|
Rep. Lou Lang
Filed: 5/29/2018
| | 10000SB1707ham003 | | LRB100 11322 SMS 40947 a |
|
|
1 | | AMENDMENT TO SENATE BILL 1707
|
2 | | AMENDMENT NO. ______. Amend Senate Bill 1707 by replacing |
3 | | everything after the enacting clause with the following:
|
4 | | "Section 5. The State Employees Group Insurance Act of 1971 |
5 | | is amended by changing Section 6.11 as follows:
|
6 | | (5 ILCS 375/6.11)
|
7 | | Sec. 6.11. Required health benefits; Illinois Insurance |
8 | | Code
requirements. The program of health
benefits shall provide |
9 | | the post-mastectomy care benefits required to be covered
by a |
10 | | policy of accident and health insurance under Section 356t of |
11 | | the Illinois
Insurance Code. The program of health benefits |
12 | | shall provide the coverage
required under Sections 356g, |
13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
15 | | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25 , and 356z.26 of |
16 | | the
Illinois Insurance Code.
The program of health benefits |
|
| | 10000SB1707ham003 | - 2 - | LRB100 11322 SMS 40947 a |
|
|
1 | | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, |
2 | | and 370c.1 of the
Illinois Insurance Code. The Department of |
3 | | Insurance shall enforce the requirements of this Section.
|
4 | | Rulemaking authority to implement Public Act 95-1045, if |
5 | | any, is conditioned on the rules being adopted in accordance |
6 | | with all provisions of the Illinois Administrative Procedure |
7 | | Act and all rules and procedures of the Joint Committee on |
8 | | Administrative Rules; any purported rule not so adopted, for |
9 | | whatever reason, is unauthorized. |
10 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
11 | | 100-138, eff. 8-18-17; revised 10-3-17.) |
12 | | Section 10. The State Finance Act is amended by changing |
13 | | Section 5.872 as follows:
|
14 | | (30 ILCS 105/5.872)
|
15 | | Sec. 5.872. The Parity Advancement Education Fund. |
16 | | (Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
|
17 | | Section 15. The Counties Code is amended by changing |
18 | | Section 5-1069.3 as follows: |
19 | | (55 ILCS 5/5-1069.3)
|
20 | | Sec. 5-1069.3. Required health benefits. If a county, |
21 | | including a home
rule
county, is a self-insurer for purposes of |
22 | | providing health insurance coverage
for its employees, the |
|
| | 10000SB1707ham003 | - 3 - | LRB100 11322 SMS 40947 a |
|
|
1 | | coverage shall include coverage for the post-mastectomy
care |
2 | | benefits required to be covered by a policy of accident and |
3 | | health
insurance under Section 356t and the coverage required |
4 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
5 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
6 | | 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
the |
7 | | Illinois Insurance Code. The coverage shall comply with |
8 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois |
9 | | Insurance Code. The Department of Insurance shall enforce the |
10 | | requirements of this Section. The requirement that health |
11 | | benefits be covered
as provided in this Section is an
exclusive |
12 | | power and function of the State and is a denial and limitation |
13 | | under
Article VII, Section 6, subsection (h) of the Illinois |
14 | | Constitution. A home
rule county to which this Section applies |
15 | | must comply with every provision of
this Section.
|
16 | | Rulemaking authority to implement Public Act 95-1045, if |
17 | | any, is conditioned on the rules being adopted in accordance |
18 | | with all provisions of the Illinois Administrative Procedure |
19 | | Act and all rules and procedures of the Joint Committee on |
20 | | Administrative Rules; any purported rule not so adopted, for |
21 | | whatever reason, is unauthorized. |
22 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
23 | | 100-138, eff. 8-18-17; revised 10-5-17.) |
24 | | Section 20. The Illinois Municipal Code is amended by |
25 | | changing Section 10-4-2.3 as follows: |
|
| | 10000SB1707ham003 | - 4 - | LRB100 11322 SMS 40947 a |
|
|
1 | | (65 ILCS 5/10-4-2.3)
|
2 | | Sec. 10-4-2.3. Required health benefits. If a |
3 | | municipality, including a
home rule municipality, is a |
4 | | self-insurer for purposes of providing health
insurance |
5 | | coverage for its employees, the coverage shall include coverage |
6 | | for
the post-mastectomy care benefits required to be covered by |
7 | | a policy of
accident and health insurance under Section 356t |
8 | | and the coverage required
under Sections 356g, 356g.5, |
9 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
10 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and |
11 | | 356z.25 , and 356z.26 of the Illinois
Insurance
Code. The |
12 | | coverage shall comply with Sections 155.22a, 355b, 356z.19, and |
13 | | 370c of
the Illinois Insurance Code. The Department of |
14 | | Insurance shall enforce the requirements of this Section. The |
15 | | requirement that health
benefits be covered as provided in this |
16 | | is an exclusive power and function of
the State and is a denial |
17 | | and limitation under Article VII, Section 6,
subsection (h) of |
18 | | the Illinois Constitution. A home rule municipality to which
|
19 | | this Section applies must comply with every provision of this |
20 | | Section.
|
21 | | Rulemaking authority to implement Public Act 95-1045, if |
22 | | any, is conditioned on the rules being adopted in accordance |
23 | | with all provisions of the Illinois Administrative Procedure |
24 | | Act and all rules and procedures of the Joint Committee on |
25 | | Administrative Rules; any purported rule not so adopted, for |
|
| | 10000SB1707ham003 | - 5 - | LRB100 11322 SMS 40947 a |
|
|
1 | | whatever reason, is unauthorized. |
2 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; |
3 | | 100-138, eff. 8-18-17; revised 10-5-17.) |
4 | | Section 25. The School Code is amended by changing Section |
5 | | 10-22.3f as follows: |
6 | | (105 ILCS 5/10-22.3f)
|
7 | | Sec. 10-22.3f. Required health benefits. Insurance |
8 | | protection and
benefits
for employees shall provide the |
9 | | post-mastectomy care benefits required to be
covered by a |
10 | | policy of accident and health insurance under Section 356t and |
11 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
12 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
13 | | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
|
14 | | the
Illinois Insurance Code.
Insurance policies shall comply |
15 | | with Section 356z.19 of the Illinois Insurance Code. The |
16 | | coverage shall comply with Sections 155.22a , and 355b , and 370c |
17 | | of
the Illinois Insurance Code. The Department of Insurance |
18 | | shall enforce the requirements of this Section.
|
19 | | Rulemaking authority to implement Public Act 95-1045, if |
20 | | any, is conditioned on the rules being adopted in accordance |
21 | | with all provisions of the Illinois Administrative Procedure |
22 | | Act and all rules and procedures of the Joint Committee on |
23 | | Administrative Rules; any purported rule not so adopted, for |
24 | | whatever reason, is unauthorized. |
|
| | 10000SB1707ham003 | - 6 - | LRB100 11322 SMS 40947 a |
|
|
1 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; |
2 | | revised 9-25-17.) |
3 | | Section 30. The Illinois Insurance Code is amended by |
4 | | changing Sections 370c and 370c.1 as follows:
|
5 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
|
6 | | Sec. 370c. Mental and emotional disorders.
|
7 | | (a)(1) On and after the effective date of this amendatory |
8 | | Act of the 100th General Assembly the effective date of this |
9 | | amendatory Act of the 97th General Assembly ,
every insurer that |
10 | | which amends, delivers, issues, or renews
group accident and |
11 | | health policies providing coverage for hospital or medical |
12 | | treatment or
services for illness on an expense-incurred basis |
13 | | shall provide offer to the
applicant or group policyholder |
14 | | subject to the insurer's standards of
insurability, coverage |
15 | | for reasonable and necessary treatment and services
for mental, |
16 | | emotional , or nervous , or substance use disorders or |
17 | | conditions , other than serious
mental illnesses as defined in |
18 | | item (2) of subsection (b), consistent with the parity |
19 | | requirements of Section 370c.1 of this Code.
|
20 | | (2) Each insured that is covered for mental, emotional, |
21 | | nervous, or substance use
disorders or conditions shall be free |
22 | | to select the physician licensed to
practice medicine in all |
23 | | its branches, licensed clinical psychologist,
licensed |
24 | | clinical social worker, licensed clinical professional |
|
| | 10000SB1707ham003 | - 7 - | LRB100 11322 SMS 40947 a |
|
|
1 | | counselor, licensed marriage and family therapist, licensed |
2 | | speech-language pathologist, or other licensed or certified |
3 | | professional at a program licensed pursuant to the Illinois |
4 | | Alcoholism and Other Drug Abuse and Dependency Act of
his |
5 | | choice to treat such disorders, and
the insurer shall pay the |
6 | | covered charges of such physician licensed to
practice medicine |
7 | | in all its branches, licensed clinical psychologist,
licensed |
8 | | clinical social worker, licensed clinical professional |
9 | | counselor, licensed marriage and family therapist, licensed |
10 | | speech-language pathologist, or other licensed or certified |
11 | | professional at a program licensed pursuant to the Illinois |
12 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the |
13 | | limits of coverage, provided (i)
the disorder or condition |
14 | | treated is covered by the policy, and (ii) the
physician, |
15 | | licensed psychologist, licensed clinical social worker, |
16 | | licensed
clinical professional counselor, licensed marriage |
17 | | and family therapist, licensed speech-language pathologist, or |
18 | | other licensed or certified professional at a program licensed |
19 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and |
20 | | Dependency Act is
authorized to provide said services under the |
21 | | statutes of this State and in
accordance with accepted |
22 | | principles of his profession.
|
23 | | (3) Insofar as this Section applies solely to licensed |
24 | | clinical social
workers, licensed clinical professional |
25 | | counselors, licensed marriage and family therapists, licensed |
26 | | speech-language pathologists, and other licensed or certified |
|
| | 10000SB1707ham003 | - 8 - | LRB100 11322 SMS 40947 a |
|
|
1 | | professionals at programs licensed pursuant to the Illinois |
2 | | Alcoholism and Other Drug Abuse and Dependency Act, those |
3 | | persons who may
provide services to individuals shall do so
|
4 | | after the licensed clinical social worker, licensed clinical |
5 | | professional
counselor, licensed marriage and family |
6 | | therapist, licensed speech-language pathologist, or other |
7 | | licensed or certified professional at a program licensed |
8 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and |
9 | | Dependency Act has informed the patient of the
desirability of |
10 | | the patient conferring with the patient's primary care
|
11 | | physician and the licensed clinical social worker, licensed |
12 | | clinical
professional counselor, licensed marriage and family |
13 | | therapist, licensed speech-language pathologist, or other |
14 | | licensed or certified professional at a program licensed |
15 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and |
16 | | Dependency Act has
provided written
notification to the |
17 | | patient's primary care physician, if any, that services
are |
18 | | being provided to the patient. That notification may, however, |
19 | | be
waived by the patient on a written form. Those forms shall |
20 | | be retained by
the licensed clinical social worker, licensed |
21 | | clinical professional counselor, licensed marriage and family |
22 | | therapist, licensed speech-language pathologist, or other |
23 | | licensed or certified professional at a program licensed |
24 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and |
25 | | Dependency Act
for a period of not less than 5 years .
|
26 | | (4) "Mental, emotional, nervous, or substance use disorder |
|
| | 10000SB1707ham003 | - 9 - | LRB100 11322 SMS 40947 a |
|
|
1 | | or condition" means a condition or disorder that involves a |
2 | | mental health condition or substance use disorder that falls |
3 | | under any of the diagnostic categories listed in the mental and |
4 | | behavioral disorders chapter of the current edition of the |
5 | | International Classification of Disease or that is listed in |
6 | | the most recent version of the Diagnostic and Statistical |
7 | | Manual of Mental Disorders. |
8 | | (b)(1) (Blank). An insurer that provides coverage for |
9 | | hospital or medical
expenses under a group or individual policy |
10 | | of accident and health insurance or
health care plan amended, |
11 | | delivered, issued, or renewed on or after the effective
date of |
12 | | this amendatory Act of the 100th General Assembly shall provide |
13 | | coverage
under the policy for treatment of serious mental |
14 | | illness and substance use disorders consistent with the parity |
15 | | requirements of Section 370c.1 of this Code. This subsection |
16 | | does not apply to any group policy of accident and health |
17 | | insurance or health care plan for any plan year of a small |
18 | | employer as defined in Section 5 of the Illinois Health |
19 | | Insurance Portability and Accountability Act.
|
20 | | (2) (Blank). "Serious mental illness" means the following |
21 | | psychiatric illnesses as
defined in the most current edition of |
22 | | the Diagnostic and Statistical Manual
(DSM) published by the |
23 | | American Psychiatric Association:
|
24 | | (A) schizophrenia;
|
25 | | (B) paranoid and other psychotic disorders;
|
26 | | (C) bipolar disorders (hypomanic, manic, depressive, |
|
| | 10000SB1707ham003 | - 10 - | LRB100 11322 SMS 40947 a |
|
|
1 | | and mixed);
|
2 | | (D) major depressive disorders (single episode or |
3 | | recurrent);
|
4 | | (E) schizoaffective disorders (bipolar or depressive);
|
5 | | (F) pervasive developmental disorders;
|
6 | | (G) obsessive-compulsive disorders;
|
7 | | (H) depression in childhood and adolescence;
|
8 | | (I) panic disorder; |
9 | | (J) post-traumatic stress disorders (acute, chronic, |
10 | | or with delayed onset); and
|
11 | | (K) eating disorders, including, but not limited to, |
12 | | anorexia nervosa, bulimia nervosa, pica, rumination |
13 | | disorder, avoidant/restrictive food intake disorder, other |
14 | | specified feeding or eating disorder (OSFED), and any other |
15 | | eating disorder contained in the most recent version of the |
16 | | Diagnostic and Statistical Manual of Mental Disorders |
17 | | published by the American Psychiatric Association. |
18 | | (2.5) (Blank). "Substance use disorder" means the |
19 | | following mental disorders as defined in the most current |
20 | | edition of the Diagnostic and Statistical Manual (DSM) |
21 | | published by the American Psychiatric Association: |
22 | | (A) substance abuse disorders; |
23 | | (B) substance dependence disorders; and |
24 | | (C) substance induced disorders. |
25 | | (3) Unless otherwise prohibited by federal law and |
26 | | consistent with the parity requirements of Section 370c.1 of |
|
| | 10000SB1707ham003 | - 11 - | LRB100 11322 SMS 40947 a |
|
|
1 | | this Code, the reimbursing insurer that amends, delivers, |
2 | | issues, or renews a group or individual policy of accident and |
3 | | health insurance, a qualified health plan offered through the |
4 | | health insurance marketplace, or , a provider of treatment of |
5 | | mental, emotional, nervous,
serious mental illness or |
6 | | substance use disorders or conditions disorder shall furnish |
7 | | medical records or other necessary data
that substantiate that |
8 | | initial or continued treatment is at all times medically
|
9 | | necessary. An insurer shall provide a mechanism for the timely |
10 | | review by a
provider holding the same license and practicing in |
11 | | the same specialty as the
patient's provider, who is |
12 | | unaffiliated with the insurer, jointly selected by
the patient |
13 | | (or the patient's next of kin or legal representative if the
|
14 | | patient is unable to act for himself or herself), the patient's |
15 | | provider, and
the insurer in the event of a dispute between the |
16 | | insurer and patient's
provider regarding the medical necessity |
17 | | of a treatment proposed by a patient's
provider. If the |
18 | | reviewing provider determines the treatment to be medically
|
19 | | necessary, the insurer shall provide reimbursement for the |
20 | | treatment. Future
contractual or employment actions by the |
21 | | insurer regarding the patient's
provider may not be based on |
22 | | the provider's participation in this procedure.
Nothing |
23 | | prevents
the insured from agreeing in writing to continue |
24 | | treatment at his or her
expense. When making a determination of |
25 | | the medical necessity for a treatment
modality for mental, |
26 | | emotional, nervous, serious mental illness or substance use |
|
| | 10000SB1707ham003 | - 12 - | LRB100 11322 SMS 40947 a |
|
|
1 | | disorders or conditions disorder , an insurer must make the |
2 | | determination in a
manner that is consistent with the manner |
3 | | used to make that determination with
respect to other diseases |
4 | | or illnesses covered under the policy, including an
appeals |
5 | | process. Medical necessity determinations for substance use |
6 | | disorders shall be made in accordance with appropriate patient |
7 | | placement criteria established by the American Society of |
8 | | Addiction Medicine. No additional criteria may be used to make |
9 | | medical necessity determinations for substance use disorders.
|
10 | | (4) A group health benefit plan amended, delivered, issued, |
11 | | or renewed on or after the effective date of this amendatory |
12 | | Act of the 100th General Assembly or an individual policy of |
13 | | accident and health insurance or a qualified health plan |
14 | | offered through the health insurance marketplace amended, |
15 | | delivered, issued, or renewed on or after the effective date of |
16 | | this amendatory Act of the 100th General Assembly the effective |
17 | | date of this amendatory Act of the 97th General Assembly :
|
18 | | (A) shall provide coverage based upon medical |
19 | | necessity for the
treatment of a mental, emotional, |
20 | | nervous, or mental illness and substance use disorder or |
21 | | condition disorders consistent with the parity |
22 | | requirements of Section 370c.1 of this Code; provided, |
23 | | however, that in each calendar year coverage shall not be |
24 | | less than the following:
|
25 | | (i) 45 days of inpatient treatment; and
|
26 | | (ii) beginning on June 26, 2006 (the effective date |
|
| | 10000SB1707ham003 | - 13 - | LRB100 11322 SMS 40947 a |
|
|
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 |
16 | | individual policy of accident and health insurance or a |
17 | | qualified health plan offered through the health insurance |
18 | | marketplace may not count toward the number
of outpatient |
19 | | visits required to be covered under this Section an outpatient
|
20 | | visit for the purpose of medication management and shall cover |
21 | | the outpatient
visits under the same terms and conditions as it |
22 | | covers outpatient visits for
the treatment of physical illness.
|
23 | | (5.5) An individual or group health benefit plan amended, |
24 | | delivered, issued, or renewed on or after the effective date of |
25 | | this amendatory Act of the 99th General Assembly shall offer |
26 | | coverage for medically necessary acute treatment services and |
|
| | 10000SB1707ham003 | - 14 - | LRB100 11322 SMS 40947 a |
|
|
1 | | medically necessary clinical stabilization services. The |
2 | | treating provider shall base all treatment recommendations and |
3 | | the health benefit plan shall base all medical necessity |
4 | | determinations for substance use disorders in accordance with |
5 | | the most current edition of the Treatment Criteria for |
6 | | Addictive, Substance-Related, and Co-Occurring Conditions |
7 | | established by the American Society of Addiction Medicine |
8 | | Patient Placement Criteria . The treating provider shall base |
9 | | all treatment recommendations and the health benefit plan shall |
10 | | base all medical necessity determinations for |
11 | | medication-assisted treatment in accordance with the most |
12 | | current Treatment Criteria for Addictive, Substance-Related, |
13 | | and Co-Occurring Conditions established by the American |
14 | | Society of Addiction Medicine. |
15 | | As used in this subsection: |
16 | | "Acute treatment services" means 24-hour medically |
17 | | supervised addiction treatment that provides evaluation and |
18 | | withdrawal management and may include biopsychosocial |
19 | | assessment, individual and group counseling, psychoeducational |
20 | | groups, and discharge planning. |
21 | | "Clinical stabilization services" means 24-hour treatment, |
22 | | usually following acute treatment services for substance |
23 | | abuse, which may include intensive education and counseling |
24 | | regarding the nature of addiction and its consequences, relapse |
25 | | prevention, outreach to families and significant others, and |
26 | | aftercare planning for individuals beginning to engage in |
|
| | 10000SB1707ham003 | - 15 - | LRB100 11322 SMS 40947 a |
|
|
1 | | recovery from addiction. |
2 | | (6) An issuer of a group health benefit
plan may provide or |
3 | | offer coverage required under this Section through a
managed |
4 | | care plan.
|
5 | | (6.5) An individual or group health benefit plan amended, |
6 | | delivered, issued, or renewed on or after the effective date of |
7 | | this amendatory Act of the 100th General Assembly: |
8 | | (A) shall not impose prior authorization requirements, |
9 | | other than those established under the Treatment Criteria |
10 | | for Addictive, Substance-Related, and Co-Occurring |
11 | | Conditions established by the American Society of |
12 | | Addiction Medicine, on a prescription medication approved |
13 | | by the United States Food and Drug Administration that is |
14 | | prescribed or administered for the treatment of substance |
15 | | use disorders; |
16 | | (B) shall not impose any step therapy 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, before authorizing coverage for a |
21 | | prescription medication approved by the United States Food |
22 | | and Drug Administration that is prescribed or administered |
23 | | for the treatment of substance use disorders; |
24 | | (C) shall place all prescription medications approved |
25 | | by the United States Food and Drug Administration |
26 | | prescribed or administered for the treatment of substance |
|
| | 10000SB1707ham003 | - 16 - | LRB100 11322 SMS 40947 a |
|
|
1 | | use disorders on, for brand medications, the lowest tier of |
2 | | the drug formulary developed and maintained by the |
3 | | individual or group health benefit plan that covers brand |
4 | | medications and, for generic medications, the lowest tier |
5 | | of the drug formulary developed and maintained by the |
6 | | individual or group health benefit plan that covers generic |
7 | | medications; and |
8 | | (D) shall not exclude coverage for a prescription |
9 | | medication approved by the United States Food and Drug |
10 | | Administration for the treatment of substance use |
11 | | disorders and any associated counseling or wraparound |
12 | | services on the grounds that such medications and services |
13 | | were court ordered. |
14 | | (7) (Blank).
|
15 | | (8)
(Blank).
|
16 | | (9) With respect to all mental, emotional, nervous, or |
17 | | substance use disorders or conditions , coverage for inpatient |
18 | | treatment shall include coverage for treatment in a residential |
19 | | treatment center certified or licensed by the Department of |
20 | | Public Health or the Department of Human Services. |
21 | | (c) This Section shall not be interpreted to require |
22 | | coverage for speech therapy or other habilitative services for |
23 | | those individuals covered under Section 356z.15
of this Code. |
24 | | (d) With respect to a group or individual policy of |
25 | | accident and health insurance or a qualified health plan |
26 | | offered through the health insurance marketplace, the |
|
| | 10000SB1707ham003 | - 17 - | LRB100 11322 SMS 40947 a |
|
|
1 | | Department and, with respect to medical assistance, the |
2 | | Department of Healthcare and Family Services shall each enforce |
3 | | the requirements of this Section and Sections 356z.23 and |
4 | | 370c.1 of this Code, the Paul Wellstone and Pete Domenici |
5 | | Mental Health Parity and Addiction Equity Act of 2008, 42 |
6 | | U.S.C. 18031(j), and any amendments to, and federal guidance or |
7 | | regulations issued under, those Acts, including, but not |
8 | | limited to, final regulations issued under the Paul Wellstone |
9 | | and Pete Domenici Mental Health Parity and Addiction Equity Act |
10 | | of 2008 and final regulations applying the Paul Wellstone and |
11 | | Pete Domenici Mental Health Parity and Addiction Equity Act of |
12 | | 2008 to Medicaid managed care organizations, the Children's |
13 | | Health Insurance Program, and alternative benefit plans. |
14 | | Specifically, the Department and the Department of Healthcare |
15 | | and Family Services shall take action: |
16 | | (1) proactively ensuring compliance by individual and |
17 | | group policies, including by requiring that insurers |
18 | | submit comparative analyses, as set forth in paragraph (6) |
19 | | of subsection (k) of Section 370c.1, demonstrating how they |
20 | | design and apply nonquantitative treatment limitations, |
21 | | both as written and in operation, for mental, emotional, |
22 | | nervous, or substance use disorder or condition benefits as |
23 | | compared to how they design and apply nonquantitative |
24 | | treatment limitations, as written and in operation, for |
25 | | medical and surgical benefits; |
26 | | (2) evaluating all consumer or provider complaints |
|
| | 10000SB1707ham003 | - 18 - | LRB100 11322 SMS 40947 a |
|
|
1 | | regarding mental, emotional, nervous, or substance use |
2 | | disorder or condition coverage for possible parity |
3 | | violations; |
4 | | (3) performing parity compliance market conduct |
5 | | examinations or, in the case of the Department of |
6 | | Healthcare and Family Services, parity compliance audits |
7 | | of individual and group plans and policies, including, but |
8 | | not limited to, reviews of: |
9 | | (A) nonquantitative treatment limitations, |
10 | | including, but not limited to, prior authorization |
11 | | requirements, concurrent review, retrospective review, |
12 | | step therapy, network admission standards, |
13 | | reimbursement rates, and geographic restrictions; |
14 | | (B) denials of authorization, payment, and |
15 | | coverage; and |
16 | | (C) other specific criteria as may be determined by |
17 | | the Department. |
18 | | The findings and the conclusions of the parity compliance |
19 | | market conduct examinations and audits shall be made public. |
20 | | The Director may adopt rules to effectuate any provisions |
21 | | of the Paul Wellstone and Pete Domenici Mental Health Parity |
22 | | and Addiction Equity Act of 2008 that relate to the business of |
23 | | insurance. |
24 | | (d) The Department shall enforce the requirements of State |
25 | | and federal parity law, which includes ensuring compliance by |
26 | | individual and group policies; detecting violations of the law |
|
| | 10000SB1707ham003 | - 19 - | LRB100 11322 SMS 40947 a |
|
|
1 | | by individual and group policies proactively monitoring |
2 | | discriminatory practices; accepting, evaluating, and |
3 | | responding to complaints regarding such violations; and |
4 | | ensuring violations are appropriately remedied and deterred. |
5 | | (e) Availability of plan information. |
6 | | (1) The criteria for medical necessity determinations |
7 | | made under a group health plan , an individual policy of |
8 | | accident and health insurance, or a qualified health plan |
9 | | offered through the health insurance marketplace with |
10 | | respect to mental health or substance use disorder benefits |
11 | | (or health insurance coverage offered in connection with |
12 | | the plan with respect to such benefits) must be made |
13 | | available by the plan administrator (or the health |
14 | | insurance issuer offering such coverage) to any current or |
15 | | potential participant, beneficiary, or contracting |
16 | | provider upon request. |
17 | | (2) The reason for any denial under a group health |
18 | | benefit plan , an individual policy of accident and health |
19 | | insurance, or a qualified health plan offered through the |
20 | | health insurance marketplace (or health insurance coverage |
21 | | offered in connection with such plan or policy ) of |
22 | | reimbursement or payment for services with respect to |
23 | | mental , emotional, nervous, health or substance use |
24 | | disorders or conditions disorder benefits in the case of |
25 | | any participant or beneficiary must be made available |
26 | | within a reasonable time and in a reasonable manner and in |
|
| | 10000SB1707ham003 | - 20 - | LRB100 11322 SMS 40947 a |
|
|
1 | | readily understandable language by the plan administrator |
2 | | (or the health insurance issuer offering such coverage) to |
3 | | the participant or beneficiary upon request. |
4 | | (f) As used in this Section, "group policy of accident and |
5 | | health insurance" and "group health benefit plan" includes (1) |
6 | | State-regulated employer-sponsored group health insurance |
7 | | plans written in Illinois or which purport to provide coverage |
8 | | for a resident of this State; and (2) State employee health |
9 | | plans. |
10 | | (Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.) |
11 | | (215 ILCS 5/370c.1) |
12 | | Sec. 370c.1. Mental , emotional, nervous, or substance use |
13 | | disorder or condition health and addiction parity. |
14 | | (a) On and after the effective date of this amendatory Act |
15 | | of the 99th General Assembly, every insurer that amends, |
16 | | delivers, issues, or renews a group or individual policy of |
17 | | accident and health insurance or a qualified health plan |
18 | | offered through the Health Insurance Marketplace in this State |
19 | | providing coverage for hospital or medical treatment and for |
20 | | the treatment of mental, emotional, nervous, or substance use |
21 | | disorders or conditions shall ensure that: |
22 | | (1) the financial requirements applicable to such |
23 | | mental, emotional, nervous, or substance use disorder or |
24 | | condition benefits are no more restrictive than the |
25 | | predominant financial requirements applied to |
|
| | 10000SB1707ham003 | - 21 - | LRB100 11322 SMS 40947 a |
|
|
1 | | substantially all hospital and medical benefits covered by |
2 | | the policy and that there are no separate cost-sharing |
3 | | requirements that are applicable only with respect to |
4 | | mental, emotional, nervous, or substance use disorder or |
5 | | condition benefits; and |
6 | | (2) the treatment limitations applicable to such |
7 | | mental, emotional, nervous, or substance use disorder or |
8 | | condition benefits are no more restrictive than the |
9 | | predominant treatment limitations applied to substantially |
10 | | all hospital and medical benefits covered by the policy and |
11 | | that there are no separate treatment limitations that are |
12 | | applicable only with respect to mental, emotional, |
13 | | nervous, or substance use disorder or condition benefits. |
14 | | (b) The following provisions shall apply concerning |
15 | | aggregate lifetime limits: |
16 | | (1) In the case of a group or individual policy of |
17 | | accident and health insurance or a qualified health plan |
18 | | offered through the Health Insurance Marketplace amended, |
19 | | delivered, issued, or renewed in this State on or after the |
20 | | effective date of this amendatory Act of the 99th General |
21 | | Assembly that provides coverage for hospital or medical |
22 | | treatment and for the treatment of mental, emotional, |
23 | | nervous, or substance use disorders or conditions the |
24 | | following provisions shall apply: |
25 | | (A) if the policy does not include an aggregate |
26 | | lifetime limit on substantially all hospital and |
|
| | 10000SB1707ham003 | - 22 - | LRB100 11322 SMS 40947 a |
|
|
1 | | medical benefits, then the policy may not impose any |
2 | | aggregate lifetime limit on mental, emotional, |
3 | | nervous, or substance use disorder or condition |
4 | | benefits; or |
5 | | (B) if the policy includes an aggregate lifetime |
6 | | limit on substantially all hospital and medical |
7 | | benefits (in this subsection referred to as the |
8 | | "applicable lifetime limit"), then the policy shall |
9 | | either: |
10 | | (i) apply the applicable lifetime limit both |
11 | | to the hospital and medical benefits to which it |
12 | | otherwise would apply and to mental, emotional, |
13 | | nervous, or substance use disorder or condition |
14 | | benefits and not distinguish in the application of |
15 | | the limit between the hospital and medical |
16 | | benefits and mental, emotional, nervous, or |
17 | | substance use disorder or condition benefits; or |
18 | | (ii) not include any aggregate lifetime limit |
19 | | on mental, emotional, nervous, or substance use |
20 | | disorder or condition benefits that is less than |
21 | | the applicable lifetime limit. |
22 | | (2) In the case of a policy that is not described in |
23 | | paragraph (1) of subsection (b) of this Section and that |
24 | | includes no or different aggregate lifetime limits on |
25 | | different categories of hospital and medical benefits, the |
26 | | Director shall establish rules under which subparagraph |
|
| | 10000SB1707ham003 | - 23 - | LRB100 11322 SMS 40947 a |
|
|
1 | | (B) of paragraph (1) of subsection (b) of this Section is |
2 | | applied to such policy with respect to mental, emotional, |
3 | | nervous, or substance use disorder or condition benefits by |
4 | | substituting for the applicable lifetime limit an average |
5 | | aggregate lifetime limit that is computed taking into |
6 | | account the weighted average of the aggregate lifetime |
7 | | limits applicable to such categories. |
8 | | (c) The following provisions shall apply concerning annual |
9 | | limits: |
10 | | (1) In the case of a group or individual policy of |
11 | | accident and health insurance or a qualified health plan |
12 | | offered through the Health Insurance Marketplace amended, |
13 | | delivered, issued, or renewed in this State on or after the |
14 | | effective date of this amendatory Act of the 99th General |
15 | | Assembly that provides coverage for hospital or medical |
16 | | treatment and for the treatment of mental, emotional, |
17 | | nervous, or substance use disorders or conditions the |
18 | | following provisions shall apply: |
19 | | (A) if the policy does not include an annual limit |
20 | | on substantially all hospital and medical benefits, |
21 | | then the policy may not impose any annual limits on |
22 | | mental, emotional, nervous, or substance use disorder |
23 | | or condition benefits; or |
24 | | (B) if the policy includes an annual limit on |
25 | | substantially all hospital and medical benefits (in |
26 | | this subsection referred to as the "applicable annual |
|
| | 10000SB1707ham003 | - 24 - | LRB100 11322 SMS 40947 a |
|
|
1 | | limit"), then the policy shall either: |
2 | | (i) apply the applicable annual limit both to |
3 | | the hospital and medical benefits to which it |
4 | | otherwise would apply and to mental, emotional, |
5 | | nervous, or substance use disorder or condition |
6 | | benefits and not distinguish in the application of |
7 | | the limit between the hospital and medical |
8 | | benefits and mental, emotional, nervous, or |
9 | | substance use disorder or condition benefits; or |
10 | | (ii) not include any annual limit on mental, |
11 | | emotional, nervous, or substance use disorder or |
12 | | condition benefits that is less than the |
13 | | applicable annual limit. |
14 | | (2) In the case of a policy that is not described in |
15 | | paragraph (1) of subsection (c) of this Section and that |
16 | | includes no or different annual limits on different |
17 | | categories of hospital and medical benefits, the Director |
18 | | shall establish rules under which subparagraph (B) of |
19 | | paragraph (1) of subsection (c) of this Section is applied |
20 | | to such policy with respect to mental, emotional, nervous, |
21 | | or substance use disorder or condition benefits by |
22 | | substituting for the applicable annual limit an average |
23 | | annual limit that is computed taking into account the |
24 | | weighted average of the annual limits applicable to such |
25 | | categories. |
26 | | (d) With respect to mental, emotional, nervous, or |
|
| | 10000SB1707ham003 | - 25 - | LRB100 11322 SMS 40947 a |
|
|
1 | | substance use disorders or conditions , an insurer shall use |
2 | | policies and procedures for the election and placement of |
3 | | mental, emotional, nervous, or substance use disorder or |
4 | | condition substance abuse treatment drugs on their formulary |
5 | | that are no less favorable to the insured as those policies and |
6 | | procedures the insurer uses for the selection and placement of |
7 | | other drugs for medical or surgical conditions and shall follow |
8 | | the expedited coverage determination requirements for |
9 | | substance abuse treatment drugs set forth in Section 45.2 of |
10 | | the Managed Care Reform and Patient Rights Act. |
11 | | (e) This Section shall be interpreted in a manner |
12 | | consistent with all applicable federal parity regulations |
13 | | including, but not limited to, the Paul Wellstone and Pete |
14 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 , |
15 | | final regulations issued under the Paul Wellstone and Pete |
16 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 |
17 | | and final regulations applying the Paul Wellstone and Pete |
18 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 |
19 | | to Medicaid managed care organizations, the Children's Health |
20 | | Insurance Program, and alternative benefit plans at 78 FR |
21 | | 68240 . |
22 | | (f) The provisions of subsections (b) and (c) of this |
23 | | Section shall not be interpreted to allow the use of lifetime |
24 | | or annual limits otherwise prohibited by State or federal law. |
25 | | (g) As used in this Section: |
26 | | "Financial requirement" includes deductibles, copayments, |
|
| | 10000SB1707ham003 | - 26 - | LRB100 11322 SMS 40947 a |
|
|
1 | | coinsurance, and out-of-pocket maximums, but does not include |
2 | | an aggregate lifetime limit or an annual limit subject to |
3 | | subsections (b) and (c). |
4 | | "Mental, emotional, nervous, or substance use disorder or |
5 | | condition" means a condition or disorder that involves a mental |
6 | | health condition or substance use disorder that falls under any |
7 | | of the diagnostic categories listed in the mental and |
8 | | behavioral disorders chapter of the current edition of the |
9 | | International Classification of Disease or that is listed in |
10 | | the most recent version of the Diagnostic and Statistical |
11 | | Manual of Mental Disorders. |
12 | | "Treatment limitation" includes limits on benefits based |
13 | | on the frequency of treatment, number of visits, days of |
14 | | coverage, days in a waiting period, or other similar limits on |
15 | | the scope or duration of treatment. "Treatment limitation" |
16 | | includes both quantitative treatment limitations, which are |
17 | | expressed numerically (such as 50 outpatient visits per year), |
18 | | and nonquantitative treatment limitations, which otherwise |
19 | | limit the scope or duration of treatment. A permanent exclusion |
20 | | of all benefits for a particular condition or disorder shall |
21 | | not be considered a treatment limitation. "Nonquantitative |
22 | | treatment" means those limitations as described under federal |
23 | | regulations (26 CFR 54.9812-1). "Nonquantitative treatment |
24 | | limitations" include, but are not limited to, those limitations |
25 | | described under federal regulations 26 CFR 54.9812-1, 29 CFR |
26 | | 2590.712, and 45 CFR 146.136.
|
|
| | 10000SB1707ham003 | - 27 - | LRB100 11322 SMS 40947 a |
|
|
1 | | (h) The Department of Insurance shall implement the |
2 | | following education initiatives: |
3 | | (1) By January 1, 2016, the Department shall develop a |
4 | | plan for a Consumer Education Campaign on parity. The |
5 | | Consumer Education Campaign shall focus its efforts |
6 | | throughout the State and include trainings in the northern, |
7 | | southern, and central regions of the State, as defined by |
8 | | the Department, as well as each of the 5 managed care |
9 | | regions of the State as identified by the Department of |
10 | | Healthcare and Family Services. Under this Consumer |
11 | | Education Campaign, the Department shall: (1) by January 1, |
12 | | 2017, provide at least one live training in each region on |
13 | | parity for consumers and providers and one webinar training |
14 | | to be posted on the Department website and (2) establish a |
15 | | consumer hotline to assist consumers in navigating the |
16 | | parity process by March 1, 2017 2016 . By January 1, 2018 |
17 | | the Department shall issue a report to the General Assembly |
18 | | on the success of the Consumer Education Campaign, which |
19 | | shall indicate whether additional training is necessary or |
20 | | would be recommended. |
21 | | (2) The Department, in coordination with the |
22 | | Department of Human Services and the Department of |
23 | | Healthcare and Family Services, shall convene a working |
24 | | group of health care insurance carriers, mental health |
25 | | advocacy groups, substance abuse patient advocacy groups, |
26 | | and mental health physician groups for the purpose of |
|
| | 10000SB1707ham003 | - 28 - | LRB100 11322 SMS 40947 a |
|
|
1 | | discussing issues related to the treatment and coverage of |
2 | | mental, emotional, nervous, or substance use abuse |
3 | | disorders or conditions and compliance with parity |
4 | | obligations under State and federal law. Compliance shall |
5 | | be measured, tracked, and shared during the meetings of the |
6 | | working group and mental illness . The working group shall |
7 | | meet once before January 1, 2016 and shall meet |
8 | | semiannually thereafter. The Department shall issue an |
9 | | annual report to the General Assembly that includes a list |
10 | | of the health care insurance carriers, mental health |
11 | | advocacy groups, substance abuse patient advocacy groups, |
12 | | and mental health physician groups that participated in the |
13 | | working group meetings, details on the issues and topics |
14 | | covered, and any legislative recommendations developed by |
15 | | the working group . |
16 | | (3) Not later than August 1 of each year, the |
17 | | Department, in conjunction with the Department of |
18 | | Healthcare and Family Services, shall issue a joint report |
19 | | to the General Assembly and provide an educational |
20 | | presentation to the General Assembly. The report and |
21 | | presentation shall: |
22 | | (A) Cover the methodology the Departments use to |
23 | | check for compliance with the federal Paul Wellstone |
24 | | and Pete Domenici Mental Health Parity and Addiction |
25 | | Equity Act of 2008, 42 U.S.C. 18031(j), and any federal |
26 | | regulations or guidance relating to the compliance and |
|
| | 10000SB1707ham003 | - 29 - | LRB100 11322 SMS 40947 a |
|
|
1 | | oversight of the federal Paul Wellstone and Pete |
2 | | Domenici Mental Health Parity and Addiction Equity Act |
3 | | of 2008 and 42 U.S.C. 18031(j). |
4 | | (B) Cover the methodology the Departments use to |
5 | | check for compliance with this Section and Sections |
6 | | 356z.23 and 370c of this Code. |
7 | | (C) Identify market conduct examinations or, in |
8 | | the case of the Department of Healthcare and Family |
9 | | Services, audits conducted or completed during the |
10 | | preceding 12-month period regarding compliance with |
11 | | parity in mental, emotional, nervous, and substance |
12 | | use disorder or condition benefits under State and |
13 | | federal laws and summarize the results of such market |
14 | | conduct examinations and audits. This shall include: |
15 | | (i) the number of market conduct examinations |
16 | | and audits initiated and completed; |
17 | | (ii) the benefit classifications examined by |
18 | | each market conduct examination and audit; |
19 | | (iii) the subject matter of each market |
20 | | conduct examination and audit, including |
21 | | quantitative and non-quantitative treatment |
22 | | limitations; and |
23 | | (iv) a summary of the basis for the final |
24 | | decision rendered in each market conduct |
25 | | examination and audit. |
26 | | Individually identifiable information shall be |
|
| | 10000SB1707ham003 | - 30 - | LRB100 11322 SMS 40947 a |
|
|
1 | | excluded from the reports consistent with federal |
2 | | privacy protections. |
3 | | (D) Detail any educational or corrective actions |
4 | | the Departments have taken to ensure compliance with |
5 | | the federal Paul Wellstone and Pete Domenici Mental |
6 | | Health Parity and Addiction Equity Act of 2008, 42 |
7 | | U.S.C. 18031(j), this Section, and Sections 356z.23 |
8 | | and 370c of this Code. |
9 | | (E) The report must be written in non-technical, |
10 | | readily understandable language and shall be made |
11 | | available to the public by, among such other means as |
12 | | the Departments find appropriate, posting the report |
13 | | on the Departments' websites. |
14 | | (i) The Parity Advancement Education Fund is created as a |
15 | | special fund in the State treasury. Moneys from fines and |
16 | | penalties collected from insurers for violations of this |
17 | | Section shall be deposited into the Fund. Moneys deposited into |
18 | | the Fund for appropriation by the General Assembly to the |
19 | | Department of Insurance shall be used for the purpose of |
20 | | providing financial support of the Consumer Education |
21 | | Campaign , parity compliance advocacy, and other initiatives |
22 | | that support parity implementation and enforcement on behalf of |
23 | | consumers . |
24 | | (j) The Department of Insurance and the Department of |
25 | | Healthcare and Family Services shall convene and provide |
26 | | technical support to a workgroup of 11 members that shall be |
|
| | 10000SB1707ham003 | - 31 - | LRB100 11322 SMS 40947 a |
|
|
1 | | comprised of 3 mental health parity experts recommended by an |
2 | | organization advocating on behalf of mental health parity |
3 | | appointed by the President of the Senate; 3 behavioral health |
4 | | providers recommended by an organization that represents |
5 | | behavioral health providers appointed by the Speaker of the |
6 | | House of Representatives; 2 representing Medicaid managed care |
7 | | organizations recommended by an organization that represents |
8 | | Medicaid managed care plans appointed by the Minority Leader of |
9 | | the House of Representatives; 2 representing commercial |
10 | | insurers recommended by an organization that represents |
11 | | insurers appointed by the Minority Leader of the Senate; and a |
12 | | representative of an organization that represents Medicaid |
13 | | managed care plans appointed by the Governor. |
14 | | The workgroup shall provide recommendations to the General |
15 | | Assembly on health plan data reporting requirements that |
16 | | separately break out data on mental, emotional, nervous, or |
17 | | substance use disorder or condition benefits and data on other |
18 | | medical benefits, including physical health and related health |
19 | | services no later than December 31, 2019. The recommendations |
20 | | to the General Assembly shall be filed with the Clerk of the |
21 | | House of Representatives and the Secretary of the Senate in |
22 | | electronic form only, in the manner that the Clerk and the |
23 | | Secretary shall direct. This workgroup shall take into account |
24 | | federal requirements and recommendations on mental health |
25 | | parity reporting for the Medicaid program. This workgroup shall |
26 | | also develop the format and provide any needed definitions for |
|
| | 10000SB1707ham003 | - 32 - | LRB100 11322 SMS 40947 a |
|
|
1 | | reporting requirements in subsection (k). The research and |
2 | | evaluation of the working group shall include, but not be |
3 | | limited to: |
4 | | (1) claims denials due to benefit limits, if |
5 | | applicable; |
6 | | (2) administrative denials for no prior authorization; |
7 | | (3) denials due to not meeting medical necessity; |
8 | | (4) denials that went to external review and whether |
9 | | they were upheld or overturned for medical necessity; |
10 | | (5) out-of-network claims; |
11 | | (6) emergency care claims; |
12 | | (7) network directory providers in the outpatient |
13 | | benefits classification who filed no claims in the last 6 |
14 | | months, if applicable; |
15 | | (8) the impact of existing and pertinent limitations |
16 | | and restrictions related to approved services, licensed |
17 | | providers, reimbursement levels, and reimbursement |
18 | | methodologies within the Division of Mental Health, the |
19 | | Division of Substance Use Prevention and Recovery |
20 | | programs, the Department of Healthcare and Family |
21 | | Services, and, to the extent possible, federal regulations |
22 | | and law; and |
23 | | (9) when reporting and publishing should begin. |
24 | | Representatives from the Department of Healthcare and |
25 | | Family Services, representatives from the Division of Mental |
26 | | Health, and representatives from the Division of Substance Use |
|
| | 10000SB1707ham003 | - 33 - | LRB100 11322 SMS 40947 a |
|
|
1 | | Prevention and Recovery shall provide technical advice to the |
2 | | workgroup. |
3 | | (k) An insurer that amends, delivers, issues, or renews a |
4 | | group or individual policy of accident and health insurance or |
5 | | a qualified health plan offered through the health insurance |
6 | | marketplace in this State providing coverage for hospital or |
7 | | medical treatment and for the treatment of mental, emotional, |
8 | | nervous, or substance use disorders or conditions shall submit |
9 | | an annual report, the format and definitions for which will be |
10 | | developed by the workgroup in subsection (j), to the |
11 | | Department, or, with respect to medical assistance, the |
12 | | Department of Healthcare and Family Services starting on or |
13 | | before July 1, 2020 that contains the following information |
14 | | separately for inpatient in-network benefits, inpatient |
15 | | out-of-network benefits, outpatient in-network benefits, |
16 | | outpatient out-of-network benefits, emergency care benefits, |
17 | | and prescription drug benefits in the case of accident and |
18 | | health insurance or qualified health plans, or inpatient, |
19 | | outpatient, emergency care, and prescription drug benefits in |
20 | | the case of medical assistance: |
21 | | (1) A summary of the plan's pharmacy management |
22 | | processes for mental, emotional, nervous, or substance use |
23 | | disorder or condition benefits compared to those for other |
24 | | medical benefits. |
25 | | (2) A summary of the internal processes of review for |
26 | | experimental benefits and unproven technology for mental, |
|
| | 10000SB1707ham003 | - 34 - | LRB100 11322 SMS 40947 a |
|
|
1 | | emotional, nervous, or substance use disorder or condition |
2 | | benefits and those for
other medical benefits. |
3 | | (3) A summary of how the plan's policies and procedures |
4 | | for utilization management for mental, emotional, nervous, |
5 | | or substance use disorder or condition benefits compare to |
6 | | those for other medical benefits. |
7 | | (4) A description of the process used to develop or |
8 | | select the medical necessity criteria for mental, |
9 | | emotional, nervous, or substance use disorder or condition |
10 | | benefits and the process used to develop or select the |
11 | | medical necessity criteria for medical and surgical |
12 | | benefits. |
13 | | (5) Identification of all nonquantitative treatment |
14 | | limitations that are applied to both mental, emotional, |
15 | | nervous, or substance use disorder or condition benefits |
16 | | and medical and surgical benefits within each |
17 | | classification of benefits. |
18 | | (6) The results of an analysis that demonstrates that |
19 | | for the medical necessity criteria described in |
20 | | subparagraph (A) and for each nonquantitative treatment |
21 | | limitation identified in subparagraph (B), as written and |
22 | | in operation, the processes, strategies, evidentiary |
23 | | standards, or other factors used in applying the medical |
24 | | necessity criteria and each nonquantitative treatment |
25 | | limitation to mental, emotional, nervous, or substance use |
26 | | disorder or condition benefits within each classification |
|
| | 10000SB1707ham003 | - 35 - | LRB100 11322 SMS 40947 a |
|
|
1 | | of benefits are comparable to, and are applied no more |
2 | | stringently than, the processes, strategies, evidentiary |
3 | | standards, or other factors used in applying the medical |
4 | | necessity criteria and each nonquantitative treatment |
5 | | limitation to medical and surgical benefits within the |
6 | | corresponding classification of benefits; at a minimum, |
7 | | the results of the analysis shall: |
8 | | (A) identify the factors used to determine that a |
9 | | nonquantitative treatment limitation applies to a |
10 | | benefit, including factors that were considered but |
11 | | rejected; |
12 | | (B) identify and define the specific evidentiary |
13 | | standards used to define the factors and any other |
14 | | evidence relied upon in designing each nonquantitative |
15 | | treatment limitation; |
16 | | (C) provide the comparative analyses, including |
17 | | the results of the analyses, performed to determine |
18 | | that the processes and strategies used to design each |
19 | | nonquantitative treatment limitation, as written, for |
20 | | mental, emotional, nervous, or substance use disorder |
21 | | or condition benefits are comparable to, and are |
22 | | applied no more stringently than, the processes and |
23 | | strategies used to design each nonquantitative |
24 | | treatment limitation, as written, for medical and |
25 | | surgical benefits; |
26 | | (D) provide the comparative analyses, including |
|
| | 10000SB1707ham003 | - 36 - | LRB100 11322 SMS 40947 a |
|
|
1 | | the results of the analyses, performed to determine |
2 | | that the processes and strategies used to apply each |
3 | | nonquantitative treatment limitation, in operation, |
4 | | for mental, emotional, nervous, or substance use |
5 | | disorder or condition benefits are comparable to, and |
6 | | applied no more stringently than, the processes or |
7 | | strategies used to apply each nonquantitative |
8 | | treatment limitation, in operation, for medical and |
9 | | surgical benefits; and |
10 | | (E) disclose the specific findings and conclusions |
11 | | reached by the insurer that the results of the analyses |
12 | | described in subparagraphs (C) and (D) indicate that |
13 | | the insurer is in compliance with this Section and the |
14 | | Mental Health Parity and Addiction Equity Act of 2008 |
15 | | and its implementing regulations, which includes 42 |
16 | | CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any |
17 | | other related federal regulations found in the Code of |
18 | | Federal Regulations. |
19 | | (7) Any other information necessary to clarify data |
20 | | provided in accordance with this Section requested by the |
21 | | Director, including information that may be proprietary or |
22 | | have commercial value, under the requirements of Section 30 |
23 | | of the Viatical Settlements Act of 2009. |
24 | | (l) An insurer that amends, delivers, issues, or renews a |
25 | | group or individual policy of accident and health insurance or |
26 | | a qualified health plan offered through the health insurance |
|
| | 10000SB1707ham003 | - 37 - | LRB100 11322 SMS 40947 a |
|
|
1 | | marketplace in this State providing coverage for hospital or |
2 | | medical treatment and for the treatment of mental, emotional, |
3 | | nervous, or substance use disorders or conditions on or after |
4 | | the effective date of this amendatory Act of the 100th General |
5 | | Assembly shall, in advance of the plan year, make available to |
6 | | the Department or, with respect to medical assistance, the |
7 | | Department of Healthcare and Family Services and to all plan |
8 | | participants and beneficiaries the information required in |
9 | | subparagraphs (C) through (E) of paragraph (6) of subsection |
10 | | (k). For plan participants and medical assistance |
11 | | beneficiaries, the information required in subparagraphs (C) |
12 | | through (E) of paragraph (6) of subsection (k) shall be made |
13 | | available on a publicly-available website whose web address is |
14 | | prominently displayed in plan and managed care organization |
15 | | informational and marketing materials. |
16 | | (m) In conjunction with its compliance examination program |
17 | | conducted in accordance with the Illinois State Auditing Act, |
18 | | the Auditor General shall undertake a review of
compliance by |
19 | | the Department and the Department of Healthcare and Family |
20 | | Services with Section 370c and this Section. Any
findings |
21 | | resulting from the review conducted under this Section shall be |
22 | | included in the applicable State agency's compliance |
23 | | examination report. Each compliance examination report shall |
24 | | be issued in accordance with Section 3-14 of the Illinois State
|
25 | | Auditing Act. A copy of each report shall also be delivered to
|
26 | | the head of the applicable State agency and posted on the |