HFS REIMBURSEMENT PARITY

Illinois General Assembly - Full Text of HR0746

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HR0746 - 104th General Assembly

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HR0746
LRB104 21206 RMO 35716 r
1
HOUSE RESOLUTION

2

WHEREAS, The Medicaid program administered by the Illinois
3
Department of Healthcare and Family Services (HFS) provides
4
health coverage to more than three million Illinois residents,
5
including low-income families, seniors, individuals with
6
disabilities, and children; and

7

WHEREAS, Community pharmacies serve as one of the most
8
accessible health care providers for Medicaid recipients,
9
ensuring access to life-saving medications, medication therapy
10
management, clinical consultation, and pharmacist-provided
11
patient care services; and

12

WHEREAS, The Medicaid fee-for-service (FFS) pharmacy
13
reimbursement methodology is designed to reimburse pharmacies
14
using transparent ingredient cost benchmarks along with a
15
professional dispensing fee, which reflects the cost of safely
16
dispensing medications, including pharmacist review, drug
17
utilization review, compliance with federal and state
18
regulatory requirements, patient counseling, and maintaining
19
pharmacy operations; and

20

WHEREAS, Under the Medicaid managed care system, pharmacy
21
reimbursement is frequently determined through contracts
22
between managed care organizations (MCOs) and pharmacy benefit

HR0746
- 2 -
LRB104 21206 RMO 35716 r
1
managers (PBMs), which may reimburse pharmacies at rates that
2
differ from the Medicaid FFS methodology, creating payment
3
instability and uncertainty for pharmacy providers; and

4

WHEREAS, Reimbursement below the Medicaid FFS benchmark
5
can create financial pressure on pharmacies serving Medicaid
6
beneficiaries, particularly independent pharmacies and
7
pharmacies located in rural and underserved communities; and

8

WHEREAS, Numerous states have identified cost savings and
9
improved transparency when Medicaid pharmacy reimbursement
10
systems utilize transparent reimbursement methodologies tied
11
to the state's FFS payment methodology, including ingredient
12
cost benchmarks and professional dispensing fees; and

13

WHEREAS, Transparent reimbursement models tied to Medicaid
14
FFS benchmarks improve accountability, reduce administrative
15
inefficiencies, and ensure that taxpayer funds are directed
16
toward patient care and pharmacy services rather than
17
unnecessary intermediary costs; and

18

WHEREAS, Illinois has experienced a growing number of
19
pharmacy closures and the emergence of pharmacy deserts,
20
particularly in rural and medically underserved communities,
21
where the loss of local pharmacies can significantly reduce
22
access to medications and pharmacist-provided care services;

HR0746
- 3 -
LRB104 21206 RMO 35716 r
1
and

2

WHEREAS, Pharmacy closures and network instability
3
disproportionately impact Medicaid recipients, who often rely
4
on nearby community pharmacies due to transportation barriers
5
and limited access to other health care providers; and

6

WHEREAS, Ensuring that pharmacy providers participating in
7
Medicaid managed care are reimbursed at no less than the rate
8
paid under the Medicaid FFS program, including the same
9
professional dispensing fee, can strengthen pharmacy network
10
stability, preserve patient access to medications, and promote
11
continuity of care; and

12

WHEREAS, Aligning Medicaid managed care pharmacy
13
reimbursement with the state's FFS reimbursement methodology
14
can increase transparency, reduce administrative
15
inefficiencies, and support the long-term sustainability of
16
pharmacy providers serving Medicaid beneficiaries; therefore,
17
be it

18

RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE ONE
19
HUNDRED FOURTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, that
20
we urge the Illinois Department of Healthcare and Family
21
Services (HFS) to ensure that pharmacies participating in
22
Medicaid managed care networks are reimbursed for covered

HR0746
- 4 -
LRB104 21206 RMO 35716 r
1
outpatient prescription drugs at a rate no less than the
2
reimbursement that would be paid under the Illinois Medicaid
3
fee-for-service pharmacy program, including both the
4
ingredient cost methodology and the professional dispensing
5
fee; and be it further

6

RESOLVED, That we urge HFS to implement such reimbursement
7
parity through Medicaid managed care organization contracts
8
and pharmacy benefit manager agreements to ensure consistent,
9
transparent, and fair pharmacy reimbursement across the
10
Medicaid program; and be it further

11

RESOLVED, That we urge HFS to monitor and report to the
12
General Assembly on the impact of reimbursement parity on
13
pharmacy network participation, patient access to medications,
14
and pharmacy closures within the State; and be it further

15

RESOLVED, That we encourage HFS to evaluate the effect of
16
reimbursement parity on pharmacy deserts, rural health access,
17
and Medicaid beneficiary access to pharmacist-provided patient
18
care services, including medication counseling, chronic
19
disease management support, HIV PrEP/PEP, contraception
20
assessment, and preventive health services; and be it further

21

RESOLVED, That a suitable copy of this resolution be
22
delivered to the Director of the Illinois Department of

HR0746
- 5 -
LRB104 21206 RMO 35716 r
1
Healthcare and Family Services.

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