Illinois General Assembly - Full Text of SB0697
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Full Text of SB0697  102nd General Assembly

SB0697 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB0697

 

Introduced 2/25/2021, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c  from Ch. 73, par. 982c
215 ILCS 180/35
215 ILCS 180/40

    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 shall provide coverage for medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions. Provides that an insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public program. Provides that an insurer shall base any medical necessity determination or the utilization review criteria on current generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care. Provides that in conducting utilization review of covered health care services and benefits for the diagnosis, prevention, and treatment of mental, emotional, and nervous disorders or conditions in children, adolescents, and adults, an insurer shall exclusively apply the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty. Provides that an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in the treatment criteria. Provides that the Director may, after appropriate notice and opportunity for hearing, assess a civil penalty between $5,000 and $20,000 for each violation. Amends the Health Carrier External Review Act. Provides that independent review organization shall comply with specified requirements for an adverse determination or final adverse determination involving mental, emotional, nervous, or substance use disorders or conditions. Makes other changes. Effective immediately.


LRB102 17144 BMS 22576 b

 

 

A BILL FOR

 

SB0697LRB102 17144 BMS 22576 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 1. This Act may be referred to as the Generally
5Accepted Standards of Behavioral Health Care Act of 2021.
 
6    Section 2. The General Assembly finds and declares the
7following:
8    (a) The State of Illinois and the entire country faces a
9mental health and addiction crisis.
10        (1) One in 5 adults experience a mental health
11    disorder, and data from 2017 shows that one in 12 had a
12    substance use disorder. The COVID-19 pandemic has
13    exacerbated the nation's mental health and addiction
14    crisis. According the U.S. Center for Disease Control and
15    Prevention, since the start of the COVID-19 pandemic,
16    Americans have experienced higher rates of depression,
17    anxiety, and trauma, and rates of substance use and
18    suicidal ideation have increased.
19        (2) Nationally, the suicide rate has increased 35% in
20    the past 20 years. According to the Illinois Department of
21    Public Health, more than 1,000 Illinoisans die by suicide
22    every year, including 1,439 deaths in 2019, and it is the
23    third leading cause of death among young adults aged 15 to

 

 

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1    34.
2        (3) Between 2013 and 2019, Illinois saw a 1,861%
3    increase in synthetic opioid overdose deaths and a 68%
4    increase in heroin overdose deaths. In 2019 alone, there
5    were 2.3 and 2 times as many opioid deaths as homicides and
6    car crash deaths, respectively.
7        (4) Communities of color are disproportionately
8    impacted by lack of access to and inequities in mental
9    health and substance use disorder care.
10            (A) According to the Substance Abuse and Mental
11        Health Services Administration, two-thirds of Black
12        and Hispanic Americans with a mental illness and
13        nearly 90% with a substance use disorder do not
14        receive medically necessary treatment.
15            (B) Data from the U.S. Census Bureau demonstrates
16        that Black Americans saw the highest increases in
17        rates of anxiety and depression in 2020.
18            (C) Data from the Illinois Department of Public
19        Health reveals that Black Illinoisans are hospitalized
20        for opioid overdoses at a rate 6 times higher than
21        white Illinoisans.
22            (D) In the first half of 2020, the number of
23        suicides among Black Chicagoans had increased 106%
24        from the previous year. Nationally, from 2001 to 2017,
25        suicide rates doubled among Black girls aged 13 to 19
26        and increased 60% for Black boys of the same age.

 

 

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1            (E) According to the Substance Abuse and Mental
2        Health Services Administration, between 2008 and 2018
3        there were significant increases in serious mental
4        illness and suicide ideation in Hispanics aged 18 to
5        25 and there remains a large gap in treatment need
6        among Hispanics.
7        (5) According the U.S. Center for Disease Control and
8    Prevention, children with adverse childhood experiences
9    are more likely to experience negative outcomes like
10    post-traumatic stress disorder, increased anxiety and
11    depression, suicide, and substance use. A 2020 report from
12    Mental Health America shows that 62.1% of Illinois youth
13    with severe depression do not receive any mental health
14    treatment. Survey results found that 80% of college
15    students report that COVID-19 has negatively impacted
16    their mental health.
17        (6) In rural communities, between 2001 and 2015, the
18    suicide rate increased by 27%, and between 1999 and 2015
19    the overdose rate increased 325%.
20        (7) According to the U.S. Department of Veterans
21    Affairs, 154 veterans died by suicide in 2018, which
22    accounts for more than 10% of all suicide deaths reported
23    by the Illinois Department of Public Health in the same
24    year, despite only accounting for approximately 5.7% of
25    the State's total population. Nationally, between 2008 and
26    2017, more than 6,000 veterans died by suicide each year.

 

 

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1        (8) According to the National Alliance on Mental
2    Illness, 2,000,000 people with mental illness are
3    incarcerated every year, where they do not receive the
4    treatment they need.
5    (b) A recent landmark federal court ruling offers a
6concrete demonstration of how the mental health and addiction
7crisis described in subsection (a) is worsened through the
8denial of medically necessary mental health and substance use
9disorder treatment.
10        (1) In March 2019, the United States District Court of
11    the Northern District of California ruled in Wit v. United
12    Behavioral Health, 2019 WL 1033730 (Wit; N.D.CA Mar. 5,
13    2019), that United Behavioral Health created flawed level
14    of care placement criteria that were inconsistent with
15    generally accepted standards of mental health and
16    substance use disorder care in order to "mitigate" the
17    requirements of the federal Mental Health Parity and
18    Addiction Equity Act of 2008.
19        (2) As described by the federal court in Wit, the 8
20    generally accepted standards of mental health and
21    substance use disorder care require all of the following:
22            (A) Effective treatment of underlying conditions,
23        rather than mere amelioration of current symptoms,
24        such as suicidality or psychosis.
25            (B) Treatment of co-occurring behavioral health
26        disorders or medical conditions in a coordinated

 

 

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1        manner.
2            (C) Treatment at the least intensive and
3        restrictive level of care that is safe and effective
4        and meets the needs of the patient's condition; a
5        lower level or less intensive care is appropriate only
6        if it safe and just as effective as treatment at a
7        higher level or service intensity.
8            (D) Erring on the side of caution, by placing
9        patients in higher levels of care when there is
10        ambiguity as to the appropriate level of care, or when
11        the recommended level of care is not available.
12            (E) Treatment to maintain functioning or prevent
13        deterioration.
14            (F) Treatment of mental health and substance use
15        disorders for an appropriate duration based on
16        individual patient needs rather than on specific time
17        limits.
18            (G) Accounting for the unique needs of children
19        and adolescents when making level of care decisions.
20            (H) Applying multidimensional assessments of
21        patient needs when making determinations regarding the
22        appropriate level of care.
23        (3) The court in Wit found that all parties' expert
24    witnesses regarded the American Society of Addiction
25    Medicine (ASAM) criteria for substance use disorders and
26    Level of Care Utilization System (LOCUS), Child and

 

 

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1    Adolescent Level of Care Utilization System (CALOCUS),
2    Child and Adolescent Service Intensity Instrument (CASII),
3    and Early Childhood Service Intensity Instrument (ECSII)
4    criteria for mental health disorders as prime examples of
5    level of care criteria that are fully consistent with
6    generally accepted standards of mental health and
7    substance use care.
8        (4) In particular, the coverage of intermediate levels
9    of care, such as residential treatment, which are
10    essential components of the level of care continuum called
11    for by nonprofit, and clinical specialty associations such
12    as the American Society of Addiction Medicine, are often
13    denied through overly restrictive medical necessity
14    determinations.
15        (5) On November 3, 2020, the court issued a remedies
16    order requiring United Behavioral Health to reprocess
17    67,000 mental health and substance use disorder claims and
18    mandating that, for the next decade, United Behavioral
19    Health must use the relevant nonprofit clinical society
20    guidelines for its medical necessity determinations.
21        (6) The court's findings also demonstrated how United
22    Behavioral Health was in violation of Section 370c of the
23    Illinois Insurance Code for its failure to use the
24    American Society of Addiction Medicine Criteria for
25    substance use disorders. The results of market conduct
26    examinations released by the Illinois Department of

 

 

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1    Insurance on July 15, 2020 confirmed these findings citing
2    United Healthcare and CIGNA for their failure to use the
3    American Society of Addiction Medicine Criteria when
4    making medical necessity determinations for substance use
5    disorders as required by Illinois law.
6    (c) Insurers should not be permitted to deny medically
7necessary mental health and substance use disorder care
8through the use of utilization review practices and criteria
9that are inconsistent with generally accepted standards of
10mental health and substance use disorder care.
11        (1) Illinois parity law (Sections 370c and 370c.1 of
12    the Illinois Insurance Code) requires that health plans
13    treat illnesses of the brain, such as addiction and
14    depression, the same way they treat illness of other parts
15    of the body, such as cancer and diabetes. The Illinois
16    General Assembly significantly strengthened Illinois'
17    parity law, which incorporates provisions of the federal
18    Paul Wellstone and Pete Domenici Mental Health Parity and
19    Addiction Equity Act of 2008, in both 2015 and 2018.
20        (2) While the federal Patient Protection and
21    Affordable Care Act includes mental health and addiction
22    coverage as one of the 10 essential health benefits, it
23    does not contain a definition for medical necessity, and
24    despite the Patient Protection and Affordable Care Act,
25    needed mental health and addiction coverage can be denied
26    through overly restrictive medical necessity

 

 

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1    determinations.
2        (3) Despite the strong actions taken by the Illinois
3    General Assembly, the court in Wit v. United Behavioral
4    Health demonstrated how insurers can mitigate compliance
5    with parity laws due by denying medically necessary mental
6    health and treatment by using flawed medical necessity
7    criteria.
8        (4) When medically necessary mental health and
9    substance use disorder care is denied, the manifestations
10    of the mental health and addiction crisis described in
11    subsection (a) are severely exacerbated. Individuals with
12    mental health and substance use disorders often have their
13    conditions worsen, sometimes ending up in the criminal
14    justice system or on the streets, resulting in increased
15    emergency hospitalizations, harm to individuals and
16    communities, and higher costs to taxpayers.
17        (5) In order to realize the promise of mental health
18    and addiction parity and remove barriers to mental health
19    and substance use disorder care for all Illinoisans,
20    insurers must be required to cover medically necessary
21    mental health and substance use disorder care and follow
22    generally accepted standards of mental health and
23    substance use disorder care.
 
24    Section 5. The Illinois Insurance Code is amended by
25changing Section 370c as follows:
 

 

 

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1    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
2    Sec. 370c. Mental and emotional disorders.
3    (a)(1) On and after the effective date of this amendatory
4Act of the 102nd General Assembly January 1, 2019 (the
5effective date of this amendatory Act of the 101st General
6Assembly Public Act 100-1024), every insurer that amends,
7delivers, issues, or renews group accident and health policies
8providing coverage for hospital or medical treatment or
9services for illness on an expense-incurred basis shall
10provide coverage for the medically necessary treatment of
11reasonable and necessary treatment and services for mental,
12emotional, nervous, or substance use disorders or conditions
13consistent with the parity requirements of Section 370c.1 of
14this Code.
15    (2) Each insured that is covered for mental, emotional,
16nervous, or substance use disorders or conditions shall be
17free to select the physician licensed to practice medicine in
18all its branches, licensed clinical psychologist, licensed
19clinical social worker, licensed clinical professional
20counselor, licensed marriage and family therapist, licensed
21speech-language pathologist, or other licensed or certified
22professional at a program licensed pursuant to the Substance
23Use Disorder Act of his or her choice to treat such disorders,
24and the insurer shall pay the covered charges of such
25physician licensed to practice medicine in all its branches,

 

 

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

 

 

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1has informed the patient of the desirability of the patient
2conferring with the patient's primary care physician.
3    (4) "Mental, emotional, nervous, or substance use disorder
4or condition" means a condition or disorder that involves a
5mental health condition or substance use disorder that falls
6under any of the diagnostic categories listed in the mental
7and behavioral disorders chapter of the current edition of the
8World Health Organization's International Classification of
9Disease or that is listed in the most recent version of the
10American Psychiatric Association's Diagnostic and Statistical
11Manual of Mental Disorders. Changes in terminology,
12organization, or classification of mental, emotional, nervous,
13or substance use disorder or condition in future versions of
14the American Psychiatric Association's Diagnostic and
15Statistical Manual of Mental Disorders or the World Health
16Organization's International Statistical Classification of
17Diseases and Related Health Problems shall not affect the
18conditions covered by this Section as long as a condition is
19commonly understood to be a mental, emotional, nervous, or
20substance use disorder or condition by health care providers
21practicing in relevant clinical specialties. "Mental,
22emotional, nervous, or substance use disorder or condition"
23includes any mental health condition that occurs during
24pregnancy or during the postpartum period and includes, but is
25not limited to, postpartum depression.
26    (5) Medically necessary treatment and medical necessity

 

 

SB0697- 12 -LRB102 17144 BMS 22576 b

1determinations shall be interpreted and made in a manner that
2is consistent with and pursuant to subsections (h) through
3(t).
4    (b)(1) (Blank).
5    (2) (Blank).
6    (2.5) (Blank).
7    (3) Unless otherwise prohibited by federal law and
8consistent with the parity requirements of Section 370c.1 of
9this Code, the reimbursing insurer that amends, delivers,
10issues, or renews a group or individual policy of accident and
11health insurance, a qualified health plan offered through the
12health insurance marketplace, or a provider of treatment of
13mental, emotional, nervous, or substance use disorders or
14conditions shall furnish medical records or other necessary
15data that substantiate that initial or continued treatment is
16at all times medically necessary. An insurer shall provide a
17mechanism for the timely review by a provider holding the same
18license and practicing in the same specialty as the patient's
19provider, who is unaffiliated with the insurer, jointly
20selected by the patient (or the patient's next of kin or legal
21representative if the patient is unable to act for himself or
22herself), the patient's provider, and the insurer in the event
23of a dispute between the insurer and patient's provider
24regarding the medical necessity of a treatment proposed by a
25patient's provider. If the reviewing provider determines the
26treatment to be medically necessary, the insurer shall provide

 

 

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1reimbursement for the treatment. Future contractual or
2employment actions by the insurer regarding the patient's
3provider may not be based on the provider's participation in
4this procedure. Nothing prevents the insured from agreeing in
5writing to continue treatment at his or her expense. When
6making a determination of the medical necessity for a
7treatment modality for mental, emotional, nervous, or
8substance use disorders or conditions, an insurer must make
9the determination in a manner that is consistent with the
10manner used to make that determination with respect to other
11diseases or illnesses covered under the policy, including an
12appeals process. Medical necessity determinations for
13substance use disorders shall be made in accordance with
14appropriate patient placement criteria established by the
15American Society of Addiction Medicine. No additional criteria
16may be used to make medical necessity determinations for
17substance use disorders.
18    (4) A group health benefit plan amended, delivered,
19issued, or renewed on or after January 1, 2019 (the effective
20date of Public Act 100-1024) or an individual policy of
21accident and health insurance or a qualified health plan
22offered through the health insurance marketplace amended,
23delivered, issued, or renewed on or after January 1, 2019 (the
24effective date of Public Act 100-1024):
25        (A) shall provide coverage based upon medical
26    necessity for the treatment of a mental, emotional,

 

 

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1    nervous, or substance use disorder or condition consistent
2    with the parity requirements of Section 370c.1 of this
3    Code; provided, however, that in each calendar year
4    coverage shall not be less than the following:
5            (i) 45 days of inpatient treatment; and
6            (ii) beginning on June 26, 2006 (the effective
7        date of Public Act 94-921), 60 visits for outpatient
8        treatment including group and individual outpatient
9        treatment; and
10            (iii) for plans or policies delivered, issued for
11        delivery, renewed, or modified after January 1, 2007
12        (the effective date of Public Act 94-906), 20
13        additional outpatient visits for speech therapy for
14        treatment of pervasive developmental disorders that
15        will be in addition to speech therapy provided
16        pursuant to item (ii) of this subparagraph (A); and
17        (B) may not include a lifetime limit on the number of
18    days of inpatient treatment or the number of outpatient
19    visits covered under the plan.
20        (C) (Blank).
21    (5) An issuer of a group health benefit plan or an
22individual policy of accident and health insurance or a
23qualified health plan offered through the health insurance
24marketplace may not count toward the number of outpatient
25visits required to be covered under this Section an outpatient
26visit for the purpose of medication management and shall cover

 

 

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1the outpatient visits under the same terms and conditions as
2it covers outpatient visits for the treatment of physical
3illness.
4    (5.5) An individual or group health benefit plan amended,
5delivered, issued, or renewed on or after September 9, 2015
6(the effective date of Public Act 99-480) shall offer coverage
7for medically necessary acute treatment services and medically
8necessary clinical stabilization services. The treating
9provider shall base all treatment recommendations and the
10health benefit plan shall base all medical necessity
11determinations for substance use disorders in accordance with
12the most current edition of the Treatment Criteria for
13Addictive, Substance-Related, and Co-Occurring Conditions
14established by the American Society of Addiction Medicine. The
15treating provider shall base all treatment recommendations and
16the health benefit plan shall base all medical necessity
17determinations for medication-assisted treatment in accordance
18with the most current Treatment Criteria for Addictive,
19Substance-Related, and Co-Occurring Conditions established by
20the American Society of Addiction Medicine.
21    As used in this subsection:
22    "Acute treatment services" means 24-hour medically
23supervised addiction treatment that provides evaluation and
24withdrawal management and may include biopsychosocial
25assessment, individual and group counseling, psychoeducational
26groups, and discharge planning.

 

 

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1    "Clinical stabilization services" means 24-hour treatment,
2usually following acute treatment services for substance
3abuse, which may include intensive education and counseling
4regarding the nature of addiction and its consequences,
5relapse prevention, outreach to families and significant
6others, and aftercare planning for individuals beginning to
7engage in recovery from addiction.
8    (6) An issuer of a group health benefit plan may provide or
9offer coverage required under this Section through a managed
10care plan.
11    (6.5) An individual or group health benefit plan amended,
12delivered, issued, or renewed on or after January 1, 2019 (the
13effective date of Public Act 100-1024):
14        (A) shall not impose prior authorization requirements,
15    other than those established under the Treatment Criteria
16    for Addictive, Substance-Related, and Co-Occurring
17    Conditions established by the American Society of
18    Addiction Medicine, on a prescription medication approved
19    by the United States Food and Drug Administration that is
20    prescribed or administered for the treatment of substance
21    use disorders;
22        (B) shall not impose any step therapy requirements,
23    other than those established under the Treatment Criteria
24    for Addictive, Substance-Related, and Co-Occurring
25    Conditions established by the American Society of
26    Addiction Medicine, before authorizing coverage for a

 

 

SB0697- 17 -LRB102 17144 BMS 22576 b

1    prescription medication approved by the United States Food
2    and Drug Administration that is prescribed or administered
3    for the treatment of substance use disorders;
4        (C) shall place all prescription medications approved
5    by the United States Food and Drug Administration
6    prescribed or administered for the treatment of substance
7    use disorders on, for brand medications, the lowest tier
8    of the drug formulary developed and maintained by the
9    individual or group health benefit plan that covers brand
10    medications and, for generic medications, the lowest tier
11    of the drug formulary developed and maintained by the
12    individual or group health benefit plan that covers
13    generic medications; and
14        (D) shall not exclude coverage for a prescription
15    medication approved by the United States Food and Drug
16    Administration for the treatment of substance use
17    disorders and any associated counseling or wraparound
18    services on the grounds that such medications and services
19    were court ordered.
20    (7) (Blank).
21    (8) (Blank).
22    (9) With respect to all mental, emotional, nervous, or
23substance use disorders or conditions, coverage for inpatient
24treatment shall include coverage for treatment in a
25residential treatment center certified or licensed by the
26Department of Public Health or the Department of Human

 

 

SB0697- 18 -LRB102 17144 BMS 22576 b

1Services.
2    (c) This Section shall not be interpreted to require
3coverage for speech therapy or other habilitative services for
4those individuals covered under Section 356z.15 of this Code.
5    (d) With respect to a group or individual policy of
6accident and health insurance or a qualified health plan
7offered through the health insurance marketplace, the
8Department and, with respect to medical assistance, the
9Department of Healthcare and Family Services shall each
10enforce the requirements of this Section and Sections 356z.23
11and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
12Mental Health Parity and Addiction Equity Act of 2008, 42
13U.S.C. 18031(j), and any amendments to, and federal guidance
14or regulations issued under, those Acts, including, but not
15limited to, final regulations issued under the Paul Wellstone
16and Pete Domenici Mental Health Parity and Addiction Equity
17Act of 2008 and final regulations applying the Paul Wellstone
18and Pete Domenici Mental Health Parity and Addiction Equity
19Act of 2008 to Medicaid managed care organizations, the
20Children's Health Insurance Program, and alternative benefit
21plans. Specifically, the Department and the Department of
22Healthcare and Family Services shall take action:
23        (1) proactively ensuring compliance by individual and
24    group policies, including by requiring that insurers
25    submit comparative analyses, as set forth in paragraph (6)
26    of subsection (k) of Section 370c.1, demonstrating how

 

 

SB0697- 19 -LRB102 17144 BMS 22576 b

1    they design and apply nonquantitative treatment
2    limitations, both as written and in operation, for mental,
3    emotional, nervous, or substance use disorder or condition
4    benefits as compared to how they design and apply
5    nonquantitative treatment limitations, as written and in
6    operation, for medical and surgical benefits;
7        (2) evaluating all consumer or provider complaints
8    regarding mental, emotional, nervous, or substance use
9    disorder or condition coverage for possible parity
10    violations;
11        (3) performing parity compliance market conduct
12    examinations or, in the case of the Department of
13    Healthcare and Family Services, parity compliance audits
14    of individual and group plans and policies, including, but
15    not limited to, reviews of:
16            (A) nonquantitative treatment limitations,
17        including, but not limited to, prior authorization
18        requirements, concurrent review, retrospective review,
19        step therapy, network admission standards,
20        reimbursement rates, and geographic restrictions;
21            (B) denials of authorization, payment, and
22        coverage; and
23            (C) other specific criteria as may be determined
24        by the Department.
25    The findings and the conclusions of the parity compliance
26market conduct examinations and audits shall be made public.

 

 

SB0697- 20 -LRB102 17144 BMS 22576 b

1    The Director may adopt rules to effectuate any provisions
2of the Paul Wellstone and Pete Domenici Mental Health Parity
3and Addiction Equity Act of 2008 that relate to the business of
4insurance.
5    (e) Availability of plan information.
6        (1) The criteria for medical necessity determinations
7    made under a group health plan, an individual policy of
8    accident and health insurance, or a qualified health plan
9    offered through the health insurance marketplace with
10    respect to mental health or substance use disorder
11    benefits (or health insurance coverage offered in
12    connection with the plan with respect to such benefits)
13    must be made available by the plan administrator (or the
14    health insurance issuer offering such coverage) to any
15    current or potential participant, beneficiary, or
16    contracting provider upon request.
17        (2) The reason for any denial under a group health
18    benefit plan, an individual policy of accident and health
19    insurance, or a qualified health plan offered through the
20    health insurance marketplace (or health insurance coverage
21    offered in connection with such plan or policy) of
22    reimbursement or payment for services with respect to
23    mental, emotional, nervous, or substance use disorders or
24    conditions benefits in the case of any participant or
25    beneficiary must be made available within a reasonable
26    time and in a reasonable manner and in readily

 

 

SB0697- 21 -LRB102 17144 BMS 22576 b

1    understandable language by the plan administrator (or the
2    health insurance issuer offering such coverage) to the
3    participant or beneficiary upon request.
4    (f) As used in this Section, "group policy of accident and
5health insurance" and "group health benefit plan" includes (1)
6State-regulated employer-sponsored group health insurance
7plans written in Illinois or which purport to provide coverage
8for a resident of this State; and (2) State employee health
9plans.
10    (g) (1) As used in this subsection:
11    "Benefits", with respect to insurers, means the benefits
12provided for treatment services for inpatient and outpatient
13treatment of substance use disorders or conditions at American
14Society of Addiction Medicine levels of treatment 2.1
15(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
16(Clinically Managed Low-Intensity Residential), 3.3
17(Clinically Managed Population-Specific High-Intensity
18Residential), 3.5 (Clinically Managed High-Intensity
19Residential), and 3.7 (Medically Monitored Intensive
20Inpatient) and OMT (Opioid Maintenance Therapy) services.
21    "Benefits", with respect to managed care organizations,
22means the benefits provided for treatment services for
23inpatient and outpatient treatment of substance use disorders
24or conditions at American Society of Addiction Medicine levels
25of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
26Hospitalization), 3.5 (Clinically Managed High-Intensity

 

 

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1Residential), and 3.7 (Medically Monitored Intensive
2Inpatient) and OMT (Opioid Maintenance Therapy) services.
3    "Substance use disorder treatment provider or facility"
4means a licensed physician, licensed psychologist, licensed
5psychiatrist, licensed advanced practice registered nurse, or
6licensed, certified, or otherwise State-approved facility or
7provider of substance use disorder treatment.
8    (2) A group health insurance policy, an individual health
9benefit plan, or qualified health plan that is offered through
10the health insurance marketplace, small employer group health
11plan, and large employer group health plan that is amended,
12delivered, issued, executed, or renewed in this State, or
13approved for issuance or renewal in this State, on or after
14January 1, 2019 (the effective date of Public Act 100-1023)
15shall comply with the requirements of this Section and Section
16370c.1. The services for the treatment and the ongoing
17assessment of the patient's progress in treatment shall follow
18the requirements of 77 Ill. Adm. Code 2060.
19    (3) Prior authorization shall not be utilized for the
20benefits under this subsection. The substance use disorder
21treatment provider or facility shall notify the insurer of the
22initiation of treatment. For an insurer that is not a managed
23care organization, the substance use disorder treatment
24provider or facility notification shall occur for the
25initiation of treatment of the covered person within 2
26business days. For managed care organizations, the substance

 

 

SB0697- 23 -LRB102 17144 BMS 22576 b

1use disorder treatment provider or facility notification shall
2occur in accordance with the protocol set forth in the
3provider agreement for initiation of treatment within 24
4hours. If the managed care organization is not capable of
5accepting the notification in accordance with the contractual
6protocol during the 24-hour period following admission, the
7substance use disorder treatment provider or facility shall
8have one additional business day to provide the notification
9to the appropriate managed care organization. Treatment plans
10shall be developed in accordance with the requirements and
11timeframes established in 77 Ill. Adm. Code 2060. If the
12substance use disorder treatment provider or facility fails to
13notify the insurer of the initiation of treatment in
14accordance with these provisions, the insurer may follow its
15normal prior authorization processes.
16    (4) For an insurer that is not a managed care
17organization, if an insurer determines that benefits are no
18longer medically necessary, the insurer shall notify the
19covered person, the covered person's authorized
20representative, if any, and the covered person's health care
21provider in writing of the covered person's right to request
22an external review pursuant to the Health Carrier External
23Review Act. The notification shall occur within 24 hours
24following the adverse determination.
25    Pursuant to the requirements of the Health Carrier
26External Review Act, the covered person or the covered

 

 

SB0697- 24 -LRB102 17144 BMS 22576 b

1person's authorized representative may request an expedited
2external review. An expedited external review may not occur if
3the substance use disorder treatment provider or facility
4determines that continued treatment is no longer medically
5necessary. Under this subsection, a request for expedited
6external review must be initiated within 24 hours following
7the adverse determination notification by the insurer. Failure
8to request an expedited external review within 24 hours shall
9preclude a covered person or a covered person's authorized
10representative from requesting an expedited external review.
11    If an expedited external review request meets the criteria
12of the Health Carrier External Review Act, an independent
13review organization shall make a final determination of
14medical necessity within 72 hours. If an independent review
15organization upholds an adverse determination, an insurer
16shall remain responsible to provide coverage of benefits
17through the day following the determination of the independent
18review organization. A decision to reverse an adverse
19determination shall comply with the Health Carrier External
20Review Act.
21    (5) The substance use disorder treatment provider or
22facility shall provide the insurer with 7 business days'
23advance notice of the planned discharge of the patient from
24the substance use disorder treatment provider or facility and
25notice on the day that the patient is discharged from the
26substance use disorder treatment provider or facility.

 

 

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1    (6) The benefits required by this subsection shall be
2provided to all covered persons with a diagnosis of substance
3use disorder or conditions. The presence of additional related
4or unrelated diagnoses shall not be a basis to reduce or deny
5the benefits required by this subsection.
6    (7) Nothing in this subsection shall be construed to
7require an insurer to provide coverage for any of the benefits
8in this subsection.
9    (h) As used in this Section:
10    "Generally accepted standards of mental, emotional,
11nervous, or substance use disorder or condition care" means
12standards of care and clinical practice that are generally
13recognized by health care providers practicing in relevant
14clinical specialties such as psychiatry, psychology, clinical
15sociology, social work, addiction medicine and counseling, and
16behavioral health treatment. Valid, evidence-based sources
17reflecting generally accepted standards of mental, emotional,
18nervous, or substance use disorder or condition care include
19peer-reviewed scientific studies and medical literature,
20recommendations of nonprofit health care provider professional
21associations and specialty societies, including, but not
22limited to, patient placement criteria and clinical practice
23guidelines, recommendations of federal government agencies,
24and drug labeling approved by the United States Food and Drug
25Administration.
26    "Medically necessary treatment of mental, emotional,

 

 

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1nervous, or substance use disorders or conditions" means a
2service or product addressing the specific needs of that
3patient, for the purpose of screening, preventing, diagnosing,
4managing, or treating an illness, injury, condition, or its
5symptoms, including minimizing the progression of an illness,
6injury, condition, or its symptoms in a manner that is all of
7the following:
8        (1) in accordance with the generally accepted
9    standards of mental, emotional, nervous, or substance use
10    disorder or condition care;
11        (2) clinically appropriate in terms of type,
12    frequency, extent, site, and duration; and
13        (3) not primarily for the economic benefit of the
14    insurer, purchaser, or for the convenience of the patient,
15    treating physician, or other health care provider.
16    "Utilization review" means either of the following:
17        (1) prospectively, retrospectively, or concurrently
18    reviewing and approving, modifying, delaying, or denying,
19    based in whole or in part on medical necessity, requests
20    by health care providers, insureds, or their authorized
21    representatives for coverage of health care services
22    before, retrospectively, or concurrently with the
23    provision of health care services to insureds.
24        (2) evaluating the medical necessity, appropriateness,
25    level of care, service intensity, efficacy, or efficiency
26    of health care services, benefits, procedures, or

 

 

SB0697- 27 -LRB102 17144 BMS 22576 b

1    settings, under any circumstances, to determine whether a
2    health care service or benefit subject to a medical
3    necessity coverage requirement in an insurance policy is
4    covered as medically necessary for an insured.
5    "Utilization review criteria" means patient placement
6criteria or any criteria, standards, protocols, or guidelines
7used by an insurer to conduct utilization review.
8    (i)(1) Every insurer that amends, delivers, issues, or
9renews a group or individual policy of accident and health
10insurance or a qualified health plan offered through the
11health insurance marketplace in this State and Medicaid
12managed care organizations providing coverage for hospital or
13medical treatment on or after January 1, 2022 shall, pursuant
14to subsections (h) through (s), provide coverage for medically
15necessary treatment of mental, emotional, nervous, or
16substance use disorders or conditions.
17    (2) An insurer shall not limit benefits or coverage for
18mental, emotional, nervous, or substance use disorders or
19conditions to short-term or acute treatment at any level of
20placement.
21    (3) All medical necessity determinations made by the
22insurer concerning service intensity, level of care placement,
23continued stay, and transfer or discharge of insureds
24diagnosed with mental, emotional, nervous, or substance use
25disorders or conditions shall be conducted in accordance with
26the requirements of subsections (k) through (u).

 

 

SB0697- 28 -LRB102 17144 BMS 22576 b

1    (4) An insurer that authorizes a specific type of
2treatment by a provider pursuant to this Section shall not
3rescind or modify the authorization after that provider
4renders the health care service in good faith and pursuant to
5this authorization for any reason, including, but not limited
6to, the insurer's subsequent rescission, cancellation, or
7modification of the insured's or policyholder's contract, or
8the insured's or policyholder's eligibility.
9    (j) An insurer shall not limit benefits or coverage for
10medically necessary services on the basis that those services
11should be or could be covered by a public program, including,
12but not limited to, special education or an individualized
13education program, Medicaid, Medicare, Supplemental Security
14Income, or Social Security Disability Insurance, and shall not
15include or enforce a contract term that excludes otherwise
16covered benefits on the basis that those services should be or
17could be covered by a public program.
18    (k) An insurer shall base any medical necessity
19determination or the utilization review criteria that the
20insurer, and any entity acting on the insurer's behalf,
21applies to determine the medical necessity of health care
22services and benefits for the diagnosis, prevention, and
23treatment of mental, emotional, nervous, or substance use
24disorders or conditions on current generally accepted
25standards of mental, emotional, nervous, or substance use
26disorder or condition care. All denials and appeals shall be

 

 

SB0697- 29 -LRB102 17144 BMS 22576 b

1reviewed by a professional with experience or expertise
2comparable to the provider requesting the authorization.
3    (l) In conducting utilization review of all covered health
4care services and benefits for the diagnosis, prevention, and
5treatment of mental, emotional, and nervous disorders or
6conditions in children, adolescents, and adults, an insurer
7shall exclusively apply the criteria and guidelines set forth
8in the most recent versions of the treatment criteria
9developed by the nonprofit professional association for the
10relevant clinical specialty. Pursuant to subsection (b), in
11conducting utilization review of all covered services and
12benefits for the diagnosis, prevention, and treatment of
13substance use disorders an insurer shall use the most recent
14edition of the patient placement criteria established by the
15American Society of Addiction Medicine.
16    (m) In conducting utilization review involving level of
17care placement decisions or any other patient care decisions
18that are within the scope of the sources specified in
19subsection (l), an insurer shall not apply different,
20additional, conflicting, or more restrictive utilization
21review criteria than the criteria and guidelines set forth in
22those sources. For all level of care placement decisions, the
23insurer shall authorize placement at the level of care
24consistent with the assessment of the insured using the
25relevant criteria and guidelines as specified in subsection
26(l). If that level of placement is not available, the insurer

 

 

SB0697- 30 -LRB102 17144 BMS 22576 b

1shall authorize the next higher level of care. In the event of
2disagreement, the insurer shall provide full detail of its
3assessment using the relevant criteria and guidelines as
4specified in subsection (l) to the provider of the service.
5    (n) An insurer shall only engage applicable qualified
6providers in the treatment of mental, emotional, nervous, or
7substance use disorders or conditions or the appropriate
8subspecialty therein and who possess an active professional
9license or certificate, to review, approve, or deny services.
10    (o) This Section does not in any way limit the rights of a
11patient under the Medical Patient Rights Act.
12    (p) This Section does not in any way limit early and
13periodic screening, diagnostic, and treatment benefits as
14defined under 42 U.S.C. 1396d(r).
15    (q) To ensure the proper use of the criteria described in
16subsection (l), every insurer shall do all of the following:
17        (1) Sponsor a formal education program by nonprofit
18    clinical specialty associations to educate the insurer's
19    staff, including any third parties contracted with the
20    insurer to review claims, conduct utilization reviews, or
21    make medical necessity determinations about the clinical
22    review criteria.
23        (2) Make the education program available to other
24    stakeholders, including the insurer's participating or
25    contracted providers and potential participants,
26    beneficiaries, or covered lives. The education program

 

 

SB0697- 31 -LRB102 17144 BMS 22576 b

1    must be provided, at minimum, on a quarterly basis,
2    in-person or digitally, or recordings of the education
3    program must be made available to the aforementioned
4    stakeholders.
5        (3) Provide, at no cost, the clinical review criteria
6    and any training material or resources to providers and
7    insured patients.
8        (4) Track, identify, and analyze how the clinical
9    review criteria are used to certify care, deny care, and
10    support the appeals process.
11        (5) Conduct interrater reliability testing to ensure
12    consistency in utilization review decision making that
13    covers how medical necessity decisions are made; this
14    assessment shall cover all aspects of utilization review
15    as defined in subsection (h).
16        (6) Run interrater reliability reports about how the
17    clinical guidelines are used in conjunction with the
18    utilization review process and parity compliance
19    activities.
20        (7) Achieve interrater reliability pass rates of at
21    least 90% and, if this threshold is not met, immediately
22    provide for the remediation of poor interrater reliability
23    and interrater reliability testing for all new staff
24    before they can conduct utilization review without
25    supervision.
26        (8) Submit to the Department of Insurance or, in the

 

 

SB0697- 32 -LRB102 17144 BMS 22576 b

1    case of Medicaid managed care organizations, the
2    Department of Healthcare and Family Services every year on
3    or before July 1 results of interrater reliability reports
4    and a summary of the remediation actions taken for those
5    with pass rates lower than 90%.
6    (r) This Section applies to all health care services and
7benefits for the diagnosis, prevention, and treatment of
8mental, emotional, nervous, or substance use disorders or
9conditions covered by an insurance policy, including
10prescription drugs.
11    (s) This Section applies to an insurer that amends,
12delivers, issues, or renews a group or individual policy of
13accident and health insurance or a qualified health plan
14offered through the health insurance marketplace in this State
15providing coverage for hospital or medical treatment and
16conducts utilization review as defined in this Section,
17including Medicaid managed care organizations, and any entity
18or contracting provider that performs utilization review or
19utilization management functions on an insurer's behalf.
20    (t) If the Director determines that an insurer has
21violated this Section, the Director may, after appropriate
22notice and opportunity for hearing in accordance with Section
231016 of this Code, by order, assess a civil penalty between
24$5,000 and $20,000 for each violation. Moneys collected from
25penalties shall be deposited into the Parity Advancement Fund
26established in subsection (i) of Section 370c.1.

 

 

SB0697- 33 -LRB102 17144 BMS 22576 b

1    (u) An insurer shall not adopt, impose, or enforce terms
2in its policies or provider agreements, in writing or in
3operation, that undermine, alter, or conflict with the
4requirements of this Section.
5    (v) The provisions of this Section are severable. If any
6provision of this Section or its application is held invalid,
7that invalidity shall not affect other provisions or
8applications that can be given effect without the invalid
9provision or application.
10(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
11100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
128-16-19; revised 9-20-19.)
 
13    Section 10. The Health Carrier External Review Act is
14amended by changing Sections 35 and 40 as follows:
 
15    (215 ILCS 180/35)
16    Sec. 35. Standard external review.
17    (a) Within 4 months after the date of receipt of a notice
18of an adverse determination or final adverse determination, a
19covered person or the covered person's authorized
20representative may file a request for an external review with
21the Director. Within one business day after the date of
22receipt of a request for external review, the Director shall
23send a copy of the request to the health carrier.
24    (b) Within 5 business days following the date of receipt

 

 

SB0697- 34 -LRB102 17144 BMS 22576 b

1of the external review request, the health carrier shall
2complete a preliminary review of the request to determine
3whether:
4        (1) the individual is or was a covered person in the
5    health benefit plan at the time the health care service
6    was requested or at the time the health care service was
7    provided;
8        (2) the health care service that is the subject of the
9    adverse determination or the final adverse determination
10    is a covered service under the covered person's health
11    benefit plan, but the health carrier has determined that
12    the health care service is not covered;
13        (3) the covered person has exhausted the health
14    carrier's internal appeal process unless the covered
15    person is not required to exhaust the health carrier's
16    internal appeal process pursuant to this Act;
17        (4) (blank); and
18        (5) the covered person has provided all the
19    information and forms required to process an external
20    review, as specified in this Act.
21    (c) Within one business day after completion of the
22preliminary review, the health carrier shall notify the
23Director and covered person and, if applicable, the covered
24person's authorized representative in writing whether the
25request is complete and eligible for external review. If the
26request:

 

 

SB0697- 35 -LRB102 17144 BMS 22576 b

1        (1) is not complete, the health carrier shall inform
2    the Director and covered person and, if applicable, the
3    covered person's authorized representative in writing and
4    include in the notice what information or materials are
5    required by this Act to make the request complete; or
6        (2) is not eligible for external review, the health
7    carrier shall inform the Director and covered person and,
8    if applicable, the covered person's authorized
9    representative in writing and include in the notice the
10    reasons for its ineligibility.
11    The Department may specify the form for the health
12carrier's notice of initial determination under this
13subsection (c) and any supporting information to be included
14in the notice.
15    The notice of initial determination of ineligibility shall
16include a statement informing the covered person and, if
17applicable, the covered person's authorized representative
18that a health carrier's initial determination that the
19external review request is ineligible for review may be
20appealed to the Director by filing a complaint with the
21Director.
22    Notwithstanding a health carrier's initial determination
23that the request is ineligible for external review, the
24Director may determine that a request is eligible for external
25review and require that it be referred for external review. In
26making such determination, the Director's decision shall be in

 

 

SB0697- 36 -LRB102 17144 BMS 22576 b

1accordance with the terms of the covered person's health
2benefit plan, unless such terms are inconsistent with
3applicable law, and shall be subject to all applicable
4provisions of this Act.
5    (d) Whenever the Director receives notice that a request
6is eligible for external review following the preliminary
7review conducted pursuant to this Section, within one business
8day after the date of receipt of the notice, the Director
9shall:
10        (1) assign an independent review organization from the
11    list of approved independent review organizations compiled
12    and maintained by the Director pursuant to this Act and
13    notify the health carrier of the name of the assigned
14    independent review organization; and
15        (2) notify in writing the covered person and, if
16    applicable, the covered person's authorized representative
17    of the request's eligibility and acceptance for external
18    review and the name of the independent review
19    organization.
20    The Director shall include in the notice provided to the
21covered person and, if applicable, the covered person's
22authorized representative a statement that the covered person
23or the covered person's authorized representative may, within
245 business days following the date of receipt of the notice
25provided pursuant to item (2) of this subsection (d), submit
26in writing to the assigned independent review organization

 

 

SB0697- 37 -LRB102 17144 BMS 22576 b

1additional information that the independent review
2organization shall consider when conducting the external
3review. The independent review organization is not required
4to, but may, accept and consider additional information
5submitted after 5 business days.
6    (e) The assignment by the Director of an approved
7independent review organization to conduct an external review
8in accordance with this Section shall be done on a random basis
9among those independent review organizations approved by the
10Director pursuant to this Act.
11    (f) Within 5 business days after the date of receipt of the
12notice provided pursuant to item (1) of subsection (d) of this
13Section, the health carrier or its designee utilization review
14organization shall provide to the assigned independent review
15organization the documents and any information considered in
16making the adverse determination or final adverse
17determination; in such cases, the following provisions shall
18apply:
19        (1) Except as provided in item (2) of this subsection
20    (f), failure by the health carrier or its utilization
21    review organization to provide the documents and
22    information within the specified time frame shall not
23    delay the conduct of the external review.
24        (2) If the health carrier or its utilization review
25    organization fails to provide the documents and
26    information within the specified time frame, the assigned

 

 

SB0697- 38 -LRB102 17144 BMS 22576 b

1    independent review organization may terminate the external
2    review and make a decision to reverse the adverse
3    determination or final adverse determination.
4        (3) Within one business day after making the decision
5    to terminate the external review and make a decision to
6    reverse the adverse determination or final adverse
7    determination under item (2) of this subsection (f), the
8    independent review organization shall notify the Director,
9    the health carrier, the covered person and, if applicable,
10    the covered person's authorized representative, of its
11    decision to reverse the adverse determination.
12    (g) Upon receipt of the information from the health
13carrier or its utilization review organization, the assigned
14independent review organization shall review all of the
15information and documents and any other information submitted
16in writing to the independent review organization by the
17covered person and the covered person's authorized
18representative.
19    (h) Upon receipt of any information submitted by the
20covered person or the covered person's authorized
21representative, the independent review organization shall
22forward the information to the health carrier within 1
23business day.
24        (1) Upon receipt of the information, if any, the
25    health carrier may reconsider its adverse determination or
26    final adverse determination that is the subject of the

 

 

SB0697- 39 -LRB102 17144 BMS 22576 b

1    external review.
2        (2) Reconsideration by the health carrier of its
3    adverse determination or final adverse determination shall
4    not delay or terminate the external review.
5        (3) The external review may only be terminated if the
6    health carrier decides, upon completion of its
7    reconsideration, to reverse its adverse determination or
8    final adverse determination and provide coverage or
9    payment for the health care service that is the subject of
10    the adverse determination or final adverse determination.
11    In such cases, the following provisions shall apply:
12            (A) Within one business day after making the
13        decision to reverse its adverse determination or final
14        adverse determination, the health carrier shall notify
15        the Director, the covered person and, if applicable,
16        the covered person's authorized representative, and
17        the assigned independent review organization in
18        writing of its decision.
19            (B) Upon notice from the health carrier that the
20        health carrier has made a decision to reverse its
21        adverse determination or final adverse determination,
22        the assigned independent review organization shall
23        terminate the external review.
24    (i) In addition to the documents and information provided
25by the health carrier or its utilization review organization
26and the covered person and the covered person's authorized

 

 

SB0697- 40 -LRB102 17144 BMS 22576 b

1representative, if any, the independent review organization,
2to the extent the information or documents are available and
3the independent review organization considers them
4appropriate, shall consider the following in reaching a
5decision:
6        (1) the covered person's pertinent medical records;
7        (2) the covered person's health care provider's
8    recommendation;
9        (3) consulting reports from appropriate health care
10    providers and other documents submitted by the health
11    carrier or its designee utilization review organization,
12    the covered person, the covered person's authorized
13    representative, or the covered person's treating provider;
14        (4) the terms of coverage under the covered person's
15    health benefit plan with the health carrier to ensure that
16    the independent review organization's decision is not
17    contrary to the terms of coverage under the covered
18    person's health benefit plan with the health carrier,
19    unless the terms are inconsistent with applicable law;
20        (5) the most appropriate practice guidelines, which
21    shall include applicable evidence-based standards and may
22    include any other practice guidelines developed by the
23    federal government, national or professional medical
24    societies, boards, and associations;
25        (6) any applicable clinical review criteria developed
26    and used by the health carrier or its designee utilization

 

 

SB0697- 41 -LRB102 17144 BMS 22576 b

1    review organization;
2        (7) the opinion of the independent review
3    organization's clinical reviewer or reviewers after
4    considering items (1) through (6) of this subsection (i)
5    to the extent the information or documents are available
6    and the clinical reviewer or reviewers considers the
7    information or documents appropriate;
8        (8) (blank); and
9        (9) in the case of medically necessary determinations
10    for substance use disorders, the patient placement
11    criteria established by the American Society of Addiction
12    Medicine.
13    (i-5) For an adverse determination or final adverse
14determination involving mental, emotional, nervous, or
15substance use disorders or conditions, the independent review
16organization shall:
17        (1) consider the documents and information as set
18    forth in subsection (i), except that all practice
19    guidelines and clinical review criteria must be consistent
20    with the requirements set forth in Section 370c of the
21    Illinois Insurance Code; and
22        (2) make its decision, pursuant to subsection (j),
23    whether to uphold or reverse the adverse determination or
24    final adverse determination based on whether the service
25    constitutes medically necessary treatment of a mental,
26    emotional, nervous, or substance use disorders or

 

 

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1    condition as defined in Section 370c of the Illinois
2    Insurance Code.
3    (j) Within 5 days after the date of receipt of all
4necessary information, but in no event more than 45 days after
5the date of receipt of the request for an external review, the
6assigned independent review organization shall provide written
7notice of its decision to uphold or reverse the adverse
8determination or the final adverse determination to the
9Director, the health carrier, the covered person, and, if
10applicable, the covered person's authorized representative. In
11reaching a decision, the assigned independent review
12organization is not bound by any claim determinations reached
13prior to the submission of information to the independent
14review organization. In such cases, the following provisions
15shall apply:
16        (1) The independent review organization shall include
17    in the notice:
18            (A) a general description of the reason for the
19        request for external review;
20            (B) the date the independent review organization
21        received the assignment from the Director to conduct
22        the external review;
23            (C) the time period during which the external
24        review was conducted;
25            (D) references to the evidence or documentation,
26        including the evidence-based standards, considered in

 

 

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1        reaching its decision;
2            (E) the date of its decision;
3            (F) the principal reason or reasons for its
4        decision, including what applicable, if any,
5        evidence-based standards that were a basis for its
6        decision; and
7            (G) the rationale for its decision.
8        (2) (Blank).
9        (3) (Blank).
10        (4) Upon receipt of a notice of a decision reversing
11    the adverse determination or final adverse determination,
12    the health carrier immediately shall approve the coverage
13    that was the subject of the adverse determination or final
14    adverse determination.
15(Source: P.A. 99-480, eff. 9-9-15.)
 
16    (215 ILCS 180/40)
17    Sec. 40. Expedited external review.
18    (a) A covered person or a covered person's authorized
19representative may file a request for an expedited external
20review with the Director either orally or in writing:
21        (1) immediately after the date of receipt of a notice
22    prior to a final adverse determination as provided by
23    subsection (b) of Section 20 of this Act;
24        (2) immediately after the date of receipt of a notice
25    upon final adverse determination as provided by subsection

 

 

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1    (c) of Section 20 of this Act; or
2        (3) if a health carrier fails to provide a decision on
3    request for an expedited internal appeal within 48 hours
4    as provided by item (2) of Section 30 of this Act.
5    (b) Upon receipt of a request for an expedited external
6review, the Director shall immediately send a copy of the
7request to the health carrier. Immediately upon receipt of the
8request for an expedited external review, the health carrier
9shall determine whether the request meets the reviewability
10requirements set forth in subsection (b) of Section 35. In
11such cases, the following provisions shall apply:
12        (1) The health carrier shall immediately notify the
13    Director, the covered person, and, if applicable, the
14    covered person's authorized representative of its
15    eligibility determination.
16        (2) The notice of initial determination shall include
17    a statement informing the covered person and, if
18    applicable, the covered person's authorized representative
19    that a health carrier's initial determination that an
20    external review request is ineligible for review may be
21    appealed to the Director.
22        (3) The Director may determine that a request is
23    eligible for expedited external review notwithstanding a
24    health carrier's initial determination that the request is
25    ineligible and require that it be referred for external
26    review.

 

 

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1        (4) In making a determination under item (3) of this
2    subsection (b), the Director's decision shall be made in
3    accordance with the terms of the covered person's health
4    benefit plan, unless such terms are inconsistent with
5    applicable law, and shall be subject to all applicable
6    provisions of this Act.
7        (5) The Director may specify the form for the health
8    carrier's notice of initial determination under this
9    subsection (b) and any supporting information to be
10    included in the notice.
11    (c) Upon receipt of the notice that the request meets the
12reviewability requirements, the Director shall immediately
13assign an independent review organization from the list of
14approved independent review organizations compiled and
15maintained by the Director to conduct the expedited review. In
16such cases, the following provisions shall apply:
17        (1) The assignment of an approved independent review
18    organization to conduct an external review in accordance
19    with this Section shall be made from those approved
20    independent review organizations qualified to conduct
21    external review as required by Sections 50 and 55 of this
22    Act.
23        (2) The Director shall immediately notify the health
24    carrier of the name of the assigned independent review
25    organization. Immediately upon receipt from the Director
26    of the name of the independent review organization

 

 

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1    assigned to conduct the external review, but in no case
2    more than 24 hours after receiving such notice, the health
3    carrier or its designee utilization review organization
4    shall provide or transmit all necessary documents and
5    information considered in making the adverse determination
6    or final adverse determination to the assigned independent
7    review organization electronically or by telephone or
8    facsimile or any other available expeditious method.
9        (3) If the health carrier or its utilization review
10    organization fails to provide the documents and
11    information within the specified timeframe, the assigned
12    independent review organization may terminate the external
13    review and make a decision to reverse the adverse
14    determination or final adverse determination.
15        (4) Within one business day after making the decision
16    to terminate the external review and make a decision to
17    reverse the adverse determination or final adverse
18    determination under item (3) of this subsection (c), the
19    independent review organization shall notify the Director,
20    the health carrier, the covered person, and, if
21    applicable, the covered person's authorized representative
22    of its decision to reverse the adverse determination or
23    final adverse determination.
24    (d) In addition to the documents and information provided
25by the health carrier or its utilization review organization
26and any documents and information provided by the covered

 

 

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1person and the covered person's authorized representative, the
2independent review organization, to the extent the information
3or documents are available and the independent review
4organization considers them appropriate, shall consider
5information as required by subsection (i) of Section 35 of
6this Act in reaching a decision.
7    (d-5) For expedited external reviews involving mental,
8emotional, nervous, or substance use disorders or conditions,
9the independent review organization shall consider documents
10and information and shall make a decision to uphold or reverse
11the adverse determination or final adverse determination
12pursuant to subsection (i-5) of Section 35.
13    (e) As expeditiously as the covered person's medical
14condition or circumstances requires, but in no event more than
1572 hours after the date of receipt of the request for an
16expedited external review, the assigned independent review
17organization shall:
18        (1) make a decision to uphold or reverse the final
19    adverse determination; and
20        (2) notify the Director, the health carrier, the
21    covered person, the covered person's health care provider,
22    and, if applicable, the covered person's authorized
23    representative, of the decision.
24    (f) In reaching a decision, the assigned independent
25review organization is not bound by any decisions or
26conclusions reached during the health carrier's utilization

 

 

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1review process or the health carrier's internal appeal
2process.
3    (g) Upon receipt of notice of a decision reversing the
4adverse determination or final adverse determination, the
5health carrier shall immediately approve the coverage that was
6the subject of the adverse determination or final adverse
7determination.
8    (h) If the notice provided pursuant to subsection (e) of
9this Section was not in writing, then within 48 hours after the
10date of providing that notice, the assigned independent review
11organization shall provide written confirmation of the
12decision to the Director, the health carrier, the covered
13person, and, if applicable, the covered person's authorized
14representative including the information set forth in
15subsection (j) of Section 35 of this Act as applicable.
16    (i) An expedited external review may not be provided for
17retrospective adverse or final adverse determinations.
18    (j) The assignment by the Director of an approved
19independent review organization to conduct an external review
20in accordance with this Section shall be done on a random basis
21among those independent review organizations approved by the
22Director pursuant to this Act.
23(Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11;
2497-574, eff. 8-26-11.)
 
25    Section 99. Effective date. This Act takes effect upon
26becoming law.