103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB2362

 

Introduced 2/10/2023, by Sen. Rachel Ventura

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
215 ILCS 5/356z.61 new
215 ILCS 5/370c  from Ch. 73, par. 982c
215 ILCS 5/370c.1
215 ILCS 5/370c.3 new
305 ILCS 5/5-16.8
720 ILCS 5/49-7 new

    Amends the Illinois Insurance Code. Provides that every insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace in the State and Medicaid managed care organizations providing coverage for hospital or medical treatment on or after January 1, 2024 shall provide coverage for medically necessary treatment of vision, hearing, and dental disorders or conditions. Sets forth provisions concerning availability of plan information, notification, external review, limitations on benefits for medically necessary services, and medical necessity determinations. Provides that if the Director of Insurance determines that an insurer has violated the provisions, the Director may assess a civil penalty between $1,000 and $5,000 for each violation. Sets forth provisions concerning vision, hearing, and dental disorder or condition parity. Makes other changes. Makes conforming changes in the State Employees Group Insurance Act of 1971 and the Medical Assistance Article of the Illinois Public Aid Code. Amends the Criminal Code of 2012. Establishes the offense of criminal violation of health benefit parity.


LRB103 29039 BMS 55425 b

 

 

A BILL FOR

 

SB2362LRB103 29039 BMS 55425 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 State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    (Text of Section before amendment by P.A. 102-768)
8    Sec. 6.11. Required health benefits; Illinois Insurance
9Code requirements. The program of health benefits shall
10provide the post-mastectomy care benefits required to be
11covered by a policy of accident and health insurance under
12Section 356t of the Illinois Insurance Code. The program of
13health benefits shall provide the coverage required under
14Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
15356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
16356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
17356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
18356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51,
19356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of
20the Illinois Insurance Code. The program of health benefits
21must comply with Sections 155.22a, 155.37, 355b, 356z.19,
22370c, and 370c.1 and Article XXXIIB of the Illinois Insurance
23Code. The Department of Insurance shall enforce the

 

 

SB2362- 2 -LRB103 29039 BMS 55425 b

1requirements of this Section with respect to Sections 370c and
2370c.1 of the Illinois Insurance Code; all other requirements
3of this Section shall be enforced by the Department of Central
4Management Services.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
12101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
131-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
14eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
15102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
161-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816,
17eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
18revised 12-13-22.)
 
19    (Text of Section after amendment by P.A. 102-768)
20    Sec. 6.11. Required health benefits; Illinois Insurance
21Code requirements. The program of health benefits shall
22provide the post-mastectomy care benefits required to be
23covered by a policy of accident and health insurance under
24Section 356t of the Illinois Insurance Code. The program of
25health benefits shall provide the coverage required under

 

 

SB2362- 3 -LRB103 29039 BMS 55425 b

1Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
2356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
3356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
4356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
5356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51,
6356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, and
7356z.60, and 356z.61 of the Illinois Insurance Code. The
8program of health benefits must comply with Sections 155.22a,
9155.37, 355b, 356z.19, 370c, and 370c.1, and 370c.3 and
10Article XXXIIB of the Illinois Insurance Code. The Department
11of Insurance shall enforce the requirements of this Section
12with respect to Sections 370c and 370c.1 of the Illinois
13Insurance Code; all other requirements of this Section shall
14be enforced by the Department of Central Management Services.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
22101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
231-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
24eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
25102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff.
261-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813,

 

 

SB2362- 4 -LRB103 29039 BMS 55425 b

1eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23;
2102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
 
3    Section 10. The Illinois Insurance Code is amended by
4changing Sections 370c and 370c.1 and by adding Sections
5356z.61 and 370c.3 as follows:
 
6    (215 ILCS 5/356z.61 new)
7    Sec. 356z.61. Vision, hearing, and dental disorders.
8    (a) As used in this Section:
9    "Group policy of accident and health insurance" and "group
10health benefit plan" includes (1) State-regulated
11employer-sponsored group health insurance plans written in
12Illinois or which purport to provide coverage for a resident
13of this State; and (2) State employee health plans.
14    "Medically necessary treatment of vision, hearing, and
15dental disorders or conditions" means a service or product
16addressing the specific needs of that patient for the purpose
17of screening, preventing, diagnosing, managing, or treating an
18illness, injury, or condition or its symptoms and
19comorbidities, including minimizing the progression of an
20illness, injury, or condition or its symptoms and
21comorbidities in a manner that is all of the following:
22        (1) in accordance with the generally accepted
23    standards of care; and
24        (2) not primarily for the economic benefit of the

 

 

SB2362- 5 -LRB103 29039 BMS 55425 b

1    insurer, purchaser, or for the convenience of the patient,
2    treating physician, or other health care provider.
3    "Utilization review" means either of the following:
4        (1) Prospectively, retrospectively, or concurrently
5    reviewing and approving, modifying, delaying, or denying,
6    based in whole or in part on medical necessity, requests
7    by health care providers, insureds, or their authorized
8    representatives for coverage of health care services
9    before, retrospectively, or concurrently with the
10    provision of health care services to insureds.
11        (2) Evaluating the medical necessity, appropriateness,
12    level of care, service intensity, efficacy, or efficiency
13    of health care services, benefits, procedures, or
14    settings, under any circumstances, to determine whether a
15    health care service or benefit subject to a medical
16    necessity coverage requirement in an insurance policy is
17    covered as medically necessary for an insured.
18    "Utilization review criteria" means patient placement
19criteria or any criteria, standards, protocols, or guidelines
20used by an insurer to conduct utilization review.
21    (b)(1) On and after the effective date of this amendatory
22Act of the 103rd General Assembly, every insurer that amends,
23delivers, issues, or renews group accident and health policies
24providing coverage for hospital or medical treatment or
25services for illness on an expense-incurred basis shall
26provide coverage for the medically necessary treatment of

 

 

SB2362- 6 -LRB103 29039 BMS 55425 b

1vision, hearing, and dental disorders or conditions consistent
2with the parity requirements of Section 370c.3.
3        (2) Each insured that is covered for vision, hearing,
4    and dental disorders or conditions shall be free to select
5    the physician licensed to practice medicine in all of its
6    branches of his or her choice to treat such disorders or
7    conditions, and the insurer shall pay the covered charges
8    of such physician licensed to practice medicine in all of
9    its branches up to the limits of coverage, so long as (i)
10    the disorder or condition treated is covered by the
11    policy, and (ii) the physician is authorized to provide
12    said services under the laws of this State and in
13    accordance with accepted principles of his or her
14    profession.
15    (c)(1) Unless otherwise prohibited by federal law and
16consistent with the parity requirements of Section 370c.3, the
17reimbursing insurer that amends, delivers, issues, or renews a
18group or individual policy of accident and health insurance, a
19qualified health plan offered through the health insurance
20marketplace, or a provider of treatment of vision, hearing,
21and dental disorders or conditions shall furnish medical
22records or other necessary data that substantiate that initial
23or continued treatment is at all times medically necessary. An
24insurer shall provide a mechanism for the timely review by a
25provider holding the same license and practicing in the same
26specialty as the patient's provider who is unaffiliated with

 

 

SB2362- 7 -LRB103 29039 BMS 55425 b

1the insurer, jointly selected by the patient or the patient's
2next of kin or legal representative if the patient is unable to
3act for himself or herself, the patient's provider, and the
4insurer if there is a dispute between the insurer and
5patient's provider regarding the medical necessity of a
6treatment proposed by a patient's provider. If the reviewing
7provider determines the treatment to be medically necessary,
8then the insurer shall provide reimbursement for the
9treatment. Future contractual or employment actions by the
10insurer regarding the patient's provider may not be based on
11the provider's participation in this procedure. Nothing
12prevents the insured from agreeing in writing to continue
13treatment at his or her expense. When making a determination
14of the medical necessity for a treatment modality for vision,
15hearing, and dental disorders or conditions an insurer must
16make the determination in a manner that is consistent with the
17manner used to make that determination with respect to other
18diseases or illnesses covered under the policy, including an
19appeals process.
20        (2) A group health benefit plan, an individual policy
21    of accident and health insurance, or a qualified health
22    plan offered through the health insurance marketplace that
23    is amended, delivered, issued, or renewed on or after the
24    effective date of this amendatory Act of the 103rd General
25    Assembly shall provide coverage based upon medical
26    necessity for the treatment of vision, hearing, and dental

 

 

SB2362- 8 -LRB103 29039 BMS 55425 b

1    disorders or conditions consistent with the parity
2    requirements of Section 370c.3.
3        (3) An issuer of a group health benefit plan, an
4    individual policy of accident and health insurance, or a
5    qualified health plan offered through the health insurance
6    marketplace shall cover the outpatient visits for vision,
7    hearing, and dental disorders or conditions under the same
8    terms and conditions as it covers outpatient visits for
9    the treatment of other physical illness.
10        (4) An issuer of a group health benefit plan may
11    provide or offer coverage required under this Section
12    through a managed care plan.
13    (d) Availability of plan information.
14        (1) The criteria for medical necessity determinations
15    made under a group health plan, an individual policy of
16    accident and health insurance, or a qualified health plan
17    offered through the health insurance marketplace with
18    respect to vision, hearing, and dental disorders or
19    conditions, or health insurance coverage offered in
20    connection with the plan, with respect to such benefits
21    must be made available by the plan administrator, or the
22    health insurance issuer offering such coverage, to any
23    current or potential participant, beneficiary, or
24    contracting provider upon request.
25        (2) The reason for any denial under a group health
26    benefit plan, an individual policy of accident and health

 

 

SB2362- 9 -LRB103 29039 BMS 55425 b

1    insurance, or a qualified health plan offered through the
2    health insurance marketplace, or health insurance coverage
3    offered in connection with such plan or policy, of
4    reimbursement or payment for services with respect to
5    vision, hearing, and dental disorders or conditions
6    benefits in the case of any participant or beneficiary
7    must be made available within a reasonable time and in a
8    reasonable manner and in readily understandable language
9    by the plan administrator, or the health insurance issuer
10    offering such coverage, to the participant or beneficiary
11    upon request.
12    (e)(1) If an insurer determines that treatment is no
13longer medically necessary, the insurer shall notify the
14covered person, the covered person's authorized
15representative, if any, and the covered person's health care
16provider in writing of the covered person's right to request
17an external review pursuant to the Health Carrier External
18Review Act. The notification shall occur within 24 hours
19following the adverse determination.
20        (2) Pursuant to the requirements of the Health Carrier
21    External Review Act, the covered person or the covered
22    person's authorized representative may request an
23    expedited external review. Under this subsection, a
24    request for expedited external review must be initiated
25    within 24 hours following the adverse determination
26    notification by the insurer. Failure to request an

 

 

SB2362- 10 -LRB103 29039 BMS 55425 b

1    expedited external review within 24 hours shall preclude a
2    covered person or a covered person's authorized
3    representative from requesting an expedited external
4    review.
5        (3) If an expedited external review request meets the
6    criteria of the Health Carrier External Review Act, an
7    independent review organization shall make a final
8    determination of medical necessity within 72 hours. If an
9    independent review organization upholds an adverse
10    determination, an insurer shall remain responsible to
11    provide coverage of benefits through the day following the
12    determination of the independent review organization. A
13    decision to reverse an adverse determination shall comply
14    with the Health Carrier External Review Act.
15    (f)(1) Every insurer that amends, delivers, issues, or
16renews a group or individual policy of accident and health
17insurance or a qualified health plan offered through the
18health insurance marketplace in this State and Medicaid
19managed care organizations providing coverage for hospital or
20medical treatment on or after January 1, 2024 shall provide
21coverage for medically necessary treatment of vision, hearing,
22and dental disorders or conditions.
23        (2) An insurer shall not set a specific limit on the
24    duration of benefits or coverage of medically necessary
25    treatment of vision, hearing, and dental disorders or
26    conditions or limit coverage only to alleviation of the

 

 

SB2362- 11 -LRB103 29039 BMS 55425 b

1    insured's current symptoms.
2        (3) An insurer that authorizes a specific type of
3    treatment by a provider pursuant to this Section shall not
4    rescind or modify the authorization after that provider
5    renders the health care service in good faith and pursuant
6    to this authorization for any reason, including, but not
7    limited to, the insurer's subsequent cancellation or
8    modification of the insured's or policyholder's contract
9    or the insured's or policyholder's eligibility. Nothing in
10    this Section shall require the insurer to cover a
11    treatment when the authorization was granted based on a
12    material misrepresentation by the insured, the
13    policyholder, or the provider. Nothing in this Section
14    shall require Medicaid managed care organizations to pay
15    for services if the individual was not eligible for
16    Medicaid at the time the service was rendered. Nothing in
17    this Section shall require an insurer to pay for services
18    if the individual was not the insurer's enrollee at the
19    time services were rendered. As used in this paragraph,
20    "material" means a fact or situation that is not merely
21    technical in nature and results in or could result in a
22    substantial change in the situation.
23    (g) An insurer shall not limit benefits or coverage for
24medically necessary services on the basis that those services
25should be or could be covered by a public entitlement program,
26including, but not limited to, special education or an

 

 

SB2362- 12 -LRB103 29039 BMS 55425 b

1individualized education program, Medicaid, Medicare,
2supplemental security income, or social security disability
3insurance, and shall not include or enforce a contract term
4that excludes otherwise covered benefits on the basis that
5those services should be or could be covered by a public
6entitlement program. Nothing in this subsection shall be
7construed to require an insurer to cover benefits that have
8been authorized and provided for a covered person by a public
9entitlement program. Medicaid managed care organizations are
10not subject to this subsection.
11    (h) An insurer shall base any medical necessity
12determination or the utilization review criteria that the
13insurer and any entity acting on the insurer's behalf applies
14to determine the medical necessity of health care services and
15benefits for the diagnosis, prevention, and treatment of
16vision, hearing, and dental disorders or conditions on current
17generally accepted standards of vision, hearing, and dental
18disorders or conditions care. All denials and appeals shall be
19reviewed by a professional with experience or expertise
20comparable to the provider requesting the authorization.
21    (i) This Section does not in any way limit the rights of a
22patient under the Medical Patient Rights Act.
23    (j) This Section does not in any way limit early and
24periodic screening, diagnostic, and treatment benefits as
25defined under 42 U.S.C. 1396d(r).
26    (k) Every insurer shall do all of the following:

 

 

SB2362- 13 -LRB103 29039 BMS 55425 b

1        (1) Educate the insurer's staff, including any third
2    parties contracted with the insurer to review claims,
3    conduct utilization reviews, or make medical necessity
4    determinations about the utilization review criteria.
5        (2) Make the educational program available to other
6    stakeholders, including the insurer's participating or
7    contracted providers and potential participants,
8    beneficiaries, or covered lives. The education program
9    must be provided at least once a year, in-person or
10    digitally, or recordings of the education program must be
11    made available to the aforementioned stakeholders.
12        (3) Provide, at no cost, the utilization review
13    criteria and any training material or resources to
14    providers and insured patients upon request. No
15    restrictions shall be placed upon the insured's or
16    treating provider's access right to utilization review
17    criteria obtained under this paragraph at any point in
18    time, including before an initial request for
19    authorization.
20        (4) Track, identify, and analyze how the utilization
21    review criteria are used to certify care, deny care, and
22    support the appeals process.
23        (5) Conduct interrater reliability testing to ensure
24    consistency in utilization review decision making that
25    covers how medical necessity decisions are made; this
26    assessment shall cover all aspects of utilization review.

 

 

SB2362- 14 -LRB103 29039 BMS 55425 b

1        (6) Run interrater reliability reports about how the
2    clinical guidelines are used in conjunction with the
3    utilization review process and parity compliance
4    activities.
5        (7) Achieve interrater reliability pass rates of at
6    least 90%, and if this threshold is not met, immediately
7    provide for the remediation of poor interrater reliability
8    and interrater reliability testing for all new staff
9    before they can conduct utilization review without
10    supervision.
11        (8) Maintain documentation of interrater reliability
12    testing and the remediation actions taken for those with
13    pass rates lower than 90% and submit to the Department or,
14    in the case of Medicaid managed care organizations, the
15    Department of Healthcare and Family Services the testing
16    results and a summary of remedial actions as part of
17    parity compliance reporting set forth in Section 370c.3.
18    (l) This Section applies to all health care services and
19benefits for the diagnosis, prevention, and treatment of
20vision, hearing, and dental disorders or conditions covered by
21an insurance policy, including prescription drugs.
22    (m) This Section applies to an insurer that amends,
23delivers, issues, or renews a group or individual policy of
24accident and health insurance or a qualified health plan
25offered through the health insurance marketplace in this State
26providing coverage for hospital or medical treatment that

 

 

SB2362- 15 -LRB103 29039 BMS 55425 b

1conducts utilization review as defined in this Section,
2including Medicaid managed care organizations and any entity
3or contracting provider that performs utilization review or
4utilization management functions on an insurer's behalf.
5    (n) If the Director determines that an insurer has
6violated this Section, the Director may, after appropriate
7notice and opportunity for hearing, by order, assess a civil
8penalty between $1,000 and $5,000 for each violation. Moneys
9collected from penalties shall be deposited into the Parity
10Advancement Fund. Nothing in this Section shall be construed
11to limit criminal liability.
12    (o) If an insurer commits a violation of this Section, the
13insurer shall be given 30 days' notice to rectify that
14violation. Failure to rectify the violation within the 30-day
15notice period and any subsequent violation of this Section by
16the insurer shall constitute a Class A misdemeanor and result
17in criminal liability pursuant to Section 49-7 of the Criminal
18Code of 2012.
19    (p) An insurer shall not adopt, impose, or enforce terms
20in its policies or provider agreements, in writing or in
21operation, that undermine, alter, or conflict with the
22requirements of this Section.
23    (q) The provisions of this Section are severable. If any
24provision of this Section or its application to any person or
25circumstance is held invalid, the invalidity of that provision
26or application does not affect other provisions or

 

 

SB2362- 16 -LRB103 29039 BMS 55425 b

1applications of this Section that can be given effect without
2the invalid provision or application.
 
3    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
4    Sec. 370c. Mental and emotional disorders.
5    (a)(1) On and after January 1, 2022 (the effective date of
6Public Act 102-579), every insurer that amends, delivers,
7issues, or renews group accident and health policies providing
8coverage for hospital or medical treatment or services for
9illness on an expense-incurred basis shall provide coverage
10for the medically necessary treatment of mental, emotional,
11nervous, or substance use disorders or conditions consistent
12with the parity requirements of Section 370c.1 of this Code.
13    (2) Each insured that is covered for mental, emotional,
14nervous, or substance use disorders or conditions shall be
15free to select the physician licensed to practice medicine in
16all its branches, licensed clinical psychologist, licensed
17clinical social worker, licensed clinical professional
18counselor, licensed marriage and family therapist, licensed
19speech-language pathologist, or other licensed or certified
20professional at a program licensed pursuant to the Substance
21Use Disorder Act of his or her choice to treat such disorders,
22and the insurer shall pay the covered charges of such
23physician licensed to practice medicine in all its branches,
24licensed clinical psychologist, licensed clinical social
25worker, licensed clinical professional counselor, licensed

 

 

SB2362- 17 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 18 -LRB103 29039 BMS 55425 b

1    (4) "Mental, emotional, nervous, or substance use disorder
2or condition" means a condition or disorder that involves a
3mental health condition or substance use disorder that falls
4under any of the diagnostic categories listed in the mental
5and behavioral disorders chapter of the current edition of the
6World Health Organization's International Classification of
7Disease or that is listed in the most recent version of the
8American Psychiatric Association's Diagnostic and Statistical
9Manual of Mental Disorders. "Mental, emotional, nervous, or
10substance use disorder or condition" includes any mental
11health condition that occurs during pregnancy or during the
12postpartum period and includes, but is not limited to,
13postpartum depression.
14    (5) Medically necessary treatment and medical necessity
15determinations shall be interpreted and made in a manner that
16is consistent with and pursuant to subsections (h) through
17(t).
18    (b)(1) (Blank).
19    (2) (Blank).
20    (2.5) (Blank).
21    (3) Unless otherwise prohibited by federal law and
22consistent with the parity requirements of Section 370c.1 of
23this Code, the reimbursing insurer that amends, delivers,
24issues, or renews a group or individual policy of accident and
25health insurance, a qualified health plan offered through the
26health insurance marketplace, or a provider of treatment of

 

 

SB2362- 19 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 20 -LRB103 29039 BMS 55425 b

1substance use disorders shall be made in accordance with
2appropriate patient placement criteria established by the
3American Society of Addiction Medicine. No additional criteria
4may be used to make medical necessity determinations for
5substance use disorders.
6    (4) A group health benefit plan amended, delivered,
7issued, or renewed on or after January 1, 2019 (the effective
8date of Public Act 100-1024) or an individual policy of
9accident and health insurance or a qualified health plan
10offered through the health insurance marketplace amended,
11delivered, issued, or renewed on or after January 1, 2019 (the
12effective date of Public Act 100-1024):
13        (A) shall provide coverage based upon medical
14    necessity for the treatment of a mental, emotional,
15    nervous, or substance use disorder or condition consistent
16    with the parity requirements of Section 370c.1 of this
17    Code; provided, however, that in each calendar year
18    coverage shall not be less than the following:
19            (i) 45 days of inpatient treatment; and
20            (ii) beginning on June 26, 2006 (the effective
21        date of Public Act 94-921), 60 visits for outpatient
22        treatment including group and individual outpatient
23        treatment; and
24            (iii) for plans or policies delivered, issued for
25        delivery, renewed, or modified after January 1, 2007
26        (the effective date of Public Act 94-906), 20

 

 

SB2362- 21 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 22 -LRB103 29039 BMS 55425 b

1Addictive, Substance-Related, and Co-Occurring Conditions
2established by the American Society of Addiction Medicine. The
3treating provider shall base all treatment recommendations and
4the health benefit plan shall base all medical necessity
5determinations for medication-assisted treatment in accordance
6with the most current Treatment Criteria for Addictive,
7Substance-Related, and Co-Occurring Conditions established by
8the American Society of Addiction Medicine.
9    As used in this subsection:
10    "Acute treatment services" means 24-hour medically
11supervised addiction treatment that provides evaluation and
12withdrawal management and may include biopsychosocial
13assessment, individual and group counseling, psychoeducational
14groups, and discharge planning.
15    "Clinical stabilization services" means 24-hour treatment,
16usually following acute treatment services for substance
17abuse, which may include intensive education and counseling
18regarding the nature of addiction and its consequences,
19relapse prevention, outreach to families and significant
20others, and aftercare planning for individuals beginning to
21engage in recovery from addiction.
22    (6) An issuer of a group health benefit plan may provide or
23offer coverage required under this Section through a managed
24care plan.
25    (6.5) An individual or group health benefit plan amended,
26delivered, issued, or renewed on or after January 1, 2019 (the

 

 

SB2362- 23 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 24 -LRB103 29039 BMS 55425 b

1    generic medications; and
2        (D) shall not exclude coverage for a prescription
3    medication approved by the United States Food and Drug
4    Administration for the treatment of substance use
5    disorders and any associated counseling or wraparound
6    services on the grounds that such medications and services
7    were court ordered.
8    (7) (Blank).
9    (8) (Blank).
10    (9) With respect to all mental, emotional, nervous, or
11substance use disorders or conditions, coverage for inpatient
12treatment shall include coverage for treatment in a
13residential treatment center certified or licensed by the
14Department of Public Health or the Department of Human
15Services.
16    (c) This Section shall not be interpreted to require
17coverage for speech therapy or other habilitative services for
18those individuals covered under Section 356z.15 of this Code.
19    (d) With respect to a group or individual policy of
20accident and health insurance or a qualified health plan
21offered through the health insurance marketplace, the
22Department and, with respect to medical assistance, the
23Department of Healthcare and Family Services shall each
24enforce the requirements of this Section and Sections 356z.23
25and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
26Mental Health Parity and Addiction Equity Act of 2008, 42

 

 

SB2362- 25 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 26 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 27 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 28 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 29 -LRB103 29039 BMS 55425 b

1approved for issuance or renewal in this State, on or after
2January 1, 2019 (the effective date of Public Act 100-1023)
3shall comply with the requirements of this Section and Section
4370c.1. The services for the treatment and the ongoing
5assessment of the patient's progress in treatment shall follow
6the requirements of 77 Ill. Adm. Code 2060.
7    (3) Prior authorization shall not be utilized for the
8benefits under this subsection. The substance use disorder
9treatment provider or facility shall notify the insurer of the
10initiation of treatment. For an insurer that is not a managed
11care organization, the substance use disorder treatment
12provider or facility notification shall occur for the
13initiation of treatment of the covered person within 2
14business days. For managed care organizations, the substance
15use disorder treatment provider or facility notification shall
16occur in accordance with the protocol set forth in the
17provider agreement for initiation of treatment within 24
18hours. If the managed care organization is not capable of
19accepting the notification in accordance with the contractual
20protocol during the 24-hour period following admission, the
21substance use disorder treatment provider or facility shall
22have one additional business day to provide the notification
23to the appropriate managed care organization. Treatment plans
24shall be developed in accordance with the requirements and
25timeframes established in 77 Ill. Adm. Code 2060. If the
26substance use disorder treatment provider or facility fails to

 

 

SB2362- 30 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 31 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 32 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 33 -LRB103 29039 BMS 55425 b

1    frequency, extent, site, and duration; and
2        (3) not primarily for the economic benefit of the
3    insurer, purchaser, or for the convenience of the patient,
4    treating physician, or other health care provider.
5    "Utilization review" means either of the following:
6        (1) prospectively, retrospectively, or concurrently
7    reviewing and approving, modifying, delaying, or denying,
8    based in whole or in part on medical necessity, requests
9    by health care providers, insureds, or their authorized
10    representatives for coverage of health care services
11    before, retrospectively, or concurrently with the
12    provision of health care services to insureds.
13        (2) evaluating the medical necessity, appropriateness,
14    level of care, service intensity, efficacy, or efficiency
15    of health care services, benefits, procedures, or
16    settings, under any circumstances, to determine whether a
17    health care service or benefit subject to a medical
18    necessity coverage requirement in an insurance policy is
19    covered as medically necessary for an insured.
20    "Utilization review criteria" means patient placement
21criteria or any criteria, standards, protocols, or guidelines
22used by an insurer to conduct utilization review.
23    (i)(1) Every insurer that amends, delivers, issues, or
24renews a group or individual policy of accident and health
25insurance or a qualified health plan offered through the
26health insurance marketplace in this State and Medicaid

 

 

SB2362- 34 -LRB103 29039 BMS 55425 b

1managed care organizations providing coverage for hospital or
2medical treatment on or after January 1, 2023 shall, pursuant
3to subsections (h) through (s), provide coverage for medically
4necessary treatment of mental, emotional, nervous, or
5substance use disorders or conditions.
6    (2) An insurer shall not set a specific limit on the
7duration of benefits or coverage of medically necessary
8treatment of mental, emotional, nervous, or substance use
9disorders or conditions or limit coverage only to alleviation
10of the insured's current symptoms.
11    (3) All medical necessity determinations made by the
12insurer concerning service intensity, level of care placement,
13continued stay, and transfer or discharge of insureds
14diagnosed with mental, emotional, nervous, or substance use
15disorders or conditions shall be conducted in accordance with
16the requirements of subsections (k) through (u).
17    (4) An insurer that authorizes a specific type of
18treatment by a provider pursuant to this Section shall not
19rescind or modify the authorization after that provider
20renders the health care service in good faith and pursuant to
21this authorization for any reason, including, but not limited
22to, the insurer's subsequent cancellation or modification of
23the insured's or policyholder's contract, or the insured's or
24policyholder's eligibility. Nothing in this Section shall
25require the insurer to cover a treatment when the
26authorization was granted based on a material

 

 

SB2362- 35 -LRB103 29039 BMS 55425 b

1misrepresentation by the insured, the policyholder, or the
2provider. Nothing in this Section shall require Medicaid
3managed care organizations to pay for services if the
4individual was not eligible for Medicaid at the time the
5service was rendered. Nothing in this Section shall require an
6insurer to pay for services if the individual was not the
7insurer's enrollee at the time services were rendered. As used
8in this paragraph, "material" means a fact or situation that
9is not merely technical in nature and results in or could
10result in a substantial change in the situation.
11    (j) An insurer shall not limit benefits or coverage for
12medically necessary services on the basis that those services
13should be or could be covered by a public entitlement program,
14including, but not limited to, special education or an
15individualized education program, Medicaid, Medicare,
16Supplemental Security Income, or Social Security Disability
17Insurance, and shall not include or enforce a contract term
18that excludes otherwise covered benefits on the basis that
19those services should be or could be covered by a public
20entitlement program. Nothing in this subsection shall be
21construed to require an insurer to cover benefits that have
22been authorized and provided for a covered person by a public
23entitlement program. Medicaid managed care organizations are
24not subject to this subsection.
25    (k) An insurer shall base any medical necessity
26determination or the utilization review criteria that the

 

 

SB2362- 36 -LRB103 29039 BMS 55425 b

1insurer, and any entity acting on the insurer's behalf,
2applies to determine the medical necessity of health care
3services and benefits for the diagnosis, prevention, and
4treatment of mental, emotional, nervous, or substance use
5disorders or conditions on current generally accepted
6standards of mental, emotional, nervous, or substance use
7disorder or condition care. All denials and appeals shall be
8reviewed by a professional with experience or expertise
9comparable to the provider requesting the authorization.
10    (l) For medical necessity determinations relating to level
11of care placement, continued stay, and transfer or discharge
12of insureds diagnosed with mental, emotional, and nervous
13disorders or conditions, an insurer shall apply the patient
14placement criteria set forth in the most recent version of the
15treatment criteria developed by an unaffiliated nonprofit
16professional association for the relevant clinical specialty
17or, for Medicaid managed care organizations, patient placement
18criteria determined by the Department of Healthcare and Family
19Services that are consistent with generally accepted standards
20of mental, emotional, nervous or substance use disorder or
21condition care. Pursuant to subsection (b), in conducting
22utilization review of all covered services and benefits for
23the diagnosis, prevention, and treatment of substance use
24disorders an insurer shall use the most recent edition of the
25patient placement criteria established by the American Society
26of Addiction Medicine.

 

 

SB2362- 37 -LRB103 29039 BMS 55425 b

1    (m) For medical necessity determinations relating to level
2of care placement, continued stay, and transfer or discharge
3that are within the scope of the sources specified in
4subsection (l), an insurer shall not apply different,
5additional, conflicting, or more restrictive utilization
6review criteria than the criteria set forth in those sources.
7For all level of care placement decisions, the insurer shall
8authorize placement at the level of care consistent with the
9assessment of the insured using the relevant patient placement
10criteria as specified in subsection (l). If that level of
11placement is not available, the insurer shall authorize the
12next higher level of care. In the event of disagreement, the
13insurer shall provide full detail of its assessment using the
14relevant criteria as specified in subsection (l) to the
15provider of the service and the patient.
16    Nothing in this subsection or subsection (l) prohibits an
17insurer from applying utilization review criteria that were
18developed in accordance with subsection (k) to health care
19services and benefits for mental, emotional, and nervous
20disorders or conditions that are not related to medical
21necessity determinations for level of care placement,
22continued stay, and transfer or discharge. If an insurer
23purchases or licenses utilization review criteria pursuant to
24this subsection, the insurer shall verify and document before
25use that the criteria were developed in accordance with
26subsection (k).

 

 

SB2362- 38 -LRB103 29039 BMS 55425 b

1    (n) In conducting utilization review that is outside the
2scope of the criteria as specified in subsection (l) or
3relates to the advancements in technology or in the types or
4levels of care that are not addressed in the most recent
5versions of the sources specified in subsection (l), an
6insurer shall conduct utilization review in accordance with
7subsection (k).
8    (o) This Section does not in any way limit the rights of a
9patient under the Medical Patient Rights Act.
10    (p) This Section does not in any way limit early and
11periodic screening, diagnostic, and treatment benefits as
12defined under 42 U.S.C. 1396d(r).
13    (q) To ensure the proper use of the criteria described in
14subsection (l), every insurer shall do all of the following:
15        (1) Educate the insurer's staff, including any third
16    parties contracted with the insurer to review claims,
17    conduct utilization reviews, or make medical necessity
18    determinations about the utilization review criteria.
19        (2) Make the educational program available to other
20    stakeholders, including the insurer's participating or
21    contracted providers and potential participants,
22    beneficiaries, or covered lives. The education program
23    must be provided at least once a year, in-person or
24    digitally, or recordings of the education program must be
25    made available to the aforementioned stakeholders.
26        (3) Provide, at no cost, the utilization review

 

 

SB2362- 39 -LRB103 29039 BMS 55425 b

1    criteria and any training material or resources to
2    providers and insured patients upon request. For
3    utilization review criteria not concerning level of care
4    placement, continued stay, and transfer or discharge used
5    by the insurer pursuant to subsection (m), the insurer may
6    place the criteria on a secure, password-protected website
7    so long as the access requirements of the website do not
8    unreasonably restrict access to insureds or their
9    providers. No restrictions shall be placed upon the
10    insured's or treating provider's access right to
11    utilization review criteria obtained under this paragraph
12    at any point in time, including before an initial request
13    for authorization.
14        (4) Track, identify, and analyze how the utilization
15    review criteria are used to certify care, deny care, and
16    support the appeals process.
17        (5) Conduct interrater reliability testing to ensure
18    consistency in utilization review decision making that
19    covers how medical necessity decisions are made; this
20    assessment shall cover all aspects of utilization review
21    as defined in subsection (h).
22        (6) Run interrater reliability reports about how the
23    clinical guidelines are used in conjunction with the
24    utilization review process and parity compliance
25    activities.
26        (7) Achieve interrater reliability pass rates of at

 

 

SB2362- 40 -LRB103 29039 BMS 55425 b

1    least 90% and, if this threshold is not met, immediately
2    provide for the remediation of poor interrater reliability
3    and interrater reliability testing for all new staff
4    before they can conduct utilization review without
5    supervision.
6        (8) Maintain documentation of interrater reliability
7    testing and the remediation actions taken for those with
8    pass rates lower than 90% and submit to the Department of
9    Insurance or, in the case of Medicaid managed care
10    organizations, the Department of Healthcare and Family
11    Services the testing results and a summary of remedial
12    actions as part of parity compliance reporting set forth
13    in subsection (k) of Section 370c.1.
14    (r) This Section applies to all health care services and
15benefits for the diagnosis, prevention, and treatment of
16mental, emotional, nervous, or substance use disorders or
17conditions covered by an insurance policy, including
18prescription drugs.
19    (s) This Section applies to an insurer that amends,
20delivers, issues, or renews a group or individual policy of
21accident and health insurance or a qualified health plan
22offered through the health insurance marketplace in this State
23providing coverage for hospital or medical treatment and
24conducts utilization review as defined in this Section,
25including Medicaid managed care organizations, and any entity
26or contracting provider that performs utilization review or

 

 

SB2362- 41 -LRB103 29039 BMS 55425 b

1utilization management functions on an insurer's behalf.
2    (t) If the Director determines that an insurer has
3violated this Section, the Director may, after appropriate
4notice and opportunity for hearing, by order, assess a civil
5penalty between $1,000 and $5,000 for each violation. Moneys
6collected from penalties shall be deposited into the Parity
7Advancement Fund established in subsection (i) of Section
8370c.1. Nothing in this Section shall be construed to limit
9criminal liability.
10    (u) If an insurer commits a violation of this Section, the
11insurer shall be given 30 days' notice to rectify that
12violation. Failure to rectify the violation within the 30-day
13notice period and any subsequent violation of this Section by
14the insurer shall constitute a Class A misdemeanor and shall
15result in criminal liability pursuant to Section 49-7 of the
16Criminal Code of 2012.
17    (v) (u) An insurer shall not adopt, impose, or enforce
18terms in its policies or provider agreements, in writing or in
19operation, that undermine, alter, or conflict with the
20requirements of this Section.
21    (w) (v) The provisions of this Section are severable. If
22any provision of this Section or its application is held
23invalid, that invalidity shall not affect other provisions or
24applications that can be given effect without the invalid
25provision or application.
26(Source: P.A. 101-81, eff. 7-12-19; 101-386, eff. 8-16-19;

 

 

SB2362- 42 -LRB103 29039 BMS 55425 b

1102-558, eff. 8-20-21; 102-579, eff. 1-1-22; 102-813, eff.
25-13-22.)
 
3    (215 ILCS 5/370c.1)
4    Sec. 370c.1. Mental, emotional, nervous, or substance use
5disorder or condition parity.
6    (a) On and after July 23, 2021 (the effective date of
7Public Act 102-135), every insurer that amends, delivers,
8issues, or renews a group or individual policy of accident and
9health insurance or a qualified health plan offered through
10the Health Insurance Marketplace in this State providing
11coverage for hospital or medical treatment and for the
12treatment of mental, emotional, nervous, or substance use
13disorders or conditions shall ensure prior to policy issuance
14that:
15        (1) the financial requirements applicable to such
16    mental, emotional, nervous, or substance use disorder or
17    condition benefits are no more restrictive than the
18    predominant financial requirements applied to
19    substantially all hospital and medical benefits covered by
20    the policy and that there are no separate cost-sharing
21    requirements that are applicable only with respect to
22    mental, emotional, nervous, or substance use disorder or
23    condition benefits; and
24        (2) the treatment limitations applicable to such
25    mental, emotional, nervous, or substance use disorder or

 

 

SB2362- 43 -LRB103 29039 BMS 55425 b

1    condition benefits are no more restrictive than the
2    predominant treatment limitations applied to substantially
3    all hospital and medical benefits covered by the policy
4    and that there are no separate treatment limitations that
5    are applicable only with respect to mental, emotional,
6    nervous, or substance use disorder or condition benefits.
7    (b) The following provisions shall apply concerning
8aggregate lifetime limits:
9        (1) In the case of a group or individual policy of
10    accident and health insurance or a qualified health plan
11    offered through the Health Insurance Marketplace amended,
12    delivered, issued, or renewed in this State on or after
13    September 9, 2015 (the effective date of Public Act
14    99-480) that provides coverage for hospital or medical
15    treatment and for the treatment of mental, emotional,
16    nervous, or substance use disorders or conditions the
17    following provisions shall apply:
18            (A) if the policy does not include an aggregate
19        lifetime limit on substantially all hospital and
20        medical benefits, then the policy may not impose any
21        aggregate lifetime limit on mental, emotional,
22        nervous, or substance use disorder or condition
23        benefits; or
24            (B) if the policy includes an aggregate lifetime
25        limit on substantially all hospital and medical
26        benefits (in this subsection referred to as the

 

 

SB2362- 44 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 45 -LRB103 29039 BMS 55425 b

1    (c) The following provisions shall apply concerning annual
2limits:
3        (1) In the case of a group or individual policy of
4    accident and health insurance or a qualified health plan
5    offered through the Health Insurance Marketplace amended,
6    delivered, issued, or renewed in this State on or after
7    September 9, 2015 (the effective date of Public Act
8    99-480) that provides coverage for hospital or medical
9    treatment and for the treatment of mental, emotional,
10    nervous, or substance use disorders or conditions the
11    following provisions shall apply:
12            (A) if the policy does not include an annual limit
13        on substantially all hospital and medical benefits,
14        then the policy may not impose any annual limits on
15        mental, emotional, nervous, or substance use disorder
16        or condition benefits; or
17            (B) if the policy includes an annual limit on
18        substantially all hospital and medical benefits (in
19        this subsection referred to as the "applicable annual
20        limit"), then the policy shall either:
21                (i) apply the applicable annual limit both to
22            the hospital and medical benefits to which it
23            otherwise would apply and to mental, emotional,
24            nervous, or substance use disorder or condition
25            benefits and not distinguish in the application of
26            the limit between the hospital and medical

 

 

SB2362- 46 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 47 -LRB103 29039 BMS 55425 b

1coverage determination requirements for substance abuse
2treatment drugs set forth in Section 45.2 of the Managed Care
3Reform and Patient Rights Act.
4    (e) This Section shall be interpreted in a manner
5consistent with all applicable federal parity regulations
6including, but not limited to, the Paul Wellstone and Pete
7Domenici Mental Health Parity and Addiction Equity Act of
82008, final regulations issued under the Paul Wellstone and
9Pete Domenici Mental Health Parity and Addiction Equity Act of
102008 and final regulations applying the Paul Wellstone and
11Pete Domenici Mental Health Parity and Addiction Equity Act of
122008 to Medicaid managed care organizations, the Children's
13Health Insurance Program, and alternative benefit plans.
14    (f) The provisions of subsections (b) and (c) of this
15Section shall not be interpreted to allow the use of lifetime
16or annual limits otherwise prohibited by State or federal law.
17    (g) As used in this Section:
18    "Financial requirement" includes deductibles, copayments,
19coinsurance, and out-of-pocket maximums, but does not include
20an aggregate lifetime limit or an annual limit subject to
21subsections (b) and (c).
22    "Mental, emotional, nervous, or substance use disorder or
23condition" means a condition or disorder that involves a
24mental health condition or substance use disorder that falls
25under any of the diagnostic categories listed in the mental
26and behavioral disorders chapter of the current edition of the

 

 

SB2362- 48 -LRB103 29039 BMS 55425 b

1International Classification of Disease or that is listed in
2the most recent version of the Diagnostic and Statistical
3Manual of Mental Disorders.
4    "Treatment limitation" includes limits on benefits based
5on the frequency of treatment, number of visits, days of
6coverage, days in a waiting period, or other similar limits on
7the scope or duration of treatment. "Treatment limitation"
8includes both quantitative treatment limitations, which are
9expressed numerically (such as 50 outpatient visits per year),
10and nonquantitative treatment limitations, which otherwise
11limit the scope or duration of treatment. A permanent
12exclusion of all benefits for a particular condition or
13disorder shall not be considered a treatment limitation.
14"Nonquantitative treatment" means those limitations as
15described under federal regulations (26 CFR 54.9812-1).
16"Nonquantitative treatment limitations" include, but are not
17limited to, those limitations described under federal
18regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
19146.136.
20    (h) The Department of Insurance shall implement the
21following education initiatives:
22        (1) By January 1, 2016, the Department shall develop a
23    plan for a Consumer Education Campaign on parity. The
24    Consumer Education Campaign shall focus its efforts
25    throughout the State and include trainings in the
26    northern, southern, and central regions of the State, as

 

 

SB2362- 49 -LRB103 29039 BMS 55425 b

1    defined by the Department, as well as each of the 5 managed
2    care regions of the State as identified by the Department
3    of Healthcare and Family Services. Under this Consumer
4    Education Campaign, the Department shall: (1) by January
5    1, 2017, provide at least one live training in each region
6    on parity for consumers and providers and one webinar
7    training to be posted on the Department website and (2)
8    establish a consumer hotline to assist consumers in
9    navigating the parity process by March 1, 2017. By January
10    1, 2018 the Department shall issue a report to the General
11    Assembly on the success of the Consumer Education
12    Campaign, which shall indicate whether additional training
13    is necessary or would be recommended.
14        (2) The Department, in coordination with the
15    Department of Human Services and the Department of
16    Healthcare and Family Services, shall convene a working
17    group of health care insurance carriers, mental health
18    advocacy groups, substance abuse patient advocacy groups,
19    and mental health physician groups for the purpose of
20    discussing issues related to the treatment and coverage of
21    mental, emotional, nervous, or substance use disorders or
22    conditions and compliance with parity obligations under
23    State and federal law. Compliance shall be measured,
24    tracked, and shared during the meetings of the working
25    group. The working group shall meet once before January 1,
26    2016 and shall meet semiannually thereafter. The

 

 

SB2362- 50 -LRB103 29039 BMS 55425 b

1    Department shall issue an annual report to the General
2    Assembly that includes a list of the health care insurance
3    carriers, mental health advocacy groups, substance abuse
4    patient advocacy groups, and mental health physician
5    groups that participated in the working group meetings,
6    details on the issues and topics covered, and any
7    legislative recommendations developed by the working
8    group.
9        (3) Not later than January 1 of each year, the
10    Department, in conjunction with the Department of
11    Healthcare and Family Services, shall issue a joint report
12    to the General Assembly and provide an educational
13    presentation to the General Assembly. The report and
14    presentation shall:
15            (A) Cover the methodology the Departments use to
16        check for compliance with the federal Paul Wellstone
17        and Pete Domenici Mental Health Parity and Addiction
18        Equity Act of 2008, 42 U.S.C. 18031(j), and any
19        federal regulations or guidance relating to the
20        compliance and oversight of the federal Paul Wellstone
21        and Pete Domenici Mental Health Parity and Addiction
22        Equity Act of 2008 and 42 U.S.C. 18031(j).
23            (B) Cover the methodology the Departments use to
24        check for compliance with this Section and Sections
25        356z.23, and 370c, and 370c.3 of this Code.
26            (C) Identify market conduct examinations or, in

 

 

SB2362- 51 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 52 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 53 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 54 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 55 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 56 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 57 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 58 -LRB103 29039 BMS 55425 b

1        strategies used to apply each nonquantitative
2        treatment limitation, in operation, for medical and
3        surgical benefits; and
4            (E) disclose the specific findings and conclusions
5        reached by the insurer that the results of the
6        analyses described in subparagraphs (C) and (D)
7        indicate that the insurer is in compliance with this
8        Section and the Mental Health Parity and Addiction
9        Equity Act of 2008 and its implementing regulations,
10        which includes 42 CFR Parts 438, 440, and 457 and 45
11        CFR 146.136 and any other related federal regulations
12        found in the Code of Federal Regulations.
13        (7) Any other information necessary to clarify data
14    provided in accordance with this Section requested by the
15    Director, including information that may be proprietary or
16    have commercial value, under the requirements of Section
17    30 of the Viatical Settlements Act of 2009.
18    (l) An insurer that amends, delivers, issues, or renews a
19group or individual policy of accident and health insurance or
20a qualified health plan offered through the health insurance
21marketplace in this State providing coverage for hospital or
22medical treatment and for the treatment of mental, emotional,
23nervous, or substance use disorders or conditions on or after
24January 1, 2019 (the effective date of Public Act 100-1024)
25shall, in advance of the plan year, make available to the
26Department or, with respect to medical assistance, the

 

 

SB2362- 59 -LRB103 29039 BMS 55425 b

1Department of Healthcare and Family Services and to all plan
2participants and beneficiaries the information required in
3subparagraphs (C) through (E) of paragraph (6) of subsection
4(k). For plan participants and medical assistance
5beneficiaries, the information required in subparagraphs (C)
6through (E) of paragraph (6) of subsection (k) shall be made
7available on a publicly-available website whose web address is
8prominently displayed in plan and managed care organization
9informational and marketing materials.
10    (m) In conjunction with its compliance examination program
11conducted in accordance with the Illinois State Auditing Act,
12the Auditor General shall undertake a review of compliance by
13the Department and the Department of Healthcare and Family
14Services with Section 370c and this Section. Any findings
15resulting from the review conducted under this Section shall
16be included in the applicable State agency's compliance
17examination report. Each compliance examination report shall
18be issued in accordance with Section 3-14 of the Illinois
19State Auditing Act. A copy of each report shall also be
20delivered to the head of the applicable State agency and
21posted on the Auditor General's website.
22(Source: P.A. 102-135, eff. 7-23-21; 102-579, eff. 8-25-21;
23102-813, eff. 5-13-22.)
 
24    (215 ILCS 5/370c.3 new)
25    Sec. 370c.3. Vision, hearing, and dental disorder or

 

 

SB2362- 60 -LRB103 29039 BMS 55425 b

1condition parity.
2    (a) As used in this Section:
3    "Financial requirement" includes deductibles, copayments,
4coinsurance, and out-of-pocket maximums, but does not include
5an aggregate lifetime limit or an annual limit subject to
6subsections (b) and (c).
7    "Treatment limitation" includes limits on benefits based
8on the frequency of treatment, number of visits, days of
9coverage, days in a waiting period, or other similar limits on
10the scope or duration of treatment. "Treatment limitation"
11includes both quantitative treatment limitations, which are
12expressed numerically (such as 50 outpatient visits per year),
13and nonquantitative treatment limitations, which otherwise
14limit the scope or duration of treatment. A permanent
15exclusion of all benefits for a particular condition or
16disorder shall not be considered a treatment limitation.
17"Nonquantitative treatment" means those limitations as
18described under federal regulations (26 CFR 54.9812-1).
19"Nonquantitative treatment limitations" include, but are not
20limited to, those limitations described under federal
21regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
22146.136.
23    (b) On and after the effective date of this amendatory Act
24of the 103rd General Assembly, every insurer that amends,
25delivers, issues, or renews a group or individual policy of
26accident and health insurance or a qualified health plan

 

 

SB2362- 61 -LRB103 29039 BMS 55425 b

1offered through the health insurance marketplace in this State
2providing coverage for hospital or medical treatment and for
3the treatment of a vision, hearing, or dental disorder or
4condition shall ensure before policy issuance that:
5        (1) the financial requirements applicable to such
6    vision, hearing, or dental disorder or condition benefits
7    are no more restrictive than the predominant financial
8    requirements applied to substantially all hospital and
9    medical benefits covered by the policy and that there are
10    no separate cost-sharing requirements that are applicable
11    only with respect to vision, hearing, or dental disorder
12    or condition benefits; and
13        (2) the treatment limitations applicable to such
14    vision, hearing, or dental disorder or condition benefits
15    are no more restrictive than the predominant treatment
16    limitations applied to substantially all hospital and
17    medical benefits covered by the policy and that there are
18    no separate treatment limitations that are applicable only
19    with respect to vision, hearing, or dental disorder or
20    condition benefits.
21    (c) The following provisions shall apply concerning
22aggregate lifetime limits:
23        (1) In the case of a group or individual policy of
24    accident and health insurance or a qualified health plan
25    offered through the health insurance marketplace amended,
26    delivered, issued, or renewed in this State on or after

 

 

SB2362- 62 -LRB103 29039 BMS 55425 b

1    the effective date of this amendatory Act of the 103rd
2    General Assembly that provides coverage for hospital or
3    medical treatment and for the treatment of a vision,
4    hearing, or dental disorder or condition, the following
5    provisions shall apply:
6            (A) if the policy does not include an aggregate
7        lifetime limit on substantially all hospital and
8        medical benefits, then the policy may not impose any
9        aggregate lifetime limit on vision, hearing, dental
10        disorder or condition benefits; or
11            (B) if the policy includes an aggregate lifetime
12        limit on substantially all hospital and medical
13        benefits, then the policy shall either:
14                (i) apply the aggregate lifetime limit both to
15            the hospital and medical benefits to which it
16            otherwise would apply and to vision, hearing, and
17            dental disorder or condition benefits and not
18            distinguish in the application of the limit
19            between the hospital and medical benefits and
20            vision, hearing, and dental disorder or condition
21            benefits; or
22                (ii) not include any aggregate lifetime limit
23            on vision, hearing, and dental disorder or
24            condition benefits that is less than the aggregate
25            lifetime limit on substantially all hospital and
26            medical benefits.

 

 

SB2362- 63 -LRB103 29039 BMS 55425 b

1        (2) In the case of a policy that is not described in
2    paragraph (1) of subsection (b) and that includes no or
3    different aggregate lifetime limits on different
4    categories of hospital and medical benefits, the
5    Department shall adopt rules under which subparagraph (B)
6    of paragraph (1) of subsection (b) is applied to such
7    policy with respect to vision, hearing, and dental
8    disorder or condition benefits by substituting the
9    aggregate lifetime limit on substantially all hospital and
10    medical benefits with an average aggregate lifetime limit
11    that is computed taking into account the weighted average
12    of the aggregate lifetime limits applicable to such
13    categories.
14    (d) The following provisions shall apply concerning annual
15limits:
16        (1) In the case of a group or individual policy of
17    accident and health insurance or a qualified health plan
18    offered through the health insurance marketplace amended,
19    delivered, issued, or renewed in this State on or after
20    the effective date of this amendatory Act of the 103rd
21    General Assembly that provides coverage for hospital or
22    medical treatment and for the treatment of a vision,
23    hearing, or dental disorder or condition, the following
24    provisions shall apply:
25            (A) if the policy does not include an annual limit
26        on substantially all hospital and medical benefits,

 

 

SB2362- 64 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 65 -LRB103 29039 BMS 55425 b

1    condition benefits by substituting the annual limit on
2    substantially all hospital and medical benefits with an
3    average annual limit that is computed taking into account
4    the weighted average of the annual limits applicable to
5    such categories.
6    (e) With respect to a vision, hearing, and dental disorder
7or condition, an insurer shall use policies and procedures for
8the election and placement of vision, hearing, and dental
9disorder or condition treatment drugs on their formulary that
10are no less favorable to the insured as those policies and
11procedures the insurer uses for the selection and placement of
12drugs for medical or surgical conditions and shall follow the
13expedited coverage determination requirements for substance
14abuse treatment drugs set forth in Section 45.2 of the Managed
15Care Reform and Patient Rights Act.
16    (f) The provisions of subsections (c) and (d) shall not be
17interpreted to allow the use of lifetime or annual limits
18otherwise prohibited by State or federal law.
19    (g) An insurer that amends, delivers, issues, or renews a
20group or individual policy of accident and health insurance or
21a qualified health plan offered through the health insurance
22marketplace in this State providing coverage for hospital or
23medical treatment and for the treatment of vision, hearing, or
24dental disorders or conditions shall submit an annual report
25that contains the following information separately for
26inpatient in-network benefits, inpatient out-of-network

 

 

SB2362- 66 -LRB103 29039 BMS 55425 b

1benefits, outpatient in-network benefits, outpatient
2out-of-network benefits, emergency care benefits, and
3prescription drug benefits in the case of accident and health
4insurance or qualified health plans, or inpatient, outpatient,
5emergency care, and prescription drug benefits in the case of
6medical assistance:
7        (1) A summary of the plan's pharmacy management
8    processes for vision, hearing, and dental disorder or
9    condition benefits compared to those for other medical
10    benefits.
11        (2) A summary of the internal processes of review for
12    experimental benefits and unproven technology for vision,
13    hearing, and dental disorder or condition benefits and
14    those for other medical benefits.
15        (3) A summary of how the plan's policies and
16    procedures for utilization management for vision, hearing,
17    and dental disorder or condition benefits compare to those
18    for other medical benefits.
19        (4) A description of the process used to develop or
20    select the medical necessity criteria for vision, hearing,
21    and dental disorder or condition benefits and the process
22    used to develop or select the medical necessity criteria
23    for medical and surgical benefits.
24        (5) Identification of all nonquantitative treatment
25    limitations that are applied to vision, hearing, and
26    dental disorder or condition benefits and medical and

 

 

SB2362- 67 -LRB103 29039 BMS 55425 b

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

 

 

SB2362- 68 -LRB103 29039 BMS 55425 b

1            (C) provide the comparative analyses, including
2        the results of the analyses, performed to determine
3        that the processes and strategies used to design each
4        nonquantitative treatment limitation, as written, for
5        vision, hearing, and dental disorder or condition
6        benefits are comparable to, and are applied no more
7        stringently than, the processes and strategies used to
8        design each nonquantitative treatment limitation, as
9        written, for medical and surgical benefits;
10            (D) provide the comparative analyses, including
11        the results of the analyses, performed to determine
12        that the processes and strategies used to apply each
13        nonquantitative treatment limitation, in operation,
14        for vision, hearing, and dental disorder or condition
15        benefits are comparable to, and applied no more
16        stringently than, the processes or strategies used to
17        apply each nonquantitative treatment limitation, in
18        operation, for medical and surgical benefits; and
19            (E) disclose the specific findings and conclusions
20        reached by the insurer that the results of the
21        analyses described in subparagraphs (C) and (D) of
22        this paragraph indicate that the insurer is in
23        compliance with this Section.
24        (7) Any other information necessary to clarify data
25    provided in accordance with this Section requested by the
26    Director, including information that may be proprietary or

 

 

SB2362- 69 -LRB103 29039 BMS 55425 b

1    have commercial value, under the requirements of Section
2    30 of the Viatical Settlements Act of 2009.
3    (h) An insurer that amends, delivers, issues, or renews a
4group or individual policy of accident and health insurance or
5a qualified health plan offered through the health insurance
6marketplace in this State providing coverage for hospital or
7medical treatment and for the treatment of vision, hearing, or
8dental disorder or condition on or after the effective date of
9this amendatory Act of the 103rd General Assembly shall, in
10advance of the plan year, make available to the Department or,
11with respect to medical assistance, the Department of
12Healthcare and Family Services and to all plan participants
13and beneficiaries the information required in subparagraphs
14(C) through (E) of paragraph (6) of subsection (g). For plan
15participants and medical assistance beneficiaries, the
16information required in subparagraphs (C) through (E) of
17paragraph (6) of subsection (g) shall be made available on a
18publicly available website with a web address that is
19prominently displayed in plan and managed care organization
20informational and marketing materials.
21    (i) In conjunction with its compliance examination program
22conducted in accordance with the Illinois State Auditing Act,
23the Auditor General shall undertake a review of compliance by
24the Department and the Department of Healthcare and Family
25Services with Section 370c and this Section. Any findings
26resulting from the review conducted under this Section shall

 

 

SB2362- 70 -LRB103 29039 BMS 55425 b

1be included in the applicable State agency's compliance
2examination report. Each compliance examination report shall
3be issued in accordance with Section 3-14 of the Illinois
4State Auditing Act. A copy of each report shall also be
5delivered to the head of the applicable State agency and
6posted on the Auditor General's website.
 
7    Section 15. The Illinois Public Aid Code is amended by
8changing Section 5-16.8 as follows:
 
9    (305 ILCS 5/5-16.8)
10    Sec. 5-16.8. Required health benefits. The medical
11assistance program shall (i) provide the post-mastectomy care
12benefits required to be covered by a policy of accident and
13health insurance under Section 356t and the coverage required
14under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
15356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,
16356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60, and
17356z.61 of the Illinois Insurance Code, (ii) be subject to the
18provisions of Sections 356z.19, 356z.44, 356z.49, 364.01,
19370c, and 370c.1, and 370c.3 of the Illinois Insurance Code,
20and (iii) be subject to the provisions of subsection (d-5) of
21Section 10 of the Network Adequacy and Transparency Act.
22    The Department, by rule, shall adopt a model similar to
23the requirements of Section 356z.39 of the Illinois Insurance
24Code.

 

 

SB2362- 71 -LRB103 29039 BMS 55425 b

1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate
4of reimbursement for services or other payments in accordance
5with Section 5-5e.
6    To ensure full access to the benefits set forth in this
7Section, on and after January 1, 2016, the Department shall
8ensure that provider and hospital reimbursement for
9post-mastectomy care benefits required under this Section are
10no lower than the Medicare reimbursement rate.
11(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20;
12101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff.
131-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144,
14eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
15102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff.
161-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093,
17eff. 1-1-23; 102-1117, eff. 1-13-23.)
 
18    Section 20. The Criminal Code of 2012 is amended by adding
19Section 49-7 as follows:
 
20    (720 ILCS 5/49-7 new)
21    Sec. 49-7. Criminal violation of health benefit parity.
22    (a) A person commits a criminal violation of health
23benefit parity if he or she knowingly and without legal
24justification, by any means, causes Sections 356z.61, 370c, or

 

 

SB2362- 72 -LRB103 29039 BMS 55425 b

1370c.3 of the Illinois Insurance Code to be violated.
2    (b) Criminal violation of health benefit parity is a Class
3A misdemeanor.
4    (c) Nothing in this Section shall be construed to limit
5further liability for civil damages or penalties resulting
6from other negligent conduct or intentional misconduct by any
7person.
 
8    Section 95. No acceleration or delay. Where this Act makes
9changes in a statute that is represented in this Act by text
10that is not yet or no longer in effect (for example, a Section
11represented by multiple versions), the use of that text does
12not accelerate or delay the taking effect of (i) the changes
13made by this Act or (ii) provisions derived from any other
14Public Act.