101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB3425

 

Introduced 2/14/2020, by Sen. Melinda Bush

 

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

    Amends the Illinois Insurance Code. Provides that a workgroup convened by the Department of Insurance and the Department of Healthcare and Family Services shall provide recommendations to the General Assembly on health plan data reporting requirements that separately break out data on mental, emotional, nervous, or substance use disorder or condition benefits and data on other medical benefits no later than May 31, 2020 (rather than December 31, 2019). Effective immediately.


LRB101 17932 BMS 67368 b

 

 

A BILL FOR

 

SB3425LRB101 17932 BMS 67368 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, 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:
17        (1) the financial requirements applicable to such
18    mental, emotional, nervous, or substance use disorder or
19    condition benefits are no more restrictive than the
20    predominant financial requirements applied to
21    substantially all hospital and medical benefits covered by
22    the policy and that there are no separate cost-sharing
23    requirements that are applicable only with respect to

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1condition treatment drugs on their formulary that are no less
2favorable to the insured as those policies and procedures the
3insurer uses for the selection and placement of drugs for
4medical or surgical conditions and shall follow the expedited
5coverage determination requirements for substance abuse
6treatment drugs set forth in Section 45.2 of the Managed Care
7Reform and Patient Rights Act.
8    (e) This Section shall be interpreted in a manner
9consistent with all applicable federal parity regulations
10including, but not limited to, the Paul Wellstone and Pete
11Domenici Mental Health Parity and Addiction Equity Act of 2008,
12final regulations issued under the Paul Wellstone and Pete
13Domenici Mental Health Parity and Addiction Equity Act of 2008
14and final regulations applying the Paul Wellstone and Pete
15Domenici Mental Health Parity and Addiction Equity Act of 2008
16to Medicaid managed care organizations, the Children's Health
17Insurance Program, and alternative benefit plans.
18    (f) The provisions of subsections (b) and (c) of this
19Section shall not be interpreted to allow the use of lifetime
20or annual limits otherwise prohibited by State or federal law.
21    (g) As used in this Section:
22    "Financial requirement" includes deductibles, copayments,
23coinsurance, and out-of-pocket maximums, but does not include
24an aggregate lifetime limit or an annual limit subject to
25subsections (b) and (c).
26    "Mental, emotional, nervous, or substance use disorder or

 

 

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1condition" means a condition or disorder that involves a mental
2health condition or substance use disorder that falls under any
3of the diagnostic categories listed in the mental and
4behavioral disorders chapter of the current edition of the
5International Classification of Disease or that is listed in
6the most recent version of the Diagnostic and Statistical
7Manual of Mental Disorders.
8    "Treatment limitation" includes limits on benefits based
9on the frequency of treatment, number of visits, days of
10coverage, days in a waiting period, or other similar limits on
11the scope or duration of treatment. "Treatment limitation"
12includes both quantitative treatment limitations, which are
13expressed numerically (such as 50 outpatient visits per year),
14and nonquantitative treatment limitations, which otherwise
15limit the scope or duration of treatment. A permanent exclusion
16of all benefits for a particular condition or disorder shall
17not be considered a treatment limitation. "Nonquantitative
18treatment" means those limitations as described under federal
19regulations (26 CFR 54.9812-1). "Nonquantitative treatment
20limitations" include, but are not limited to, those limitations
21described under federal regulations 26 CFR 54.9812-1, 29 CFR
222590.712, and 45 CFR 146.136.
23    (h) The Department of Insurance shall implement the
24following education initiatives:
25        (1) By January 1, 2016, the Department shall develop a
26    plan for a Consumer Education Campaign on parity. The

 

 

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1    Consumer Education Campaign shall focus its efforts
2    throughout the State and include trainings in the northern,
3    southern, and central regions of the State, as defined by
4    the Department, as well as each of the 5 managed care
5    regions of the State as identified by the Department of
6    Healthcare and Family Services. Under this Consumer
7    Education Campaign, the Department shall: (1) by January 1,
8    2017, provide at least one live training in each region on
9    parity for consumers and providers and one webinar training
10    to be posted on the Department website and (2) establish a
11    consumer hotline to assist consumers in navigating the
12    parity process by March 1, 2017. By January 1, 2018 the
13    Department shall issue a report to the General Assembly on
14    the success of the Consumer Education Campaign, which shall
15    indicate whether additional training is necessary or would
16    be recommended.
17        (2) The Department, in coordination with the
18    Department of Human Services and the Department of
19    Healthcare and Family Services, shall convene a working
20    group of health care insurance carriers, mental health
21    advocacy groups, substance abuse patient advocacy groups,
22    and mental health physician groups for the purpose of
23    discussing issues related to the treatment and coverage of
24    mental, emotional, nervous, or substance use disorders or
25    conditions and compliance with parity obligations under
26    State and federal law. Compliance shall be measured,

 

 

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1    tracked, and shared during the meetings of the working
2    group. The working group shall meet once before January 1,
3    2016 and shall meet semiannually thereafter. The
4    Department shall issue an annual report to the General
5    Assembly that includes a list of the health care insurance
6    carriers, mental health advocacy groups, substance abuse
7    patient advocacy groups, and mental health physician
8    groups that participated in the working group meetings,
9    details on the issues and topics covered, and any
10    legislative recommendations developed by the working
11    group.
12        (3) Not later than August 1 of each year, the
13    Department, in conjunction with the Department of
14    Healthcare and Family Services, shall issue a joint report
15    to the General Assembly and provide an educational
16    presentation to the General Assembly. The report and
17    presentation shall:
18            (A) Cover the methodology the Departments use to
19        check for compliance with the federal Paul Wellstone
20        and Pete Domenici Mental Health Parity and Addiction
21        Equity Act of 2008, 42 U.S.C. 18031(j), and any federal
22        regulations or guidance relating to the compliance and
23        oversight of the federal Paul Wellstone and Pete
24        Domenici Mental Health Parity and Addiction Equity Act
25        of 2008 and 42 U.S.C. 18031(j).
26            (B) Cover the methodology the Departments use to

 

 

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1        check for compliance with this Section and Sections
2        356z.23 and 370c of this Code.
3            (C) Identify market conduct examinations or, in
4        the case of the Department of Healthcare and Family
5        Services, audits conducted or completed during the
6        preceding 12-month period regarding compliance with
7        parity in mental, emotional, nervous, and substance
8        use disorder or condition benefits under State and
9        federal laws and summarize the results of such market
10        conduct examinations and audits. This shall include:
11                (i) the number of market conduct examinations
12            and audits initiated and completed;
13                (ii) the benefit classifications examined by
14            each market conduct examination and audit;
15                (iii) the subject matter of each market
16            conduct examination and audit, including
17            quantitative and nonquantitative treatment
18            limitations; and
19                (iv) a summary of the basis for the final
20            decision rendered in each market conduct
21            examination and audit.
22            Individually identifiable information shall be
23        excluded from the reports consistent with federal
24        privacy protections.
25            (D) Detail any educational or corrective actions
26        the Departments have taken to ensure compliance with

 

 

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1        the federal Paul Wellstone and Pete Domenici Mental
2        Health Parity and Addiction Equity Act of 2008, 42
3        U.S.C. 18031(j), this Section, and Sections 356z.23
4        and 370c of this Code.
5            (E) The report must be written in non-technical,
6        readily understandable language and shall be made
7        available to the public by, among such other means as
8        the Departments find appropriate, posting the report
9        on the Departments' websites.
10    (i) The Parity Advancement Fund is created as a special
11fund in the State treasury. Moneys from fines and penalties
12collected from insurers for violations of this Section shall be
13deposited into the Fund. Moneys deposited into the Fund for
14appropriation by the General Assembly to the Department shall
15be used for the purpose of providing financial support of the
16Consumer Education Campaign, parity compliance advocacy, and
17other initiatives that support parity implementation and
18enforcement on behalf of consumers.
19    (j) The Department of Insurance and the Department of
20Healthcare and Family Services shall convene and provide
21technical support to a workgroup of 11 members that shall be
22comprised of 3 mental health parity experts recommended by an
23organization advocating on behalf of mental health parity
24appointed by the President of the Senate; 3 behavioral health
25providers recommended by an organization that represents
26behavioral health providers appointed by the Speaker of the

 

 

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1House of Representatives; 2 representing Medicaid managed care
2organizations recommended by an organization that represents
3Medicaid managed care plans appointed by the Minority Leader of
4the House of Representatives; 2 representing commercial
5insurers recommended by an organization that represents
6insurers appointed by the Minority Leader of the Senate; and a
7representative of an organization that represents Medicaid
8managed care plans appointed by the Governor.
9    The workgroup shall provide recommendations to the General
10Assembly on health plan data reporting requirements that
11separately break out data on mental, emotional, nervous, or
12substance use disorder or condition benefits and data on other
13medical benefits, including physical health and related health
14services no later than May 31, 2020 December 31, 2019. The
15recommendations to the General Assembly shall be filed with the
16Clerk of the House of Representatives and the Secretary of the
17Senate in electronic form only, in the manner that the Clerk
18and the Secretary shall direct. This workgroup shall take into
19account federal requirements and recommendations on mental
20health parity reporting for the Medicaid program. This
21workgroup shall also develop the format and provide any needed
22definitions for reporting requirements in subsection (k). The
23research and evaluation of the working group shall include, but
24not be limited to:
25        (1) claims denials due to benefit limits, if
26    applicable;

 

 

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1        (2) administrative denials for no prior authorization;
2        (3) denials due to not meeting medical necessity;
3        (4) denials that went to external review and whether
4    they were upheld or overturned for medical necessity;
5        (5) out-of-network claims;
6        (6) emergency care claims;
7        (7) network directory providers in the outpatient
8    benefits classification who filed no claims in the last 6
9    months, if applicable;
10        (8) the impact of existing and pertinent limitations
11    and restrictions related to approved services, licensed
12    providers, reimbursement levels, and reimbursement
13    methodologies within the Division of Mental Health, the
14    Division of Substance Use Prevention and Recovery
15    programs, the Department of Healthcare and Family
16    Services, and, to the extent possible, federal regulations
17    and law; and
18        (9) when reporting and publishing should begin.
19    Representatives from the Department of Healthcare and
20Family Services, representatives from the Division of Mental
21Health, and representatives from the Division of Substance Use
22Prevention and Recovery shall provide technical advice to the
23workgroup.
24    (k) An insurer that amends, delivers, issues, or renews a
25group or individual policy of accident and health insurance or
26a qualified health plan offered through the health insurance

 

 

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1marketplace in this State providing coverage for hospital or
2medical treatment and for the treatment of mental, emotional,
3nervous, or substance use disorders or conditions shall submit
4an annual report, the format and definitions for which will be
5developed by the workgroup in subsection (j), to the
6Department, or, with respect to medical assistance, the
7Department of Healthcare and Family Services starting on or
8before July 1, 2020 that contains the following information
9separately for inpatient in-network benefits, inpatient
10out-of-network benefits, outpatient in-network benefits,
11outpatient out-of-network benefits, emergency care benefits,
12and prescription drug benefits in the case of accident and
13health insurance or qualified health plans, or inpatient,
14outpatient, emergency care, and prescription drug benefits in
15the case of medical assistance:
16        (1) A summary of the plan's pharmacy management
17    processes for mental, emotional, nervous, or substance use
18    disorder or condition benefits compared to those for other
19    medical benefits.
20        (2) A summary of the internal processes of review for
21    experimental benefits and unproven technology for mental,
22    emotional, nervous, or substance use disorder or condition
23    benefits and those for other medical benefits.
24        (3) A summary of how the plan's policies and procedures
25    for utilization management for mental, emotional, nervous,
26    or substance use disorder or condition benefits compare to

 

 

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1    those for other medical benefits.
2        (4) A description of the process used to develop or
3    select the medical necessity criteria for mental,
4    emotional, nervous, or substance use disorder or condition
5    benefits and the process used to develop or select the
6    medical necessity criteria for medical and surgical
7    benefits.
8        (5) Identification of all nonquantitative treatment
9    limitations that are applied to both mental, emotional,
10    nervous, or substance use disorder or condition benefits
11    and medical and surgical benefits within each
12    classification of benefits.
13        (6) The results of an analysis that demonstrates that
14    for the medical necessity criteria described in
15    subparagraph (A) and for each nonquantitative treatment
16    limitation identified in subparagraph (B), as written and
17    in operation, the processes, strategies, evidentiary
18    standards, or other factors used in applying the medical
19    necessity criteria and each nonquantitative treatment
20    limitation to mental, emotional, nervous, or substance use
21    disorder or condition benefits within each classification
22    of benefits are comparable to, and are applied no more
23    stringently than, the processes, strategies, evidentiary
24    standards, or other factors used in applying the medical
25    necessity criteria and each nonquantitative treatment
26    limitation to medical and surgical benefits within the

 

 

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

 

 

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1        applied no more stringently than, the processes or
2        strategies used to apply each nonquantitative
3        treatment limitation, in operation, for medical and
4        surgical benefits; and
5            (E) disclose the specific findings and conclusions
6        reached by the insurer that the results of the analyses
7        described in subparagraphs (C) and (D) indicate that
8        the insurer is in compliance with this Section and the
9        Mental Health Parity and Addiction Equity Act of 2008
10        and its implementing regulations, which includes 42
11        CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any
12        other related federal regulations found in the Code of
13        Federal Regulations.
14        (7) Any other information necessary to clarify data
15    provided in accordance with this Section requested by the
16    Director, including information that may be proprietary or
17    have commercial value, under the requirements of Section 30
18    of the Viatical Settlements Act of 2009.
19    (l) An insurer that amends, delivers, issues, or renews a
20group or individual policy of accident and health insurance or
21a qualified health plan offered through the health insurance
22marketplace in this State providing coverage for hospital or
23medical treatment and for the treatment of mental, emotional,
24nervous, or substance use disorders or conditions on or after
25the effective date of this amendatory Act of the 100th General
26Assembly shall, in advance of the plan year, make available to

 

 

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1the Department or, with respect to medical assistance, the
2Department of Healthcare and Family Services and to all plan
3participants and beneficiaries the information required in
4subparagraphs (C) through (E) of paragraph (6) of subsection
5(k). For plan participants and medical assistance
6beneficiaries, the information required in subparagraphs (C)
7through (E) of paragraph (6) of subsection (k) shall be made
8available on a publicly-available website whose web address is
9prominently displayed in plan and managed care organization
10informational and marketing materials.
11    (m) In conjunction with its compliance examination program
12conducted in accordance with the Illinois State Auditing Act,
13the Auditor General shall undertake a review of compliance by
14the Department and the Department of Healthcare and Family
15Services with Section 370c and this Section. Any findings
16resulting from the review conducted under this Section shall be
17included in the applicable State agency's compliance
18examination report. Each compliance examination report shall
19be issued in accordance with Section 3-14 of the Illinois State
20Auditing Act. A copy of each report shall also be delivered to
21the head of the applicable State agency and posted on the
22Auditor General's website.
23(Source: P.A. 99-480, eff. 9-9-15; 100-1024, eff. 1-1-19.)
 
24    Section 99. Effective date. This Act takes effect upon
25becoming law.