HB2211ham001 104TH GENERAL ASSEMBLY

Rep. Tony M. McCombie

Filed: 3/20/2026

10400HB2211ham001 LRB104 11681 KTG 35732 a

AMENDMENT TO HOUSE BILL 2211

AMENDMENT NO. ______. Amend House Bill 2211 by replacing everything after the enacting clause with the following:

"Section 5. The Illinois Public Aid Code is amended by changing Section 5-5.12b as follows:

(305 ILCS 5/5-5.12b)

Sec. 5-5.12b. Critical access care pharmacy program.

(a) As used in this Section:

"Critical access care pharmacy" means:

(1) a pharmacy located in an area within Illinois that is designated by the federal Health Resources and Services Administration as a Rural Health Area;

(2) a pharmacy located in an area within Illinois that is designated by the Department of Commerce and Economic Opportunity as an underserved area; or

(3) an Illinois-based brick and mortar retail pharmacy located in Illinois that is owned by a person or entity with an ownership or control interest in fewer than 10 pharmacies, and is either located:

(A) in a county with fewer than 50,000 residents; or

(B) in a county with 50,000 or more residents and in an area within Illinois that is designated as a Medically Underserved Area or Medically Underserved Population by the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services, including Governor's Exceptions as provided in paragraph (4) of subsection (c) of Section 605-60 of the Department of Commerce and Economic Opportunity Law, and

has attested and been approved by the Department for participation in the critical access care pharmacy program.

"Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018.

"Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter.

"Ownership or control interest" has the meaning given to "person with an ownership or control interest" in 42 CFR 455.101.

(b) Subject to appropriations and federal approval, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois.

(c) The critical access care pharmacy program disbursed by the managed care plans shall not exceed $45,000,000 annually and individual payment amounts per prescription shall not exceed the brand name dispensing rate that the Department would have reimbursed to a critical access care pharmacy under the Medical Assistance Program as of July 1, 2024.

(c-5) 340B pharmacies that are participants in the critical access care pharmacy program shall only be reimbursed for the actual acquisition costs of the 340B covered drugs dispensed to participants in the State's medical assistance program as defined in the Illinois Public Aid Code.

(d) Annually, beginning January 1, 2026, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018.

(d-5) Beginning January 1, 2026, unless notified by the Department, a pharmacy that is approved as a critical access care pharmacy retains its critical access care pharmacy status in future quarters within a calendar year.

(d-10) Beginning no later than the first day of the third quarter of calendar year 2026, the Department, in cooperation with the Department of Public Health, shall review new Medically Underserved Area, Medically Underserved Population, and Rural Health Area designations as they are published by the federal Health Resources and Services Administration (HRSA). Upon review of the new HRSA designations, the Department shall remove from the list of critical access care pharmacies those pharmacies that are no longer eligible for critical access care pharmacy status. The Department shall also approve and add any newly eligible pharmacy to the list of critical access care pharmacies for the quarter beginning after the date upon which the pharmacy became eligible under the new HRSA designations. The Department shall notify each pharmacy of any change in its eligibility status, whether an attestation is required, and when the change in eligibility will take effect no later than 4 weeks before the first day of the quarter for which the pharmacy is to be added to or removed from the list of critical access care pharmacies.

(d-15) A pharmacy shall be required to submit a new attestation whenever a change in its eligibility status occurs, except that a pharmacy shall be automatically added to the list of critical access care pharmacies for the first quarter after new HRSA data and designations are released. A pharmacy need not reapply or reattest if it becomes newly eligible and has filed an attestation after the first day of the fourth quarter of the prior calendar year; except that the Department may, at the Director's discretion, require a newly eligible pharmacy to submit a new attestation.

(e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018. This payment shall sunset on December 31, 2025.

(f) Effective January 1, 2026, the Department shall issue a quarterly directed critical access care pharmacy program payment to critical access care pharmacies for any prescription drug dispensed to a managed care client.

(g) The Department may adopt rules necessary to implement this Section. The rules may include, but are not limited to, permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy meets the other requirements of a critical access care pharmacy in subsection (a).

(h) No later than July 1, 2026, the Department shall propose rules concerning the administration of the critical access care pharmacy program, including, but not limited to, a complete and timely appeals process for denied requests for critical access care pharmacy status, to take effect no later than the first day of the fourth quarter of calendar year 2026.

(i) Upon successful appeal, a pharmacy denied critical access care pharmacy status for the fourth quarter of calendar year 2026, or a later quarter or calendar year, shall receive critical access care pharmacy funds equal to the funds the pharmacy would have received if it had been approved as a critical access care pharmacy, plus interest, for each quarter after the initial denial was issued.

(j) The Department shall include on its webpage concerning critical access care pharmacies, and in any program notices, clear and complete information regarding the eligibility criteria and appeals process. Denial notices must be sent at least 4 weeks prior to the first day of the quarter they take effect, and include clear and complete information on the appeals process. The Department shall publish eligibility criteria, scoring methodologies, and anonymized denial summaries by region, and establish a clear, publicly available appeals process.

(k) The Department shall provide a method of accepting documents supporting an attestation including, but not limited to, patient distribution maps and drive-time analyses, at the time the attestation is submitted, while the application is being processed, and for the purpose of appeal.

(l) The Department shall conduct an annual evaluation of Medicaid network adequacy using time-based access standards to ensure beneficiaries maintain reasonable pharmacy access. This evaluation shall trigger Department review of eligibility criteria if gaps in the Medicaid network are identified. The results of the Medicaid network evaluation and review of eligibility criteria shall be presented in a report to the General Assembly no later than 3 months after the evaluation is conducted, which shall also include the substance and evaluation of eligibility criteria, scoring methodologies, anonymized denial summaries by region, and the appeals process.

(Source: P.A. 104-27, eff. 1-1-26.)

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