Rep. Sue Scherer

Filed: 3/21/2019

 

 


 

 


 
10100HB0466ham001LRB101 03397 RAB 56512 a

1
AMENDMENT TO HOUSE BILL 466

2    AMENDMENT NO. ______. Amend House Bill 466 by replacing
3everything after the enacting clause with the following:
 
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, emotional, nervous, or substance use
8disorder or condition parity.
9    (a) On and after the effective date of this amendatory Act
10of the 99th General Assembly, every insurer that amends,
11delivers, issues, or renews a group or individual policy of
12accident and health insurance or a qualified health plan
13offered through the Health Insurance Marketplace in this State
14providing coverage for hospital or medical treatment and for
15the treatment of mental, emotional, nervous, or substance use
16disorders or conditions shall ensure that:

 

 

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1        (1) the financial requirements applicable to such
2    mental, emotional, nervous, or substance use disorder or
3    condition benefits are no more restrictive than the
4    predominant financial requirements applied to
5    substantially all hospital and medical benefits covered by
6    the policy and that there are no separate cost-sharing
7    requirements that are applicable only with respect to
8    mental, emotional, nervous, or substance use disorder or
9    condition benefits; and
10        (2) the treatment limitations applicable to such
11    mental, emotional, nervous, or substance use disorder or
12    condition benefits are no more restrictive than the
13    predominant treatment limitations applied to substantially
14    all hospital and medical benefits covered by the policy and
15    that there are no separate treatment limitations that are
16    applicable only with respect to mental, emotional,
17    nervous, or substance use disorder or condition benefits.
18    (b) The following provisions shall apply concerning
19aggregate lifetime limits:
20        (1) In the case of a group or individual policy of
21    accident and health insurance or a qualified health plan
22    offered through the Health Insurance Marketplace amended,
23    delivered, issued, or renewed in this State on or after the
24    effective date of this amendatory Act of the 99th General
25    Assembly that provides coverage for hospital or medical
26    treatment and for the treatment of mental, emotional,

 

 

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1    nervous, or substance use disorders or conditions the
2    following provisions shall apply:
3            (A) if the policy does not include an aggregate
4        lifetime limit on substantially all hospital and
5        medical benefits, then the policy may not impose any
6        aggregate lifetime limit on mental, emotional,
7        nervous, or substance use disorder or condition
8        benefits; or
9            (B) if the policy includes an aggregate lifetime
10        limit on substantially all hospital and medical
11        benefits (in this subsection referred to as the
12        "applicable lifetime limit"), then the policy shall
13        either:
14                (i) apply the applicable lifetime limit both
15            to the hospital and medical benefits to which it
16            otherwise would apply and to mental, emotional,
17            nervous, or substance use disorder or condition
18            benefits and not distinguish in the application of
19            the limit between the hospital and medical
20            benefits and mental, emotional, nervous, or
21            substance use disorder or condition benefits; or
22                (ii) not include any aggregate lifetime limit
23            on mental, emotional, nervous, or substance use
24            disorder or condition benefits that is less than
25            the applicable lifetime limit.
26        (2) In the case of a policy that is not described in

 

 

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1    paragraph (1) of subsection (b) of this Section and that
2    includes no or different aggregate lifetime limits on
3    different categories of hospital and medical benefits, the
4    Director shall establish rules under which subparagraph
5    (B) of paragraph (1) of subsection (b) of this Section is
6    applied to such policy with respect to mental, emotional,
7    nervous, or substance use disorder or condition benefits by
8    substituting for the applicable lifetime limit an average
9    aggregate lifetime limit that is computed taking into
10    account the weighted average of the aggregate lifetime
11    limits applicable to such categories.
12    (c) The following provisions shall apply concerning annual
13limits:
14        (1) In the case of a group or individual policy of
15    accident and health insurance or a qualified health plan
16    offered through the Health Insurance Marketplace amended,
17    delivered, issued, or renewed in this State on or after the
18    effective date of this amendatory Act of the 99th General
19    Assembly that provides coverage for hospital or medical
20    treatment and for the treatment of mental, emotional,
21    nervous, or substance use disorders or conditions the
22    following provisions shall apply:
23            (A) if the policy does not include an annual limit
24        on substantially all hospital and medical benefits,
25        then the policy may not impose any annual limits on
26        mental, emotional, nervous, or substance use disorder

 

 

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

 

 

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1    annual limit that is computed taking into account the
2    weighted average of the annual limits applicable to such
3    categories.
4    (d) With respect to mental, emotional, nervous, or
5substance use disorders or conditions, an insurer shall use
6policies and procedures for the election and placement of
7mental, emotional, nervous, or substance use disorder or
8condition treatment drugs on their formulary that are no less
9favorable to the insured as those policies and procedures the
10insurer uses for the selection and placement of drugs for
11medical or surgical conditions and shall follow the expedited
12coverage determination requirements for substance abuse
13treatment drugs set forth in Section 45.2 of the Managed Care
14Reform and Patient Rights Act.
15    (e) This Section shall be interpreted in a manner
16consistent with all applicable federal parity regulations
17including, but not limited to, the Paul Wellstone and Pete
18Domenici Mental Health Parity and Addiction Equity Act of 2008,
19final regulations issued under the Paul Wellstone and Pete
20Domenici Mental Health Parity and Addiction Equity Act of 2008
21and final regulations applying the Paul Wellstone and Pete
22Domenici Mental Health Parity and Addiction Equity Act of 2008
23to Medicaid managed care organizations, the Children's Health
24Insurance Program, and alternative benefit plans.
25    (f) The provisions of subsections (b) and (c) of this
26Section shall not be interpreted to allow the use of lifetime

 

 

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1or annual limits otherwise prohibited by State or federal law.
2    (g) As used in this Section:
3    "Financial requirement" includes deductibles, copayments,
4coinsurance, and out-of-pocket maximums, but does not include
5an aggregate lifetime limit or an annual limit subject to
6subsections (b) and (c).
7    "Mental, emotional, nervous, or substance use disorder or
8condition" means a condition or disorder that involves a mental
9health condition or substance use disorder that falls under any
10of the diagnostic categories listed in the mental and
11behavioral disorders chapter of the current edition of the
12International Classification of Disease or that is listed in
13the most recent version of the Diagnostic and Statistical
14Manual of Mental Disorders.
15    "Treatment limitation" includes limits on benefits based
16on the frequency of treatment, number of visits, days of
17coverage, days in a waiting period, or other similar limits on
18the scope or duration of treatment. "Treatment limitation"
19includes both quantitative treatment limitations, which are
20expressed numerically (such as 50 outpatient visits per year),
21and nonquantitative treatment limitations, which otherwise
22limit the scope or duration of treatment. A permanent exclusion
23of all benefits for a particular condition or disorder shall
24not be considered a treatment limitation. "Nonquantitative
25treatment" means those limitations as described under federal
26regulations (26 CFR 54.9812-1). "Nonquantitative treatment

 

 

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1limitations" include, but are not limited to, those limitations
2described under federal regulations 26 CFR 54.9812-1, 29 CFR
32590.712, and 45 CFR 146.136.
4    (h) The Department of Insurance shall implement the
5following education initiatives:
6        (1) By January 1, 2016, the Department shall develop a
7    plan for a Consumer Education Campaign on parity. The
8    Consumer Education Campaign shall focus its efforts
9    throughout the State and include trainings in the northern,
10    southern, and central regions of the State, as defined by
11    the Department, as well as each of the 5 managed care
12    regions of the State as identified by the Department of
13    Healthcare and Family Services. Under this Consumer
14    Education Campaign, the Department shall: (1) by January 1,
15    2017, provide at least one live training in each region on
16    parity for consumers and providers and one webinar training
17    to be posted on the Department website and (2) establish a
18    consumer hotline to assist consumers in navigating the
19    parity process by March 1, 2017. By January 1, 2018 the
20    Department shall issue a report to the General Assembly on
21    the success of the Consumer Education Campaign, which shall
22    indicate whether additional training is necessary or would
23    be recommended.
24        (2) The Department, in coordination with the
25    Department of Human Services and the Department of
26    Healthcare and Family Services, shall convene a working

 

 

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1    group of health care insurance carriers, mental health
2    advocacy groups, substance abuse patient advocacy groups,
3    and mental health physician groups for the purpose of
4    discussing issues related to the treatment and coverage of
5    mental, emotional, nervous, or substance use disorders or
6    conditions and compliance with parity obligations under
7    State and federal law. Compliance shall be measured,
8    tracked, and shared during the meetings of the working
9    group. The working group shall meet once before January 1,
10    2016 and shall meet semiannually thereafter. The
11    Department shall issue an annual report to the General
12    Assembly that includes a list of the health care insurance
13    carriers, mental health advocacy groups, substance abuse
14    patient advocacy groups, and mental health physician
15    groups that participated in the working group meetings,
16    details on the issues and topics covered, and any
17    legislative recommendations developed by the working
18    group.
19        (3) Not later than August 1 of each year, the
20    Department, in conjunction with the Department of
21    Healthcare and Family Services, shall issue a joint report
22    to the General Assembly and provide an educational
23    presentation to the General Assembly. The report and
24    presentation shall:
25            (A) Cover the methodology the Departments use to
26        check for compliance with the federal Paul Wellstone

 

 

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1        and Pete Domenici Mental Health Parity and Addiction
2        Equity Act of 2008, 42 U.S.C. 18031(j), and any federal
3        regulations or guidance relating to the compliance and
4        oversight of the federal Paul Wellstone and Pete
5        Domenici Mental Health Parity and Addiction Equity Act
6        of 2008 and 42 U.S.C. 18031(j).
7            (B) Cover the methodology the Departments use to
8        check for compliance with this Section and Sections
9        356z.23 and 370c of this Code.
10            (C) Identify market conduct examinations or, in
11        the case of the Department of Healthcare and Family
12        Services, audits conducted or completed during the
13        preceding 12-month period regarding compliance with
14        parity in mental, emotional, nervous, and substance
15        use disorder or condition benefits under State and
16        federal laws and summarize the results of such market
17        conduct examinations and audits. This shall include:
18                (i) the number of market conduct examinations
19            and audits initiated and completed;
20                (ii) the benefit classifications examined by
21            each market conduct examination and audit;
22                (iii) the subject matter of each market
23            conduct examination and audit, including
24            quantitative and nonquantitative treatment
25            limitations; and
26                (iv) a summary of the basis for the final

 

 

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1            decision rendered in each market conduct
2            examination and audit.
3            Individually identifiable information shall be
4        excluded from the reports consistent with federal
5        privacy protections.
6            (D) Detail any educational or corrective actions
7        the Departments have taken to ensure compliance with
8        the federal Paul Wellstone and Pete Domenici Mental
9        Health Parity and Addiction Equity Act of 2008, 42
10        U.S.C. 18031(j), this Section, and Sections 356z.23
11        and 370c of this Code.
12            (E) The report must be written in non-technical,
13        readily understandable language and shall be made
14        available to the public by, among such other means as
15        the Departments find appropriate, posting the report
16        on the Departments' websites.
17    (i) The Parity Advancement Fund is created as a special
18fund in the State treasury. Moneys from fines and penalties
19collected from insurers for violations of this Section shall be
20deposited into the Fund. Moneys deposited into the Fund for
21appropriation by the General Assembly to the Department shall
22be used for the purpose of providing financial support of the
23Consumer Education Campaign, parity compliance advocacy, and
24other initiatives that support parity implementation and
25enforcement on behalf of consumers.
26    (j) The Department of Insurance and the Department of

 

 

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1Healthcare and Family Services shall convene and provide
2technical support to a workgroup of 11 members that shall be
3comprised of 3 mental health parity experts recommended by an
4organization advocating on behalf of mental health parity
5appointed by the President of the Senate; 3 behavioral health
6providers recommended by an organization that represents
7behavioral health providers appointed by the Speaker of the
8House of Representatives; 2 representing Medicaid managed care
9organizations recommended by an organization that represents
10Medicaid managed care plans appointed by the Minority Leader of
11the House of Representatives; 2 representing commercial
12insurers recommended by an organization that represents
13insurers appointed by the Minority Leader of the Senate; and a
14representative of an organization that represents Medicaid
15managed care plans appointed by the Governor.
16    The workgroup shall provide recommendations to the General
17Assembly on health plan data reporting requirements that
18separately break out data on mental, emotional, nervous, or
19substance use disorder or condition benefits and data on other
20medical benefits, including physical health and related health
21services no later than December 31, 2019. The recommendations
22to the General Assembly shall be filed with the Clerk of the
23House of Representatives and the Secretary of the Senate in
24electronic form only, in the manner that the Clerk and the
25Secretary shall direct. This workgroup shall take into account
26federal requirements and recommendations on mental health

 

 

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1parity reporting for the Medicaid program. This workgroup shall
2also develop the format and provide any needed definitions for
3reporting requirements in subsection (k). The research and
4evaluation of the working group shall include, but not be
5limited to:
6        (1) claims denials due to benefit limits, if
7    applicable;
8        (2) administrative denials for no prior authorization;
9        (3) denials due to not meeting medical necessity;
10        (4) denials that went to external review and whether
11    they were upheld or overturned for medical necessity;
12        (5) out-of-network claims;
13        (6) emergency care claims;
14        (7) network directory providers in the outpatient
15    benefits classification who filed no claims in the last 6
16    months, if applicable;
17        (8) the impact of existing and pertinent limitations
18    and restrictions related to approved services, licensed
19    providers, reimbursement levels, and reimbursement
20    methodologies within the Division of Mental Health, the
21    Division of Substance Use Prevention and Recovery
22    programs, the Department of Healthcare and Family
23    Services, and, to the extent possible, federal regulations
24    and law; and
25        (9) when reporting and publishing should begin.
26    Representatives from the Department of Healthcare and

 

 

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1Family Services, representatives from the Division of Mental
2Health, and representatives from the Division of Substance Use
3Prevention and Recovery shall provide technical advice to the
4workgroup.
5    (k) An insurer that amends, delivers, issues, or renews a
6group or individual policy of accident and health insurance or
7a qualified health plan offered through the health insurance
8marketplace in this State providing coverage for hospital or
9medical treatment and for the treatment of mental, emotional,
10nervous, or substance use disorders or conditions shall submit
11an annual report, the format and definitions for which will be
12developed by the workgroup in subsection (j), to the
13Department, or, with respect to medical assistance, the
14Department of Healthcare and Family Services starting on or
15before July 1, 2020 that contains the following information
16separately for inpatient in-network benefits, inpatient
17out-of-network benefits, outpatient in-network benefits,
18outpatient out-of-network benefits, emergency care benefits,
19and prescription drug benefits in the case of accident and
20health insurance or qualified health plans, or inpatient,
21outpatient, emergency care, and prescription drug benefits in
22the case of medical assistance:
23        (1) A summary of the plan's pharmacy management
24    processes for mental, emotional, nervous, or substance use
25    disorder or condition benefits compared to those for other
26    medical benefits.

 

 

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1        (2) A summary of the internal processes of review for
2    experimental benefits and unproven technology for mental,
3    emotional, nervous, or substance use disorder or condition
4    benefits and those for other medical benefits.
5        (3) A summary of how the plan's policies and procedures
6    for utilization management for mental, emotional, nervous,
7    or substance use disorder or condition benefits compare to
8    those for other medical benefits.
9        (4) A description of the process used to develop or
10    select the medical necessity criteria for mental,
11    emotional, nervous, or substance use disorder or condition
12    benefits and the process used to develop or select the
13    medical necessity criteria for medical and surgical
14    benefits.
15        (5) Identification of all nonquantitative treatment
16    limitations that are applied to both mental, emotional,
17    nervous, or substance use disorder or condition benefits
18    and medical and surgical benefits within each
19    classification of benefits.
20        (6) The results of an analysis that demonstrates that
21    for the medical necessity criteria described in
22    subparagraph (A) and for each nonquantitative treatment
23    limitation identified in subparagraph (B), as written and
24    in operation, the processes, strategies, evidentiary
25    standards, or other factors used in applying the medical
26    necessity criteria and each nonquantitative treatment

 

 

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1    limitation to mental, emotional, nervous, or substance use
2    disorder or condition benefits within each classification
3    of benefits are comparable to, and are applied no more
4    stringently than, the processes, strategies, evidentiary
5    standards, or other factors used in applying the medical
6    necessity criteria and each nonquantitative treatment
7    limitation to medical and surgical benefits within the
8    corresponding classification of benefits; at a minimum,
9    the results of the analysis shall:
10            (A) identify the factors used to determine that a
11        nonquantitative treatment limitation applies to a
12        benefit, including factors that were considered but
13        rejected;
14            (B) identify and define the specific evidentiary
15        standards used to define the factors and any other
16        evidence relied upon in designing each nonquantitative
17        treatment limitation;
18            (C) provide the comparative analyses, including
19        the results of the analyses, performed to determine
20        that the processes and strategies used to design each
21        nonquantitative treatment limitation, as written, for
22        mental, emotional, nervous, or substance use disorder
23        or condition benefits are comparable to, and are
24        applied no more stringently than, the processes and
25        strategies used to design each nonquantitative
26        treatment limitation, as written, for medical and

 

 

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1        surgical benefits;
2            (D) provide the comparative analyses, including
3        the results of the analyses, performed to determine
4        that the processes and strategies used to apply each
5        nonquantitative treatment limitation, in operation,
6        for mental, emotional, nervous, or substance use
7        disorder or condition benefits are comparable to, and
8        applied no more stringently than, the processes or
9        strategies used to apply each nonquantitative
10        treatment limitation, in operation, for medical and
11        surgical benefits; and
12            (E) disclose the specific findings and conclusions
13        reached by the insurer that the results of the analyses
14        described in subparagraphs (C) and (D) indicate that
15        the insurer is in compliance with this Section and the
16        Mental Health Parity and Addiction Equity Act of 2008
17        and its implementing regulations, which includes 42
18        CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any
19        other related federal regulations found in the Code of
20        Federal Regulations.
21        (7) Any other information necessary to clarify data
22    provided in accordance with this Section requested by the
23    Director, including information that may be proprietary or
24    have commercial value, under the requirements of Section 30
25    of the Viatical Settlements Act of 2009.
26    (l) An insurer that amends, delivers, issues, or renews a

 

 

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1group or individual policy of accident and health insurance or
2a qualified health plan offered through the health insurance
3marketplace in this State providing coverage for hospital or
4medical treatment and for the treatment of mental, emotional,
5nervous, or substance use disorders or conditions on or after
6the effective date of this amendatory Act of the 100th General
7Assembly shall, in advance of the plan year, make available to
8the Department or, with respect to medical assistance, the
9Department of Healthcare and Family Services and to all plan
10participants and beneficiaries the information required in
11subparagraphs (C) through (E) of paragraph (6) of subsection
12(k). For plan participants and medical assistance
13beneficiaries, the information required in subparagraphs (C)
14through (E) of paragraph (6) of subsection (k) shall be made
15available on a publicly-available website whose web address is
16prominently displayed in plan and managed care organization
17informational and marketing materials.
18    (m) In conjunction with its compliance examination program
19conducted in accordance with the Illinois State Auditing Act,
20the Auditor General shall undertake a review of compliance by
21the Department and the Department of Healthcare and Family
22Services with Section 370c and this Section. Any findings
23resulting from the review conducted under this Section shall be
24included in the applicable State agency's compliance
25examination report. Each compliance examination report shall
26be issued in accordance with Section 3-14 of the Illinois State

 

 

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1Auditing Act. A copy of each report shall also be delivered to
2the head of the applicable State agency and posted on the
3Auditor General's website.
4    (n) A policy of accident and health insurance amended,
5delivered, issued, or renewed on or after the effective date of
6this amendatory Act of the 101st General Assembly shall provide
7coverage for treatment of substance use disorders or conditions
8that is, at a minimum, equivalent to the coverage provided
9under Article V of the Illinois Public Aid Code.
10(Source: P.A. 99-480, eff. 9-9-15; 100-1024, eff. 1-1-19.)".