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SB 1844

MEDICAID-MENTAL HLTH-DRUG RPTS

104th Regular Session Introduced by Mary Edly-Allen and 4 co-sponsors

Prohibits routine prior authorization and most utilization management for FDA‑approved mental health drugs in Medicaid, with limited exceptions and quarterly transparency reports.

Rule 3-9(a) / Re-referred to Assignments
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Bill Summary · SB 1844

SB 1844 — Medicaid: mental health prescription prior authorization & reporting (305 ILCS 5/5‑5.12f)

Status & key dates
- Filed: Feb 5, 2025 (Sen. Sara Feigenholtz). Companion: HB 2494.
- Enacted: Signed by Governor 5/28/2025. Effective: 9/1/2025.
- Reporting requirement begins for dates of service on and after 7/1/2025; quarterly reports due 60 days after quarter end (example: quarter ending 9/30/25 → report due 11/29/25).

Purpose
- Remove barriers to timely treatment of serious mental illness (SMI) in Illinois Medicaid by prohibiting routine prior authorization (PA) mandates and other utilization management controls for FDA‑approved prescription drugs recognized as effective for treating mental illnesses listed in the Diagnostic and Statistical Manual and the Department of Human Services’ SMI/ICD‑10 list.

Major provisions
1. Prohibition on prior authorization and utilization management
- Under both fee‑for‑service (FFS) and managed care Medicaid programs, the Department of Healthcare and Family Services (HFS) and managed care organizations (MCOs) may not impose PA mandates or utilization management controls on FDA‑approved drugs used to treat specified mental illnesses, except as described below.

  1. Limited exceptions (when PA/controls are permitted)

    • Patient changed providers (including outpatient/inpatient transition) and is stable on a previously prescribed drug.
    • Patient changed insurance coverage and is stable on a drug for which prior authorization was previously obtained under prior coverage.
    • Dosage or frequency modification of a drug previously prescribed with PA as part of the same treatment (subject to federal rules on maximum dosage/safety edits, e.g., 42 C.F.R. §456.703).

  2. Permitted safety edits

    • Clinically appropriate drug utilization review (DUR) edits: drug‑drug, drug‑age, drug‑dose, etc.
    • Generic substitution when an equivalent generic exists (same dosage/formulation).
    • Any utilization management needed to comply with court consent decrees or federal waivers.

  3. Definition of “serious mental illness”

    • Explicit ICD‑10 codes are listed (e.g., schizophrenia F20.x, schizoaffective F25.x, bipolar disorders F31.xx, major depressive disorder F32/F33, PTSD F43.10, OCD F42, eating disorders F50.x, etc.).

  4. Reporting and transparency

    • HFS and all MCOs must file quarterly compliance reports (beginning with dates of service 7/1/2025). HFS must post an FFS report and each MCO’s report on its website. Reports are due 60 days after the quarter (with next‑business‑day adjustment for holidays/weekends).
    • Required report elements include (for drugs covered by subsection (a)):
      • Number of denied prescriptions and estimated net cost to the State, summarized by each allowed safety‑edit category (subsection (b)); include PA denials and step therapy exception requests.
      • Number of denied prescriptions and estimated net cost, summarized by each non‑allowed category (those prohibited under subsection (a)); include PA denials and step therapy exception requests.
      • Number of denied prescriptions and estimated gross cost for denials for any other reasons; include PA denials, step therapy exception requests, number of step edits per medication, and related rebate revenue.
      • Number of approved/paid prescriptions and net cost for prescriptions summarized by other reasons not specified above; includes PA denials, step therapy exception requests, etc.
    • HFS may sanction MCOs that fail to file required reports.

Other notes
- The section includes a non‑conflict clause respecting federal Medicaid drug rebate law (Social Security Act §1927(a)(1), (b)(1)(A)).
- Intended impacts: improve continuity of care for Medicaid enrollees with SMI, increase transparency about denials and costs, and hold MCOs accountable for compliance. Potential effects include administrative/reporting burden on HFS and MCOs and changes in prescribing/payment patterns.

Compiled from official sources — confirm details with the bill’s official record.

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