Full Text of HB3259 102nd General Assembly
HB3259 102ND GENERAL ASSEMBLY |
| | 102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022 HB3259 Introduced 2/19/2021, by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/370c | from Ch. 73, par. 982c |
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Amends the Illinois Insurance Code. In provisions concerning mental and emotional disorders, provides that every insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis shall provide coverage for the diagnosis and medically necessary treatment (rather than reasonable and necessary treatment and services for) of mental, emotional, nervous, or substance use disorders or conditions. Provides that every insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance providing coverage for hospital or medical treatment on or after January 1, 2022 shall provide coverage for medically necessary treatment of mental health and substance use disorders. Provides that an insurer that authorizes a specific type of treatment by a provider shall not rescind or modify the authorization after that provider renders the health care service. Provides that if services for the medically necessary treatment of a mental health or substance use disorder are not available in-network within the geographic and timely access standards set by law or regulation, the insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary follow-up services, and the insured shall pay no more in total for benefits rendered than the cost sharing that the insured would pay for the same covered services received from an in-network provider. 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 entitlement program. Provides that every insurer shall sponsor an education program, make the program available to other stakeholders, provide clinical review criteria at no cost to providers and insured patients, conduct interrater reliability testing, and achieve interrate pass rates of at least 90% or comply with specified requirements if the 90% threshold is not met. Defines terms.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 370c as follows:
| 6 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 7 | | Sec. 370c. Mental and emotional disorders.
| 8 | | (a)(1) On and after August 16, 2019 January 1, 2019 (the | 9 | | effective date of Public Act 101-386 this amendatory Act of | 10 | | the 101st General Assembly Public Act 100-1024 ),
every insurer | 11 | | that amends, delivers, issues, or renews
group accident and | 12 | | health policies providing coverage for hospital or medical | 13 | | treatment or
services for illness on an expense-incurred basis | 14 | | shall provide coverage for the diagnosis and medically | 15 | | necessary treatment of reasonable and necessary treatment and | 16 | | services
for mental, emotional, nervous, or substance use | 17 | | disorders or conditions consistent with the parity | 18 | | requirements of Section 370c.1 of this Code.
| 19 | | (2) Each insured that is covered for mental, emotional, | 20 | | nervous, or substance use
disorders or conditions shall be | 21 | | free to select the physician licensed to
practice medicine in | 22 | | all its branches, licensed clinical psychologist,
licensed | 23 | | clinical social worker, licensed clinical professional |
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| 1 | | counselor, licensed marriage and family therapist, licensed | 2 | | speech-language pathologist, or other licensed or certified | 3 | | professional at a program licensed pursuant to the Substance | 4 | | Use Disorder Act of
his choice to treat such disorders, and
the | 5 | | insurer shall pay the covered charges of such physician | 6 | | licensed to
practice medicine in all its branches, licensed | 7 | | clinical psychologist,
licensed clinical social worker, | 8 | | licensed clinical professional counselor, licensed marriage | 9 | | and family therapist, licensed speech-language pathologist, or | 10 | | other licensed or certified professional at a program licensed | 11 | | pursuant to the Substance Use Disorder Act up
to the limits of | 12 | | coverage, provided (i)
the disorder or condition treated is | 13 | | covered by the policy, and (ii) the
physician, licensed | 14 | | psychologist, licensed clinical social worker, licensed
| 15 | | clinical professional counselor, licensed marriage and family | 16 | | therapist, licensed speech-language pathologist, or other | 17 | | licensed or certified professional at a program licensed | 18 | | pursuant to the Substance Use Disorder Act is
authorized to | 19 | | provide said services under the statutes of this State and in
| 20 | | accordance with accepted principles of his profession.
| 21 | | (3) Insofar as this Section applies solely to licensed | 22 | | clinical social
workers, licensed clinical professional | 23 | | counselors, licensed marriage and family therapists, licensed | 24 | | speech-language pathologists, and other licensed or certified | 25 | | professionals at programs licensed pursuant to the Substance | 26 | | Use Disorder Act, those persons who may
provide services to |
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| 1 | | individuals shall do so
after the licensed clinical social | 2 | | worker, licensed clinical professional
counselor, licensed | 3 | | marriage and family therapist, licensed speech-language | 4 | | pathologist, or other licensed or certified professional at a | 5 | | program licensed pursuant to the Substance Use Disorder Act | 6 | | has informed the patient of the
desirability of the patient | 7 | | conferring with the patient's primary care
physician.
| 8 | | (4) "Mental, emotional, nervous, or substance use disorder | 9 | | or condition" means a condition or disorder that involves a | 10 | | mental health condition or substance use disorder that falls | 11 | | under any of the diagnostic categories listed in the mental | 12 | | and behavioral disorders chapter of the current edition of the | 13 | | International Classification of Disease or that is listed in | 14 | | the most recent version of the Diagnostic and Statistical | 15 | | Manual of Mental Disorders. "Mental, emotional, nervous, or | 16 | | substance use disorder or condition" includes any mental | 17 | | health condition that occurs during pregnancy or during the | 18 | | postpartum period and includes, but is not limited to, | 19 | | postpartum depression. | 20 | | (b)(1) (Blank).
| 21 | | (2) (Blank).
| 22 | | (2.5) (Blank). | 23 | | (3) Unless otherwise prohibited by federal law and | 24 | | consistent with the parity requirements of Section 370c.1 of | 25 | | this Code, the reimbursing insurer that amends, delivers, | 26 | | issues, or renews a group or individual policy of accident and |
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| 1 | | health insurance, a qualified health plan offered through the | 2 | | health insurance marketplace, or a provider of treatment of | 3 | | mental, emotional, nervous,
or substance use disorders or | 4 | | conditions shall furnish medical records or other necessary | 5 | | data
that substantiate that initial or continued treatment is | 6 | | at all times medically
necessary. An insurer shall provide a | 7 | | mechanism for the timely review by a
provider holding the same | 8 | | license and practicing in the same specialty as the
patient's | 9 | | provider, who is unaffiliated with the insurer, jointly | 10 | | selected by
the patient (or the patient's next of kin or legal | 11 | | representative if the
patient is unable to act for himself or | 12 | | herself), the patient's provider, and
the insurer in the event | 13 | | of a dispute between the insurer and patient's
provider | 14 | | regarding the medical necessity of a treatment proposed by a | 15 | | patient's
provider. If the reviewing provider determines the | 16 | | treatment to be medically
necessary, the insurer shall provide | 17 | | reimbursement for the treatment. Future
contractual or | 18 | | employment actions by the insurer regarding the patient's
| 19 | | provider may not be based on the provider's participation in | 20 | | this procedure.
Nothing prevents
the insured from agreeing in | 21 | | writing to continue treatment at his or her
expense. When | 22 | | making a determination of the medical necessity for a | 23 | | treatment
modality for mental, emotional, nervous, or | 24 | | substance use disorders or conditions, an insurer must make | 25 | | the determination in a
manner that is consistent with the | 26 | | manner used to make that determination with
respect to other |
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| 1 | | diseases or illnesses covered under the policy, including an
| 2 | | appeals process. Medical necessity determinations for | 3 | | substance use disorders shall be made in accordance with | 4 | | appropriate patient placement criteria established by the | 5 | | American Society of Addiction Medicine. No additional criteria | 6 | | may be used to make medical necessity determinations for | 7 | | substance use disorders.
| 8 | | (4) A group health benefit plan amended, delivered, | 9 | | issued, or renewed on or after January 1, 2019 (the effective | 10 | | date of Public Act 100-1024) or an individual policy of | 11 | | accident and health insurance or a qualified health plan | 12 | | offered through the health insurance marketplace amended, | 13 | | delivered, issued, or renewed on or after January 1, 2019 (the | 14 | | effective date of Public Act 100-1024):
| 15 | | (A) shall provide coverage based upon medical | 16 | | necessity for the
treatment of a mental, emotional, | 17 | | nervous, or substance use disorder or condition consistent | 18 | | with the parity requirements of Section 370c.1 of this | 19 | | Code; provided, however, that in each calendar year | 20 | | coverage shall not be less than the following:
| 21 | | (i) 45 days of inpatient treatment; and
| 22 | | (ii) beginning on June 26, 2006 (the effective | 23 | | date of Public Act 94-921), 60 visits for outpatient | 24 | | treatment including group and individual
outpatient | 25 | | treatment; and | 26 | | (iii) for plans or policies delivered, issued for |
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| 1 | | delivery, renewed, or modified after January 1, 2007 | 2 | | (the effective date of Public Act 94-906),
20 | 3 | | additional outpatient visits for speech therapy for | 4 | | treatment of pervasive developmental disorders that | 5 | | will be in addition to speech therapy provided | 6 | | pursuant to item (ii) of this subparagraph (A); and
| 7 | | (B) may not include a lifetime limit on the number of | 8 | | days of inpatient
treatment or the number of outpatient | 9 | | visits covered under the plan.
| 10 | | (C) (Blank).
| 11 | | (5) An issuer of a group health benefit plan or an | 12 | | individual policy of accident and health insurance or a | 13 | | qualified health plan offered through the health insurance | 14 | | marketplace may not count toward the number
of outpatient | 15 | | visits required to be covered under this Section an outpatient
| 16 | | visit for the purpose of medication management and shall cover | 17 | | the outpatient
visits under the same terms and conditions as | 18 | | it covers outpatient visits for
the treatment of physical | 19 | | illness.
| 20 | | (5.5) An individual or group health benefit plan amended, | 21 | | delivered, issued, or renewed on or after September 9, 2015 | 22 | | (the effective date of Public Act 99-480) shall offer coverage | 23 | | for medically necessary acute treatment services and medically | 24 | | necessary clinical stabilization services. The treating | 25 | | provider shall base all treatment recommendations and the | 26 | | health benefit plan shall base all medical necessity |
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| 1 | | determinations for substance use disorders in accordance with | 2 | | the most current edition of the Treatment Criteria for | 3 | | Addictive, Substance-Related, and Co-Occurring Conditions | 4 | | established by the American Society of Addiction Medicine. The | 5 | | treating provider shall base all treatment recommendations and | 6 | | the health benefit plan shall base all medical necessity | 7 | | determinations for medication-assisted treatment in accordance | 8 | | with the most current Treatment Criteria for Addictive, | 9 | | Substance-Related, and Co-Occurring Conditions established by | 10 | | the American Society of Addiction Medicine. | 11 | | As used in this subsection: | 12 | | "Acute treatment services" means 24-hour medically | 13 | | supervised addiction treatment that provides evaluation and | 14 | | withdrawal management and may include biopsychosocial | 15 | | assessment, individual and group counseling, psychoeducational | 16 | | groups, and discharge planning. | 17 | | "Clinical stabilization services" means 24-hour treatment, | 18 | | usually following acute treatment services for substance | 19 | | abuse, which may include intensive education and counseling | 20 | | regarding the nature of addiction and its consequences, | 21 | | relapse prevention, outreach to families and significant | 22 | | others, and aftercare planning for individuals beginning to | 23 | | engage in recovery from addiction. | 24 | | (6) An issuer of a group health benefit
plan may provide or | 25 | | offer coverage required under this Section through a
managed | 26 | | care plan.
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| 1 | | (6.5) An individual or group health benefit plan amended, | 2 | | delivered, issued, or renewed on or after January 1, 2019 (the | 3 | | effective date of Public Act 100-1024): | 4 | | (A) shall not impose prior authorization requirements, | 5 | | other than those established under the Treatment Criteria | 6 | | for Addictive, Substance-Related, and Co-Occurring | 7 | | Conditions established by the American Society of | 8 | | Addiction Medicine, on a prescription medication approved | 9 | | by the United States Food and Drug Administration that is | 10 | | prescribed or administered for the treatment of substance | 11 | | use disorders; | 12 | | (B) shall not impose any step therapy requirements, | 13 | | other than those established under the Treatment Criteria | 14 | | for Addictive, Substance-Related, and Co-Occurring | 15 | | Conditions established by the American Society of | 16 | | Addiction Medicine, before authorizing coverage for a | 17 | | prescription medication approved by the United States Food | 18 | | and Drug Administration that is prescribed or administered | 19 | | for the treatment of substance use disorders; | 20 | | (C) shall place all prescription medications approved | 21 | | by the United States Food and Drug Administration | 22 | | prescribed or administered for the treatment of substance | 23 | | use disorders on, for brand medications, the lowest tier | 24 | | of the drug formulary developed and maintained by the | 25 | | individual or group health benefit plan that covers brand | 26 | | medications and, for generic medications, the lowest tier |
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| 1 | | of the drug formulary developed and maintained by the | 2 | | individual or group health benefit plan that covers | 3 | | generic medications; and | 4 | | (D) shall not exclude coverage for a prescription | 5 | | medication approved by the United States Food and Drug | 6 | | Administration for the treatment of substance use | 7 | | disorders and any associated counseling or wraparound | 8 | | services on the grounds that such medications and services | 9 | | were court ordered. | 10 | | (7) (Blank).
| 11 | | (8)
(Blank).
| 12 | | (9) With respect to all mental, emotional, nervous, or | 13 | | substance use disorders or conditions, coverage for inpatient | 14 | | treatment shall include coverage for treatment in a | 15 | | residential treatment center certified or licensed by the | 16 | | Department of Public Health or the Department of Human | 17 | | Services. | 18 | | (c) This Section shall not be interpreted to require | 19 | | coverage for speech therapy or other habilitative services for | 20 | | those individuals covered under Section 356z.15
of this Code. | 21 | | (d) With respect to a group or individual policy of | 22 | | accident and health insurance or a qualified health plan | 23 | | offered through the health insurance marketplace, the | 24 | | Department and, with respect to medical assistance, the | 25 | | Department of Healthcare and Family Services shall each | 26 | | enforce the requirements of this Section and Sections 356z.23 |
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| 1 | | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 2 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 3 | | U.S.C. 18031(j), and any amendments to, and federal guidance | 4 | | or regulations issued under, those Acts, including, but not | 5 | | limited to, final regulations issued under the Paul Wellstone | 6 | | and Pete Domenici Mental Health Parity and Addiction Equity | 7 | | Act of 2008 and final regulations applying the Paul Wellstone | 8 | | and Pete Domenici Mental Health Parity and Addiction Equity | 9 | | Act of 2008 to Medicaid managed care organizations, the | 10 | | Children's Health Insurance Program, and alternative benefit | 11 | | plans. Specifically, the Department and the Department of | 12 | | Healthcare and Family Services shall take action: | 13 | | (1) proactively ensuring compliance by individual and | 14 | | group policies, including by requiring that insurers | 15 | | submit comparative analyses, as set forth in paragraph (6) | 16 | | of subsection (k) of Section 370c.1, demonstrating how | 17 | | they design and apply nonquantitative treatment | 18 | | limitations, both as written and in operation, for mental, | 19 | | emotional, nervous, or substance use disorder or condition | 20 | | benefits as compared to how they design and apply | 21 | | nonquantitative treatment limitations, as written and in | 22 | | operation, for medical and surgical benefits; | 23 | | (2) evaluating all consumer or provider complaints | 24 | | regarding mental, emotional, nervous, or substance use | 25 | | disorder or condition coverage for possible parity | 26 | | violations; |
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| 1 | | (3) performing parity compliance market conduct | 2 | | examinations or, in the case of the Department of | 3 | | Healthcare and Family Services, parity compliance audits | 4 | | of individual and group plans and policies, including, but | 5 | | not limited to, reviews of: | 6 | | (A) nonquantitative treatment limitations, | 7 | | including, but not limited to, prior authorization | 8 | | requirements, concurrent review, retrospective review, | 9 | | step therapy, network admission standards, | 10 | | reimbursement rates, and geographic restrictions; | 11 | | (B) denials of authorization, payment, and | 12 | | coverage; and | 13 | | (C) other specific criteria as may be determined | 14 | | by the Department. | 15 | | The findings and the conclusions of the parity compliance | 16 | | market conduct examinations and audits shall be made public. | 17 | | The Director may adopt rules to effectuate any provisions | 18 | | of the Paul Wellstone and Pete Domenici Mental Health Parity | 19 | | and Addiction Equity Act of 2008 that relate to the business of | 20 | | insurance. | 21 | | (e) Availability of plan information. | 22 | | (1) The criteria for medical necessity determinations | 23 | | made under a group health plan, an individual policy of | 24 | | accident and health insurance, or a qualified health plan | 25 | | offered through the health insurance marketplace with | 26 | | respect to mental health or substance use disorder |
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| 1 | | benefits (or health insurance coverage offered in | 2 | | connection with the plan with respect to such benefits) | 3 | | must be made available by the plan administrator (or the | 4 | | health insurance issuer offering such coverage) to any | 5 | | current or potential participant, beneficiary, or | 6 | | contracting provider upon request. | 7 | | (2) The reason for any denial under a group health | 8 | | benefit plan, an individual policy of accident and health | 9 | | insurance, or a qualified health plan offered through the | 10 | | health insurance marketplace (or health insurance coverage | 11 | | offered in connection with such plan or policy) of | 12 | | reimbursement or payment for services with respect to | 13 | | mental, emotional, nervous, or substance use disorders or | 14 | | conditions benefits in the case of any participant or | 15 | | beneficiary must be made available within a reasonable | 16 | | time and in a reasonable manner and in readily | 17 | | understandable language by the plan administrator (or the | 18 | | health insurance issuer offering such coverage) to the | 19 | | participant or beneficiary upon request. | 20 | | (f) As used in this Section, "group policy of accident and | 21 | | health insurance" and "group health benefit plan" includes (1) | 22 | | State-regulated employer-sponsored group health insurance | 23 | | plans written in Illinois or which purport to provide coverage | 24 | | for a resident of this State; and (2) State employee health | 25 | | plans. | 26 | | (g) (1) As used in this subsection: |
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| 1 | | "Benefits", with respect to insurers, means
the benefits | 2 | | provided for treatment services for inpatient and outpatient | 3 | | treatment of substance use disorders or conditions at American | 4 | | Society of Addiction Medicine levels of treatment 2.1 | 5 | | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | 6 | | (Clinically Managed Low-Intensity Residential), 3.3 | 7 | | (Clinically Managed Population-Specific High-Intensity | 8 | | Residential), 3.5 (Clinically Managed High-Intensity | 9 | | Residential), and 3.7 (Medically Monitored Intensive | 10 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 11 | | "Benefits", with respect to managed care organizations, | 12 | | means the benefits provided for treatment services for | 13 | | inpatient and outpatient treatment of substance use disorders | 14 | | or conditions at American Society of Addiction Medicine levels | 15 | | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | 16 | | Hospitalization), 3.5 (Clinically Managed High-Intensity | 17 | | Residential), and 3.7 (Medically Monitored Intensive | 18 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 19 | | "Substance use disorder treatment provider or facility" | 20 | | means a licensed physician, licensed psychologist, licensed | 21 | | psychiatrist, licensed advanced practice registered nurse, or | 22 | | licensed, certified, or otherwise State-approved facility or | 23 | | provider of substance use disorder treatment. | 24 | | (2) A group health insurance policy, an individual health | 25 | | benefit plan, or qualified health plan that is offered through | 26 | | the health insurance marketplace, small employer group health |
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| 1 | | plan, and large employer group health plan that is amended, | 2 | | delivered, issued, executed, or renewed in this State, or | 3 | | approved for issuance or renewal in this State, on or after | 4 | | January 1, 2019 (the effective date of Public Act 100-1023) | 5 | | shall comply with the requirements of this Section and Section | 6 | | 370c.1. The services for the treatment and the ongoing | 7 | | assessment of the patient's progress in treatment shall follow | 8 | | the requirements of 77 Ill. Adm. Code 2060. | 9 | | (3) Prior authorization shall not be utilized for the | 10 | | benefits under this subsection. The substance use disorder | 11 | | treatment provider or facility shall notify the insurer of the | 12 | | initiation of treatment. For an insurer that is not a managed | 13 | | care organization, the substance use disorder treatment | 14 | | provider or facility notification shall occur for the | 15 | | initiation of treatment of the covered person within 2 | 16 | | business days. For managed care organizations, the substance | 17 | | use disorder treatment provider or facility notification shall | 18 | | occur in accordance with the protocol set forth in the | 19 | | provider agreement for initiation of treatment within 24 | 20 | | hours. If the managed care organization is not capable of | 21 | | accepting the notification in accordance with the contractual | 22 | | protocol during the 24-hour period following admission, the | 23 | | substance use disorder treatment provider or facility shall | 24 | | have one additional business day to provide the notification | 25 | | to the appropriate managed care organization. Treatment plans | 26 | | shall be developed in accordance with the requirements and |
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| 1 | | timeframes established in 77 Ill. Adm. Code 2060. If the | 2 | | substance use disorder treatment provider or facility fails to | 3 | | notify the insurer of the initiation of treatment in | 4 | | accordance with these provisions, the insurer may follow its | 5 | | normal prior authorization processes. | 6 | | (4) For an insurer that is not a managed care | 7 | | organization, if an insurer determines that benefits are no | 8 | | longer medically necessary, the insurer shall notify the | 9 | | covered person, the covered person's authorized | 10 | | representative, if any, and the covered person's health care | 11 | | provider in writing of the covered person's right to request | 12 | | an external review pursuant to the Health Carrier External | 13 | | Review Act. The notification shall occur within 24 hours | 14 | | following the adverse determination. | 15 | | Pursuant to the requirements of the Health Carrier | 16 | | External Review Act, the covered person or the covered | 17 | | person's authorized representative may request an expedited | 18 | | external review.
An expedited external review may not occur if | 19 | | the substance use disorder treatment provider or facility | 20 | | determines that continued treatment is no longer medically | 21 | | necessary. Under this subsection, a request for expedited | 22 | | external review must be initiated within 24 hours following | 23 | | the adverse determination notification by the insurer. Failure | 24 | | to request an expedited external review within 24 hours shall | 25 | | preclude a covered person or a covered person's authorized | 26 | | representative from requesting an expedited external review. |
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| 1 | | If an expedited external review request meets the criteria | 2 | | of the Health Carrier External Review Act, an independent | 3 | | review organization shall make a final determination of | 4 | | medical necessity within 72 hours. If an independent review | 5 | | organization upholds an adverse determination, an insurer | 6 | | shall remain responsible to provide coverage of benefits | 7 | | through the day following the determination of the independent | 8 | | review organization. A decision to reverse an adverse | 9 | | determination shall comply with the Health Carrier External | 10 | | Review Act. | 11 | | (5) The substance use disorder treatment provider or | 12 | | facility shall provide the insurer with 7 business days' | 13 | | advance notice of the planned discharge of the patient from | 14 | | the substance use disorder treatment provider or facility and | 15 | | notice on the day that the patient is discharged from the | 16 | | substance use disorder treatment provider or facility. | 17 | | (6) The benefits required by this subsection shall be | 18 | | provided to all covered persons with a diagnosis of substance | 19 | | use disorder or conditions. The presence of additional related | 20 | | or unrelated diagnoses shall not be a basis to reduce or deny | 21 | | the benefits required by this subsection. | 22 | | (7) Nothing in this subsection shall be construed to | 23 | | require an insurer to provide coverage for any of the benefits | 24 | | in this subsection. | 25 | | (h) As used in this Section: | 26 | | (1) "Generally accepted standards of mental health and |
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| 1 | | substance use disorder care" means standards of care and | 2 | | clinical practice that are generally recognized by health | 3 | | care providers practicing in relevant clinical specialties | 4 | | such as psychiatry, psychology, clinical sociology, | 5 | | addiction medicine and counseling, and behavioral health | 6 | | treatment. "Generally accepted standards of mental health | 7 | | and substance use disorder care" include peer-reviewed | 8 | | scientific studies and medical literature, recommendations | 9 | | of nonprofit health care provider professional | 10 | | associations and specialty societies, including, but not | 11 | | limited to, patient placement criteria and clinical | 12 | | practice guidelines, recommendations of federal government | 13 | | agencies, and drug labeling approved by the United States | 14 | | Food and Drug Administration. | 15 | | (2) "Medically necessary treatment of a mental health | 16 | | or substance use disorder" means a service or product | 17 | | addressing the specific needs of that patient, for the | 18 | | purpose of screening, preventing, diagnosing, managing or | 19 | | treating an illness, injury, condition, or its symptoms, | 20 | | including minimizing the progression of an illness, | 21 | | injury, condition, or its symptoms in a manner that is all | 22 | | of the following: | 23 | | (A) in accordance with the generally accepted | 24 | | standards of mental health and substance use disorder | 25 | | care; | 26 | | (B) clinically appropriate in terms of type, |
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| 1 | | frequency, extent, site, and duration; and | 2 | | (C) not primarily for the economic benefit of the | 3 | | insurer, purchaser, or for the convenience of the | 4 | | patient, treating physician, or other health care | 5 | | provider. | 6 | | (3) "Mental health and substance use disorders" means | 7 | | a mental health condition or substance use disorder that | 8 | | falls under any of the diagnostic categories listed in the | 9 | | mental and behavioral disorders chapter of the most recent | 10 | | edition of the World Health Organization's International | 11 | | Statistical Classification of Diseases and Related Health | 12 | | Problems or that is listed in the most recent version of | 13 | | the American Psychiatric Association's Diagnostic and | 14 | | Statistical Manual of Mental Disorders. Changes in | 15 | | terminology, organization, or classification of mental | 16 | | health and substance use disorders in future versions of | 17 | | the American Psychiatric Association's Diagnostic and | 18 | | Statistical Manual of Mental Disorders or the World Health | 19 | | Organization's International Statistical Classification | 20 | | of Diseases and Related Health Problems shall not affect | 21 | | the conditions covered by this Section as long as a | 22 | | condition is commonly understood to be a mental health or | 23 | | substance use disorder by health care providers practicing | 24 | | in relevant clinical specialties. | 25 | | (4) "Utilization review" means either of the | 26 | | following: |
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| 1 | | (A) prospectively, retrospectively, or | 2 | | concurrently reviewing and approving, modifying, | 3 | | delaying, or denying, based in whole or in part on | 4 | | medical necessity, requests by health care providers, | 5 | | insureds, or their authorized representatives for | 6 | | coverage of health care services before, | 7 | | retrospectively, or concurrent with the provision of | 8 | | health care services to insureds; or | 9 | | (B) evaluating the medical necessity, | 10 | | appropriateness, level of care, service intensity, | 11 | | efficacy, or efficiency of health care services, | 12 | | benefits, procedures, or settings, under any | 13 | | circumstances, to determine whether a health care | 14 | | service or benefit subject to a medical necessity | 15 | | coverage requirement in an insurance policy is covered | 16 | | as medically necessary for an insured. | 17 | | (5) "Utilization review criteria" means any criteria, | 18 | | standards, protocols, or guidelines used by an insurer to | 19 | | conduct utilization review. | 20 | | (i) Every insurer that amends, delivers, issues, or renews | 21 | | a group or individual policy of accident and health insurance | 22 | | providing coverage for hospital or medical treatment on or | 23 | | after January 1, 2022 shall, pursuant to subsections (h) | 24 | | through (n), provide coverage for medically necessary | 25 | | treatment of mental health and substance use disorders. | 26 | | (j) An insurer that authorizes a specific type of |
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| 1 | | treatment by a provider pursuant to this Section shall not | 2 | | rescind or modify the authorization after that provider | 3 | | renders the health care service in good faith and pursuant to | 4 | | this authorization for any reason, including, but not limited | 5 | | to, the insurer's subsequent rescission, cancellation, or | 6 | | modification of the insured's or policyholder's contract, or | 7 | | the insured's subsequent determination that it did not make an | 8 | | accurate determination of the insured's or policyholder's | 9 | | eligibility. | 10 | | (k) If services for the medically necessary treatment of a | 11 | | mental health or substance use disorder are not available | 12 | | in-network within the geographic and timely access standards | 13 | | set by law or regulation, the insurer shall arrange coverage | 14 | | to ensure the delivery of medically necessary out-of-network | 15 | | services and any medically necessary follow-up services that, | 16 | | to the maximum extent possible, meet those geographic and | 17 | | timely access standards. The insured shall pay no more in | 18 | | total for benefits rendered than the cost sharing that the | 19 | | insured would pay for the same covered services received from | 20 | | an in-network provider. | 21 | | (l) An insurer shall not limit benefits or coverage for | 22 | | medically necessary services on the basis that those services | 23 | | should be or could be covered by a public entitlement program, | 24 | | including, but not limited to, special education or an | 25 | | individualized education program, Medicaid, Medicare, | 26 | | Supplemental Security Income, or Social Security Disability |
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| 1 | | Insurance, and shall not include or enforce a contract term | 2 | | that excludes otherwise covered benefits on the basis that | 3 | | those services should be or could be covered by a public | 4 | | entitlement program. | 5 | | (m) In conducting utilization review involving level of | 6 | | care placement decisions or any other patient care decisions | 7 | | concerning services and benefits for the diagnosis, | 8 | | prevention, and treatment of mental health and substance use | 9 | | disorders, an insurer shall apply the level of care placement | 10 | | criteria and practice guidelines set forth in the most recent | 11 | | versions of the criteria and practice guidelines developed by | 12 | | the nonprofit professional association for the relevant | 13 | | clinical specialty. For all level of care placement decisions | 14 | | for non-substance-use disorders, the insurer shall authorize | 15 | | placement at the level of care consistent with the insured's | 16 | | score using the relevant level of care placement criteria and | 17 | | guidelines or at a higher level. | 18 | | (n) Every insurer shall do all of the following: | 19 | | (1) sponsor a formal education program by nonprofit | 20 | | clinical specialty associations to educate the insurer's | 21 | | staff, including any third parties contracted with the | 22 | | insurer to review claims, conduct utilization reviews, or | 23 | | make medical necessity determinations about the clinical | 24 | | review criteria; | 25 | | (2) make the education program available to other | 26 | | stakeholders, including the insurer's participating |
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| 1 | | provider and covered lives; | 2 | | (3) provide, at no cost, the clinical review criteria | 3 | | and any training material or resources to providers and | 4 | | insured patients; | 5 | | (4) conduct interrater reliability testing to ensure | 6 | | consistency in utilization review decision making covering | 7 | | how medical necessity decisions are made; and | 8 | | (5) achieve interrater reliability pass rates of at | 9 | | least 90% and, if this threshold is not met, immediately | 10 | | provide for the remediation of poor interrater reliability | 11 | | and interrater reliability testing for all new staff | 12 | | before they can conduct utilization review without | 13 | | supervision. | 14 | | (Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19; | 15 | | 100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff. | 16 | | 8-16-19; revised 9-20-19.)
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