Rep. Lou Lang

Filed: 3/16/2017

 

 


 

 


 
10000HB0068ham001LRB100 03757 SMS 23221 a

1
AMENDMENT TO HOUSE BILL 68

2    AMENDMENT NO. ______. Amend House Bill 68 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The State Finance Act is amended by changing
5Section 5.872 as follows:
 
6    (30 ILCS 105/5.872)
7    Sec. 5.872. The Parity Advancement Education Fund.
8(Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
 
9    Section 10. The Illinois Insurance Code is amended by
10changing Sections 370c and 370c.1 as follows:
 
11    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
12    Sec. 370c. Mental and emotional disorders.
13    (a) (1) On and after the effective date of this amendatory
14Act of the 100th General Assembly the effective date of this

 

 

10000HB0068ham001- 2 -LRB100 03757 SMS 23221 a

1amendatory Act of the 97th General Assembly, every insurer that
2which amends, delivers, issues, or renews group accident and
3health policies providing coverage for hospital or medical
4treatment or services for illness on an expense-incurred basis
5shall provide offer to the applicant or group policyholder
6subject to the insurer's standards of insurability, coverage
7for reasonable and necessary treatment and services for mental,
8emotional, or nervous, or substance use disorders or
9conditions, other than serious mental illnesses as defined in
10item (2) of subsection (b), consistent with the parity
11requirements of Section 370c.1 of this Code.
12    (2) Each insured that is covered for mental, emotional,
13nervous, or substance use disorders or conditions shall be free
14to select the physician licensed to practice medicine in all
15its branches, licensed clinical psychologist, licensed
16clinical social worker, licensed clinical professional
17counselor, licensed marriage and family therapist, licensed
18speech-language pathologist, or other licensed or certified
19professional at a program licensed pursuant to the Illinois
20Alcoholism and Other Drug Abuse and Dependency Act of his
21choice to treat such disorders, and the insurer shall pay the
22covered charges of such physician licensed to practice medicine
23in all its branches, licensed clinical psychologist, licensed
24clinical social worker, licensed clinical professional
25counselor, licensed marriage and family therapist, licensed
26speech-language pathologist, or other licensed or certified

 

 

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1professional at a program licensed pursuant to the Illinois
2Alcoholism and Other Drug Abuse and Dependency Act up to the
3limits of coverage, provided (i) the disorder or condition
4treated is covered by the policy, and (ii) the physician,
5licensed psychologist, licensed clinical social worker,
6licensed clinical professional counselor, licensed marriage
7and family therapist, licensed speech-language pathologist, or
8other licensed or certified professional at a program licensed
9pursuant to the Illinois Alcoholism and Other Drug Abuse and
10Dependency Act is authorized to provide said services under the
11statutes of this State and in accordance with accepted
12principles of his profession.
13    (3) Insofar as this Section applies solely to licensed
14clinical social workers, licensed clinical professional
15counselors, licensed marriage and family therapists, licensed
16speech-language pathologists, and other licensed or certified
17professionals at programs licensed pursuant to the Illinois
18Alcoholism and Other Drug Abuse and Dependency Act, those
19persons who may provide services to individuals shall do so
20after the licensed clinical social worker, licensed clinical
21professional counselor, licensed marriage and family
22therapist, licensed speech-language pathologist, or other
23licensed or certified professional at a program licensed
24pursuant to the Illinois Alcoholism and Other Drug Abuse and
25Dependency Act has informed the patient of the desirability of
26the patient conferring with the patient's primary care

 

 

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1physician and the licensed clinical social worker, licensed
2clinical professional counselor, licensed marriage and family
3therapist, licensed speech-language pathologist, or other
4licensed or certified professional at a program licensed
5pursuant to the Illinois Alcoholism and Other Drug Abuse and
6Dependency Act has provided written notification to the
7patient's primary care physician, if any, that services are
8being provided to the patient. That notification may, however,
9be waived by the patient on a written form. Those forms shall
10be retained by the licensed clinical social worker, licensed
11clinical professional counselor, licensed marriage and family
12therapist, licensed speech-language pathologist, or other
13licensed or certified professional at a program licensed
14pursuant to the Illinois Alcoholism and Other Drug Abuse and
15Dependency Act for a period of not less than 5 years.
16    (4) "Mental, emotional, nervous, or substance use disorder
17or condition" means a condition or disorder that involves a
18mental health condition or substance use disorder that falls
19under any of the diagnostic categories listed in the mental and
20behavioral disorders chapter of the current edition of the
21International Classification of Disease or that is listed in
22the most recent version of the Diagnostic and Statistical
23Manual of Mental Disorders.
24    (b) (1) (Blank). An insurer that provides coverage for
25hospital or medical expenses under a group policy of accident
26and health insurance or health care plan amended, delivered,

 

 

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1issued, or renewed on or after the effective date of this
2amendatory Act of the 97th General Assembly shall provide
3coverage under the policy for treatment of serious mental
4illness and substance use disorders consistent with the parity
5requirements of Section 370c.1 of this Code. This subsection
6does not apply to any group policy of accident and health
7insurance or health care plan for any plan year of a small
8employer as defined in Section 5 of the Illinois Health
9Insurance Portability and Accountability Act.
10    (2) (Blank). "Serious mental illness" means the following
11psychiatric illnesses as defined in the most current edition of
12the Diagnostic and Statistical Manual (DSM) published by the
13American Psychiatric Association:
14        (A) schizophrenia;
15        (B) paranoid and other psychotic disorders;
16        (C) bipolar disorders (hypomanic, manic, depressive,
17    and mixed);
18        (D) major depressive disorders (single episode or
19    recurrent);
20        (E) schizoaffective disorders (bipolar or depressive);
21        (F) pervasive developmental disorders;
22        (G) obsessive-compulsive disorders;
23        (H) depression in childhood and adolescence;
24        (I) panic disorder;
25        (J) post-traumatic stress disorders (acute, chronic,
26    or with delayed onset); and

 

 

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1        (K) anorexia nervosa and bulimia nervosa.
2    (2.5) (Blank). "Substance use disorder" means the
3following mental disorders as defined in the most current
4edition of the Diagnostic and Statistical Manual (DSM)
5published by the American Psychiatric Association:
6        (A) substance abuse disorders;
7        (B) substance dependence disorders; and
8        (C) substance induced disorders.
9    (3) Unless otherwise prohibited by federal law and
10consistent with the parity requirements of Section 370c.1 of
11this Code, the reimbursing insurer that amends, delivers,
12issues, or renews a group or individual policy of accident and
13health insurance, a qualified health plan offered through the
14health insurance marketplace, or , a provider of treatment of
15mental, emotional, nervous, or serious mental illness or
16substance use disorders or conditions disorder shall furnish
17medical records or other necessary data that substantiate that
18initial or continued treatment is at all times medically
19necessary. An insurer shall provide a mechanism for the timely
20review by a provider holding the same license and practicing in
21the same specialty as the patient's provider, who is
22unaffiliated with the insurer, jointly selected by the patient
23(or the patient's next of kin or legal representative if the
24patient is unable to act for himself or herself), the patient's
25provider, and the insurer in the event of a dispute between the
26insurer and patient's provider regarding the medical necessity

 

 

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1of a treatment proposed by a patient's provider. If the
2reviewing provider determines the treatment to be medically
3necessary, the insurer shall provide reimbursement for the
4treatment. Future contractual or employment actions by the
5insurer regarding the patient's provider may not be based on
6the provider's participation in this procedure. Nothing
7prevents the insured from agreeing in writing to continue
8treatment at his or her expense. When making a determination of
9the medical necessity for a treatment modality for mental,
10emotional, nervous, or serious mental illness or substance use
11disorders or conditions disorder, an insurer must make the
12determination in a manner that is consistent with the manner
13used to make that determination with respect to other diseases
14or illnesses covered under the policy, including an appeals
15process. Medical necessity determinations for substance use
16disorders shall be made in accordance with appropriate patient
17placement criteria established by the American Society of
18Addiction Medicine. No additional criteria may be used to make
19medical necessity determinations for substance use disorders.
20    (4) A group health benefit plan amended, delivered, issued,
21or renewed on or after the effective date of this amendatory
22Act of the 100th General Assembly or an individual policy of
23accident and health insurance or a qualified health plan
24offered through the health insurance marketplace amended,
25delivered, issued, or renewed on or after the effective date of
26this amendatory Act of the 100th General Assembly the effective

 

 

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1date of this amendatory Act of the 97th General Assembly :
2        (A) shall provide coverage based upon medical
3    necessity for the treatment of a mental, emotional,
4    nervous, or mental illness and substance use disorder or
5    condition disorders consistent with the parity
6    requirements of Section 370c.1 of this Code; provided,
7    however, that in each calendar year coverage shall not be
8    less than the following:
9            (i) 45 days of inpatient treatment; and
10            (ii) beginning on June 26, 2006 (the effective date
11        of Public Act 94-921), 60 visits for outpatient
12        treatment including group and individual outpatient
13        treatment; and
14            (iii) for plans or policies delivered, issued for
15        delivery, renewed, or modified after January 1, 2007
16        (the effective date of Public Act 94-906), 20
17        additional outpatient visits for speech therapy for
18        treatment of pervasive developmental disorders that
19        will be in addition to speech therapy provided pursuant
20        to item (ii) of this subparagraph (A); and
21        (B) may not include a lifetime limit on the number of
22    days of inpatient treatment or the number of outpatient
23    visits covered under the plan.
24        (C) (Blank).
25    (5) An issuer of a group health benefit plan or an
26individual policy of accident and health insurance or a

 

 

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1qualified health plan offered through the health insurance
2marketplace may not count toward the number of outpatient
3visits required to be covered under this Section an outpatient
4visit for the purpose of medication management and shall cover
5the outpatient visits under the same terms and conditions as it
6covers outpatient visits for the treatment of physical illness.
7    (5.5) An individual or group health benefit plan amended,
8delivered, issued, or renewed on or after the effective date of
9this amendatory Act of the 99th General Assembly shall offer
10coverage for medically necessary acute treatment services and
11medically necessary clinical stabilization services. The
12treating provider shall base all treatment recommendations and
13the health benefit plan shall base all medical necessity
14determinations for substance use disorders in accordance with
15the most current edition of the Treatment Criteria for
16Addictive, Substance-Related, and Co-Occurring Conditions
17established by the American Society of Addiction Medicine
18Patient Placement Criteria. The treating provider shall base
19all treatment recommendations and the health benefit plan shall
20base all medical necessity determinations for
21medication-assisted treatment in accordance with the most
22current Treatment Criteria for Addictive, Substance-Related,
23and Co-Occurring Conditions established by the American
24Society of Addiction Medicine.
25    As used in this subsection:
26    "Acute treatment services" means 24-hour medically

 

 

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1supervised addiction treatment that provides evaluation and
2withdrawal management and may include biopsychosocial
3assessment, individual and group counseling, psychoeducational
4groups, and discharge planning.
5    "Clinical stabilization services" means 24-hour treatment,
6usually following acute treatment services for substance
7abuse, which may include intensive education and counseling
8regarding the nature of addiction and its consequences, relapse
9prevention, outreach to families and significant others, and
10aftercare planning for individuals beginning to engage in
11recovery from addiction.
12    (6) An issuer of a group health benefit plan may provide or
13offer coverage required under this Section through a managed
14care plan.
15    (7) (Blank).
16    (8) (Blank).
17    (9) With respect to all mental, emotional, nervous, or
18substance use disorders or conditions, coverage for inpatient
19treatment shall include coverage for treatment in a residential
20treatment center certified or licensed by the Department of
21Public Health or the Department of Human Services.
22    (c) This Section shall not be interpreted to require
23coverage for speech therapy or other habilitative services for
24those individuals covered under Section 356z.15 of this Code.
25    (d) With respect to a group or individual policy of
26accident and health insurance or a qualified health plan

 

 

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1offered through the health insurance marketplace, the The
2Department, and with respect to medical assistance, the
3Department of Healthcare and Family Services, shall each
4enforce the requirements of this Section and Sections 356z.23
5and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
6Mental Health Parity and Addiction Equity Act of 2008, 42
7U.S.C. 18031(j), and any amendments to, and federal guidance or
8regulations issued under, those Acts, including, but not
9limited to, final regulations issued under the Paul Wellstone
10and Pete Domenici Mental Health Parity and Addiction Equity Act
11of 2008 and final regulations applying the Paul Wellstone and
12Pete Domenici Mental Health Parity and Addiction Equity Act of
132008 to Medicaid managed care organizations, the Children's
14Health Insurance Program, and alternative benefit plans.
15Specifically, the Department and the Department of Healthcare
16and Family Services shall take action: State and federal parity
17law, which includes
18        (1) ensuring compliance by individual and group
19    policies;
20        (2) detecting violations of the law by individual and
21    group policies proactively monitoring discriminatory
22    practices;
23        (3) accepting, evaluating, and responding to
24    complaints regarding such violations;
25        (4) maintaining and regularly reviewing for possible
26    parity violations a publicly available consumer complaint

 

 

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1    log regarding mental, emotional, nervous, or substance use
2    disorders or conditions coverage;
3        (5) performing parity compliance pre-market and
4    post-market conduct examinations of individual and group
5    plans and policies, including, but not limited to, reviews
6    of:
7            (A) network adequacy using established criteria as
8        set forth in federal and State requirements for medical
9        assistance and individual or group health policies;
10            (B) reimbursement rates;
11            (C) denials of authorization, payment, and
12        coverage;
13            (D) prior authorization requirements; and
14            (E) other specific criteria as shall be set forth
15        in rules adopted by the Department.
16    The findings and conclusions of the parity compliance
17market conduct examinations shall be made public and shall be
18reported to the General Assembly.
19    The Director shall adopt rules to effectuate any provisions
20of the Paul Wellstone and Pete Domenici Mental Health Parity
21and Addiction Equity Act of 2008 that relate to the business of
22insurance. and ensuring violations are appropriately remedied
23and deterred.
24    (e) Availability of plan information.
25        (1) The criteria for medical necessity determinations
26    made under a group health plan, an individual policy of

 

 

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1    accident and health insurance, or a qualified health plan
2    offered through the health insurance marketplace with
3    respect to mental health or substance use disorder benefits
4    (or health insurance coverage offered in connection with
5    the plan with respect to such benefits) must be made
6    available by the plan administrator (or the health
7    insurance issuer offering such coverage) to any current or
8    potential participant, beneficiary, or contracting
9    provider upon request.
10        (2) The reason for any denial under a group health
11    benefit plan, an individual policy of accident and health
12    insurance, or a qualified health plan offered through the
13    health insurance marketplace (or health insurance coverage
14    offered in connection with such plan or policy) of
15    reimbursement or payment for services with respect to
16    mental, emotional, nervous, health or substance use
17    disorders or conditions disorder benefits in the case of
18    any participant or beneficiary must be made available
19    within a reasonable time and in a reasonable manner and in
20    readily understandable language by the plan administrator
21    (or the health insurance issuer offering such coverage) to
22    the participant or beneficiary upon request.
23        (3) The following information under a group health
24    benefit plan, an individual policy of accident and health
25    insurance, or a qualified health plan offered through the
26    health insurance marketplace (or health insurance coverage

 

 

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1    offered in connection with such plan or policy) must be
2    made available upon request:
3            (A) a Summary Plan Description, or similar summary
4        information;
5            (B) the specific plan or policy language regarding
6        the imposition of a nonquantitative treatment
7        limitation (such as a preauthorization requirement);
8            (C) the specific underlying processes, strategies,
9        evidentiary standards, and other factors (including,
10        but not limited to, all evidence) considered by the
11        plan or policy (including factors that were relied upon
12        and were rejected) in determining that a
13        nonquantitative treatment limitation applies to any
14        particular mental health or substance use disorder
15        benefit;
16            (D) information regarding the application of a
17        nonquantitative treatment limitation to any medical or
18        surgical benefits within any benefit classification at
19        issue;
20            (E) the specific underlying processes, strategies,
21        evidentiary standards, and other factors (including,
22        but not limited to, all evidence) considered by the
23        plan or policy (including factors that were relied upon
24        and were rejected) in determining the extent to which a
25        nonquantitative treatment limitation applies to a
26        particular medical or surgical benefit within a

 

 

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1        benefit classification at issue; and
2            (F) any analyses performed by the plan or under the
3        policy as to how any nonquantitative treatment
4        limitation complies with this Section and Sections
5        356z.23 and 370c.1 of this Code, the Paul Wellstone and
6        Pete Domenici Mental Health Parity and Addiction
7        Equity Act of 2008, 42 U.S.C. 18031(j), and any
8        amendments to, and federal guidance or regulations
9        issued under, those Acts, including, but not limited
10        to, final regulations issued under the Paul Wellstone
11        and Pete Domenici Mental Health Parity and Addiction
12        Equity Act of 2008 and final regulations applying the
13        Paul Wellstone and Pete Domenici Mental Health Parity
14        and Addiction Equity Act of 2008 to Medicaid managed
15        care organizations, the Children's Health Insurance
16        Program, and alternative benefit plans.
17    (f) As used in this Section, "group policy of accident and
18health insurance" and "group health benefit plan" includes (1)
19State-regulated employer-sponsored group health insurance
20plans written in Illinois or which purport to provide coverage
21for a resident of this State; and (2) State employee health
22plans.
23    (g) The General Assembly decrees that it is the public
24policy of the State of Illinois to allow for private
25enforcement of mental, emotional, nervous, or substance use
26disorder or condition parity protections in a court of

 

 

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1competent jurisdiction, without administrative exhaustion or
2arbitration, even if otherwise required by an insurance policy.
3    Members, patients, subscribers, enrollees, and providers
4(in-network and out-of-network) on behalf of members,
5patients, subscribers, and enrollees have the right to commence
6a civil action against any group health plan, an issuer of an
7individual policy of accident and health insurance, or a
8qualified health plan offered through the health insurance
9marketplace (or health insurance coverage offered in
10connection with such plan or policy) that violates the
11provisions of this Section, such that any member of a group
12health plan or an individual covered under a policy of accident
13and health insurance or a qualified health plan offered through
14the health insurance marketplace (or health insurance coverage
15offered in connection with such plan or policy) authorized
16representative of such plan or related entity, advocacy
17organization representing the interests of members of a health
18plan carrier or related entity, health care providers, or
19organization representing the interests of providers
20reimbursed by a health plan carrier or related entity, against
21which the violation is alleged, shall have standing to commence
22a civil action in a court of competent jurisdiction.
23    The remedy under this Section is limited to a $5,000
24penalty for each act or offense; injunctive relief; general and
25special damages, which may be trebled; restitution of premium;
26and attorney's fees and costs.

 

 

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1    A violation consists of any violation of this Section or
2Section 370c.1 of this Code, the Paul Wellstone and Pete
3Domenici Mental Health Parity and Addiction Equity Act of 2008,
442 U.S.C. 18031(j), and any amendments to, and federal guidance
5or regulations issued under, those acts, including, but not
6limited to, final regulations issued under the Paul Wellstone
7and Pete Domenici Mental Health Parity and Addiction Equity Act
8of 2008 and final regulations applying the Paul Wellstone and
9Pete Domenici Mental Health Parity and Addiction Equity Act of
102008 to Medicaid Managed Care Organizations, Children's Health
11Insurance Programs (CHIP), and Alternative Benefit Plans.
12    A violation of this Section shall not be contingent upon
13the plaintiff proving the medical necessity of any prescribed
14procedure, service, or medication.
15(Source: P.A. 99-480, eff. 9-9-15.)
 
16    (215 ILCS 5/370c.1)
17    Sec. 370c.1. Mental, emotional, nervous, or substance use
18disorder or condition health and addiction parity.
19    (a) On and after the effective date of this amendatory Act
20of the 99th General Assembly, every insurer that amends,
21delivers, issues, or renews a group or individual policy of
22accident and health insurance or a qualified health plan
23offered through the Health Insurance Marketplace in this State
24providing coverage for hospital or medical treatment and for
25the treatment of mental, emotional, nervous, or substance use

 

 

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1disorders or conditions shall ensure that:
2        (1) the financial requirements applicable to such
3    mental, emotional, nervous, or substance use disorder or
4    condition benefits are no more restrictive than the
5    predominant financial requirements applied to
6    substantially all hospital and medical benefits covered by
7    the policy and that there are no separate cost-sharing
8    requirements that are applicable only with respect to
9    mental, emotional, nervous, or substance use disorder or
10    condition benefits; and
11        (2) the treatment limitations applicable to such
12    mental, emotional, nervous, or substance use disorder or
13    condition benefits are no more restrictive than the
14    predominant treatment limitations applied to substantially
15    all hospital and medical benefits covered by the policy and
16    that there are no separate treatment limitations that are
17    applicable only with respect to mental, emotional,
18    nervous, or substance use disorder or condition benefits.
19    (b) The following provisions shall apply concerning
20aggregate lifetime limits:
21        (1) In the case of a group or individual policy of
22    accident and health insurance or a qualified health plan
23    offered through the Health Insurance Marketplace amended,
24    delivered, issued, or renewed in this State on or after the
25    effective date of this amendatory Act of the 99th General
26    Assembly that provides coverage for hospital or medical

 

 

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1    treatment and for the treatment of mental, emotional,
2    nervous, or substance use disorders or conditions the
3    following provisions shall apply:
4            (A) if the policy does not include an aggregate
5        lifetime limit on substantially all hospital and
6        medical benefits, then the policy may not impose any
7        aggregate lifetime limit on mental, emotional,
8        nervous, or substance use disorder or condition
9        benefits; or
10            (B) if the policy includes an aggregate lifetime
11        limit on substantially all hospital and medical
12        benefits (in this subsection referred to as the
13        "applicable lifetime limit"), then the policy shall
14        either:
15                (i) apply the applicable lifetime limit both
16            to the hospital and medical benefits to which it
17            otherwise would apply and to mental, emotional,
18            nervous, or substance use disorder or condition
19            benefits and not distinguish in the application of
20            the limit between the hospital and medical
21            benefits and mental, emotional, nervous, or
22            substance use disorder or condition benefits; or
23                (ii) not include any aggregate lifetime limit
24            on mental, emotional, nervous, or substance use
25            disorder or condition benefits that is less than
26            the applicable lifetime limit.

 

 

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1        (2) In the case of a policy that is not described in
2    paragraph (1) of subsection (b) of this Section and that
3    includes no or different aggregate lifetime limits on
4    different categories of hospital and medical benefits, the
5    Director shall establish rules under which subparagraph
6    (B) of paragraph (1) of subsection (b) of this Section is
7    applied to such policy with respect to mental, emotional,
8    nervous, or substance use disorder or condition benefits by
9    substituting for the applicable lifetime limit an average
10    aggregate lifetime limit that is computed taking into
11    account the weighted average of the aggregate lifetime
12    limits applicable to such categories.
13    (c) The following provisions shall apply concerning annual
14limits:
15        (1) In the case of a group or individual policy of
16    accident and health insurance or a qualified health plan
17    offered through the Health Insurance Marketplace amended,
18    delivered, issued, or renewed in this State on or after the
19    effective date of this amendatory Act of the 99th General
20    Assembly that provides coverage for hospital or medical
21    treatment and for the treatment of mental, emotional,
22    nervous, or substance use disorders or conditions the
23    following provisions shall apply:
24            (A) if the policy does not include an annual limit
25        on substantially all hospital and medical benefits,
26        then the policy may not impose any annual limits on

 

 

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1        mental, emotional, nervous, or substance use disorder
2        or condition benefits; or
3            (B) if the policy includes an annual limit on
4        substantially all hospital and medical benefits (in
5        this subsection referred to as the "applicable annual
6        limit"), then the policy shall either:
7                (i) apply the applicable annual limit both to
8            the hospital and medical benefits to which it
9            otherwise would apply and to mental, emotional,
10            nervous, or substance use disorder or condition
11            benefits and not distinguish in the application of
12            the limit between the hospital and medical
13            benefits and mental, emotional, nervous, or
14            substance use disorder or condition benefits; or
15                (ii) not include any annual limit on mental,
16            emotional, nervous, or substance use disorder or
17            condition benefits that is less than the
18            applicable annual limit.
19        (2) In the case of a policy that is not described in
20    paragraph (1) of subsection (c) of this Section and that
21    includes no or different annual limits on different
22    categories of hospital and medical benefits, the Director
23    shall establish rules under which subparagraph (B) of
24    paragraph (1) of subsection (c) of this Section is applied
25    to such policy with respect to mental, emotional, nervous,
26    or substance use disorder or condition benefits by

 

 

10000HB0068ham001- 22 -LRB100 03757 SMS 23221 a

1    substituting for the applicable annual limit an average
2    annual limit that is computed taking into account the
3    weighted average of the annual limits applicable to such
4    categories.
5    (d) With respect to mental, emotional, nervous, or
6substance use disorders or conditions, an insurer shall use
7policies and procedures for the election and placement of
8mental, emotional, nervous, or substance use disorder or
9condition substance abuse treatment drugs on their formulary
10that are no less favorable to the insured as those policies and
11procedures the insurer uses for the selection and placement of
12other drugs for medical or surgical conditions and shall follow
13the expedited coverage determination requirements for
14substance abuse treatment drugs set forth in Section 45.2 of
15the Managed Care Reform and Patient Rights Act.
16    (e) This Section shall be interpreted in a manner
17consistent with all applicable federal parity regulations
18including, but not limited to, the Paul Wellstone and Pete
19Domenici Mental Health Parity and Addiction Equity Act of 2008,
20final regulations issued under the Paul Wellstone and Pete
21Domenici Mental Health Parity and Addiction Equity Act of 2008
22and final regulations applying the Paul Wellstone and Pete
23Domenici Mental Health Parity and Addiction Equity Act of 2008
24to Medicaid managed care organizations, the Children's Health
25Insurance Program, and alternative benefit plans at 78 FR
2668240.

 

 

10000HB0068ham001- 23 -LRB100 03757 SMS 23221 a

1    (f) The provisions of subsections (b) and (c) of this
2Section shall not be interpreted to allow the use of lifetime
3or annual limits otherwise prohibited by State or federal law.
4    (g) As used in this Section:
5    "Financial requirement" includes deductibles, copayments,
6coinsurance, and out-of-pocket maximums, but does not include
7an aggregate lifetime limit or an annual limit subject to
8subsections (b) and (c).
9    "Mental, emotional, nervous, or substance use disorder or
10condition" means a condition or disorder that involves a mental
11health condition or substance use disorder that falls under any
12of the diagnostic categories listed in the mental and
13behavioral disorders chapter of the current edition of the
14International Classification of Disease or that is listed in
15the most recent version of the Diagnostic and Statistical
16Manual of Mental Disorders.
17    "Treatment limitation" includes limits on benefits based
18on the frequency of treatment, number of visits, days of
19coverage, days in a waiting period, or other similar limits on
20the scope or duration of treatment. "Treatment limitation"
21includes both quantitative treatment limitations, which are
22expressed numerically (such as 50 outpatient visits per year),
23and nonquantitative treatment limitations, which otherwise
24limit the scope or duration of treatment. A permanent exclusion
25of all benefits for a particular condition or disorder shall
26not be considered a treatment limitation. "Nonquantitative

 

 

10000HB0068ham001- 24 -LRB100 03757 SMS 23221 a

1treatment" means those limitations as described under federal
2regulations (26 CFR 54.9812-1). Nonquantitative treatment
3limitations include, but are not limited to:
4        (1) medical management standards limiting or excluding
5    benefits based on medical necessity or medical
6    appropriateness, or based on whether the treatment is
7    experimental or investigative;
8        (2) formulary design for prescription drugs;
9        (3) for plans with multiple network tiers (such as
10    preferred providers and participating providers), network
11    tier design;
12        (4) standards for provider admission to participate in
13    a network, including reimbursement rates;
14        (5) plan methods for determining usual, customary, and
15    reasonable charges;
16        (6) refusal to pay for higher-cost therapies until it
17    can be shown that a lower-cost therapy is not effective
18    (also known as fail-first policies or step therapy
19    protocols);
20        (7) exclusions based on failure to complete a course of
21    treatment;
22        (8) restrictions based on geographic location,
23    facility type, provider specialty, and other criteria that
24    limit the scope or duration of benefits for services
25    provided under the plan or coverage;
26        (9) in-network and out-of-network geographic

 

 

10000HB0068ham001- 25 -LRB100 03757 SMS 23221 a

1    limitations;
2        (10) standards for providing access to out-of-network
3    providers;
4        (11) limitations on inpatient services for situations
5    where the participant is a threat to self or others;
6        (12) exclusions for court-ordered and involuntary
7    holds;
8        (13) experimental treatment limitations;
9        (14) service coding;
10        (15) exclusions for services provided by clinical
11    social workers, physicians, licensed psychologists,
12    licensed clinical professional counselors, licensed
13    marriage and family therapists, licensed speech-language
14    pathologists, or other licensed or certified professionals
15    at a program licensed pursuant to the Illinois Alcoholism
16    and Other Drug Abuse and Dependency Act;
17        (16) network adequacy as set forth in federal and State
18    requirements for medical assistance and individual or
19    group health policies; and
20        (17) provider reimbursement rates, including
21    reimbursement rates for mental, emotional, nervous, or
22    substance use disorder or condition screenings or
23    diagnostic tests performed in primary care and integrated
24    settings.
25    (h) The Department of Insurance shall implement the
26following education initiatives:

 

 

10000HB0068ham001- 26 -LRB100 03757 SMS 23221 a

1        (1) By January 1, 2016, the Department shall develop a
2    plan for a Consumer Education Campaign on parity. The
3    Consumer Education Campaign shall focus its efforts
4    throughout the State and include trainings in the northern,
5    southern, and central regions of the State, as defined by
6    the Department, as well as each of the 5 managed care
7    regions of the State as identified by the Department of
8    Healthcare and Family Services. Under this Consumer
9    Education Campaign, the Department shall: (1) by January 1,
10    2017, provide at least one live training in each region on
11    parity for consumers and providers and one webinar training
12    to be posted on the Department website and (2) establish a
13    consumer hotline to assist consumers in navigating the
14    parity process by March 1, 2017 2016. By January 1, 2018
15    the Department shall issue a report to the General Assembly
16    on the success of the Consumer Education Campaign, which
17    shall indicate whether additional training is necessary or
18    would be recommended.
19        (2) The Department, in coordination with the
20    Department of Human Services and the Department of
21    Healthcare and Family Services, shall convene a working
22    group of health care insurance carriers, mental health
23    advocacy groups, substance abuse patient advocacy groups,
24    and mental health physician groups for the purpose of
25    discussing issues related to the treatment and coverage of
26    mental, emotional, nervous, or substance use abuse

 

 

10000HB0068ham001- 27 -LRB100 03757 SMS 23221 a

1    disorders or conditions and compliance with parity
2    obligations under State and federal law. Compliance shall
3    be measured, tracked, and shared during the meetings of the
4    working group and mental illness. The working group shall
5    meet once before January 1, 2016 and shall meet
6    semiannually thereafter. The Department shall issue an
7    annual report to the General Assembly that includes a list
8    of the health care insurance carriers, mental health
9    advocacy groups, substance abuse patient advocacy groups,
10    and mental health physician groups that participated in the
11    working group meetings, details on the issues and topics
12    covered, and any legislative recommendations developed by
13    the working group.
14        (3) Not later than August 1 of each year, the
15    Department, in conjunction with the Department of
16    Healthcare and Family Services, shall issue a joint report
17    to the General Assembly and provide an educational
18    presentation to the General Assembly. The report and
19    presentation shall:
20            (A) Cover the methodology the Departments use to
21        check for compliance with the federal Paul Wellstone
22        and Pete Domenici Mental Health Parity and Addiction
23        Equity Act of 2008, 42 U.S.C. 18031(j), and any federal
24        regulations or guidance relating to the compliance and
25        oversight of the federal Paul Wellstone and Pete
26        Domenici Mental Health Parity and Addiction Equity Act

 

 

10000HB0068ham001- 28 -LRB100 03757 SMS 23221 a

1        of 2008 and 42 U.S.C. 18031(j).
2            (B) Cover the methodology the Departments use to
3        check for compliance with this Section and Sections
4        356z.23 and 370c of this Code.
5            (C) Identify pre-market and post-market conduct
6        examinations conducted or completed during the
7        preceding 12-month period regarding compliance with
8        parity in mental, emotional, nervous, and substance
9        use disorder or condition benefits under State and
10        federal laws and summarize the results of such market
11        conduct examinations. This shall include:
12                (i) the number of market conduct examinations
13            initiated and completed;
14                (ii) the benefit classifications examined by
15            each market conduct examination;
16                (iii) the subject matter of each market
17            conduct examination, including quantitative and
18            non-quantitative treatment limitations; and
19                (iv) a summary of the basis for the final
20            decision rendered in each market conduct
21            examination.
22            Individually identifiable information shall be
23        excluded from the reports consistent with federal
24        privacy protections.
25            (D) Detail any educational or corrective actions
26        the Departments have taken to ensure compliance with

 

 

10000HB0068ham001- 29 -LRB100 03757 SMS 23221 a

1        the federal Paul Wellstone and Pete Domenici Mental
2        Health Parity and Addiction Equity Act of 2008, 42
3        U.S.C. 18031(j), this Section, and Sections 356z.23
4        and 370c of this Code.
5            (E) The report must be written in non-technical,
6        readily understandable language and shall be made
7        available to the public by, among such other means as
8        the Departments find appropriate, posting the report
9        on the Departments' websites.
10        (4) In the event of uncertainty or disagreement with
11    respect to the application, interpretation,
12    implementation, or enforcement of the federal Paul
13    Wellstone and Pete Domenici Mental Health Parity and
14    Addiction Equity Act of 2008, 42 U.S.C. 18031(j), and any
15    amendments to, and federal guidance or regulations issued
16    under, those Acts, including, but not limited to, final
17    regulations issued under the Paul Wellstone and Pete
18    Domenici Mental Health Parity and Addiction Equity Act of
19    2008, final regulations applying the Paul Wellstone and
20    Pete Domenici Mental Health Parity and Addiction Equity Act
21    of 2008 to Medicaid managed care organizations, the
22    Children's Health Insurance Program, and alternative
23    benefit plans, Section 370c of this Code, and this Section,
24    the Department and the Department of Healthcare and Family
25    Services may request a formal written opinion from the
26    Attorney General. The requests and opinions shall be issued

 

 

10000HB0068ham001- 30 -LRB100 03757 SMS 23221 a

1    in accordance with State law and policies of the Attorney
2    General. The Departments shall inform the public on their
3    websites and in writing that any aggrieved beneficiary may
4    ask the Departments to request a formal written opinion
5    from the Attorney General.
6    (i) The Parity Advancement Education Fund is created as a
7special fund in the State treasury. Moneys from fines and
8penalties collected from insurers for violations of this
9Section shall be deposited into the Fund. Moneys deposited into
10the Fund for appropriation by the General Assembly to the
11Department of Insurance shall be used for the purpose of
12providing financial support of the Consumer Education
13Campaign, parity compliance advocacy, and other initiatives
14that support parity implementation and enforcement on behalf of
15consumers and to the Department of Human Services for treatment
16grants.
17    (j) An insurer that amends, delivers, issues, or renews a
18group or individual policy of accident and health insurance or
19a qualified health plan offered through the health insurance
20marketplace in this State providing coverage for hospital or
21medical treatment and for the treatment of mental, emotional,
22nervous, or substance use disorders or conditions shall submit
23an annual report to the Department, or with respect to medical
24assistance the Department of Healthcare and Family Services, on
25or before March 1 that contains the following information
26separately for inpatient in-network benefits, inpatient

 

 

10000HB0068ham001- 31 -LRB100 03757 SMS 23221 a

1out-of-network benefits, outpatient in-network benefits,
2outpatient out-of-network benefits, emergency care benefits,
3and prescription drug benefits in the case of accident and
4health insurance or qualified health plans, or inpatient,
5outpatient, emergency care, and prescription drug benefits in
6the case of medical assistance:
7        (1) The number and percentage of times a benefit limit
8    is exceeded for a mental, emotional, nervous, or substance
9    use disorder or condition benefit and the number and
10    percentage of times a benefit limit is exceeded for other
11    medical benefits.
12        (2) The number and percentage of times a co-pay or
13    co-insurance limit for a mental, emotional, nervous, or
14    substance use disorder or condition benefit is different
15    from other medical benefits.
16        (3) The number and percentage of claim denials for
17    mental, emotional, nervous, or substance use disorder or
18    condition benefits due to benefit limits and the number and
19    percentage of claim denials for other medical benefits due
20    to benefit limits.
21        (4) The number and percentage of denials for
22    experimental benefits or the use of unproven technology for
23    a mental, emotional, nervous, or substance use disorder or
24    condition benefit and the number and percentage of denials
25    for experimental benefits or the use of unproven technology
26    for other medical benefits.

 

 

10000HB0068ham001- 32 -LRB100 03757 SMS 23221 a

1        (5) The number and percentage of administrative
2    denials for no prior authorization for a mental, emotional,
3    nervous, or substance use disorder or condition benefit and
4    the number and percentage of administrative denials for no
5    prior authorization for other medical benefits.
6        (6) The number and percentage of denials due to a
7    mental, emotional, nervous, or substance use disorder or
8    condition benefit not being a covered benefit and the
9    number and percentage of denials for other medical benefits
10    not being a covered benefit.
11        (7) The number and percentage of denials due to a
12    mental, emotional, nervous, or substance use disorder or
13    condition benefit not meeting medical necessity and the
14    number and percentage of denials for other medical benefits
15    not meeting medical necessity.
16        (8) The number and percentage of denials upheld on
17    appeal for a mental, emotional, nervous, or substance use
18    disorder or condition benefit for not meeting medical
19    necessity and the number and percentage of those for other
20    medical benefits.
21        (9) The number and percentage of denials due to a
22    mental, emotional, nervous, or substance use disorder or
23    condition benefit being denied administratively or any
24    reason other than medical necessity.
25        (10) The number and percentage of denials of mental,
26    emotional, nervous, or substance use disorder or condition

 

 

10000HB0068ham001- 33 -LRB100 03757 SMS 23221 a

1    benefits that went to the plan's external quality review
2    organization, or similar reviewing body and were upheld and
3    those that were overturned for medical necessity.
4        (11) The number and percentage of continued stay review
5    denials for mental, emotional, nervous, or substance use
6    disorder or condition benefits.
7        (12) The number and percentage of out-of-network
8    claims for mental, emotional, nervous, or substance use
9    disorder or condition benefits in each classification of
10    benefits and the number and percentage of out-of-network
11    claims for other medical benefits in each classification of
12    benefits.
13        (13) The number and percentage of emergency care claims
14    for mental, emotional, nervous, or substance use disorder
15    or condition benefits in each classification of benefits
16    and the number and percentage of emergency care claims for
17    other medical benefits in each classification of benefits.
18        (14) The number and percentage of network directory
19    providers in the outpatient benefits classification who
20    filed no claims in the last 6 months of the plan's claims
21    reporting period and all pertinent summary information and
22    results respecting the tests and metrics the insurer used
23    to assess the availability of each of the following types
24    of mental, emotional, nervous, or substance use disorder or
25    condition providers: MD/DO; doctoral level non-MD/DO and
26    non-doctoral level non-MD/DO practitioners; and inpatient,

 

 

10000HB0068ham001- 34 -LRB100 03757 SMS 23221 a

1    residential, and ambulatory provider organizations.
2        (15) A summary of the plan's pharmacy management
3    processes for mental, emotional, nervous, or substance use
4    disorder or condition benefits compared to those for other
5    medical benefits.
6        (16) A summary of the internal processes of review for
7    experimental benefits and unproven technology for mental,
8    emotional, nervous, or substance use disorder or condition
9    benefits and those for other medical benefits.
10        (17) A summary of how the plan's policies and
11    procedures for utilization management for mental,
12    emotional, nervous, or substance use disorder or condition
13    benefits compare to those for other medical benefits.
14        (18) The results of an analysis that demonstrates that
15    for each nonquantitative treatment limitation, as written
16    and in operation, the processes, strategies, evidentiary
17    standards, or other factors used to apply each
18    nonquantitative treatment limitation to mental, emotional,
19    nervous, or substance use disorder or condition benefits
20    are comparable to, and are applied no more stringently than
21    the processes, strategies, evidentiary standards, or other
22    factors used to apply each nonquantitative treatment
23    limitation, as written and in operation, to medical and
24    surgical benefits; at a minimum, the results of the
25    analysis shall:
26            (A) identify the factors used to determine that a

 

 

10000HB0068ham001- 35 -LRB100 03757 SMS 23221 a

1        nonquantitative treatment limitation will apply to a
2        benefit, including factors that were considered but
3        rejected;
4            (B) identify and define the specific evidentiary
5        standards used to define the factors and any other
6        evidentiary standards relied upon in designing each
7        nonquantitative treatment limitation;
8            (C) identify and describe the methods and analyses
9        used, including the results of the analyses, to
10        determine that the processes and strategies used to
11        design each nonquantitative treatment limitation as
12        written for mental, emotional, nervous, or substance
13        use disorders or conditions benefits are comparable to
14        and no more stringent than the processes and strategies
15        used to design each nonquantitative treatment
16        limitation as written for medical and surgical
17        benefits;
18            (D) identify and describe the methods and analyses
19        used, including the results of the analyses, to
20        determine that the processes and strategies used to
21        apply each nonquantitative treatment limitation in
22        operation for mental, emotional, nervous, or substance
23        use disorders or conditions benefits are comparable to
24        and no more stringent than the processes or strategies
25        used to apply each nonquantitative treatment
26        limitation in operation for medical and surgical

 

 

10000HB0068ham001- 36 -LRB100 03757 SMS 23221 a

1        benefits; and
2            (E) disclose the specific findings and conclusions
3        reached by the insurer that the results of the analyses
4        above indicate that the insurer is in compliance with
5        this Section and the Mental Health Parity and Addiction
6        Equity Act of 2008 and its implementing regulations,
7        which includes 45 CFR 146.136 and any other relevant
8        current or future regulations.
9        (19) A certification signed by the insurer's chief
10    executive officer and chief medical officer that states
11    that the insurer has completed a comprehensive review of
12    the administrative practices of the insurer for the prior
13    calendar year for compliance with the necessary provisions
14    of this Section and Sections 356z.23 and 370c of this Code,
15    the federal Paul Wellstone and Pete Domenici Mental Health
16    Parity and Addiction Equity Act of 2008, 42 U.S.C.
17    18031(j), and any amendments to, and federal guidance or
18    regulations issued under, those Acts, including, but not
19    limited to, final regulations issued under the Paul
20    Wellstone and Pete Domenici Mental Health Parity and
21    Addiction Equity Act of 2008 and final regulations applying
22    the Paul Wellstone and Pete Domenici Mental Health Parity
23    and Addiction Equity Act of 2008 to Medicaid managed care
24    organizations, the Children's Health Insurance Program,
25    and alternative benefit plans.
26        (20) Any other information necessary to clarify data

 

 

10000HB0068ham001- 37 -LRB100 03757 SMS 23221 a

1    provided in accordance with this Section requested by the
2    Director, including information that may be proprietary or
3    have commercial value.
4    The Director shall not certify any policy of an insurer
5that fails to submit all data as required by this Section.
6    (k) There is created within the Office of the Attorney
7General an Office of Consumer Advocate, which shall assist
8consumers, insureds, health care providers, and recipients in:
9        (1) ensuring compliance with the requirements of this
10    Section;
11        (2) addressing issues related to insurance
12    availability;
13        (3) identifying and rectifying claims processing
14    issues;
15        (4) clarifying and resolving coverage questions; and
16        (5) addressing other matters related to insurance
17    consumer education and assistance.
18(Source: P.A. 99-480, eff. 9-9-15.)".