Rep. Lindsey LaPointe

Filed: 4/2/2024

 

 


 

 


 
10300HB4475ham001LRB103 36234 RPS 71770 a

1
AMENDMENT TO HOUSE BILL 4475

2    AMENDMENT NO. ______. Amend House Bill 4475 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. This Act may be referred to as the
5Strengthening Mental Health and Substance Use Parity Act.
 
6    Section 2. Purpose. The purpose of this Act is to improve
7mental health and substance use parity, specifically
8addressing network adequacy and nonquantitative treatment
9limitations that restrict access to care.
 
10    Section 3. Findings. The General Assembly finds that:
11    (1) A 2021 U.S. Surgeon General Advisory, Protecting Youth
12Mental Health, reported the COVID-19 pandemic's devastating
13impact on youth and family mental health:
14        (A) One in 3 high school students reported persistent
15    feelings of hopelessness and sadness in 2019.

 

 

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1        (B) Rates of depression and anxiety for youth doubled
2    during the pandemic.
3        (C) Black children under 13 are nearly twice as likely
4    to die by suicide than white children.
5    (2) According to a bipartisan U.S. Senate Finance
6Committee report on Mental Health Care in the United States,
7symptoms for depression and anxiety in adults increased nearly
8four-fold during the pandemic.
9    (3) In 2020, 2,944 Illinoisans lost their lives to an
10opioid overdose according to the Illinois Department of Public
11Health.
12    (4) Discriminatory commercial insurance practices that do
13not live up to the federal Mental Health Parity and Addiction
14Equity Act (MHPAEA) and Illinois' parity laws, specifically
15regarding insurance network adequacy, severely limit access to
16care.
17    (5) Commercial insurance practices disincentivize mental
18health and substance use treatment providers from
19participating in insurance networks by erecting significant
20administrative barriers and by reimbursing providers far below
21the reimbursement of other health care providers despite a
22behavioral health workforce crisis.
23        (A) Such practices lead to restrictive, narrow
24    insurance networks that restrict access care.
25        (B) 26% of psychiatrists do not participate in
26    insurance networks, according to a report in JAMA

 

 

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1    Psychiatry.
2        (C) 21% of psychologists do not participate in
3    insurance networks, according to a 2015 American
4    Psychological Association Survey.
5        (D) A significant percentage of behavioral health
6    providers do not contract with insurers, leaving patients
7    to see out-of-network providers.
8        (E) Out-of-network treatment is far more expensive for
9    the patient than in-network care.
10        (F) Mental health and substance use treatment is
11    inaccessible and unaffordable for millions of Illinoisans
12    for these reasons.
13    (6) A recent Milliman report analyzing insurance claims
14for 37,000,000 Americans, including Illinois residents, found
15major disparities in out-of-network utilization for behavioral
16health compared to other health care. The report's findings
17include:
18        (A) Illinois out-of-network behavioral health
19    utilization was 18.2% for outpatient services in 2017
20    compared to just 3.9% for medical/surgical services.
21        (B) Illinois out-of-network behavioral health
22    utilization was 12.1% in 2017 for inpatient care compared
23    to just 2.8% for medical/surgical.
24        (C) The disparity between out-of-network usage for
25    behavioral health compared to medical/surgical services
26    grew significantly between 2013 and 2017: Out-of-network

 

 

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1    behavioral health utilization for outpatient visits grew
2    by 44%, while out-of-network utilization for
3    medical/surgical services decreased by 42% over the same
4    period in Illinois.
5        (D) Nearly 14% of behavioral health office visits for
6    individuals with a preferred provider organization plan
7    were out-of-network in Illinois.
8    (7) Mental health and substance use care, which represents
9just 5.2% of all health care spending, does not drive up
10premiums.
11    (8) Improved access to behavioral health care is expected
12to reduce overall health care spending because:
13        (A) spending on physical health care is 2 to 3 times
14    higher for patients with ongoing mental health and
15    substance use diagnoses, according to a 2018 Milliman
16    research report; and
17        (B) improved utilization of mental health services has
18    been demonstrated empirically to reduce overall health
19    care spending (Biu, Yoon, & Hines, 2021).
20    (9) Illinois must strengthen its parity laws to prevent
21insurance practices that restrict access to mental health and
22substance use care.
 
23    Section 10. The Illinois Insurance Code is amended by
24adding Section 370c.3 as follows:
 

 

 

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1    (215 ILCS 5/370c.3 new)
2    Sec. 370c.3. Mental health and substance use parity.
3    (a) In this Section:
4    "Application" means a person's or facility's application
5to become a participating provider with an insurer in at least
6one of the insurer's provider networks.
7    "Applying provider" means a provider or facility that has
8submitted a completed application to become a participating
9provider or facility with an insurer.
10    "Behavioral health trainee" means any person: (1) engaged
11in the provision of mental health or substance use disorder
12clinical services as part of that person's supervised course
13of study while enrolled in a master's or doctoral psychology,
14social work, counseling, or marriage or family therapy program
15or as a postdoctoral graduate working toward licensure; and
16(2) who is working toward clinical State licensure under the
17clinical supervision of a fully licensed mental health or
18substance use disorder treatment provider.
19    "Completed application" means a person's or facility's
20application to become a participating provider that has been
21submitted to the insurer and includes all the required
22information for the application to be considered by the
23insurer according to the insurer's policies and procedures for
24verifying a provider's or facility's credentials.
25    "Contracting process" means the process by which a mental
26health or substance use disorder treatment provider or

 

 

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1facility makes a completed application with an insurer to
2become a participating provider with the insurer until the
3effective date of a final contract between the provider or
4facility and the insurer. "Contracting process" includes the
5process of verifying a provider's credentials.
6    "Participating provider" means any mental health or
7substance use disorder treatment provider that has a contract
8to provide mental health or substance use disorder services
9with an insurer.
10    (b) For all group or individual policies of accident and
11health insurance or managed care plans that are amended,
12delivered, issued, or renewed on or after January 1, 2026, or
13any contracted third party administering the behavioral health
14benefits for the insurer, reimbursement for in-network mental
15health and substance use disorder treatment services delivered
16by Illinois providers and facilities must be, on average, at
17least as favorable as professional services provided by
18in-network primary care providers. Reimbursement rates for
19services paid to Illinois mental health and substance use
20disorder treatment providers and facilities do not meet this
21required standard unless the reimbursement rates are, on
22average, equal to or greater than 141% of the Medicare
23reimbursement rate for the same service. For services not
24covered by Medicare, the reimbursement rates must be, on
25average, equal to or greater than 144% of the standard
26in-network reimbursement rate for such service on the

 

 

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1effective date of this amendatory Act of the 103rd General
2Assembly. This Section applies to all covered office,
3outpatient, inpatient, and residential mental health and
4substance use disorder services.
5    (c) A group or individual policy of accident and health
6insurance or managed care plan that is amended, delivered,
7issued, or renewed on or after January 1, 2025, or contracted
8third party administering the behavioral health benefits for
9the insurer, shall cover all medically necessary mental health
10or substance use disorder services received by the same
11insured on the same day from the same or different mental
12health or substance use provider or facility for both
13outpatient and inpatient care.
14    (d) A group or individual policy of accident and health
15insurance or managed care plan that is amended, delivered,
16issued, or renewed on or after January 1, 2025, or any
17contracted third party administering the behavioral health
18benefits for the insurer, shall cover any medically necessary
19mental health or substance use disorder service provided by a
20behavioral health trainee when the trainee is working toward
21clinical State licensure and is under the supervision of a
22fully licensed mental health or substance use disorder
23treatment provider, which is a physician licensed to practice
24medicine in all its branches, licensed clinical psychologist,
25licensed clinical social worker, licensed clinical
26professional counselor, licensed marriage and family

 

 

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1therapist, licensed speech-language pathologist, or other
2licensed or certified professional at a program licensed
3pursuant to the Substance Use Disorder Act who is engaged in
4treating mental, emotional, nervous, or substance use
5disorders or conditions. Services provided by the trainee must
6be billed under the supervising clinician's rendering National
7Provider Identifier.
8    (e) A group or individual policy of accident and health
9insurance or managed care plan that is amended, delivered,
10issued, or renewed on or after January 1, 2025, or any
11contracted third party administering the behavioral health
12benefits for the insurer, shall:
13        (1) cover medically necessary 60-minute psychotherapy
14    billed using the CPT Code 90837 for Individual Therapy;
15        (2) not impose more onerous documentation requirements
16    on the provider than is required for other psychotherapy
17    CPT Codes; and
18        (3) not audit the use of CPT Code 90837 any more
19    frequently than audits for the use of other psychotherapy
20    CPT Codes.
21    (f)(1) Any group or individual policy of accident and
22health insurance or managed care plan that is amended,
23delivered, issued, or renewed on or after January 1, 2026, or
24any contracted third party administering the behavioral health
25benefits for the insurer, shall complete the contracting
26process with a mental health or substance use disorder

 

 

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1treatment provider or facility for becoming a participating
2provider in the insurer's network, including the verification
3of the provider's credentials, within 60 days from the date of
4a completed application to the insurer to become a
5participating provider. Nothing in this paragraph (1),
6however, presumes or establishes a contract between an insurer
7and a provider.
8    (2) Any group or individual policy of accident and health
9insurance or managed care plan that is amended, delivered,
10issued, or renewed on or after January 1, 2025, or any
11contracted third party administering the behavioral health
12benefits for the insurer, shall reimburse a participating
13mental health or substance use disorder treatment provider or
14facility at the contracted reimbursement rate for any
15medically necessary services provided to an insured from the
16date of submission of the provider's or facility's completed
17application to become a participating provider with the
18insurer up to the effective date of the provider's contract.
19The provider's claims for such services shall be reimbursed
20only when submitted after the effective date of the provider's
21contract with the insurer. This paragraph (2) does not apply
22to a provider that does not have a completed contract with an
23insurer. If a provider opts to submit claims for medically
24necessary mental health or substance use disorder services
25pursuant to this paragraph (2), the provider must notify the
26insured following submission of the claims to the insurer that

 

 

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1the services provided to the insured may be treated as
2in-network services.
3    (3) Any group or individual policy of accident and health
4insurance or managed care plan that is amended, delivered,
5issued, or renewed on or after January 1, 2025, or any
6contracted third party administering the behavioral health
7benefits for the insurer, shall cover any medically necessary
8mental health or substance use disorder service provided by a
9fully licensed mental health or substance use disorder
10treatment provider affiliated with a mental health or
11substance use disorder treatment group practice who has
12submitted a completed application to become a participating
13provider with an insurer who is delivering services under the
14supervision of another fully licensed participating mental
15health or substance use disorder treatment provider within the
16same group practice up to the effective date of the applying
17provider's contract with the insurer as a participating
18provider. Services provided by the applying provider must be
19billed under the supervising licensed provider's rendering
20National Provider Identifier.
21    (4) Upon request, an insurer, or any contracted third
22party administering the behavioral health benefits for the
23insurer, shall provide an applying provider with the insurer's
24credentialing policies and procedures. An insurer, or any
25contracted third party administering the behavioral health
26benefits for the insurer, shall post the following

 

 

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1nonproprietary information on its website and make that
2information available to all applicants:
3        (A) a list of the information required to be included
4    in an application;
5        (B) a checklist of the materials that must be
6    submitted in the credentialing process; and
7        (C) designated contact information of a network
8    representative, including a designated point of contact,
9    an email address, and a telephone number, to which an
10    applicant may address any credentialing inquiries.
11    (g) The Department has the same authority to enforce this
12Section as it has to enforce compliance with Sections 370c and
13370c.1. Additionally, if the Department determines that an
14insurer or a contracted third party administering the
15behavioral health benefits for the insurer has violated this
16Section, the Department shall, after appropriate notice and
17opportunity for hearing in accordance with Section 402, by
18order assess a civil penalty of $5,000 for each violation. The
19Department shall establish any processes or procedures
20necessary to monitor compliance with this Section, including
21the ability to receive complaints from mental health and
22substance use disorder treatment providers impacted by an
23insurer's failure to comply, or a contracted third party's
24failure to comply, while ensuring adherence to all federal and
25State privacy and confidentiality laws.
26    (h) The Department shall adopt any rules necessary to

 

 

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1implement this Section by no later than May 1, 2025.
 
2    Section 15. The Health Maintenance Organization Act is
3amended by changing Section 5-3 as follows:
 
4    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
5    Sec. 5-3. Insurance Code provisions.
6    (a) Health Maintenance Organizations shall be subject to
7the provisions of Sections 133, 134, 136, 137, 139, 140,
8141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
9154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
10355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
11356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
12356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
13356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
14356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30,
15356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35,
16356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44,
17356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51,
18356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59,
19356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68,
20364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
21368d, 368e, 370c, 370c.3, 370c.1, 401, 401.1, 402, 403, 403A,
22408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
23subsection (2) of Section 367, and Articles IIA, VIII 1/2,
24XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the

 

 

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1Illinois Insurance Code.
2    (b) For purposes of the Illinois Insurance Code, except
3for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
4Health Maintenance Organizations in the following categories
5are deemed to be "domestic companies":
6        (1) a corporation authorized under the Dental Service
7    Plan Act or the Voluntary Health Services Plans Act;
8        (2) a corporation organized under the laws of this
9    State; or
10        (3) a corporation organized under the laws of another
11    state, 30% or more of the enrollees of which are residents
12    of this State, except a corporation subject to
13    substantially the same requirements in its state of
14    organization as is a "domestic company" under Article VIII
15    1/2 of the Illinois Insurance Code.
16    (c) In considering the merger, consolidation, or other
17acquisition of control of a Health Maintenance Organization
18pursuant to Article VIII 1/2 of the Illinois Insurance Code,
19        (1) the Director shall give primary consideration to
20    the continuation of benefits to enrollees and the
21    financial conditions of the acquired Health Maintenance
22    Organization after the merger, consolidation, or other
23    acquisition of control takes effect;
24        (2)(i) the criteria specified in subsection (1)(b) of
25    Section 131.8 of the Illinois Insurance Code shall not
26    apply and (ii) the Director, in making his determination

 

 

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1    with respect to the merger, consolidation, or other
2    acquisition of control, need not take into account the
3    effect on competition of the merger, consolidation, or
4    other acquisition of control;
5        (3) the Director shall have the power to require the
6    following information:
7            (A) certification by an independent actuary of the
8        adequacy of the reserves of the Health Maintenance
9        Organization sought to be acquired;
10            (B) pro forma financial statements reflecting the
11        combined balance sheets of the acquiring company and
12        the Health Maintenance Organization sought to be
13        acquired as of the end of the preceding year and as of
14        a date 90 days prior to the acquisition, as well as pro
15        forma financial statements reflecting projected
16        combined operation for a period of 2 years;
17            (C) a pro forma business plan detailing an
18        acquiring party's plans with respect to the operation
19        of the Health Maintenance Organization sought to be
20        acquired for a period of not less than 3 years; and
21            (D) such other information as the Director shall
22        require.
23    (d) The provisions of Article VIII 1/2 of the Illinois
24Insurance Code and this Section 5-3 shall apply to the sale by
25any health maintenance organization of greater than 10% of its
26enrollee population (including, without limitation, the health

 

 

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1maintenance organization's right, title, and interest in and
2to its health care certificates).
3    (e) In considering any management contract or service
4agreement subject to Section 141.1 of the Illinois Insurance
5Code, the Director (i) shall, in addition to the criteria
6specified in Section 141.2 of the Illinois Insurance Code,
7take into account the effect of the management contract or
8service agreement on the continuation of benefits to enrollees
9and the financial condition of the health maintenance
10organization to be managed or serviced, and (ii) need not take
11into account the effect of the management contract or service
12agreement on competition.
13    (f) Except for small employer groups as defined in the
14Small Employer Rating, Renewability and Portability Health
15Insurance Act and except for medicare supplement policies as
16defined in Section 363 of the Illinois Insurance Code, a
17Health Maintenance Organization may by contract agree with a
18group or other enrollment unit to effect refunds or charge
19additional premiums under the following terms and conditions:
20        (i) the amount of, and other terms and conditions with
21    respect to, the refund or additional premium are set forth
22    in the group or enrollment unit contract agreed in advance
23    of the period for which a refund is to be paid or
24    additional premium is to be charged (which period shall
25    not be less than one year); and
26        (ii) the amount of the refund or additional premium

 

 

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1    shall not exceed 20% of the Health Maintenance
2    Organization's profitable or unprofitable experience with
3    respect to the group or other enrollment unit for the
4    period (and, for purposes of a refund or additional
5    premium, the profitable or unprofitable experience shall
6    be calculated taking into account a pro rata share of the
7    Health Maintenance Organization's administrative and
8    marketing expenses, but shall not include any refund to be
9    made or additional premium to be paid pursuant to this
10    subsection (f)). The Health Maintenance Organization and
11    the group or enrollment unit may agree that the profitable
12    or unprofitable experience may be calculated taking into
13    account the refund period and the immediately preceding 2
14    plan years.
15    The Health Maintenance Organization shall include a
16statement in the evidence of coverage issued to each enrollee
17describing the possibility of a refund or additional premium,
18and upon request of any group or enrollment unit, provide to
19the group or enrollment unit a description of the method used
20to calculate (1) the Health Maintenance Organization's
21profitable experience with respect to the group or enrollment
22unit and the resulting refund to the group or enrollment unit
23or (2) the Health Maintenance Organization's unprofitable
24experience with respect to the group or enrollment unit and
25the resulting additional premium to be paid by the group or
26enrollment unit.

 

 

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1    In no event shall the Illinois Health Maintenance
2Organization Guaranty Association be liable to pay any
3contractual obligation of an insolvent organization to pay any
4refund authorized under this Section.
5    (g) Rulemaking authority to implement Public Act 95-1045,
6if any, is conditioned on the rules being adopted in
7accordance with all provisions of the Illinois Administrative
8Procedure Act and all rules and procedures of the Joint
9Committee on Administrative Rules; any purported rule not so
10adopted, for whatever reason, is unauthorized.
11(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
12102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
131-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
14eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
15102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
161-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
17eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
18103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
196-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
20eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
21    Section 99. Effective date. This Act takes effect upon
22becoming law.".