HB2438 EnrolledLRB101 08404 RAB 53474 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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
17this Code.
18    (2) Each insured that is covered for mental, emotional,
19nervous, or substance use disorders or conditions shall be free
20to select the physician licensed to practice medicine in all
21its branches, licensed clinical psychologist, licensed
22clinical social worker, licensed clinical professional
23counselor, licensed marriage and family therapist, licensed

 

 

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

 

 

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1professionals at programs licensed pursuant to the Substance
2Use Disorder Illinois Alcoholism and Other Drug Abuse and
3Dependency Act, those persons who may provide services to
4individuals shall do so after the licensed clinical social
5worker, licensed clinical professional counselor, licensed
6marriage and family therapist, licensed speech-language
7pathologist, or other licensed or certified professional at a
8program licensed pursuant to the Substance Use Disorder
9Illinois Alcoholism and Other Drug Abuse and Dependency Act has
10informed the patient of the desirability of the patient
11conferring with the patient's primary care physician.
12    (4) "Mental, emotional, nervous, or substance use disorder
13or condition" means a condition or disorder that involves a
14mental health condition or substance use disorder that falls
15under any of the diagnostic categories listed in the mental and
16behavioral disorders chapter of the current edition of the
17International Classification of Disease or that is listed in
18the most recent version of the Diagnostic and Statistical
19Manual of Mental Disorders. "Mental, emotional, nervous, or
20substance use disorder or condition" includes any mental health
21condition that occurs during pregnancy or during the postpartum
22period and includes, but is not limited to, postpartum
23depression.
24    (b)(1) (Blank).
25    (2) (Blank).
26    (2.5) (Blank).

 

 

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1    (3) Unless otherwise prohibited by federal law and
2consistent with the parity requirements of Section 370c.1 of
3this Code, the reimbursing insurer that amends, delivers,
4issues, or renews a group or individual policy of accident and
5health insurance, a qualified health plan offered through the
6health insurance marketplace, or a provider of treatment of
7mental, emotional, nervous, or substance use disorders or
8conditions shall furnish medical records or other necessary
9data that substantiate that initial or continued treatment is
10at all times medically necessary. An insurer shall provide a
11mechanism for the timely review by a provider holding the same
12license and practicing in the same specialty as the patient's
13provider, who is unaffiliated with the insurer, jointly
14selected by the patient (or the patient's next of kin or legal
15representative if the patient is unable to act for himself or
16herself), the patient's provider, and the insurer in the event
17of a dispute between the insurer and patient's provider
18regarding the medical necessity of a treatment proposed by a
19patient's provider. If the reviewing provider determines the
20treatment to be medically necessary, the insurer shall provide
21reimbursement for the treatment. Future contractual or
22employment actions by the insurer regarding the patient's
23provider may not be based on the provider's participation in
24this procedure. Nothing prevents the insured from agreeing in
25writing to continue treatment at his or her expense. When
26making a determination of the medical necessity for a treatment

 

 

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1modality for mental, emotional, nervous, or substance use
2disorders or conditions, an insurer must make the determination
3in a manner that is consistent with the manner used to make
4that determination with respect to other diseases or illnesses
5covered under the policy, including an appeals process. Medical
6necessity determinations for substance use disorders shall be
7made in accordance with appropriate patient placement criteria
8established by the American Society of Addiction Medicine. No
9additional criteria may be used to make medical necessity
10determinations for substance use disorders.
11    (4) A group health benefit plan amended, delivered, issued,
12or renewed on or after January 1, 2019 (the effective date of
13Public Act 100-1024) this amendatory Act of the 100th General
14Assembly or an individual policy of accident and health
15insurance or a qualified health plan offered through the health
16insurance marketplace amended, delivered, issued, or renewed
17on or after January 1, 2019 (the effective date of Public Act
18100-1024) this amendatory Act of the 100th General Assembly:
19        (A) shall provide coverage based upon medical
20    necessity for the treatment of a mental, emotional,
21    nervous, or substance use disorder or condition consistent
22    with the parity requirements of Section 370c.1 of this
23    Code; provided, however, that in each calendar year
24    coverage shall not be less than the following:
25            (i) 45 days of inpatient treatment; and
26            (ii) beginning on June 26, 2006 (the effective date

 

 

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1        of Public Act 94-921), 60 visits for outpatient
2        treatment including group and individual outpatient
3        treatment; and
4            (iii) for plans or policies delivered, issued for
5        delivery, renewed, or modified after January 1, 2007
6        (the effective date of Public Act 94-906), 20
7        additional outpatient visits for speech therapy for
8        treatment of pervasive developmental disorders that
9        will be in addition to speech therapy provided pursuant
10        to item (ii) of this subparagraph (A); and
11        (B) may not include a lifetime limit on the number of
12    days of inpatient treatment or the number of outpatient
13    visits covered under the plan.
14        (C) (Blank).
15    (5) An issuer of a group health benefit plan or an
16individual policy of accident and health insurance or a
17qualified health plan offered through the health insurance
18marketplace may not count toward the number of outpatient
19visits required to be covered under this Section an outpatient
20visit for the purpose of medication management and shall cover
21the outpatient visits under the same terms and conditions as it
22covers outpatient visits for the treatment of physical illness.
23    (5.5) An individual or group health benefit plan amended,
24delivered, issued, or renewed on or after September 9, 2015
25(the effective date of Public Act 99-480) this amendatory Act
26of the 99th General Assembly shall offer coverage for medically

 

 

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1necessary acute treatment services and medically necessary
2clinical stabilization services. The treating provider shall
3base all treatment recommendations and the health benefit plan
4shall base all medical necessity determinations for substance
5use disorders in accordance with the most current edition of
6the Treatment Criteria for Addictive, Substance-Related, and
7Co-Occurring Conditions established by the American Society of
8Addiction Medicine. The treating provider shall base all
9treatment recommendations and the health benefit plan shall
10base all medical necessity determinations for
11medication-assisted treatment in accordance with the most
12current Treatment Criteria for Addictive, Substance-Related,
13and Co-Occurring Conditions established by the American
14Society of Addiction Medicine.
15    As used in this subsection:
16    "Acute treatment services" means 24-hour medically
17supervised addiction treatment that provides evaluation and
18withdrawal management and may include biopsychosocial
19assessment, individual and group counseling, psychoeducational
20groups, and discharge planning.
21    "Clinical stabilization services" means 24-hour treatment,
22usually following acute treatment services for substance
23abuse, which may include intensive education and counseling
24regarding the nature of addiction and its consequences, relapse
25prevention, outreach to families and significant others, and
26aftercare planning for individuals beginning to engage in

 

 

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1recovery from addiction.
2    (6) An issuer of a group health benefit plan may provide or
3offer coverage required under this Section through a managed
4care plan.
5    (6.5) An individual or group health benefit plan amended,
6delivered, issued, or renewed on or after January 1, 2019 (the
7effective date of Public Act 100-1024) this amendatory Act of
8the 100th General Assembly:
9        (A) shall not impose prior authorization requirements,
10    other than those established under the Treatment Criteria
11    for Addictive, Substance-Related, and Co-Occurring
12    Conditions established by the American Society of
13    Addiction Medicine, on a prescription medication approved
14    by the United States Food and Drug Administration that is
15    prescribed or administered for the treatment of substance
16    use disorders;
17        (B) shall not impose any step therapy requirements,
18    other than those established under the Treatment Criteria
19    for Addictive, Substance-Related, and Co-Occurring
20    Conditions established by the American Society of
21    Addiction Medicine, before authorizing coverage for a
22    prescription medication approved by the United States Food
23    and Drug Administration that is prescribed or administered
24    for the treatment of substance use disorders;
25        (C) shall place all prescription medications approved
26    by the United States Food and Drug Administration

 

 

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1    prescribed or administered for the treatment of substance
2    use disorders on, for brand medications, the lowest tier of
3    the drug formulary developed and maintained by the
4    individual or group health benefit plan that covers brand
5    medications and, for generic medications, the lowest tier
6    of the drug formulary developed and maintained by the
7    individual or group health benefit plan that covers generic
8    medications; and
9        (D) shall not exclude coverage for a prescription
10    medication approved by the United States Food and Drug
11    Administration for the treatment of substance use
12    disorders and any associated counseling or wraparound
13    services on the grounds that such medications and services
14    were court ordered.
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
2Department and, with respect to medical assistance, the
3Department of Healthcare and Family Services shall each enforce
4the requirements of this Section and Sections 356z.23 and
5370c.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:
17        (1) proactively ensuring compliance by individual and
18    group policies, including by requiring that insurers
19    submit comparative analyses, as set forth in paragraph (6)
20    of subsection (k) of Section 370c.1, demonstrating how they
21    design and apply nonquantitative treatment limitations,
22    both as written and in operation, for mental, emotional,
23    nervous, or substance use disorder or condition benefits as
24    compared to how they design and apply nonquantitative
25    treatment limitations, as written and in operation, for
26    medical and surgical benefits;

 

 

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1        (2) evaluating all consumer or provider complaints
2    regarding mental, emotional, nervous, or substance use
3    disorder or condition coverage for possible parity
4    violations;
5        (3) performing parity compliance market conduct
6    examinations or, in the case of the Department of
7    Healthcare and Family Services, parity compliance audits
8    of individual and group plans and policies, including, but
9    not limited to, reviews of:
10            (A) nonquantitative treatment limitations,
11        including, but not limited to, prior authorization
12        requirements, concurrent review, retrospective review,
13        step therapy, network admission standards,
14        reimbursement rates, and geographic restrictions;
15            (B) denials of authorization, payment, and
16        coverage; and
17            (C) other specific criteria as may be determined by
18        the Department.
19    The findings and the conclusions of the parity compliance
20market conduct examinations and audits shall be made public.
21    The Director may adopt rules to effectuate any provisions
22of the Paul Wellstone and Pete Domenici Mental Health Parity
23and Addiction Equity Act of 2008 that relate to the business of
24insurance.
25    (e) Availability of plan information.
26        (1) The criteria for medical necessity determinations

 

 

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

 

 

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1plans written in Illinois or which purport to provide coverage
2for a resident of this State; and (2) State employee health
3plans.
4    (g) (1) As used in this subsection:
5    "Benefits", with respect to insurers, means the benefits
6provided for treatment services for inpatient and outpatient
7treatment of substance use disorders or conditions at American
8Society of Addiction Medicine levels of treatment 2.1
9(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
10(Clinically Managed Low-Intensity Residential), 3.3
11(Clinically Managed Population-Specific High-Intensity
12Residential), 3.5 (Clinically Managed High-Intensity
13Residential), and 3.7 (Medically Monitored Intensive
14Inpatient) and OMT (Opioid Maintenance Therapy) services.
15    "Benefits", with respect to managed care organizations,
16means the benefits provided for treatment services for
17inpatient and outpatient treatment of substance use disorders
18or conditions at American Society of Addiction Medicine levels
19of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
20Hospitalization), 3.5 (Clinically Managed High-Intensity
21Residential), and 3.7 (Medically Monitored Intensive
22Inpatient) and OMT (Opioid Maintenance Therapy) services.
23    "Substance use disorder treatment provider or facility"
24means a licensed physician, licensed psychologist, licensed
25psychiatrist, licensed advanced practice registered nurse, or
26licensed, certified, or otherwise State-approved facility or

 

 

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1provider of substance use disorder treatment.
2    (2) A group health insurance policy, an individual health
3benefit plan, or qualified health plan that is offered through
4the health insurance marketplace, small employer group health
5plan, and large employer group health plan that is amended,
6delivered, issued, executed, or renewed in this State, or
7approved for issuance or renewal in this State, on or after
8January 1, 2019 (the effective date of Public Act 100-1023)
9this amendatory Act of the 100th General Assembly shall comply
10with the requirements of this Section and Section 370c.1. The
11services for the treatment and the ongoing assessment of the
12patient's progress in treatment shall follow the requirements
13of 77 Ill. Adm. Code 2060.
14    (3) Prior authorization shall not be utilized for the
15benefits under this subsection. The substance use disorder
16treatment provider or facility shall notify the insurer of the
17initiation of treatment. For an insurer that is not a managed
18care organization, the substance use disorder treatment
19provider or facility notification shall occur for the
20initiation of treatment of the covered person within 2 business
21days. For managed care organizations, the substance use
22disorder treatment provider or facility notification shall
23occur in accordance with the protocol set forth in the provider
24agreement for initiation of treatment within 24 hours. If the
25managed care organization is not capable of accepting the
26notification in accordance with the contractual protocol

 

 

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

 

 

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1adverse determination notification by the insurer. Failure to
2request an expedited external review within 24 hours shall
3preclude a covered person or a covered person's authorized
4representative from requesting an expedited external review.
5    If an expedited external review request meets the criteria
6of the Health Carrier External Review Act, an independent
7review organization shall make a final determination of medical
8necessity within 72 hours. If an independent review
9organization upholds an adverse determination, an insurer
10shall remain responsible to provide coverage of benefits
11through the day following the determination of the independent
12review organization. A decision to reverse an adverse
13determination shall comply with the Health Carrier External
14Review Act.
15    (5) The substance use disorder treatment provider or
16facility shall provide the insurer with 7 business days'
17advance notice of the planned discharge of the patient from the
18substance use disorder treatment provider or facility and
19notice on the day that the patient is discharged from the
20substance use disorder treatment provider or facility.
21    (6) The benefits required by this subsection shall be
22provided to all covered persons with a diagnosis of substance
23use disorder or conditions. The presence of additional related
24or unrelated diagnoses shall not be a basis to reduce or deny
25the benefits required by this subsection.
26    (7) Nothing in this subsection shall be construed to

 

 

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1require an insurer to provide coverage for any of the benefits
2in this subsection.
3(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17;
4100-1023, eff. 1-1-19; 100-1024, eff. 1-1-19; revised
510-18-18.)
 
6    Section 99. Effective date. This Act takes effect upon
7becoming law.