Full Text of SR0329 102nd General Assembly
SR0329 102ND GENERAL ASSEMBLY |
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| 1 | | SENATE RESOLUTION
| 2 | | WHEREAS, The Medicaid program in Illinois has an immense | 3 | | and growing impact, both in terms of taxpayer dollars and in | 4 | | the effect it has on citizens across the State; and
| 5 | | WHEREAS, State resources for healthcare services are | 6 | | scarce, and many healthcare providers, including pharmacists, | 7 | | are discontinuing services or ceasing operation, leading to a | 8 | | profoundly detrimental impact on our communities and the | 9 | | expansion of pharmacy deserts; and
| 10 | | WHEREAS, Enrollment under the Illinois Department of | 11 | | Healthcare and Family Services' Medical Assistance Programs | 12 | | (Medicaid) exceeds three million; and | 13 | | WHEREAS, A sizable portion of the Medicaid population is | 14 | | currently enrolled, often mandatorily, in Managed Care | 15 | | Organizations (MCOs), making outlays to MCOS, measured in | 16 | | billions of dollars, one of the largest resources used in the | 17 | | State; and | 18 | | WHEREAS, 12,500 licensed pharmacists in Illinois provide | 19 | | medications and patient care services to assure the rational | 20 | | and safe use of all medications; and |
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| 1 | | WHEREAS, Pharmacists, as front-line health care providers, | 2 | | answered the call to aid during the ongoing COVID-19 pandemic | 3 | | and have taken on additional responsibilities of care and | 4 | | practice in order to best serve the public health needs of the | 5 | | citizens of the State of Illinois; and | 6 | | WHEREAS, A significant number of pharmacists respond to | 7 | | the charge of their community to establish a pharmacy to | 8 | | provide access to care for their patients; and | 9 | | WHEREAS, Pharmacies generate additional taxable revenue | 10 | | for the State and yet are continuously under-reimbursed below | 11 | | their cost on medications dispensed to meet their patient's | 12 | | needs; and | 13 | | WHEREAS, A number of states have performed audits on | 14 | | managed Medicaid programs and the utilization of tax dollars, | 15 | | and states, such as Ohio, have found over $208 million in | 16 | | collected fees to the benefit of pharmacy benefit managers in | 17 | | a one-year period, in addition to other operational and | 18 | | business practice concerns; and | 19 | | WHEREAS, Attorneys General, Auditors General, | 20 | | Comptrollers, and Insurance Directors have investigated, | 21 | | fined, or instituted court proceedings into the business | 22 | | practices of Pharmacy Benefit Managers (PBMs) in the states of |
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| 1 | | Arkansas, California, Colorado, Connecticut, Delaware, | 2 | | Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, | 3 | | Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, | 4 | | Minnesota, Montana, Nebraska, Nevada, New Jersey, New Mexico, | 5 | | New York, North Carolina, Ohio, Oklahoma, Oregon, | 6 | | Pennsylvania, Texas, Utah, Vermont, Virginia, Washington, West | 7 | | Virginia, and Wyoming, and in the District of Columbia; and
| 8 | | WHEREAS, The landmark December 2020 United States Supreme | 9 | | Court decision in Rutledge v. PCMA brought PBM operational and | 10 | | business practices and especially the reimbursement | 11 | | methodologies for pharmaceuticals into further question, | 12 | | including Chief Justice Roberts calling their business | 13 | | practices 'byzantine'; and
| 14 | | WHEREAS, There has been little information disseminated to | 15 | | the General Assembly in terms of how State resources are being | 16 | | spent on MCOs and on the overall healthcare outcomes for | 17 | | individuals enrolled in these MCOs; and
| 18 | | WHEREAS, It is paramount that the General Assembly stay | 19 | | engaged in Medicaid funding and corresponding healthcare | 20 | | outcome issues and be prepared to make legislative and | 21 | | administrative recommendations; therefore, be it
| 22 | | RESOLVED, BY THE SENATE OF THE ONE HUNDRED SECOND GENERAL |
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| 1 | | ASSEMBLY OF THE STATE OF ILLINOIS, that the Auditor General, | 2 | | with the assistance of the Comptroller as necessary, is | 3 | | directed to conduct an audit of Medicaid MCOs, including | 4 | | contracted and previously contracted pharmacy benefit | 5 | | managers, which includes a comparison of State expenditures | 6 | | between MCOs and the Medicaid fee-for-service program; and be | 7 | | it further | 8 | | RESOLVED, That the audit shall examine pharmacy benefits | 9 | | managers that contract with managed care organizations for the | 10 | | purpose of determining the amount of State and federal funds | 11 | | used to reimburse managed care organizations, pharmacy | 12 | | benefits managers, and pharmacies and the dollar amount of | 13 | | funds received by each respective party for fiscal year 2017, | 14 | | 2018, 2019, 2020, and 2021 with respect to the following | 15 | | issues: | 16 | | (1) The amount paid to a pharmacy provider per each | 17 | | individual claim, including ingredient cost and the amount | 18 | | of any copayment deducted from the payment; | 19 | | (2) The transmission fees charged by a pharmacy | 20 | | benefit manager to a pharmacy provider; | 21 | | (3) The amount charged by the pharmacy benefit manager | 22 | | to the medical assistance managed care organization per | 23 | | claim, including all administrative fees and processing | 24 | | charges associated with the claim; | 25 | | (4) Rebates paid by the pharmacy benefit manager to |
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| 1 | | the managed care organization and any payment from a | 2 | | pharmaceutical manufacturer to a PBM; | 3 | | (5) The Auditor General shall be provided with access | 4 | | to the following documents and information by either the | 5 | | managed care organization, the pharmacy benefits manager, | 6 | | or the pharmacy: | 7 | | (a) Contracts between the managed care | 8 | | organization and the pharmacy benefits manager; | 9 | | (b) Contracts between the pharmacy benefits | 10 | | manager and pharmacies receiving reimbursement; | 11 | | (c) Full encounter claims data showing the | 12 | | amount the managed care organization paid the pharmacy | 13 | | benefits manager; | 14 | | (d) Full encounter claims data showing the | 15 | | amount that was paid to the pharmacies by the pharmacy | 16 | | benefits managers; | 17 | | (6) Information requested from the pharmacy benefits | 18 | | manager or the pharmacy via questionnaire by the Auditor | 19 | | General; and | 20 | | (7) Any additional information or data required by the | 21 | | Auditor General or Comptroller to determine the actual | 22 | | reimbursement to the managed care organizations, pharmacy | 23 | | benefits managers, and pharmacies; and be it further | 24 | | RESOLVED, That the audit shall further examine | 25 | | reimbursement issues for Medicaid MCOs, including contracted |
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| 1 | | pharmacy benefit managers, for fiscal years 2017, 2018, 2019, | 2 | | 2020, and 2021 and should: | 3 | | (1) Provide an overview of the distribution of and | 4 | | payment for pharmaceuticals in the medical assistance | 5 | | managed care program; | 6 | | (2) Review the reimbursement practices of pharmacy | 7 | | benefit managers to pharmacies, including out-of-state | 8 | | pharmacies and pharmacies affiliated with pharmacy benefit | 9 | | managers; | 10 | | (3) Review the reimbursement practices of managed care | 11 | | organizations to pharmacy benefit managers; | 12 | | (4) Investigate and compare the reimbursement rates | 13 | | paid by pharmacy benefit managers to independent | 14 | | pharmacies and to chain pharmacies and to out-of-state | 15 | | pharmacies and to pharmacies affiliated with pharmacy | 16 | | benefit managers; | 17 | | (5) Study the best practices and laws adopted by other | 18 | | states to address concerns with pharmacy reimbursement | 19 | | practices of pharmacy benefit managers; and | 20 | | (6) Review any other data the Auditor General or | 21 | | Comptroller deems necessary to complete the audit; and be | 22 | | it further | 23 | | RESOLVED, That the audit shall further examine | 24 | | reimbursement with a comparison, in aggregate on both a dollar | 25 | | level and per prescription basis, of what the Illinois |
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| 1 | | Department of Healthcare and Family Services paid directly | 2 | | through its Medicaid Fee-For-Service (FFS) program versus what | 3 | | was charged through the MCO's to the Illinois Department of | 4 | | Healthcare and Family Services for Medicaid managed care | 5 | | prescriptions; such a comparison shall include the cost | 6 | | comparison to the top 200 drugs covered by the Illinois | 7 | | Medicaid prescription drug benefit FFS program, including all | 8 | | dispensing and other professional fees paid to Medicaid | 9 | | pharmacy providers, including comparison to out-of-state and | 10 | | pharmacies affiliated with pharmacy benefit managers; and be | 11 | | it further | 12 | | RESOLVED, That the Auditor General shall publish only | 13 | | aggregate data in the report; any information disclosed or | 14 | | produced by a pharmacy benefit manager or a medical assistance | 15 | | managed care organization for the purposes of this audit shall | 16 | | be confidential; and be it further | 17 | | RESOLVED, That on or before December 1, 2021, the Auditor | 18 | | General shall provide the results of the audit to the General | 19 | | Assembly; and be it further | 20 | | RESOLVED, That the Illinois Department of Healthcare and | 21 | | Family Services and any other State agency having information | 22 | | relevant to this audit cooperate fully and promptly with the | 23 | | Auditor General's Office in its conduct; and be it further
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| 1 | | RESOLVED, That the Auditor General commence this audit as | 2 | | soon as possible and report his findings and recommendations | 3 | | upon completion in accordance with the provisions of Section | 4 | | 3-14 of the Illinois State Auditing Act.
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