100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB2440

 

Introduced 1/30/2018, by Sen. Julie A. Morrison

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c.1

    Amends the Illinois Insurance Code. Provides than an insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan that provides coverage for hospital or medical treatment and for treatment of a mental, emotional, nervous, or substance use disorder or condition shall submit an annual report to the Department of Insurance or, with respect to medical assistance, the Department of Healthcare and Family Services on or before March 1 containing specific information. Provides that the Director of Insurance cannot certify an insurer's policy if the insurer fails to submit all specific information required.


LRB100 16053 SMS 31172 b

 

 

A BILL FOR

 

SB2440LRB100 16053 SMS 31172 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.1 as follows:
 
6    (215 ILCS 5/370c.1)
7    Sec. 370c.1. Mental health and addiction parity.
8    (a) On and after the effective date of this amendatory Act
9of the 99th General Assembly, every insurer that amends,
10delivers, issues, or renews a group or individual policy of
11accident and health insurance or a qualified health plan
12offered through the Health Insurance Marketplace in this State
13providing coverage for hospital or medical treatment and for
14the treatment of mental, emotional, nervous, or substance use
15disorders or conditions shall ensure that:
16        (1) the financial requirements applicable to such
17    mental, emotional, nervous, or substance use disorder or
18    condition benefits are no more restrictive than the
19    predominant financial requirements applied to
20    substantially all hospital and medical benefits covered by
21    the policy and that there are no separate cost-sharing
22    requirements that are applicable only with respect to
23    mental, emotional, nervous, or substance use disorder or

 

 

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1    condition benefits; and
2        (2) the treatment limitations applicable to such
3    mental, emotional, nervous, or substance use disorder or
4    condition benefits are no more restrictive than the
5    predominant treatment limitations applied to substantially
6    all hospital and medical benefits covered by the policy and
7    that there are no separate treatment limitations that are
8    applicable only with respect to mental, emotional,
9    nervous, or substance use disorder or condition benefits.
10    (b) The following provisions shall apply concerning
11aggregate lifetime limits:
12        (1) In the case of a group or 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 in this State on or after the
16    effective date of this amendatory Act of the 99th General
17    Assembly that provides coverage for hospital or medical
18    treatment and for the treatment of mental, emotional,
19    nervous, or substance use disorders or conditions the
20    following provisions shall apply:
21            (A) if the policy does not include an aggregate
22        lifetime limit on substantially all hospital and
23        medical benefits, then the policy may not impose any
24        aggregate lifetime limit on mental, emotional,
25        nervous, or substance use disorder or condition
26        benefits; or

 

 

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1            (B) if the policy includes an aggregate lifetime
2        limit on substantially all hospital and medical
3        benefits (in this subsection referred to as the
4        "applicable lifetime limit"), then the policy shall
5        either:
6                (i) apply the applicable lifetime limit both
7            to the hospital and medical benefits to which it
8            otherwise would apply and to mental, emotional,
9            nervous, or substance use disorder or condition
10            benefits and not distinguish in the application of
11            the limit between the hospital and medical
12            benefits and mental, emotional, nervous, or
13            substance use disorder or condition benefits; or
14                (ii) not include any aggregate lifetime limit
15            on mental, emotional, nervous, or substance use
16            disorder or condition benefits that is less than
17            the applicable lifetime limit.
18        (2) In the case of a policy that is not described in
19    paragraph (1) of subsection (b) of this Section and that
20    includes no or different aggregate lifetime limits on
21    different categories of hospital and medical benefits, the
22    Director shall establish rules under which subparagraph
23    (B) of paragraph (1) of subsection (b) of this Section is
24    applied to such policy with respect to mental, emotional,
25    nervous, or substance use disorder or condition benefits by
26    substituting for the applicable lifetime limit an average

 

 

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1    aggregate lifetime limit that is computed taking into
2    account the weighted average of the aggregate lifetime
3    limits applicable to such categories.
4    (c) The following provisions shall apply concerning annual
5limits:
6        (1) In the case of a group or individual policy of
7    accident and health insurance or a qualified health plan
8    offered through the Health Insurance Marketplace amended,
9    delivered, issued, or renewed in this State on or after the
10    effective date of this amendatory Act of the 99th General
11    Assembly that provides coverage for hospital or medical
12    treatment and for the treatment of mental, emotional,
13    nervous, or substance use disorders or conditions the
14    following provisions shall apply:
15            (A) if the policy does not include an annual limit
16        on substantially all hospital and medical benefits,
17        then the policy may not impose any annual limits on
18        mental, emotional, nervous, or substance use disorder
19        or condition benefits; or
20            (B) if the policy includes an annual limit on
21        substantially all hospital and medical benefits (in
22        this subsection referred to as the "applicable annual
23        limit"), then the policy shall either:
24                (i) apply the applicable annual limit both to
25            the hospital and medical benefits to which it
26            otherwise would apply and to mental, emotional,

 

 

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1            nervous, or substance use disorder or condition
2            benefits and not distinguish in the application of
3            the limit between the hospital and medical
4            benefits and mental, emotional, nervous, or
5            substance use disorder or condition benefits; or
6                (ii) not include any annual limit on mental,
7            emotional, nervous, or substance use disorder or
8            condition benefits that is less than the
9            applicable annual limit.
10        (2) In the case of a policy that is not described in
11    paragraph (1) of subsection (c) of this Section and that
12    includes no or different annual limits on different
13    categories of hospital and medical benefits, the Director
14    shall establish rules under which subparagraph (B) of
15    paragraph (1) of subsection (c) of this Section is applied
16    to such policy with respect to mental, emotional, nervous,
17    or substance use disorder or condition benefits by
18    substituting for the applicable annual limit an average
19    annual limit that is computed taking into account the
20    weighted average of the annual limits applicable to such
21    categories.
22    (d) With respect to substance use disorders, an insurer
23shall use policies and procedures for the election and
24placement of substance abuse treatment drugs on their formulary
25that are no less favorable to the insured as those policies and
26procedures the insurer uses for the selection and placement of

 

 

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1other drugs and shall follow the expedited coverage
2determination requirements for substance abuse treatment drugs
3set forth in Section 45.2 of the Managed Care Reform and
4Patient Rights Act.
5    (e) This Section shall be interpreted in a manner
6consistent with all applicable federal parity regulations
7including, but not limited to, the Mental Health Parity and
8Addiction Equity Act of 2008 at 78 FR 68240.
9    (f) The provisions of subsections (b) and (c) of this
10Section shall not be interpreted to allow the use of lifetime
11or annual limits otherwise prohibited by State or federal law.
12    (g) As used in this Section:
13    "Financial requirement" includes deductibles, copayments,
14coinsurance, and out-of-pocket maximums, but does not include
15an aggregate lifetime limit or an annual limit subject to
16subsections (b) and (c).
17    "Treatment limitation" includes limits on benefits based
18on the frequency of treatment, number of visits, days of
19coverage, days in a waiting period, or other similar limits on
20the scope or duration of treatment. "Treatment limitation"
21includes both quantitative treatment limitations, which are
22expressed numerically (such as 50 outpatient visits per year),
23and nonquantitative treatment limitations, which otherwise
24limit the scope or duration of treatment. A permanent exclusion
25of all benefits for a particular condition or disorder shall
26not be considered a treatment limitation. "Nonquantitative

 

 

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1treatment" means those limitations as described under federal
2regulations (26 CFR 54.9812-1).
3    (h) The Department of Insurance shall implement the
4following education initiatives:
5        (1) By January 1, 2016, the Department shall develop a
6    plan for a Consumer Education Campaign on parity. The
7    Consumer Education Campaign shall focus its efforts
8    throughout the State and include trainings in the northern,
9    southern, and central regions of the State, as defined by
10    the Department, as well as each of the 5 managed care
11    regions of the State as identified by the Department of
12    Healthcare and Family Services. Under this Consumer
13    Education Campaign, the Department shall: (1) by January 1,
14    2017, provide at least one live training in each region on
15    parity for consumers and providers and one webinar training
16    to be posted on the Department website and (2) establish a
17    consumer hotline to assist consumers in navigating the
18    parity process by March 1, 2016. By January 1, 2018 the
19    Department shall issue a report to the General Assembly on
20    the success of the Consumer Education Campaign, which shall
21    indicate whether additional training is necessary or would
22    be recommended.
23        (2) The Department, in coordination with the
24    Department of Human Services and the Department of
25    Healthcare and Family Services, shall convene a working
26    group of health care insurance carriers, mental health

 

 

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1    advocacy groups, substance abuse patient advocacy groups,
2    and mental health physician groups for the purpose of
3    discussing issues related to the treatment and coverage of
4    substance abuse disorders and mental illness. The working
5    group shall meet once before January 1, 2016 and shall meet
6    semiannually thereafter. The Department shall issue an
7    annual report to the General Assembly that includes a list
8    of the health care insurance carriers, mental health
9    advocacy groups, substance abuse patient advocacy groups,
10    and mental health physician groups that participated in the
11    working group meetings, details on the issues and topics
12    covered, and any legislative recommendations.
13    (i) The Parity Education Fund is created as a special fund
14in the State treasury. Moneys deposited into the Fund for
15appropriation by the General Assembly to the Department of
16Insurance shall be used for the purpose of providing financial
17support of the Consumer Education Campaign.
18    (j) An insurer that amends, delivers, issues, or renews a
19group or individual policy of accident and health insurance or
20a qualified health plan offered through the health insurance
21marketplace in this State providing coverage for hospital or
22medical treatment and for the treatment of mental, emotional,
23nervous, or substance use disorders or conditions shall submit
24an annual report to the Department or, with respect to medical
25assistance, the Department of Healthcare and Family Services on
26or before March 1 that contains the following information

 

 

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1separately for inpatient in-network benefits, inpatient
2out-of-network benefits, outpatient in-network benefits,
3outpatient out-of-network benefits, emergency care benefits,
4and prescription drug benefits in the case of accident and
5health insurance or qualified health plans, or inpatient,
6outpatient, emergency care, and prescription drug benefits in
7the case of medical assistance:
8        (1) The number and percentage of times a benefit limit
9    is exceeded for a mental, emotional, nervous, or substance
10    use disorder or condition benefit and the number and
11    percentage of times a benefit limit is exceeded for other
12    medical benefits.
13        (2) The number and percentage of times a co-pay or
14    co-insurance limit for a mental, emotional, nervous, or
15    substance use disorder or condition benefit is different
16    from other medical benefits.
17        (3) The number and percentage of claim denials for
18    mental, emotional, nervous, or substance use disorder or
19    condition benefits due to benefit limits and the number and
20    percentage of claim denials for other medical benefits due
21    to benefit limits.
22        (4) The number and percentage of denials for
23    experimental benefits or the use of unproven technology for
24    a mental, emotional, nervous, or substance use disorder or
25    condition benefit and the number and percentage of denials
26    for experimental benefits or the use of unproven technology

 

 

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1    for other medical benefits.
2        (5) The number and percentage of administrative
3    denials for no prior authorization for a mental, emotional,
4    nervous, or substance use disorder or condition benefit and
5    the number and percentage of administrative denials for no
6    prior authorization for other medical benefits.
7        (6) The number and percentage of denials due to a
8    mental, emotional, nervous, or substance use disorder or
9    condition benefit not being a covered benefit and the
10    number and percentage of denials for other medical benefits
11    not being a covered benefit.
12        (7) The number and percentage of denials due to a
13    mental, emotional, nervous, or substance use disorder or
14    condition benefit not meeting medical necessity and the
15    number and percentage of denials for other medical benefits
16    not meeting medical necessity.
17        (8) The number and percentage of denials upheld on
18    appeal for a mental, emotional, nervous, or substance use
19    disorder or condition benefit for not meeting medical
20    necessity and the number and percentage of those for other
21    medical benefits.
22        (9) The number and percentage of denials due to a
23    mental, emotional, nervous, or substance use disorder or
24    condition benefit being denied administratively or any
25    reason other than medical necessity.
26        (10) The number and percentage of denials of mental,

 

 

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1    emotional, nervous, or substance use disorder or condition
2    benefits that went to the plan's external quality review
3    organization, or similar reviewing body and were upheld and
4    those that were overturned for medical necessity.
5        (11) The number and percentage of continued stay review
6    denials for mental, emotional, nervous, or substance use
7    disorder or condition benefits.
8        (12) The number and percentage of out-of-network
9    claims for mental, emotional, nervous, or substance use
10    disorder or condition benefits in each classification of
11    benefits and the number and percentage of out-of-network
12    claims for other medical benefits in each classification of
13    benefits.
14        (13) The number and percentage of emergency care claims
15    for mental, emotional, nervous, or substance use disorder
16    or condition benefits in each classification of benefits
17    and the number and percentage of emergency care claims for
18    other medical benefits in each classification of benefits.
19        (14) The number and percentage of network directory
20    providers in the outpatient benefits classification who
21    filed no claims in the last 6 months of the plan's claims
22    reporting period and all pertinent summary information and
23    results respecting the tests and metrics the insurer used
24    to assess the availability of each of the following types
25    of mental, emotional, nervous, or substance use disorder or
26    condition providers: MD/DO; doctoral level non-MD/DO and

 

 

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1    non-doctoral level non-MD/DO practitioners; and inpatient,
2    residential, and ambulatory provider organizations.
3        (15) A summary of the plan's pharmacy management
4    processes for mental, emotional, nervous, or substance use
5    disorder or condition benefits compared to those for other
6    medical benefits.
7        (16) A summary of the internal processes of review for
8    experimental benefits and unproven technology for mental,
9    emotional, nervous, or substance use disorder or condition
10    benefits and those for other medical benefits.
11        (17) A summary of how the plan's policies and
12    procedures for utilization management for mental,
13    emotional, nervous, or substance use disorder or condition
14    benefits compare to those for other medical benefits.
15        (18) The results of an analysis that demonstrates that
16    for each nonquantitative treatment limitation, as written
17    and in operation, the processes, strategies, evidentiary
18    standards, or other factors used to apply each
19    nonquantitative treatment limitation to mental, emotional,
20    nervous, or substance use disorder or condition benefits
21    are comparable to, and are applied no more stringently than
22    the processes, strategies, evidentiary standards, or other
23    factors used to apply each nonquantitative treatment
24    limitation, as written and in operation, to medical and
25    surgical benefits; at a minimum, the results of the
26    analysis shall:

 

 

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1            (A) identify the factors used to determine that a
2        nonquantitative treatment limitation will apply to a
3        benefit, including factors that were considered but
4        rejected;
5            (B) identify and define the specific evidentiary
6        standards used to define the factors and any other
7        evidentiary standards relied upon in designing each
8        nonquantitative treatment limitation;
9            (C) identify and describe the methods and analyses
10        used, including the results of the analyses, to
11        determine that the processes and strategies used to
12        design each nonquantitative treatment limitation as
13        written for mental, emotional, nervous, or substance
14        use disorders or conditions benefits are comparable to
15        and no more stringent than the processes and strategies
16        used to design each nonquantitative treatment
17        limitation as written for medical and surgical
18        benefits;
19            (D) identify and describe the methods and analyses
20        used, including the results of the analyses, to
21        determine that the processes and strategies used to
22        apply each nonquantitative treatment limitation in
23        operation for mental, emotional, nervous, or substance
24        use disorders or conditions benefits are comparable to
25        and no more stringent than the processes or strategies
26        used to apply each nonquantitative treatment

 

 

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1        limitation in operation for medical and surgical
2        benefits; and
3            (E) disclose the specific findings and conclusions
4        reached by the insurer that the results of the analyses
5        above indicate that the insurer is in compliance with
6        this Section and the Mental Health Parity and Addiction
7        Equity Act of 2008 and its implementing regulations,
8        which includes 45 CFR 146.136 and any other relevant
9        current or future regulations.
10        (19) A certification signed by the insurer's chief
11    executive officer and chief medical officer that states
12    that the insurer has completed a comprehensive review of
13    the administrative practices of the insurer for the prior
14    calendar year for compliance with the necessary provisions
15    of this Section and Sections 356z.23 and 370c of this Code,
16    the federal Paul Wellstone and Pete Domenici Mental Health
17    Parity and Addiction Equity Act of 2008, 42 U.S.C.
18    18031(j), and any amendments to, and federal guidance or
19    regulations issued under, those Acts, including, but not
20    limited to, final regulations issued under the Paul
21    Wellstone and Pete Domenici Mental Health Parity and
22    Addiction Equity Act of 2008 and final regulations applying
23    the Paul Wellstone and Pete Domenici Mental Health Parity
24    and Addiction Equity Act of 2008 to Medicaid managed care
25    organizations, the Children's Health Insurance Program,
26    and alternative benefit plans.

 

 

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1        (20) Any other information necessary to clarify data
2    provided in accordance with this Section requested by the
3    Director, including information that may be proprietary or
4    have commercial value.
5    The Director shall not certify any policy of an insurer
6that fails to submit all data as required by this Section.
7(Source: P.A. 99-480, eff. 9-9-15.)