Sen. Laura Fine

Filed: 5/2/2023

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1364

2    AMENDMENT NO. ______. Amend House Bill 1364 on page 7,
3immediately below line 5, by inserting the following:
 
4    "Section 90. 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 July 23, 2021 (the effective date of
10Public Act 102-135), every insurer that amends, delivers,
11issues, or renews a group or individual policy of accident and
12health insurance or a qualified health plan offered through
13the Health Insurance Marketplace in this State providing
14coverage for hospital or medical treatment and for the
15treatment of mental, emotional, nervous, or substance use
16disorders or conditions shall ensure prior to policy issuance

 

 

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1that:
2        (1) the financial requirements applicable to such
3    mental, emotional, nervous, or substance use disorder or
4    condition benefits are no more restrictive than the
5    predominant financial requirements applied to
6    substantially all hospital and medical benefits covered by
7    the policy and that there are no separate cost-sharing
8    requirements that are applicable only with respect to
9    mental, emotional, nervous, or substance use disorder or
10    condition benefits; and
11        (2) the treatment limitations applicable to such
12    mental, emotional, nervous, or substance use disorder or
13    condition benefits are no more restrictive than the
14    predominant treatment limitations applied to substantially
15    all hospital and medical benefits covered by the policy
16    and that there are no separate treatment limitations that
17    are applicable only with respect to mental, emotional,
18    nervous, or substance use disorder or condition benefits.
19    (b) The following provisions shall apply concerning
20aggregate lifetime limits:
21        (1) In the case of a group or individual policy of
22    accident and health insurance or a qualified health plan
23    offered through the Health Insurance Marketplace amended,
24    delivered, issued, or renewed in this State on or after
25    September 9, 2015 (the effective date of Public Act
26    99-480) that provides coverage for hospital or medical

 

 

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

 

 

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1        (2) In the case of a policy that is not described in
2    paragraph (1) of subsection (b) of this Section and that
3    includes no or different aggregate lifetime limits on
4    different categories of hospital and medical benefits, the
5    Director shall establish rules under which subparagraph
6    (B) of paragraph (1) of subsection (b) of this Section is
7    applied to such policy with respect to mental, emotional,
8    nervous, or substance use disorder or condition benefits
9    by substituting for the applicable lifetime limit an
10    average aggregate lifetime limit that is computed taking
11    into account the weighted average of the aggregate
12    lifetime limits applicable to such categories.
13    (c) The following provisions shall apply concerning annual
14limits:
15        (1) In the case of a group or individual policy of
16    accident and health insurance or a qualified health plan
17    offered through the Health Insurance Marketplace amended,
18    delivered, issued, or renewed in this State on or after
19    September 9, 2015 (the effective date of Public Act
20    99-480) that provides coverage for hospital or medical
21    treatment and for the treatment of mental, emotional,
22    nervous, or substance use disorders or conditions the
23    following provisions shall apply:
24            (A) if the policy does not include an annual limit
25        on substantially all hospital and medical benefits,
26        then the policy may not impose any annual limits on

 

 

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

 

 

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1    substituting for the applicable annual limit an average
2    annual limit that is computed taking into account the
3    weighted average of the annual limits applicable to such
4    categories.
5    (d) With respect to mental, emotional, nervous, or
6substance use disorders or conditions, an insurer shall use
7policies and procedures for the election and placement of
8mental, emotional, nervous, or substance use disorder or
9condition treatment drugs on their formulary that are no less
10favorable to the insured as those policies and procedures the
11insurer uses for the selection and placement of drugs for
12medical or surgical conditions and shall follow the expedited
13coverage determination requirements for substance abuse
14treatment drugs set forth in Section 45.2 of the Managed Care
15Reform and Patient Rights Act.
16    (e) This Section shall be interpreted in a manner
17consistent with all applicable federal parity regulations
18including, but not limited to, the Paul Wellstone and Pete
19Domenici Mental Health Parity and Addiction Equity Act of
202008, final regulations issued under the Paul Wellstone and
21Pete Domenici Mental Health Parity and Addiction Equity Act of
222008 and final regulations applying the Paul Wellstone and
23Pete Domenici Mental Health Parity and Addiction Equity Act of
242008 to Medicaid managed care organizations, the Children's
25Health Insurance Program, and alternative benefit plans.
26    (f) The provisions of subsections (b) and (c) of this

 

 

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1Section shall not be interpreted to allow the use of lifetime
2or annual limits otherwise prohibited by State or federal law.
3    (g) As used in this Section:
4    "Financial requirement" includes deductibles, copayments,
5coinsurance, and out-of-pocket maximums, but does not include
6an aggregate lifetime limit or an annual limit subject to
7subsections (b) and (c).
8    "Mental, emotional, nervous, or substance use disorder or
9condition" 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.
16    "Treatment limitation" includes limits on benefits based
17on the frequency of treatment, number of visits, days of
18coverage, days in a waiting period, or other similar limits on
19the scope or duration of treatment. "Treatment limitation"
20includes both quantitative treatment limitations, which are
21expressed numerically (such as 50 outpatient visits per year),
22and nonquantitative treatment limitations, which otherwise
23limit the scope or duration of treatment. A permanent
24exclusion of all benefits for a particular condition or
25disorder shall not be considered a treatment limitation.
26"Nonquantitative treatment" means those limitations as

 

 

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1described under federal regulations (26 CFR 54.9812-1).
2"Nonquantitative treatment limitations" include, but are not
3limited to, those limitations described under federal
4regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
5146.136.
6    (h) The Department of Insurance shall implement the
7following education initiatives:
8        (1) By January 1, 2016, the Department shall develop a
9    plan for a Consumer Education Campaign on parity. The
10    Consumer Education Campaign shall focus its efforts
11    throughout the State and include trainings in the
12    northern, southern, and central regions of the State, as
13    defined by the Department, as well as each of the 5 managed
14    care regions of the State as identified by the Department
15    of Healthcare and Family Services. Under this Consumer
16    Education Campaign, the Department shall: (1) by January
17    1, 2017, provide at least one live training in each region
18    on parity for consumers and providers and one webinar
19    training to be posted on the Department website and (2)
20    establish a consumer hotline to assist consumers in
21    navigating the parity process by March 1, 2017. By January
22    1, 2018 the Department shall issue a report to the General
23    Assembly on the success of the Consumer Education
24    Campaign, which shall indicate whether additional training
25    is necessary or would be recommended.
26        (2) The Department, in coordination with the

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    and law; and
2        (9) when reporting and publishing should begin.
3    Representatives from the Department of Healthcare and
4Family Services, representatives from the Division of Mental
5Health, and representatives from the Division of Substance Use
6Prevention and Recovery shall provide technical advice to the
7workgroup.
8    (k) An insurer that amends, delivers, issues, or renews a
9group or individual policy of accident and health insurance or
10a qualified health plan offered through the health insurance
11marketplace in this State providing coverage for hospital or
12medical treatment and for the treatment of mental, emotional,
13nervous, or substance use disorders or conditions shall submit
14an annual report, the format and definitions for which will be
15determined developed by the workgroup in subsection (j), to
16the Department and , or, with respect to medical assistance,
17the Department of Healthcare and Family Services and posted on
18their respective websites, starting on September 1, 2023 and
19annually thereafter, or before July 1, 2020 that contains the
20following information separately for inpatient in-network
21benefits, inpatient out-of-network benefits, outpatient
22in-network benefits, outpatient out-of-network benefits,
23emergency care benefits, and prescription drug benefits in the
24case of accident and health insurance or qualified health
25plans, or inpatient, outpatient, emergency care, and
26prescription drug benefits in the case of medical assistance:

 

 

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

 

 

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

 

 

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

 

 

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1    Director, including information that may be proprietary or
2    have commercial value, under the requirements of Section
3    30 of the Viatical Settlements Act of 2009.
4    (l) An insurer that amends, delivers, issues, or renews a
5group or individual policy of accident and health insurance or
6a qualified health plan offered through the health insurance
7marketplace in this State providing coverage for hospital or
8medical treatment and for the treatment of mental, emotional,
9nervous, or substance use disorders or conditions on or after
10January 1, 2019 (the effective date of Public Act 100-1024)
11shall, in advance of the plan year, make available to the
12Department or, with respect to medical assistance, the
13Department of Healthcare and Family Services and to all plan
14participants and beneficiaries the information required in
15subparagraphs (C) through (E) of paragraph (6) of subsection
16(k). For plan participants and medical assistance
17beneficiaries, the information required in subparagraphs (C)
18through (E) of paragraph (6) of subsection (k) shall be made
19available on a publicly-available website whose web address is
20prominently displayed in plan and managed care organization
21informational and marketing materials.
22    (m) In conjunction with its compliance examination program
23conducted in accordance with the Illinois State Auditing Act,
24the Auditor General shall undertake a review of compliance by
25the Department and the Department of Healthcare and Family
26Services with Section 370c and this Section. Any findings

 

 

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1resulting from the review conducted under this Section shall
2be included in the applicable State agency's compliance
3examination report. Each compliance examination report shall
4be issued in accordance with Section 3-14 of the Illinois
5State Auditing Act. A copy of each report shall also be
6delivered to the head of the applicable State agency and
7posted on the Auditor General's website.
8(Source: P.A. 102-135, eff. 7-23-21; 102-579, eff. 8-25-21;
9102-813, eff. 5-13-22.)".