugs for the treatment of AIDS, the | 7 | | Department shall take into consideration the potential for | 8 | | non-adherence by certain populations, and shall develop | 9 | | protocols with organizations or providers primarily serving | 10 | | those with HIV/AIDS, as long as such measures intend to | 11 | | maintain cost neutrality with other utilization management | 12 | | controls such as prior approval.
For hemophilia, the Department | 13 | | shall develop a program of utilization review and control which | 14 | | may include, in the discretion of the Department, prior | 15 | | approvals. The Department may impose special standards on | 16 | | providers that dispense blood factors which shall include, in | 17 | | the discretion of the Department, staff training and education; | 18 | | patient outreach and education; case management; in-home | 19 | | patient assessments; assay management; maintenance of stock; | 20 | | emergency dispensing timeframes; data collection and | 21 | | reporting; dispensing of supplies related to blood factor | 22 | | infusions; cold chain management and packaging practices; care | 23 | | coordination; product recalls; and emergency clinical | 24 | | consultation. The Department may require patients to receive a | 25 | | comprehensive examination annually at an appropriate provider | 26 | | in 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 | 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 prior | 13 | | 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 has | 20 | | 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 |
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| 1 | | federal Public Health Services Act shall enroll in that | 2 | | program. No entity participating in the federal Drug Pricing | 3 | | Program under Section 340B of the federal Public Health | 4 | | Services Act may exclude Medicaid from their participation in | 5 | | that program, although the Department may exclude entities | 6 | | defined in Section 1905(l)(2)(B) of the Social Security Act | 7 | | 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.)
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