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1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 1. This Act may be referred to as the Emergency
5Opioid and Addiction Treatment Access Act.
6    Section 3. Findings. The General Assembly finds and
7declares the following:
8        (1) The opioid epidemic is the most significant public
9    health and public safety crisis in Illinois.
10        (2) Opioid overdoses have killed nearly 11,000 people
11    since 2008 and have now become the leading cause of death
12    nationwide for people under the age of 50.
13        (3) The opioid epidemic has devastated both rural and
14    urban Illinois residents. Families have lost their loved
15    ones to drug overdoses. Incidence of suicide are on the
16    rise. Illinois' criminal justice system is flooded with
17    individuals with critical substance use disorder treatment
18    needs.
19        (4) Speeding access to treatments will ensure that
20    Illinois residents suffering from a substance abuse crisis
21    will obtain the services they need.
22    Section 5. The Illinois Insurance Code is amended by



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1changing Section 370c as follows:
2    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
3    Sec. 370c. Mental and emotional disorders.
4    (a)(1) On and after the effective date of this amendatory
5Act of the 97th General Assembly, every insurer which amends,
6delivers, issues, or renews group accident and health policies
7providing coverage for hospital or medical treatment or
8services for illness on an expense-incurred basis shall offer
9to the applicant or group policyholder subject to the insurer's
10standards of insurability, coverage for reasonable and
11necessary treatment and services for mental, emotional or
12nervous disorders or conditions, other than serious mental
13illnesses as defined in item (2) of subsection (b), consistent
14with the parity requirements of Section 370c.1 of this Code.
15    (2) Each insured that is covered for mental, emotional,
16nervous, or substance use disorders or conditions shall be free
17to select the physician licensed to practice medicine in all
18its branches, licensed clinical psychologist, licensed
19clinical social worker, licensed clinical professional
20counselor, licensed marriage and family therapist, licensed
21speech-language pathologist, or other licensed or certified
22professional at a program licensed pursuant to the Illinois
23Alcoholism and Other Drug Abuse and Dependency Act of his
24choice to treat such disorders, and the insurer shall pay the
25covered charges of such physician licensed to practice medicine



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



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1licensed or certified professional at a program licensed
2pursuant to the Illinois Alcoholism and Other Drug Abuse and
3Dependency Act has informed the patient of the desirability of
4the patient conferring with the patient's primary care
5physician and the licensed clinical social worker, licensed
6clinical professional counselor, licensed marriage and family
7therapist, licensed speech-language pathologist, or other
8licensed or certified professional at a program licensed
9pursuant to the Illinois Alcoholism and Other Drug Abuse and
10Dependency Act has provided written notification to the
11patient's primary care physician, if any, that services are
12being provided to the patient. That notification may, however,
13be waived by the patient on a written form. Those forms shall
14be retained by the licensed clinical social worker, licensed
15clinical professional counselor, licensed marriage and family
16therapist, licensed speech-language pathologist, or other
17licensed or certified professional at a program licensed
18pursuant to the Illinois Alcoholism and Other Drug Abuse and
19Dependency Act for a period of not less than 5 years.
20    (b)(1) An insurer that provides coverage for hospital or
21medical expenses under a group or individual policy of accident
22and health insurance or health care plan amended, delivered,
23issued, or renewed on or after the effective date of this
24amendatory Act of the 100th General Assembly shall provide
25coverage under the policy for treatment of serious mental
26illness and substance use disorders consistent with the parity



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1requirements of Section 370c.1 of this Code. This subsection
2does not apply to any group policy of accident and health
3insurance or health care plan for any plan year of a small
4employer as defined in Section 5 of the Illinois Health
5Insurance Portability and Accountability Act.
6    (2) "Serious mental illness" means the following
7psychiatric illnesses as defined in the most current edition of
8the Diagnostic and Statistical Manual (DSM) published by the
9American Psychiatric Association:
10        (A) schizophrenia;
11        (B) paranoid and other psychotic disorders;
12        (C) bipolar disorders (hypomanic, manic, depressive,
13    and mixed);
14        (D) major depressive disorders (single episode or
15    recurrent);
16        (E) schizoaffective disorders (bipolar or depressive);
17        (F) pervasive developmental disorders;
18        (G) obsessive-compulsive disorders;
19        (H) depression in childhood and adolescence;
20        (I) panic disorder;
21        (J) post-traumatic stress disorders (acute, chronic,
22    or with delayed onset); and
23        (K) eating disorders, including, but not limited to,
24    anorexia nervosa, bulimia nervosa, pica, rumination
25    disorder, avoidant/restrictive food intake disorder, other
26    specified feeding or eating disorder (OSFED), and any other



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



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1necessary, the insurer shall provide reimbursement for the
2treatment. Future contractual or employment actions by the
3insurer regarding the patient's provider may not be based on
4the provider's participation in this procedure. Nothing
5prevents the insured from agreeing in writing to continue
6treatment at his or her expense. When making a determination of
7the medical necessity for a treatment modality for serious
8mental illness or substance use disorder, an insurer must make
9the determination in a manner that is consistent with the
10manner used to make that determination with respect to other
11diseases or illnesses covered under the policy, including an
12appeals process. Medical necessity determinations for
13substance use disorders shall be made in accordance with
14appropriate patient placement criteria established by the
15American Society of Addiction Medicine. No additional criteria
16may be used to make medical necessity determinations for
17substance use disorders.
18    (4) A group health benefit plan amended, delivered, issued,
19or renewed on or after the effective date of this amendatory
20Act of the 97th General Assembly:
21        (A) shall provide coverage based upon medical
22    necessity for the treatment of mental illness and substance
23    use disorders consistent with the parity requirements of
24    Section 370c.1 of this Code; provided, however, that in
25    each calendar year coverage shall not be less than the
26    following:



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1            (i) 45 days of inpatient treatment; and
2            (ii) beginning on June 26, 2006 (the effective date
3        of Public Act 94-921), 60 visits for outpatient
4        treatment including group and individual outpatient
5        treatment; and
6            (iii) for plans or policies delivered, issued for
7        delivery, renewed, or modified after January 1, 2007
8        (the effective date of Public Act 94-906), 20
9        additional outpatient visits for speech therapy for
10        treatment of pervasive developmental disorders that
11        will be in addition to speech therapy provided pursuant
12        to item (ii) of this subparagraph (A); and
13        (B) may not include a lifetime limit on the number of
14    days of inpatient treatment or the number of outpatient
15    visits covered under the plan.
16        (C) (Blank).
17    (5) An issuer of a group health benefit plan may not count
18toward the number of outpatient visits required to be covered
19under this Section an outpatient visit for the purpose of
20medication management and shall cover the outpatient visits
21under the same terms and conditions as it covers outpatient
22visits for the treatment of physical illness.
23    (5.5) An individual or group health benefit plan amended,
24delivered, issued, or renewed on or after the effective date of
25this amendatory Act of the 99th General Assembly shall offer
26coverage for medically necessary acute treatment services and



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1medically necessary clinical stabilization services. The
2treating provider shall base all treatment recommendations and
3the health benefit plan shall base all medical necessity
4determinations for substance use disorders in accordance with
5the most current edition of the American Society of Addiction
6Medicine Patient Placement Criteria.
7    As used in this subsection:
8    "Acute treatment services" means 24-hour medically
9supervised addiction treatment that provides evaluation and
10withdrawal management and may include biopsychosocial
11assessment, individual and group counseling, psychoeducational
12groups, and discharge planning.
13    "Clinical stabilization services" means 24-hour treatment,
14usually following acute treatment services for substance
15abuse, which may include intensive education and counseling
16regarding the nature of addiction and its consequences, relapse
17prevention, outreach to families and significant others, and
18aftercare planning for individuals beginning to engage in
19recovery from addiction.
20    (6) An issuer of a group health benefit plan may provide or
21offer coverage required under this Section through a managed
22care plan.
23    (7) (Blank).
24    (8) (Blank).
25    (9) With respect to substance use disorders, coverage for
26inpatient treatment shall include coverage for treatment in a



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1residential treatment center licensed by the Department of
2Public Health or the Department of Human Services.
3    (c) This Section shall not be interpreted to require
4coverage for speech therapy or other habilitative services for
5those individuals covered under Section 356z.15 of this Code.
6    (d) The Department shall enforce the requirements of State
7and federal parity law, which includes ensuring compliance by
8individual and group policies; detecting violations of the law
9by individual and group policies proactively monitoring
10discriminatory practices; accepting, evaluating, and
11responding to complaints regarding such violations; and
12ensuring violations are appropriately remedied and deterred.
13    (e) Availability of plan information.
14        (1) The criteria for medical necessity determinations
15    made under a group health plan with respect to mental
16    health or substance use disorder benefits (or health
17    insurance coverage offered in connection with the plan with
18    respect to such benefits) must be made available by the
19    plan administrator (or the health insurance issuer
20    offering such coverage) to any current or potential
21    participant, beneficiary, or contracting provider upon
22    request.
23        (2) The reason for any denial under a group health plan
24    (or health insurance coverage offered in connection with
25    such plan) of reimbursement or payment for services with
26    respect to mental health or substance use disorder benefits



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1    in the case of any participant or beneficiary must be made
2    available within a reasonable time and in a reasonable
3    manner by the plan administrator (or the health insurance
4    issuer offering such coverage) to the participant or
5    beneficiary upon request.
6    (f) As used in this Section, "group policy of accident and
7health insurance" and "group health benefit plan" includes (1)
8State-regulated employer-sponsored group health insurance
9plans written in Illinois and (2) State employee health plans.
10    (g) (1) As used in this subsection:
11    "Benefits", with respect to insurers, means the benefits
12provided for treatment services for inpatient and outpatient
13treatment of substance use disorders or conditions at American
14Society of Addiction Medicine levels of treatment 2.1
15(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
16(Clinically Managed Low-Intensity Residential), 3.3
17(Clinically Managed Population-Specific High-Intensity
18Residential), 3.5 (Clinically Managed High-Intensity
19Residential), and 3.7 (Medically Monitored Intensive
20Inpatient) and OMT (Opioid Maintenance Therapy) services.
21    "Benefits", with respect to managed care organizations,
22means the benefits provided for treatment services for
23inpatient and outpatient treatment of substance use disorders
24or conditions at American Society of Addiction Medicine levels
25of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
26Hospitalization), 3.5 (Clinically Managed High-Intensity



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1Residential), and 3.7 (Medically Monitored Intensive
2Inpatient) and OMT (Opioid Maintenance Therapy) services.
3    "Substance use disorder treatment provider or facility"
4means a licensed physician, licensed psychologist, licensed
5psychiatrist, licensed advanced practice registered nurse, or
6licensed, certified, or otherwise State-approved facility or
7provider of substance use disorder treatment.
8    (2) A group health insurance policy, an individual health
9benefit plan, or qualified health plan that is offered through
10the health insurance marketplace, small employer group health
11plan, and large employer group health plan that is amended,
12delivered, issued, executed, or renewed in this State, or
13approved for issuance or renewal in this State, on or after the
14effective date of this amendatory Act of the 100th General
15Assembly shall comply with the requirements of this Section and
16Section 370c.1. The services for the treatment and the ongoing
17assessment of the patient's progress in treatment shall follow
18the requirements of 77 Ill. Adm. Code 2060.
19    (3) Prior authorization shall not be utilized for the
20benefits under this subsection. The substance use disorder
21treatment provider or facility shall notify the insurer of the
22initiation of treatment. For an insurer that is not a managed
23care organization, the substance use disorder treatment
24provider or facility notification shall occur for the
25initiation of treatment of the covered person within 2 business
26days. For managed care organizations, the substance use



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1disorder treatment provider or facility notification shall
2occur in accordance with the protocol set forth in the provider
3agreement for initiation of treatment within 24 hours. If the
4managed care organization is not capable of accepting the
5notification in accordance with the contractual protocol
6during the 24-hour period following admission, the substance
7use disorder treatment provider or facility shall have one
8additional business day to provide the notification to the
9appropriate managed care organization. Treatment plans shall
10be developed in accordance with the requirements and timeframes
11established in 77 Ill. Adm. Code 2060. If the substance use
12disorder treatment provider or facility fails to notify the
13insurer of the initiation of treatment in accordance with these
14provisions, the insurer may follow its normal prior
15authorization processes.
16    (4) For an insurer that is not a managed care organization,
17if an insurer determines that benefits are no longer medically
18necessary, the insurer shall notify the covered person, the
19covered person's authorized representative, if any, and the
20covered person's health care provider in writing of the covered
21person's right to request an external review pursuant to the
22Health Carrier External Review Act. The notification shall
23occur within 24 hours following the adverse determination.
24    Pursuant to the requirements of the Health Carrier External
25Review Act, the covered person or the covered person's
26authorized representative may request an expedited external



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1review. An expedited external review may not occur if the
2substance use disorder treatment provider or facility
3determines that continued treatment is no longer medically
4necessary. Under this subsection, a request for expedited
5external review must be initiated within 24 hours following the
6adverse determination notification by the insurer. Failure to
7request an expedited external review within 24 hours shall
8preclude a covered person or a covered person's authorized
9representative from requesting an expedited external review.
10    If an expedited external review request meets the criteria
11of the Health Carrier External Review Act, an independent
12review organization shall make a final determination of medical
13necessity within 72 hours. If an independent review
14organization upholds an adverse determination, an insurer
15shall remain responsible to provide coverage of benefits
16through the day following the determination of the independent
17review organization. A decision to reverse an adverse
18determination shall comply with the Health Carrier External
19Review Act.
20    (5) The substance use disorder treatment provider or
21facility shall provide the insurer with 7 business days'
22advance notice of the planned discharge of the patient from the
23substance use disorder treatment provider or facility and
24notice on the day that the patient is discharged from the
25substance use disorder treatment provider or facility.
26    (6) The benefits required by this subsection shall be



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1provided to all covered persons with a diagnosis of substance
2use disorder or conditions. The presence of additional related
3or unrelated diagnoses shall not be a basis to reduce or deny
4the benefits required by this subsection.
5    (7) Nothing in this subsection shall be construed to
6require an insurer to provide coverage for any of the benefits
7in this subsection.
8(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
9    Section 99. Effective date. This Act takes effect January
101, 2019.