102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB3259

 

Introduced 2/19/2021, by Rep. Jennifer Gong-Gershowitz

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c  from Ch. 73, par. 982c

    Amends the Illinois Insurance Code. In provisions concerning mental and emotional disorders, provides that every insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis shall provide coverage for the diagnosis and medically necessary treatment (rather than reasonable and necessary treatment and services for) of mental, emotional, nervous, or substance use disorders or conditions. Provides that every insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance providing coverage for hospital or medical treatment on or after January 1, 2022 shall provide coverage for medically necessary treatment of mental health and substance use disorders. Provides that an insurer that authorizes a specific type of treatment by a provider shall not rescind or modify the authorization after that provider renders the health care service. Provides that if services for the medically necessary treatment of a mental health or substance use disorder are not available in-network within the geographic and timely access standards set by law or regulation, the insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary follow-up services, and the insured shall pay no more in total for benefits rendered than the cost sharing that the insured would pay for the same covered services received from an in-network provider. Provides that an insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program. Provides that every insurer shall sponsor an education program, make the program available to other stakeholders, provide clinical review criteria at no cost to providers and insured patients, conduct interrater reliability testing, and achieve interrate pass rates of at least 90% or comply with specified requirements if the 90% threshold is not met. Defines terms.


LRB102 11933 BMS 17269 b

 

 

A BILL FOR

 

HB3259LRB102 11933 BMS 17269 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 370c as follows:
 
6    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
7    Sec. 370c. Mental and emotional disorders.
8    (a)(1) On and after August 16, 2019 January 1, 2019 (the
9effective date of Public Act 101-386 this amendatory Act of
10the 101st General Assembly Public Act 100-1024), every insurer
11that amends, delivers, issues, or renews group accident and
12health policies providing coverage for hospital or medical
13treatment or services for illness on an expense-incurred basis
14shall provide coverage for the diagnosis and medically
15necessary treatment of reasonable and necessary treatment and
16services for mental, emotional, nervous, or substance use
17disorders or conditions consistent with the parity
18requirements of Section 370c.1 of this Code.
19    (2) Each insured that is covered for mental, emotional,
20nervous, or substance use disorders or conditions shall be
21free to select the physician licensed to practice medicine in
22all its branches, licensed clinical psychologist, licensed
23clinical social worker, licensed clinical professional

 

 

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

 

 

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1individuals shall do so after the licensed clinical social
2worker, licensed clinical professional counselor, licensed
3marriage and family therapist, licensed speech-language
4pathologist, or other licensed or certified professional at a
5program licensed pursuant to the Substance Use Disorder Act
6has informed the patient of the desirability of the patient
7conferring with the patient's primary care physician.
8    (4) "Mental, emotional, nervous, or substance use disorder
9or condition" means a condition or disorder that involves a
10mental health condition or substance use disorder that falls
11under any of the diagnostic categories listed in the mental
12and behavioral disorders chapter of the current edition of the
13International Classification of Disease or that is listed in
14the most recent version of the Diagnostic and Statistical
15Manual of Mental Disorders. "Mental, emotional, nervous, or
16substance use disorder or condition" includes any mental
17health condition that occurs during pregnancy or during the
18postpartum period and includes, but is not limited to,
19postpartum depression.
20    (b)(1) (Blank).
21    (2) (Blank).
22    (2.5) (Blank).
23    (3) Unless otherwise prohibited by federal law and
24consistent with the parity requirements of Section 370c.1 of
25this Code, the reimbursing insurer that amends, delivers,
26issues, or renews a group or individual policy of accident and

 

 

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

 

 

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1diseases or illnesses covered under the policy, including an
2appeals process. Medical necessity determinations for
3substance use disorders shall be made in accordance with
4appropriate patient placement criteria established by the
5American Society of Addiction Medicine. No additional criteria
6may be used to make medical necessity determinations for
7substance use disorders.
8    (4) A group health benefit plan amended, delivered,
9issued, or renewed on or after January 1, 2019 (the effective
10date of Public Act 100-1024) or an individual policy of
11accident and health insurance or a qualified health plan
12offered through the health insurance marketplace amended,
13delivered, issued, or renewed on or after January 1, 2019 (the
14effective date of Public Act 100-1024):
15        (A) shall provide coverage based upon medical
16    necessity for the treatment of a mental, emotional,
17    nervous, or substance use disorder or condition consistent
18    with the parity requirements of Section 370c.1 of this
19    Code; provided, however, that in each calendar year
20    coverage shall not be less than the following:
21            (i) 45 days of inpatient treatment; and
22            (ii) beginning on June 26, 2006 (the effective
23        date of Public Act 94-921), 60 visits for outpatient
24        treatment including group and individual outpatient
25        treatment; and
26            (iii) for plans or policies delivered, issued for

 

 

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

 

 

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

 

 

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

 

 

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1    of the drug formulary developed and maintained by the
2    individual or group health benefit plan that covers
3    generic medications; and
4        (D) shall not exclude coverage for a prescription
5    medication approved by the United States Food and Drug
6    Administration for the treatment of substance use
7    disorders and any associated counseling or wraparound
8    services on the grounds that such medications and services
9    were court ordered.
10    (7) (Blank).
11    (8) (Blank).
12    (9) With respect to all mental, emotional, nervous, or
13substance use disorders or conditions, coverage for inpatient
14treatment shall include coverage for treatment in a
15residential treatment center certified or licensed by the
16Department of Public Health or the Department of Human
17Services.
18    (c) This Section shall not be interpreted to require
19coverage for speech therapy or other habilitative services for
20those individuals covered under Section 356z.15 of this Code.
21    (d) With respect to a group or individual policy of
22accident and health insurance or a qualified health plan
23offered through the health insurance marketplace, the
24Department and, with respect to medical assistance, the
25Department of Healthcare and Family Services shall each
26enforce the requirements of this Section and Sections 356z.23

 

 

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1and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
2Mental Health Parity and Addiction Equity Act of 2008, 42
3U.S.C. 18031(j), and any amendments to, and federal guidance
4or regulations issued under, those Acts, including, but not
5limited to, final regulations issued under the Paul Wellstone
6and Pete Domenici Mental Health Parity and Addiction Equity
7Act of 2008 and final regulations applying the Paul Wellstone
8and Pete Domenici Mental Health Parity and Addiction Equity
9Act of 2008 to Medicaid managed care organizations, the
10Children's Health Insurance Program, and alternative benefit
11plans. Specifically, the Department and the Department of
12Healthcare and Family Services shall take action:
13        (1) proactively ensuring compliance by individual and
14    group policies, including by requiring that insurers
15    submit comparative analyses, as set forth in paragraph (6)
16    of subsection (k) of Section 370c.1, demonstrating how
17    they design and apply nonquantitative treatment
18    limitations, both as written and in operation, for mental,
19    emotional, nervous, or substance use disorder or condition
20    benefits as compared to how they design and apply
21    nonquantitative treatment limitations, as written and in
22    operation, for medical and surgical benefits;
23        (2) evaluating all consumer or provider complaints
24    regarding mental, emotional, nervous, or substance use
25    disorder or condition coverage for possible parity
26    violations;

 

 

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

 

 

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

 

 

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1    "Benefits", with respect to insurers, means the benefits
2provided for treatment services for inpatient and outpatient
3treatment of substance use disorders or conditions at American
4Society of Addiction Medicine levels of treatment 2.1
5(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
6(Clinically Managed Low-Intensity Residential), 3.3
7(Clinically Managed Population-Specific High-Intensity
8Residential), 3.5 (Clinically Managed High-Intensity
9Residential), and 3.7 (Medically Monitored Intensive
10Inpatient) and OMT (Opioid Maintenance Therapy) services.
11    "Benefits", with respect to managed care organizations,
12means the benefits provided for treatment services for
13inpatient and outpatient treatment of substance use disorders
14or conditions at American Society of Addiction Medicine levels
15of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
16Hospitalization), 3.5 (Clinically Managed High-Intensity
17Residential), and 3.7 (Medically Monitored Intensive
18Inpatient) and OMT (Opioid Maintenance Therapy) services.
19    "Substance use disorder treatment provider or facility"
20means a licensed physician, licensed psychologist, licensed
21psychiatrist, licensed advanced practice registered nurse, or
22licensed, certified, or otherwise State-approved facility or
23provider of substance use disorder treatment.
24    (2) A group health insurance policy, an individual health
25benefit plan, or qualified health plan that is offered through
26the health insurance marketplace, small employer group health

 

 

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1plan, and large employer group health plan that is amended,
2delivered, issued, executed, or renewed in this State, or
3approved for issuance or renewal in this State, on or after
4January 1, 2019 (the effective date of Public Act 100-1023)
5shall comply with the requirements of this Section and Section
6370c.1. The services for the treatment and the ongoing
7assessment of the patient's progress in treatment shall follow
8the requirements of 77 Ill. Adm. Code 2060.
9    (3) Prior authorization shall not be utilized for the
10benefits under this subsection. The substance use disorder
11treatment provider or facility shall notify the insurer of the
12initiation of treatment. For an insurer that is not a managed
13care organization, the substance use disorder treatment
14provider or facility notification shall occur for the
15initiation of treatment of the covered person within 2
16business days. For managed care organizations, the substance
17use disorder treatment provider or facility notification shall
18occur in accordance with the protocol set forth in the
19provider agreement for initiation of treatment within 24
20hours. If the managed care organization is not capable of
21accepting the notification in accordance with the contractual
22protocol during the 24-hour period following admission, the
23substance use disorder treatment provider or facility shall
24have one additional business day to provide the notification
25to the appropriate managed care organization. Treatment plans
26shall be developed in accordance with the requirements and

 

 

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

 

 

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

 

 

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1    substance use disorder care" means standards of care and
2    clinical practice that are generally recognized by health
3    care providers practicing in relevant clinical specialties
4    such as psychiatry, psychology, clinical sociology,
5    addiction medicine and counseling, and behavioral health
6    treatment. "Generally accepted standards of mental health
7    and substance use disorder care" include peer-reviewed
8    scientific studies and medical literature, recommendations
9    of nonprofit health care provider professional
10    associations and specialty societies, including, but not
11    limited to, patient placement criteria and clinical
12    practice guidelines, recommendations of federal government
13    agencies, and drug labeling approved by the United States
14    Food and Drug Administration.
15        (2) "Medically necessary treatment of a mental health
16    or substance use disorder" means a service or product
17    addressing the specific needs of that patient, for the
18    purpose of screening, preventing, diagnosing, managing or
19    treating an illness, injury, condition, or its symptoms,
20    including minimizing the progression of an illness,
21    injury, condition, or its symptoms in a manner that is all
22    of the following:
23            (A) in accordance with the generally accepted
24        standards of mental health and substance use disorder
25        care;
26            (B) clinically appropriate in terms of type,

 

 

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1        frequency, extent, site, and duration; and
2            (C) not primarily for the economic benefit of the
3        insurer, purchaser, or for the convenience of the
4        patient, treating physician, or other health care
5        provider.
6        (3) "Mental health and substance use disorders" means
7    a mental health condition or substance use disorder that
8    falls under any of the diagnostic categories listed in the
9    mental and behavioral disorders chapter of the most recent
10    edition of the World Health Organization's International
11    Statistical Classification of Diseases and Related Health
12    Problems or that is listed in the most recent version of
13    the American Psychiatric Association's Diagnostic and
14    Statistical Manual of Mental Disorders. Changes in
15    terminology, organization, or classification of mental
16    health and substance use disorders in future versions of
17    the American Psychiatric Association's Diagnostic and
18    Statistical Manual of Mental Disorders or the World Health
19    Organization's International Statistical Classification
20    of Diseases and Related Health Problems shall not affect
21    the conditions covered by this Section as long as a
22    condition is commonly understood to be a mental health or
23    substance use disorder by health care providers practicing
24    in relevant clinical specialties.
25        (4) "Utilization review" means either of the
26    following:

 

 

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1            (A) prospectively, retrospectively, or
2        concurrently reviewing and approving, modifying,
3        delaying, or denying, based in whole or in part on
4        medical necessity, requests by health care providers,
5        insureds, or their authorized representatives for
6        coverage of health care services before,
7        retrospectively, or concurrent with the provision of
8        health care services to insureds; or
9            (B) evaluating the medical necessity,
10        appropriateness, level of care, service intensity,
11        efficacy, or efficiency of health care services,
12        benefits, procedures, or settings, under any
13        circumstances, to determine whether a health care
14        service or benefit subject to a medical necessity
15        coverage requirement in an insurance policy is covered
16        as medically necessary for an insured.
17        (5) "Utilization review criteria" means any criteria,
18    standards, protocols, or guidelines used by an insurer to
19    conduct utilization review.
20    (i) Every insurer that amends, delivers, issues, or renews
21a group or individual policy of accident and health insurance
22providing coverage for hospital or medical treatment on or
23after January 1, 2022 shall, pursuant to subsections (h)
24through (n), provide coverage for medically necessary
25treatment of mental health and substance use disorders.
26    (j) An insurer that authorizes a specific type of

 

 

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1treatment by a provider pursuant to this Section shall not
2rescind or modify the authorization after that provider
3renders the health care service in good faith and pursuant to
4this authorization for any reason, including, but not limited
5to, the insurer's subsequent rescission, cancellation, or
6modification of the insured's or policyholder's contract, or
7the insured's subsequent determination that it did not make an
8accurate determination of the insured's or policyholder's
9eligibility.
10    (k) If services for the medically necessary treatment of a
11mental health or substance use disorder are not available
12in-network within the geographic and timely access standards
13set by law or regulation, the insurer shall arrange coverage
14to ensure the delivery of medically necessary out-of-network
15services and any medically necessary follow-up services that,
16to the maximum extent possible, meet those geographic and
17timely access standards. The insured shall pay no more in
18total for benefits rendered than the cost sharing that the
19insured would pay for the same covered services received from
20an in-network provider.
21    (l) An insurer shall not limit benefits or coverage for
22medically necessary services on the basis that those services
23should be or could be covered by a public entitlement program,
24including, but not limited to, special education or an
25individualized education program, Medicaid, Medicare,
26Supplemental Security Income, or Social Security Disability

 

 

HB3259- 21 -LRB102 11933 BMS 17269 b

1Insurance, and shall not include or enforce a contract term
2that excludes otherwise covered benefits on the basis that
3those services should be or could be covered by a public
4entitlement program.
5    (m) In conducting utilization review involving level of
6care placement decisions or any other patient care decisions
7concerning services and benefits for the diagnosis,
8prevention, and treatment of mental health and substance use
9disorders, an insurer shall apply the level of care placement
10criteria and practice guidelines set forth in the most recent
11versions of the criteria and practice guidelines developed by
12the nonprofit professional association for the relevant
13clinical specialty. For all level of care placement decisions
14for non-substance-use disorders, the insurer shall authorize
15placement at the level of care consistent with the insured's
16score using the relevant level of care placement criteria and
17guidelines or at a higher level.
18    (n) Every insurer shall do all of the following:
19        (1) sponsor a formal education program by nonprofit
20    clinical specialty associations to educate the insurer's
21    staff, including any third parties contracted with the
22    insurer to review claims, conduct utilization reviews, or
23    make medical necessity determinations about the clinical
24    review criteria;
25        (2) make the education program available to other
26    stakeholders, including the insurer's participating

 

 

HB3259- 22 -LRB102 11933 BMS 17269 b

1    provider and covered lives;
2        (3) provide, at no cost, the clinical review criteria
3    and any training material or resources to providers and
4    insured patients;
5        (4) conduct interrater reliability testing to ensure
6    consistency in utilization review decision making covering
7    how medical necessity decisions are made; and
8        (5) achieve interrater reliability pass rates of at
9    least 90% and, if this threshold is not met, immediately
10    provide for the remediation of poor interrater reliability
11    and interrater reliability testing for all new staff
12    before they can conduct utilization review without
13    supervision.
14(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
15100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
168-16-19; revised 9-20-19.)