Rep. C.D. Davidsmeyer

Filed: 3/26/2019

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2438

2    AMENDMENT NO. ______. Amend House Bill 2438 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 370c as follows:
 
6    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
7    Sec. 370c. Mental and emotional disorders.
8    (a)(1) On and after the effective date of this amendatory
9Act of the 101st General Assembly this amendatory Act of the
10100th General Assembly, every insurer that amends, delivers,
11issues, or renews group accident and health policies providing
12coverage for hospital or medical treatment or services for
13illness on an expense-incurred basis shall provide coverage for
14reasonable and necessary treatment and services for mental,
15emotional, nervous, or substance use disorders or conditions
16consistent with the parity requirements of Section 370c.1 of

 

 

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1this Code.
2    (2) Each insured that is covered for mental, emotional,
3nervous, or substance use disorders or conditions shall be free
4to select the physician licensed to practice medicine in all
5its branches, licensed clinical psychologist, licensed
6clinical social worker, licensed clinical professional
7counselor, licensed marriage and family therapist, licensed
8speech-language pathologist, or other licensed or certified
9professional at a program licensed pursuant to the Substance
10Use Disorder Illinois Alcoholism and Other Drug Abuse and
11Dependency Act of his choice to treat such disorders, and the
12insurer shall pay the covered charges of such physician
13licensed to practice medicine in all its branches, licensed
14clinical psychologist, licensed clinical social worker,
15licensed clinical professional counselor, licensed marriage
16and family therapist, licensed speech-language pathologist, or
17other licensed or certified professional at a program licensed
18pursuant to the Substance Use Disorder Illinois Alcoholism and
19Other Drug Abuse and Dependency Act up to the limits of
20coverage, provided (i) the disorder or condition treated is
21covered by the policy, and (ii) the physician, licensed
22psychologist, licensed clinical social worker, licensed
23clinical professional counselor, licensed marriage and family
24therapist, licensed speech-language pathologist, or other
25licensed or certified professional at a program licensed
26pursuant to the Substance Use Disorder Illinois Alcoholism and

 

 

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1Other Drug Abuse and Dependency Act is authorized to provide
2said services under the statutes of this State and in
3accordance with accepted principles of his profession.
4    (3) Insofar as this Section applies solely to licensed
5clinical social workers, licensed clinical professional
6counselors, licensed marriage and family therapists, licensed
7speech-language pathologists, and other licensed or certified
8professionals at programs licensed pursuant to the Substance
9Use Disorder Illinois Alcoholism and Other Drug Abuse and
10Dependency Act, those persons who may provide services to
11individuals shall do so after the licensed clinical social
12worker, licensed clinical professional counselor, licensed
13marriage and family therapist, licensed speech-language
14pathologist, or other licensed or certified professional at a
15program licensed pursuant to the Substance Use Disorder
16Illinois Alcoholism and Other Drug Abuse and Dependency Act has
17informed the patient of the desirability of the patient
18conferring with the patient's primary care physician.
19    (4) "Mental, emotional, nervous, or substance use disorder
20or condition" means a condition or disorder that involves a
21mental health condition or substance use disorder that falls
22under any of the diagnostic categories listed in the mental and
23behavioral disorders chapter of the current edition of the
24International Classification of Disease or that is listed in
25the most recent version of the Diagnostic and Statistical
26Manual of Mental Disorders. "Mental, emotional, nervous, or

 

 

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1substance use disorder or condition" includes any mental health
2condition that occurs during pregnancy or during the postpartum
3period and includes, but is not limited to, postpartum
4depression.
5    (b)(1) (Blank).
6    (2) (Blank).
7    (2.5) (Blank).
8    (3) Unless otherwise prohibited by federal law and
9consistent with the parity requirements of Section 370c.1 of
10this Code, the reimbursing insurer that amends, delivers,
11issues, or renews a group or individual policy of accident and
12health insurance, a qualified health plan offered through the
13health insurance marketplace, or a provider of treatment of
14mental, emotional, nervous, or substance use disorders or
15conditions shall furnish medical records or other necessary
16data that substantiate that initial or continued treatment is
17at all times medically necessary. An insurer shall provide a
18mechanism for the timely review by a provider holding the same
19license and practicing in the same specialty as the patient's
20provider, who is unaffiliated with the insurer, jointly
21selected by the patient (or the patient's next of kin or legal
22representative if the patient is unable to act for himself or
23herself), the patient's provider, and the insurer in the event
24of a dispute between the insurer and patient's provider
25regarding the medical necessity of a treatment proposed by a
26patient's provider. If the reviewing provider determines the

 

 

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1treatment to be medically necessary, the insurer shall provide
2reimbursement for the treatment. Future contractual or
3employment actions by the insurer regarding the patient's
4provider may not be based on the provider's participation in
5this procedure. Nothing prevents the insured from agreeing in
6writing to continue treatment at his or her expense. When
7making a determination of the medical necessity for a treatment
8modality for mental, emotional, nervous, or substance use
9disorders or conditions, an insurer must make the determination
10in a manner that is consistent with the manner used to make
11that determination with respect to other diseases or illnesses
12covered under the policy, including an appeals process. Medical
13necessity determinations for substance use disorders shall be
14made in accordance with appropriate patient placement criteria
15established by the American Society of Addiction Medicine. No
16additional criteria may be used to make medical necessity
17determinations for substance use disorders.
18    (4) A group health benefit plan amended, delivered, issued,
19or renewed on or after January 1, 2019 (the effective date of
20Public Act 100-1024) this amendatory Act of the 100th General
21Assembly or an individual policy of accident and health
22insurance or a qualified health plan offered through the health
23insurance marketplace amended, delivered, issued, or renewed
24on or after January 1, 2019 (the effective date of Public Act
25100-1024) this amendatory Act of the 100th General Assembly:
26        (A) shall provide coverage based upon medical

 

 

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

 

 

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1visit for the purpose of medication management and shall cover
2the outpatient visits under the same terms and conditions as it
3covers outpatient visits for the treatment of physical illness.
4    (5.5) An individual or group health benefit plan amended,
5delivered, issued, or renewed on or after September 9, 2015
6(the effective date of Public Act 99-480) this amendatory Act
7of the 99th General Assembly shall offer coverage for medically
8necessary acute treatment services and medically necessary
9clinical stabilization services. The treating provider shall
10base all treatment recommendations and the health benefit plan
11shall base all medical necessity determinations for substance
12use disorders in accordance with the most current edition of
13the Treatment Criteria for Addictive, Substance-Related, and
14Co-Occurring Conditions established by the American Society of
15Addiction Medicine. The treating provider shall base all
16treatment recommendations and the health benefit plan shall
17base all medical necessity determinations for
18medication-assisted treatment in accordance with the most
19current Treatment Criteria for Addictive, Substance-Related,
20and Co-Occurring Conditions established by the American
21Society of Addiction Medicine.
22    As used in this subsection:
23    "Acute treatment services" means 24-hour medically
24supervised addiction treatment that provides evaluation and
25withdrawal management and may include biopsychosocial
26assessment, individual and group counseling, psychoeducational

 

 

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1groups, and discharge planning.
2    "Clinical stabilization services" means 24-hour treatment,
3usually following acute treatment services for substance
4abuse, which may include intensive education and counseling
5regarding the nature of addiction and its consequences, relapse
6prevention, outreach to families and significant others, and
7aftercare planning for individuals beginning to engage in
8recovery from addiction.
9    (6) An issuer of a group health benefit plan may provide or
10offer coverage required under this Section through a managed
11care plan.
12    (6.5) An individual or group health benefit plan amended,
13delivered, issued, or renewed on or after January 1, 2019 (the
14effective date of Public Act 100-1024) this amendatory Act of
15the 100th General Assembly:
16        (A) shall not impose prior authorization requirements,
17    other than those established under the Treatment Criteria
18    for Addictive, Substance-Related, and Co-Occurring
19    Conditions established by the American Society of
20    Addiction Medicine, on a prescription medication approved
21    by the United States Food and Drug Administration that is
22    prescribed or administered for the treatment of substance
23    use disorders;
24        (B) shall not impose any step therapy requirements,
25    other than those established under the Treatment Criteria
26    for Addictive, Substance-Related, and Co-Occurring

 

 

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1    Conditions established by the American Society of
2    Addiction Medicine, before authorizing coverage for a
3    prescription medication approved by the United States Food
4    and Drug Administration that is prescribed or administered
5    for the treatment of substance use disorders;
6        (C) shall place all prescription medications approved
7    by the United States Food and Drug Administration
8    prescribed or administered for the treatment of substance
9    use disorders on, for brand medications, the lowest tier of
10    the drug formulary developed and maintained by the
11    individual or group health benefit plan that covers brand
12    medications and, for generic medications, the lowest tier
13    of the drug formulary developed and maintained by the
14    individual or group health benefit plan that covers generic
15    medications; and
16        (D) shall not exclude coverage for a prescription
17    medication approved by the United States Food and Drug
18    Administration for the treatment of substance use
19    disorders and any associated counseling or wraparound
20    services on the grounds that such medications and services
21    were court ordered.
22    (7) (Blank).
23    (8) (Blank).
24    (9) With respect to all mental, emotional, nervous, or
25substance use disorders or conditions, coverage for inpatient
26treatment shall include coverage for treatment in a residential

 

 

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1treatment center certified or 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) With respect to a group or individual policy of
7accident and health insurance or a qualified health plan
8offered through the health insurance marketplace, the
9Department and, with respect to medical assistance, the
10Department of Healthcare and Family Services shall each enforce
11the requirements of this Section and Sections 356z.23 and
12370c.1 of this Code, the Paul Wellstone and Pete Domenici
13Mental Health Parity and Addiction Equity Act of 2008, 42
14U.S.C. 18031(j), and any amendments to, and federal guidance or
15regulations issued under, those Acts, including, but not
16limited to, final regulations issued under the Paul Wellstone
17and Pete Domenici Mental Health Parity and Addiction Equity Act
18of 2008 and final regulations applying the Paul Wellstone and
19Pete Domenici Mental Health Parity and Addiction Equity Act of
202008 to Medicaid managed care organizations, the Children's
21Health Insurance Program, and alternative benefit plans.
22Specifically, the Department and the Department of Healthcare
23and Family Services shall take action:
24        (1) proactively ensuring compliance by individual and
25    group policies, including by requiring that insurers
26    submit comparative analyses, as set forth in paragraph (6)

 

 

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1    of subsection (k) of Section 370c.1, demonstrating how they
2    design and apply nonquantitative treatment limitations,
3    both as written and in operation, for mental, emotional,
4    nervous, or substance use disorder or condition benefits as
5    compared to how they design and apply nonquantitative
6    treatment limitations, as written and in operation, for
7    medical and surgical benefits;
8        (2) evaluating all consumer or provider complaints
9    regarding mental, emotional, nervous, or substance use
10    disorder or condition coverage for possible parity
11    violations;
12        (3) performing parity compliance market conduct
13    examinations or, in the case of the Department of
14    Healthcare and Family Services, parity compliance audits
15    of individual and group plans and policies, including, but
16    not limited to, reviews of:
17            (A) nonquantitative treatment limitations,
18        including, but not limited to, prior authorization
19        requirements, concurrent review, retrospective review,
20        step therapy, network admission standards,
21        reimbursement rates, and geographic restrictions;
22            (B) denials of authorization, payment, and
23        coverage; and
24            (C) other specific criteria as may be determined by
25        the Department.
26    The findings and the conclusions of the parity compliance

 

 

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1market conduct examinations and audits shall be made public.
2    The Director may adopt rules to effectuate any provisions
3of the Paul Wellstone and Pete Domenici Mental Health Parity
4and Addiction Equity Act of 2008 that relate to the business of
5insurance.
6    (e) Availability of plan information.
7        (1) The criteria for medical necessity determinations
8    made under a group health plan, an individual policy of
9    accident and health insurance, or a qualified health plan
10    offered through the health insurance marketplace with
11    respect to mental health or substance use disorder benefits
12    (or health insurance coverage offered in connection with
13    the plan with respect to such benefits) must be made
14    available by the plan administrator (or the health
15    insurance issuer offering such coverage) to any current or
16    potential participant, beneficiary, or contracting
17    provider upon request.
18        (2) The reason for any denial under a group health
19    benefit plan, an individual policy of accident and health
20    insurance, or a qualified health plan offered through the
21    health insurance marketplace (or health insurance coverage
22    offered in connection with such plan or policy) of
23    reimbursement or payment for services with respect to
24    mental, emotional, nervous, or substance use disorders or
25    conditions benefits in the case of any participant or
26    beneficiary must be made available within a reasonable time

 

 

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

 

 

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1Hospitalization), 3.5 (Clinically Managed High-Intensity
2Residential), and 3.7 (Medically Monitored Intensive
3Inpatient) and OMT (Opioid Maintenance Therapy) services.
4    "Substance use disorder treatment provider or facility"
5means a licensed physician, licensed psychologist, licensed
6psychiatrist, licensed advanced practice registered nurse, or
7licensed, certified, or otherwise State-approved facility or
8provider of substance use disorder treatment.
9    (2) A group health insurance policy, an individual health
10benefit plan, or qualified health plan that is offered through
11the health insurance marketplace, small employer group health
12plan, and large employer group health plan that is amended,
13delivered, issued, executed, or renewed in this State, or
14approved for issuance or renewal in this State, on or after
15January 1, 2019 (the effective date of Public Act 100-1023)
16this amendatory Act of the 100th General Assembly shall comply
17with the requirements of this Section and Section 370c.1. The
18services for the treatment and the ongoing assessment of the
19patient's progress in treatment shall follow the requirements
20of 77 Ill. Adm. Code 2060.
21    (3) Prior authorization shall not be utilized for the
22benefits under this subsection. The substance use disorder
23treatment provider or facility shall notify the insurer of the
24initiation of treatment. For an insurer that is not a managed
25care organization, the substance use disorder treatment
26provider or facility notification shall occur for the

 

 

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

 

 

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

 

 

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1substance use disorder treatment provider or facility.
2    (6) The benefits required by this subsection shall be
3provided to all covered persons with a diagnosis of substance
4use disorder or conditions. The presence of additional related
5or unrelated diagnoses shall not be a basis to reduce or deny
6the benefits required by this subsection.
7    (7) Nothing in this subsection shall be construed to
8require an insurer to provide coverage for any of the benefits
9in this subsection.
10(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17;
11100-1023, eff. 1-1-19; 100-1024, eff. 1-1-19; revised
1210-18-18.)
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.".