Rep. Lindsey LaPointe

Filed: 4/16/2024

 

 


 

 


 
10300HB4475ham002LRB103 36234 RPS 72341 a

1
AMENDMENT TO HOUSE BILL 4475

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

 

 

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1    feelings of hopelessness and sadness in 2019.
2        (B) Rates of depression and anxiety for youth doubled
3    during the pandemic.
4        (C) Black children under 13 are nearly twice as likely
5    to die by suicide than white children.
6    (2) According to a bipartisan U.S. Senate Finance
7Committee report on Mental Health Care in the United States,
8symptoms for depression and anxiety in adults increased nearly
9four-fold during the pandemic.
10    (3) In 2020, 2,944 Illinoisans lost their lives to an
11opioid overdose according to the Illinois Department of Public
12Health.
13    (4) Discriminatory commercial insurance practices that do
14not live up to the federal Mental Health Parity and Addiction
15Equity Act (MHPAEA) and Illinois' parity laws, specifically
16regarding insurance network adequacy, severely limit access to
17care.
18    (5) Commercial insurance practices disincentivize mental
19health and substance use treatment providers from
20participating in insurance networks by erecting significant
21administrative barriers and by reimbursing providers far below
22the reimbursement of other health care providers despite a
23behavioral health workforce crisis.
24        (A) Such practices lead to restrictive, narrow
25    insurance networks that restrict access care.
26        (B) 26% of psychiatrists do not participate in

 

 

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

 

 

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1    grew significantly between 2013 and 2017: Out-of-network
2    behavioral health utilization for outpatient visits grew
3    by 44%, while out-of-network utilization for
4    medical/surgical services decreased by 42% over the same
5    period in Illinois.
6        (D) Nearly 14% of behavioral health office visits for
7    individuals with a preferred provider organization plan
8    were out-of-network in Illinois.
9    (7) Mental health and substance use care, which represents
10just 5.2% of all health care spending, does not drive up
11premiums.
12    (8) Improved access to behavioral health care is expected
13to reduce overall health care spending because:
14        (A) spending on physical health care is 2 to 3 times
15    higher for patients with ongoing mental health and
16    substance use diagnoses, according to a 2018 Milliman
17    research report; and
18        (B) improved utilization of mental health services has
19    been demonstrated empirically to reduce overall health
20    care spending (Biu, Yoon, & Hines, 2021).
21    (9) Illinois must strengthen its parity laws to prevent
22insurance practices that restrict access to mental health and
23substance use care.
 
24    Section 10. The Illinois Insurance Code is amended by
25adding 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

 

 

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1health or substance use disorder treatment provider or
2facility makes a completed application with an insurer to
3become a participating provider with the insurer until the
4effective date of a final contract between the provider or
5facility and the insurer. "Contracting process" includes the
6process of verifying a provider's credentials.
7    "Participating provider" means any mental health or
8substance use disorder treatment provider that has a contract
9to provide mental health or substance use disorder services
10with an insurer.
11    (b) For all group or individual policies of accident and
12health insurance or managed care plans that are amended,
13delivered, issued, or renewed on or after January 1, 2026, or
14any contracted third party administering the behavioral health
15benefits for the insurer, reimbursement for in-network mental
16health and substance use disorder treatment services delivered
17by Illinois providers and facilities must be equal to or
18greater than 141% of the Medicare rate for the mental health or
19substance use disorder service delivered. For services not
20covered by Medicare, the reimbursement rates must be, on
21average, equal to or greater than 144% of the insurer's
22in-network reimbursement rate for such service on the
23effective date of this amendatory Act of the 103rd General
24Assembly. This Section applies to all covered office,
25outpatient, inpatient, and residential mental health and
26substance use disorder services.

 

 

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1    (c) A group or individual policy of accident and health
2insurance or managed care plan that is amended, delivered,
3issued, or renewed on or after January 1, 2025, or contracted
4third party administering the behavioral health benefits for
5the insurer, shall cover all medically necessary mental health
6or substance use disorder services received by the same
7insured on the same day from the same or different mental
8health or substance use provider or facility for both
9outpatient and inpatient care.
10    (d) A group or individual policy of accident and health
11insurance or managed care plan that is amended, delivered,
12issued, or renewed on or after January 1, 2025, or any
13contracted third party administering the behavioral health
14benefits for the insurer, shall cover any medically necessary
15mental health or substance use disorder service provided by a
16behavioral health trainee when the trainee is working toward
17clinical State licensure and is under the supervision of a
18fully licensed mental health or substance use disorder
19treatment provider, which is a physician licensed to practice
20medicine in all its branches, licensed clinical psychologist,
21licensed clinical social worker, licensed clinical
22professional counselor, licensed marriage and family
23therapist, licensed speech-language pathologist, or other
24licensed or certified professional at a program licensed
25pursuant to the Substance Use Disorder Act who is engaged in
26treating mental, emotional, nervous, or substance use

 

 

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1disorders or conditions. Services provided by the trainee must
2be billed under the supervising clinician's rendering National
3Provider Identifier.
4    (e) A group or individual policy of accident and health
5insurance or managed care plan that is amended, delivered,
6issued, or renewed on or after January 1, 2025, or any
7contracted third party administering the behavioral health
8benefits for the insurer, shall:
9        (1) cover medically necessary 60-minute psychotherapy
10    billed using the CPT Code 90837 for Individual Therapy;
11        (2) not impose more onerous documentation requirements
12    on the provider than is required for other psychotherapy
13    CPT Codes; and
14        (3) not audit the use of CPT Code 90837 any more
15    frequently than audits for the use of other psychotherapy
16    CPT Codes.
17    (f)(1) Any group or individual policy of accident and
18health insurance or managed care plan that is amended,
19delivered, issued, or renewed on or after January 1, 2026, or
20any contracted third party administering the behavioral health
21benefits for the insurer, shall complete the contracting
22process with a mental health or substance use disorder
23treatment provider or facility for becoming a participating
24provider in the insurer's network, including the verification
25of the provider's credentials, within 60 days from the date of
26a completed application to the insurer to become a

 

 

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

 

 

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1issued, or renewed on or after January 1, 2025, or any
2contracted third party administering the behavioral health
3benefits for the insurer, shall cover any medically necessary
4mental health or substance use disorder service provided by a
5fully licensed mental health or substance use disorder
6treatment provider affiliated with a mental health or
7substance use disorder treatment group practice who has
8submitted a completed application to become a participating
9provider with an insurer who is delivering services under the
10supervision of another fully licensed participating mental
11health or substance use disorder treatment provider within the
12same group practice up to the effective date of the applying
13provider's contract with the insurer as a participating
14provider. Services provided by the applying provider must be
15billed under the supervising licensed provider's rendering
16National Provider Identifier.
17    (4) Upon request, an insurer, or any contracted third
18party administering the behavioral health benefits for the
19insurer, shall provide an applying provider with the insurer's
20credentialing policies and procedures. An insurer, or any
21contracted third party administering the behavioral health
22benefits for the insurer, shall post the following
23nonproprietary information on its website and make that
24information available to all applicants:
25        (A) a list of the information required to be included
26    in an application;

 

 

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1        (B) a checklist of the materials that must be
2    submitted in the credentialing process; and
3        (C) designated contact information of a network
4    representative, including a designated point of contact,
5    an email address, and a telephone number, to which an
6    applicant may address any credentialing inquiries.
7    (g) The Department has the same authority to enforce this
8Section as it has to enforce compliance with Sections 370c and
9370c.1. Additionally, if the Department determines that an
10insurer or a contracted third party administering the
11behavioral health benefits for the insurer has violated this
12Section, the Department shall, after appropriate notice and
13opportunity for hearing in accordance with Section 402, by
14order assess a civil penalty of $1,000 for each violation. The
15Department shall establish any processes or procedures
16necessary to monitor compliance with this Section.
17    (h) The Department shall adopt any rules necessary to
18implement this Section by no later than May 1, 2025.
19    (i) This Section does not apply to a health care plan
20serving Medicaid populations that provides, arranges for, pays
21for, or reimburses the cost of any health care service for
22persons who are enrolled under the Illinois Public Aid Code or
23under the Children's Health Insurance Program Act.
 
24    Section 15. The Health Maintenance Organization Act is
25amended by changing Section 5-3 as follows:
 

 

 

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1    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2    Sec. 5-3. Insurance Code provisions.
3    (a) Health Maintenance Organizations shall be subject to
4the provisions of Sections 133, 134, 136, 137, 139, 140,
5141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
6154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
7355.2, 355.3, 355b, 355c, 356f, 356g.5-1, 356m, 356q, 356v,
8356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
9356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
10356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21, 356z.22,
11356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29, 356z.30,
12356z.30a, 356z.31, 356z.32, 356z.33, 356z.34, 356z.35,
13356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41, 356z.44,
14356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50, 356z.51,
15356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58, 356z.59,
16356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67, 356z.68,
17364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
18368d, 368e, 370c, 370c.3, 370c.1, 401, 401.1, 402, 403, 403A,
19408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
20subsection (2) of Section 367, and Articles IIA, VIII 1/2,
21XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
22Illinois Insurance Code.
23    (b) For purposes of the Illinois Insurance Code, except
24for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
25Health Maintenance Organizations in the following categories

 

 

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

 

 

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1        (3) the Director shall have the power to require the
2    following information:
3            (A) certification by an independent actuary of the
4        adequacy of the reserves of the Health Maintenance
5        Organization sought to be acquired;
6            (B) pro forma financial statements reflecting the
7        combined balance sheets of the acquiring company and
8        the Health Maintenance Organization sought to be
9        acquired as of the end of the preceding year and as of
10        a date 90 days prior to the acquisition, as well as pro
11        forma financial statements reflecting projected
12        combined operation for a period of 2 years;
13            (C) a pro forma business plan detailing an
14        acquiring party's plans with respect to the operation
15        of the Health Maintenance Organization sought to be
16        acquired for a period of not less than 3 years; and
17            (D) such other information as the Director shall
18        require.
19    (d) The provisions of Article VIII 1/2 of the Illinois
20Insurance Code and this Section 5-3 shall apply to the sale by
21any health maintenance organization of greater than 10% of its
22enrollee population (including, without limitation, the health
23maintenance organization's right, title, and interest in and
24to its health care certificates).
25    (e) In considering any management contract or service
26agreement subject to Section 141.1 of the Illinois Insurance

 

 

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

 

 

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1    premium, the profitable or unprofitable experience shall
2    be calculated taking into account a pro rata share of the
3    Health Maintenance Organization's administrative and
4    marketing expenses, but shall not include any refund to be
5    made or additional premium to be paid pursuant to this
6    subsection (f)). The Health Maintenance Organization and
7    the group or enrollment unit may agree that the profitable
8    or unprofitable experience may be calculated taking into
9    account the refund period and the immediately preceding 2
10    plan years.
11    The Health Maintenance Organization shall include a
12statement in the evidence of coverage issued to each enrollee
13describing the possibility of a refund or additional premium,
14and upon request of any group or enrollment unit, provide to
15the group or enrollment unit a description of the method used
16to calculate (1) the Health Maintenance Organization's
17profitable experience with respect to the group or enrollment
18unit and the resulting refund to the group or enrollment unit
19or (2) the Health Maintenance Organization's unprofitable
20experience with respect to the group or enrollment unit and
21the resulting additional premium to be paid by the group or
22enrollment unit.
23    In no event shall the Illinois Health Maintenance
24Organization Guaranty Association be liable to pay any
25contractual obligation of an insolvent organization to pay any
26refund authorized under this Section.

 

 

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1    (g) Rulemaking authority to implement Public Act 95-1045,
2if any, is conditioned on the rules being adopted in
3accordance with all provisions of the Illinois Administrative
4Procedure Act and all rules and procedures of the Joint
5Committee on Administrative Rules; any purported rule not so
6adopted, for whatever reason, is unauthorized.
7(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
8102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
91-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
10eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
11102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
121-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
13eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
14103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
156-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
16eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
 
17    Section 99. Effective date. This Act takes effect upon
18becoming law.".