Rep. Sara Feigenholtz

Filed: 5/25/2018





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2    AMENDMENT NO. ______. Amend Senate Bill 682 by replacing
3everything after the enacting clause with the following:
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



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1    individuals with critical substance use disorder treatment
2    needs.
3        (4) Speeding access to treatments will ensure that
4    Illinois residents suffering from a substance abuse crisis
5    will obtain the services they need.
6    Section 5. The Illinois Insurance Code is amended by
7changing Section 370c as follows:
8    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
9    Sec. 370c. Mental and emotional disorders.
10    (a)(1) On and after the effective date of this amendatory
11Act of the 97th General Assembly, every insurer which amends,
12delivers, issues, or renews group accident and health policies
13providing coverage for hospital or medical treatment or
14services for illness on an expense-incurred basis shall offer
15to the applicant or group policyholder subject to the insurer's
16standards of insurability, coverage for reasonable and
17necessary treatment and services for mental, emotional or
18nervous disorders or conditions, other than serious mental
19illnesses as defined in item (2) of subsection (b), consistent
20with the parity requirements of Section 370c.1 of this Code.
21    (2) Each insured that is covered for mental, emotional,
22nervous, or substance use disorders or conditions shall be free
23to select the physician licensed to practice medicine in all
24its branches, licensed clinical psychologist, licensed



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



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1speech-language pathologists, and other licensed or certified
2professionals at programs licensed pursuant to the Illinois
3Alcoholism and Other Drug Abuse and Dependency Act, those
4persons who may provide services to individuals shall do so
5after the licensed clinical social worker, licensed clinical
6professional 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 informed the patient of the desirability of
11the patient conferring with the patient's primary care
12physician and the licensed clinical social worker, licensed
13clinical professional counselor, licensed marriage and family
14therapist, licensed speech-language pathologist, or other
15licensed or certified professional at a program licensed
16pursuant to the Illinois Alcoholism and Other Drug Abuse and
17Dependency Act has provided written notification to the
18patient's primary care physician, if any, that services are
19being provided to the patient. That notification may, however,
20be waived by the patient on a written form. Those forms shall
21be retained by the licensed clinical social worker, licensed
22clinical professional counselor, licensed marriage and family
23therapist, licensed speech-language pathologist, or other
24licensed or certified professional at a program licensed
25pursuant to the Illinois Alcoholism and Other Drug Abuse and
26Dependency Act for a period of not less than 5 years.



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1    (b)(1) An insurer that provides coverage for hospital or
2medical expenses under a group or individual policy of accident
3and health insurance or health care plan amended, delivered,
4issued, or renewed on or after the effective date of this
5amendatory Act of the 100th General Assembly shall provide
6coverage under the policy for treatment of serious mental
7illness and substance use disorders consistent with the parity
8requirements of Section 370c.1 of this Code. This subsection
9does not apply to any group policy of accident and health
10insurance or health care plan for any plan year of a small
11employer as defined in Section 5 of the Illinois Health
12Insurance Portability and Accountability Act.
13    (2) "Serious mental illness" means the following
14psychiatric illnesses as defined in the most current edition of
15the Diagnostic and Statistical Manual (DSM) published by the
16American Psychiatric Association:
17        (A) schizophrenia;
18        (B) paranoid and other psychotic disorders;
19        (C) bipolar disorders (hypomanic, manic, depressive,
20    and mixed);
21        (D) major depressive disorders (single episode or
22    recurrent);
23        (E) schizoaffective disorders (bipolar or depressive);
24        (F) pervasive developmental disorders;
25        (G) obsessive-compulsive disorders;
26        (H) depression in childhood and adolescence;



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1        (I) panic disorder;
2        (J) post-traumatic stress disorders (acute, chronic,
3    or with delayed onset); and
4        (K) eating disorders, including, but not limited to,
5    anorexia nervosa, bulimia nervosa, pica, rumination
6    disorder, avoidant/restrictive food intake disorder, other
7    specified feeding or eating disorder (OSFED), and any other
8    eating disorder contained in the most recent version of the
9    Diagnostic and Statistical Manual of Mental Disorders
10    published by the American Psychiatric Association.
11    (2.5) "Substance use disorder" means the following mental
12disorders as defined in the most current edition of the
13Diagnostic and Statistical Manual (DSM) published by the
14American Psychiatric Association:
15        (A) substance abuse disorders;
16        (B) substance dependence disorders; and
17        (C) substance induced disorders.
18    (3) Unless otherwise prohibited by federal law and
19consistent with the parity requirements of Section 370c.1 of
20this Code, the reimbursing insurer, a provider of treatment of
21serious mental illness or substance use disorder shall furnish
22medical records or other necessary data that substantiate that
23initial or continued treatment is at all times medically
24necessary. An insurer shall provide a mechanism for the timely
25review by a provider holding the same license and practicing in
26the same specialty as the patient's provider, who is



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



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



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1medication management and shall cover the outpatient visits
2under the same terms and conditions as it covers outpatient
3visits for the treatment of physical illness.
4    (5.5) An individual or group health benefit plan amended,
5delivered, issued, or renewed on or after the effective date of
6this amendatory Act of the 99th General Assembly shall offer
7coverage for medically necessary acute treatment services and
8medically necessary clinical stabilization services. The
9treating provider shall base all treatment recommendations and
10the health benefit plan shall base all medical necessity
11determinations for substance use disorders in accordance with
12the most current edition of the American Society of Addiction
13Medicine Patient Placement Criteria.
14    As used in this subsection:
15    "Acute treatment services" means 24-hour medically
16supervised addiction treatment that provides evaluation and
17withdrawal management and may include biopsychosocial
18assessment, individual and group counseling, psychoeducational
19groups, and discharge planning.
20    "Clinical stabilization services" means 24-hour treatment,
21usually following acute treatment services for substance
22abuse, which may include intensive education and counseling
23regarding the nature of addiction and its consequences, relapse
24prevention, outreach to families and significant others, and
25aftercare planning for individuals beginning to engage in
26recovery from addiction.



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



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



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1Inpatient) and OMT (Opioid Maintenance Therapy) services.
2    "Benefits", with respect to managed care organizations,
3means the benefits provided for treatment services for
4inpatient and outpatient treatment of substance use disorders
5or conditions at American Society of Addiction Medicine levels
6of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
7Hospitalization), 3.5 (Clinically Managed High-Intensity
8Residential), and 3.7 (Medically Monitored Intensive
9Inpatient) and OMT (Opioid Maintenance Therapy) services.
10    "Substance use disorder treatment provider or facility"
11means a licensed physician, licensed psychologist, licensed
12psychiatrist, licensed advanced practice registered nurse, or
13licensed, certified, or otherwise State-approved facility or
14provider of substance use disorder treatment.
15    (2) A group health insurance policy, an individual health
16benefit plan, or qualified health plan that is offered through
17the health insurance marketplace, small employer group health
18plan, and large employer group health plan that is amended,
19delivered, issued, executed, or renewed in this State, or
20approved for issuance or renewal in this State, on or after the
21effective date of this amendatory Act of the 100th General
22Assembly shall comply with the requirements of this Section and
23Section 370c.1. The services for the treatment and the ongoing
24assessment of the patient's progress in treatment shall follow
25the requirements of 77 Ill. Adm. Code 2060.
26    (3) Prior authorization shall not be utilized for the



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



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



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1    (5) The substance use disorder treatment provider or
2facility shall provide the insurer with 7 business days'
3advance notice of the planned discharge of the patient from the
4substance use disorder treatment provider or facility and
5notice on the day that the patient is discharged from the
6substance use disorder treatment provider or facility.
7    (6) The benefits required by this subsection shall be
8provided to all covered persons with a diagnosis of substance
9use disorder or conditions. The presence of additional related
10or unrelated diagnoses shall not be a basis to reduce or deny
11the benefits required by this subsection.
12    (7) Nothing in this subsection shall be construed to
13require an insurer to provide coverage for any of the benefits
14in this subsection.
15(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
16    Section 99. Effective date. This Act takes effect January
171, 2019.".