093_SB1381

 
                                     LRB093 11069 DRJ 11774 b

 1        AN ACT in relation to health.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 1.  Short title. This Act may  be  cited  as  the
 5    Mental Health Drug Open Access Authorization Act.

 6        Section 5.  Legislative findings; purpose.
 7        (a)  The General Assembly finds as follows:
 8             (1)  Recipients  of  medical  assistance  under  the
 9        Illinois  Public  Aid  Code  are  often  the State's most
10        disadvantaged   citizens,   burdened   with   significant
11        medical, financial, and social  needs.  Those  recipients
12        benefit  from  an integrated approach to health care with
13        open  and  continuous  access   to   physician-prescribed
14        medications.
15             (2)  Mental  health  patients,  including,  but  not
16        limited to, patients with severe mental illnesses such as
17        schizophrenia,    bipolar    disorder   (manic-depressive
18        illness), or depression,  require  individually  tailored
19        treatments  determined by an appropriately trained health
20        care provider.
21             (3)  Medications for  mental  illness  are  not  the
22        same;  medications  can  vary greatly in effectiveness in
23        treating specific symptoms or disorders or in their  side
24        effects. Patient needs vary greatly, and not all patients
25        respond in the same way to a given treatment.
26             (4)  There  is  ample  evidence that new medications
27        offer  therapeutic  advantages  over  older  medications.
28        These new medications can  cost  more  but  can  also  be
29        better for patients.
30             (5)  The   determination  of  the  most  appropriate
31        medication for a particular patient with a mental illness
 
                            -2-      LRB093 11069 DRJ 11774 b
 1        should be made on the  basis  of  patient  acceptability,
 2        prior  individual  drug  response, individual side-effect
 3        profile, and long-term treatment planning, and should not
 4        be made on the basis of cost.
 5             (6)  As the direct caregiver, a patient's  physician
 6        should determine the most appropriate treatment.
 7        (b)  The purpose of this Act is to ensure that recipients
 8    of medical assistance under the Illinois Public Aid Code, and
 9    other  similarly  situated  patients,  who need treatment for
10    mental  illness  have  open  and  continuous  access  to  the
11    medications deemed appropriate by their physicians.

12        Section 10.  Definitions. In this Act:
13        "Cross-indicated" means that a drug is used for a purpose
14    generally held to be reasonable, appropriate, and within  the
15    community  standards  of practice even though that use is not
16    included  in  the  federal  Food  and  Drug  Administration's
17    approved label indications for the drug.
18        "Department" means the following:
19             (1)  In the case of the Children's Health  Insurance
20        Program under the Children's Health Insurance Program Act
21        or  the  medial  assistance  program  under  the Illinois
22        Public Aid Code: the Department of Public Aid.
23             (2)  In the case of the  program  of  pharmaceutical
24        assistance under the Senior Citizens and Disabled Persons
25        Property  Tax  Relief  and Pharmaceutical Assistance Act:
26        the Department of Revenue.
27             (3)  In the case of  any  other  State  prescription
28        drug   assistance   program:   the   State   agency  that
29        administers that program.
30        "Mental illness" has the meaning ascribed to that term in
31    the most recent edition of  the  Diagnostic  and  Statistical
32    Manual   of  Mental  Disorders,  published  by  the  American
33    Psychiatric Association.
 
                            -3-      LRB093 11069 DRJ 11774 b
 1        "Prior authorization" means  a  procedure  by  which  the
 2    prescriber  or  dispenser  of  a  drug  must  verify with the
 3    Department or its contractor that the proposed medical use of
 4    that drug for a  patient  meets  predetermined  criteria  for
 5    coverage under a program described in Section 15.

 6        Section  15.  Affected  programs. This Act applies to the
 7    following programs:
 8             (1)  The Children's Health Insurance  Program  under
 9        the Children's Health Insurance Program Act.
10             (2)  The  medial  assistance program under Article V
11        of the Illinois Public  Aid  Code,  as  well  as  medical
12        assistance  provided  to recipients of General Assistance
13        under Article VI of that Code.
14             (3)  The program of pharmaceutical assistance  under
15        the  Senior  Citizens  and  Disabled Persons Property Tax
16        Relief and Pharmaceutical Assistance Act.
17             (4)  Any other State  prescription  drug  assistance
18        program.

19        Section  20.  Prior  authorization of mental health drugs
20    prohibited. The Department may not use or require the use  of
21    a  prior  authorization  procedure  in  connection  with  the
22    dispensing  of  a prescription drug, or reimbursement for the
23    dispensing of a drug, that  meets  either  of  the  following
24    criteria:
25             (1)  According to the most recent edition of the AMA
26        Drug  Evaluations  or the Physician's Desk Reference, the
27        drug is:
28                  (A)  classified     as     an     anti-anxiety,
29             antidepressant,  or  antipsychotic  central  nervous
30             system drug; or
31                  (B)  cross-indicated  for  a  central   nervous
32             system drug classification.
 
                            -4-      LRB093 11069 DRJ 11774 b
 1             (2)  The  drug  is  prescribed  for the treatment of
 2        mental illness.

 3        Section 90.  The Children's Health Insurance Program  Act
 4    is amended by adding Section 27 as follows:

 5        (215 ILCS 106/27 new)
 6        Sec.  27.  Prior  authorization  of  mental  health drugs
 7    prohibited. Health benefits  coverage  provided  to  eligible
 8    children  under this Act is subject to the Mental Health Drug
 9    Open Access Authorization Act.

10        Section 93.  The Illinois Public Aid Code is  amended  by
11    changing Sections 5-5.12 and 6-11 as follows:

12        (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
13        Sec. 5-5.12.  Pharmacy payments.
14        (a)  Every   request   submitted   by   a   pharmacy  for
15    reimbursement  under  this  Article  for  prescription  drugs
16    provided to a recipient  of  aid  under  this  Article  shall
17    include   the   name  of  the  prescriber  or  an  acceptable
18    identification number as established by the Department.
19        (b)  Pharmacies providing prescription drugs  under  this
20    Article  shall  be reimbursed at a rate which shall include a
21    professional dispensing fee as  determined  by  the  Illinois
22    Department,   plus   the  current  acquisition  cost  of  the
23    prescription drug dispensed. The  Illinois  Department  shall
24    update  its  information  on  the  acquisition  costs  of all
25    prescription drugs no less frequently  than  every  30  days.
26    However,   the  Illinois  Department  may  set  the  rate  of
27    reimbursement  for  the  acquisition  cost,  by  rule,  at  a
28    percentage of the current average wholesale acquisition cost.
29        (c)  Reimbursement under this  Article  for  prescription
30    drugs  shall  be  limited  to  reimbursement for 4 brand-name
 
                            -5-      LRB093 11069 DRJ 11774 b
 1    prescription drugs per patient per  month.   This  subsection
 2    applies  only  if  (i) the brand-name drug was not prescribed
 3    for an acute or urgent condition, (ii)  the  brand-name  drug
 4    was   not  prescribed  for  Alzheimer's  disease,  arthritis,
 5    diabetes, HIV/AIDS, a mental health condition, or respiratory
 6    disease,  and  (iii)  a  therapeutically  equivalent  generic
 7    medication has been approved by the  federal  Food  and  Drug
 8    Administration.
 9        (d)  The  Department  shall  not  impose requirements for
10    prior  approval  based  on  a   preferred   drug   list   for
11    anti-retroviral  or any atypical antipsychotics, conventional
12    antipsychotics, or anticonvulsants used for the treatment  of
13    serious mental illnesses until 30 days after it has conducted
14    a  study  of  the impact of such requirements on patient care
15    and submitted a  report  to  the  Speaker  of  the  House  of
16    Representatives and the President of the Senate.  In the case
17    of  a  conflict between this subsection and the Mental Health
18    Drug Open Access Authorization Act, the  Mental  Health  Drug
19    Open Access Authorization Act controls.
20    (Source:  P.A.  92-597,  eff.  6-28-02; 92-825, eff. 8-21-02;
21    revised 9-19-02.)

22        (305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
23        Sec. 6-11.  State funded General Assistance.
24        (a)  Effective July 1, 1992,  all  State  funded  General
25    Assistance  and related medical benefits shall be governed by
26    this Section.  Other parts of this Code or other laws related
27    to General Assistance shall remain in effect  to  the  extent
28    they do not conflict with the provisions of this Section.  If
29    any  other  part  of  this  Code  or other laws of this State
30    conflict with the provisions of this Section, the  provisions
31    of this Section shall control.
32        (b)  State  funded  General Assistance shall consist of 2
33    separate programs.  One program shall be for adults  with  no
 
                            -6-      LRB093 11069 DRJ 11774 b
 1    children and shall be known as State Transitional Assistance.
 2    The other program shall be for families with children and for
 3    pregnant  women  and  shall  be  known  as  State  Family and
 4    Children Assistance.
 5        (c) (1)  To be eligible for State Transitional Assistance
 6    on or after July 1, 1992, an individual  must  be  ineligible
 7    for  assistance under any other Article of this Code, must be
 8    determined  chronically  needy,  and  must  be  one  of   the
 9    following:
10             (A)  age 18 or over or
11             (B)  married and living with a spouse, regardless of
12        age.
13        (2)  The  Illinois  Department  or the local governmental
14    unit shall  determine  whether  individuals  are  chronically
15    needy as follows:
16             (A)  Individuals  who  have applied for Supplemental
17        Security Income (SSI) and  are  awaiting  a  decision  on
18        eligibility  for  SSI  who are determined disabled by the
19        Illinois Department  using  the  SSI  standard  shall  be
20        considered  chronically  needy,  except  that individuals
21        whose disability is based solely on substance  addictions
22        (drug  abuse  and  alcoholism) and whose disability would
23        cease were their addictions to end shall be eligible only
24        for medical assistance and shall not be eligible for cash
25        assistance  under  the  State   Transitional   Assistance
26        program.
27             (B)  If  an  individual has been denied SSI due to a
28        finding of "not disabled" (either at  the  Administrative
29        Law  Judge  level  or  above, or at a lower level if that
30        determination was not appealed), the Illinois  Department
31        shall  adopt that finding and the individual shall not be
32        eligible for State Transitional Assistance or any related
33        medical  benefits.   Such  an  individual  may   not   be
34        determined  disabled  by  the  Illinois  Department for a
 
                            -7-      LRB093 11069 DRJ 11774 b
 1        period of 12 months, unless  the  individual  shows  that
 2        there has been a substantial change in his or her medical
 3        condition  or that there has been a substantial change in
 4        other factors, such as age or work experience, that might
 5        change the determination of disability.
 6             (C)  The Illinois Department, by rule,  may  specify
 7        other  categories  of  individuals  as chronically needy;
 8        nothing in this Section,  however,  shall  be  deemed  to
 9        require the inclusion of any specific category other than
10        as specified in paragraphs (A) and (B).
11        (3)  For  individuals  in  State Transitional Assistance,
12    medical assistance shall be provided in an amount and  nature
13    determined  by the Illinois Department of Public Aid by rule.
14    The amount and nature of medical assistance provided need not
15    be  the  same  as  that  provided  under  paragraph  (4)   of
16    subsection (d) of this Section, and nothing in this paragraph
17    (3)  shall  be  construed  to  require  the  coverage  of any
18    particular medical  service.  In  addition,  the  amount  and
19    nature  of  medical  assistance provided may be different for
20    different categories of  individuals  determined  chronically
21    needy.
22        (4)  The  Illinois  Department  shall determine, by rule,
23    those assistance recipients under Article  VI  who  shall  be
24    subject   to  employment,  training,  or  education  programs
25    including Earnfare, the content of those  programs,  and  the
26    penalties for failure to cooperate in those programs.
27        (5)  The  Illinois  Department  shall, by rule, establish
28    further eligibility requirements, including but  not  limited
29    to residence, need, and the level of payments.
30        (d) (1)  To  be  eligible  for  State Family and Children
31    Assistance, a family unit must be ineligible  for  assistance
32    under any other Article of this Code and must contain a child
33    who is:
34             (A)  under age 18 or
 
                            -8-      LRB093 11069 DRJ 11774 b
 1             (B)  age  18  and a full-time student in a secondary
 2        school or the equivalent level of vocational or technical
 3        training, and who may reasonably be expected to  complete
 4        the program before reaching age 19.
 5        Those  children  shall  be  eligible for State Family and
 6    Children Assistance.
 7        (2)  The natural or adoptive parents of the child  living
 8    in  the  same  household may be eligible for State Family and
 9    Children Assistance.
10        (3)  A pregnant woman whose pregnancy has  been  verified
11    shall be eligible for income maintenance assistance under the
12    State Family and Children Assistance program.
13        (4)  The amount and nature of medical assistance provided
14    under  the State Family and Children Assistance program shall
15    be determined by the Illinois Department  of  Public  Aid  by
16    rule.  The  amount  and nature of medical assistance provided
17    need not be the same as that provided under paragraph (3)  of
18    subsection (c) of this Section, and nothing in this paragraph
19    (4)  shall  be  construed  to  require  the  coverage  of any
20    particular medical service.
21        (5)  The Illinois Department shall,  by  rule,  establish
22    further  eligibility  requirements, including but not limited
23    to residence, need, and the level of payments.
24        (d-5)  Medical assistance benefits provided  to  eligible
25    recipients  under  this  Section  are  subject  to the Mental
26    Health Drug Open Access Authorization Act.
27        (e)  A  local   governmental   unit   that   chooses   to
28    participate  in  a  General  Assistance  program  under  this
29    Section  shall  provide  funding  in  accordance with Section
30    12-21.13 of  this  Act.  Local  governmental  funds  used  to
31    qualify  for  State  funding may only be expended for clients
32    eligible for assistance under this Section 6-11  and  related
33    administrative expenses.
34        (f)  In  order  to  qualify  for State funding under this
 
                            -9-      LRB093 11069 DRJ 11774 b
 1    Section, a local governmental unit shall be  subject  to  the
 2    supervision  and  the  rules  and regulations of the Illinois
 3    Department.
 4        (g)  Notwithstanding any other provision  in  this  Code,
 5    the  Illinois  Department  is  authorized  to  reduce payment
 6    levels used to determine cash grants provided  to  recipients
 7    of  State Transitional Assistance at any time within a Fiscal
 8    Year  in  order  to  ensure  that  cash  benefits  for  State
 9    Transitional   Assistance   do   not   exceed   the   amounts
10    appropriated for those  cash  benefits.  Changes  in  payment
11    levels  may  be  accomplished by emergency rule under Section
12    5-45 of the Illinois  Administrative  Procedure  Act,  except
13    that the limitation on the number of emergency rules that may
14    be  adopted  in  a  24-month  period  shall not apply and the
15    provisions of  Sections  5-115  and  5-125  of  the  Illinois
16    Administrative Procedure Act shall not apply.  This provision
17    shall  also  be applicable to any reduction in payment levels
18    made upon implementation of this amendatory Act of 1995.
19    (Source: P.A. 92-111, eff. 1-1-02.)

20        Section 95.  The Senior  Citizens  and  Disabled  Persons
21    Property  Tax  Relief  and  Pharmaceutical  Assistance Act is
22    amended by changing Section 4 as follows:

23        (320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
24        Sec. 4.  Amount of Grant.
25        (a)  In general.  Any individual 65 years or older or any
26    individual who will become 65 years old during  the  calendar
27    year  in  which a claim is filed, and any surviving spouse of
28    such a claimant, who at the time of  death  received  or  was
29    entitled  to  receive a grant pursuant to this Section, which
30    surviving spouse will become 65 years of age  within  the  24
31    months  immediately  following the death of such claimant and
32    which surviving spouse but for his or her  age  is  otherwise
 
                            -10-     LRB093 11069 DRJ 11774 b
 1    qualified  to  receive  a grant pursuant to this Section, and
 2    any disabled person whose annual  household  income  is  less
 3    than $14,000 for grant years before the 1998 grant year, less
 4    than $16,000 for the 1998 and 1999 grant years, and less than
 5    (i)  $21,218  for  a  household  containing  one person, (ii)
 6    $28,480 for  a  household  containing  2  persons,  or  (iii)
 7    $35,740  for a household containing 3 or more persons for the
 8    2000 grant year and thereafter and whose household is  liable
 9    for  payment  of  property  taxes  accrued  or  has paid rent
10    constituting property taxes accrued and is domiciled in  this
11    State  at  the  time  he  or  she  files  his or her claim is
12    entitled to claim a grant under this  Act.  With  respect  to
13    claims  filed  by  individuals  who  will become 65 years old
14    during the calendar year in  which  a  claim  is  filed,  the
15    amount of any grant to which that household is entitled shall
16    be  an  amount  equal  to  1/12  of  the  amount to which the
17    claimant would otherwise be  entitled  as  provided  in  this
18    Section,  multiplied  by  the  number  of months in which the
19    claimant was 65 in the calendar year in which  the  claim  is
20    filed.
21        (b)  Limitation.    Except   as   otherwise  provided  in
22    subsections (a) and (f) of this Section, the  maximum  amount
23    of  grant which a claimant is entitled to claim is the amount
24    by which the  property  taxes  accrued  which  were  paid  or
25    payable   during   the   last  preceding  tax  year  or  rent
26    constituting  property  taxes  accrued  upon  the  claimant's
27    residence for the last preceding taxable year exceeds 3  1/2%
28    of  the  claimant's  household income for that year but in no
29    event is the grant to exceed (i) $700 less 4.5% of  household
30    income  for  that  year  for those with a household income of
31    $14,000 or less or (ii) $70 if household income for that year
32    is more than $14,000.
33        (c)  Public aid recipients.  If household income  in  one
34    or  more  months  during  a  year includes cash assistance in
 
                            -11-     LRB093 11069 DRJ 11774 b
 1    excess of $55 per month from the Department of Public Aid  or
 2    the  Department of Human Services (acting as successor to the
 3    Department of  Public  Aid  under  the  Department  of  Human
 4    Services  Act) which was determined under regulations of that
 5    Department on a measure of need that  included  an  allowance
 6    for  actual  rent  or property taxes paid by the recipient of
 7    that assistance, the amount of grant to which that  household
 8    is  entitled, except as otherwise provided in subsection (a),
 9    shall be the product of (1) the maximum  amount  computed  as
10    specified in subsection (b) of this Section and (2) the ratio
11    of  the  number  of  months in which household income did not
12    include such cash assistance over $55 to the  number  twelve.
13    If household income did not include such cash assistance over
14    $55  for  any months during the year, the amount of the grant
15    to which the household  is  entitled  shall  be  the  maximum
16    amount  computed  as  specified  in  subsection  (b)  of this
17    Section.   For  purposes  of  this   paragraph   (c),   "cash
18    assistance"  does  not  include any amount received under the
19    federal Supplemental Security Income (SSI) program.
20        (d)  Joint ownership.  If title to the residence is  held
21    jointly  by the claimant with a person who is not a member of
22    his or her household, the amount of  property  taxes  accrued
23    used  in  computing the amount of grant to which he or she is
24    entitled shall be  the  same  percentage  of  property  taxes
25    accrued  as  is  the  percentage  of  ownership  held  by the
26    claimant in the residence.
27        (e)  More than one residence.  If a claimant has occupied
28    more than one residence in the taxable year, he  or  she  may
29    claim  only  one  residence  for any part of a month.  In the
30    case of property taxes accrued, he or she shall prorate  1/12
31    of  the  total property taxes accrued on his or her residence
32    to each  month  that  he  or  she  owned  and  occupied  that
33    residence;  and,  in  the  case of rent constituting property
34    taxes accrued, shall prorate each month's  rent  payments  to
 
                            -12-     LRB093 11069 DRJ 11774 b
 1    the residence actually occupied during that month.
 2        (f)  There   is   hereby   established   a   program   of
 3    pharmaceutical  assistance  to  the  aged  and disabled which
 4    shall be administered by the Department  in  accordance  with
 5    this Act, to consist of payments to authorized pharmacies, on
 6    behalf  of  beneficiaries  of the program, for the reasonable
 7    costs of covered prescription drugs.   Each  beneficiary  who
 8    pays  $5  for  an identification card shall pay no additional
 9    prescription costs.  Each beneficiary who  pays  $25  for  an
10    identification  card  shall  pay  $3  per  prescription.   In
11    addition,  after  a  beneficiary  receives $2,000 in benefits
12    during a State fiscal year, that beneficiary  shall  also  be
13    charged  20%  of  the  cost  of  each  prescription for which
14    payments are made by the program during the remainder of  the
15    fiscal  year.   To  become a beneficiary under this program a
16    person must: (1) be (i) 65 years of age or older, or (ii) the
17    surviving spouse of such a claimant, who at the time of death
18    received or was entitled to receive benefits pursuant to this
19    subsection, which surviving spouse will become  65  years  of
20    age  within  the 24 months immediately following the death of
21    such claimant and which surviving spouse but for his  or  her
22    age  is  otherwise  qualified to receive benefits pursuant to
23    this subsection, or (iii) disabled, and (2) be  domiciled  in
24    this  State at the time he or she files his or her claim, and
25    (3) have a maximum household income of less than $14,000  for
26    grant years before the 1998 grant year, less than $16,000 for
27    the  1998 and 1999 grant years, and less than (i) $21,218 for
28    a  household  containing  one  person,  (ii)  $28,480  for  a
29    household containing  2  persons,  or  (iii)  $35,740  for  a
30    household  containing  3 more persons for the 2000 grant year
31    and thereafter.  In addition, each eligible person  must  (1)
32    obtain an identification card from the Department, (2) at the
33    time  the card is obtained, sign a statement assigning to the
34    State of Illinois benefits which  may  be  otherwise  claimed
 
                            -13-     LRB093 11069 DRJ 11774 b
 1    under  any  private  insurance  plans,  and  (3)  present the
 2    identification card to the dispensing pharmacist.
 3        Whenever a generic equivalent for a covered  prescription
 4    drug  is  available,  the Department shall reimburse only for
 5    the reasonable costs of  the  generic  equivalent,  less  the
 6    co-pay  established  in  this Section, unless (i) the covered
 7    prescription drug contains one or more ingredients defined as
 8    a narrow therapeutic index drug at 21 CFR  320.33,  (ii)  the
 9    prescriber  indicates  on the face of the prescription "brand
10    medically necessary", and (iii) the prescriber specifies that
11    a substitution  is  not  permitted.   When  issuing  an  oral
12    prescription for covered prescription medication described in
13    item  (i)  of  this paragraph, the prescriber shall stipulate
14    "brand medically necessary" and that a  substitution  is  not
15    permitted.    If   the  covered  prescription  drug  and  its
16    authorizing prescription do  not  meet  the  criteria  listed
17    above,   the   beneficiary   may   purchase  the  non-generic
18    equivalent of the covered prescription  drug  by  paying  the
19    difference  between the generic cost and the non-generic cost
20    plus the beneficiary co-pay.
21        Pharmaceutical assistance benefits provided  to  eligible
22    persons  under this Act are subject to the Mental Health Drug
23    Open Access Authorization Act.
24        Any  person   otherwise   eligible   for   pharmaceutical
25    assistance  under this Act whose covered drugs are covered by
26    any public program for assistance in purchasing  any  covered
27    prescription  drugs  shall be ineligible for assistance under
28    this Act to the extent such costs are covered by  such  other
29    plan.
30        The   fee  to  be  charged  by  the  Department  for  the
31    identification card shall be equal to $5  per  coverage  year
32    for persons below the official poverty line as defined by the
33    United States Department of Health and Human Services and $25
34    per coverage year for all other persons.
 
                            -14-     LRB093 11069 DRJ 11774 b
 1        In  the event that 2 or more persons are eligible for any
 2    benefit  under  this  Act,  and  are  members  of  the   same
 3    household,   (1)  each  such  person  shall  be  entitled  to
 4    participate  in  the   pharmaceutical   assistance   program,
 5    provided  that he or she meets all other requirements imposed
 6    by this  subsection  and  (2)  each  participating  household
 7    member  contributes  the  fee required for that person by the
 8    preceding  paragraph  for  the  purpose   of   obtaining   an
 9    identification card.
10    (Source: P.A.  91-357,  eff.  7-29-99;  91-699,  eff. 1-1-01;
11    92-131, eff.  7-23-01;  92-519,  eff.  1-1-02;  92-651,  eff.
12    7-11-02.)

13        Section  99.  Effective date.  This Act takes effect upon
14    becoming law.