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Illinois Compiled Statutes
Information maintained by the Legislative Reference Bureau Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide. Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.
INSURANCE (215 ILCS 5/) Illinois Insurance Code. 215 ILCS 5/367m (215 ILCS 5/367m) Sec. 367m. Early intervention services. A policy of accident and health insurance that provides coverage for early intervention services must conform to the following criteria: (1) The use of private health insurance to pay for | | early intervention services under Part C of the federal Individuals with Disabilities Education Act may not count towards or result in a loss of benefits due to annual or lifetime insurance caps for an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy.
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| (2) The use of private health insurance to pay for
| | early intervention services under Part C of the federal Individuals with Disabilities Education Act may not negatively affect the availability of health insurance to an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy, and health insurance coverage may not be discontinued for these individuals due to the use of the health insurance to pay for services under Part C of the federal Individuals with Disabilities Education Act.
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| (3) The use of private health insurance to pay for
| | early intervention services under Part C of the federal Individuals with Disabilities Education Act may not be the basis for increasing the health insurance premiums of an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members covered under that health insurance policy.
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| For the purposes of this Section, "early intervention services" has the same meaning as in the Early Intervention Services System Act.
(Source: P.A. 98-41, eff. 6-28-13.)
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215 ILCS 5/368
(215 ILCS 5/368) (from Ch. 73, par. 980)
Sec. 368.
Industrial
accident and health insurance.
(1) Industrial accident and health insurance is hereby declared to be
that form of accident and health insurance in which the premium is payable
weekly.
(2) Any insurance company authorized to write accident and health
insurance in this State shall have power to issue industrial accident and
health policies. No policy of industrial accident and health insurance may
be issued or delivered in this State unless it has printed thereon the
words "Industrial Policy," a copy of the form thereof shall have been filed
with the department and approved by it in accordance with section 355.
(Source: Laws 1951, p. 611.)
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215 ILCS 5/368a
(215 ILCS 5/368a)
Sec. 368a. Timely payment for health care services.
(a) This Section applies to insurers, health maintenance organizations,
managed care plans, health care plans, preferred provider organizations, third
party
administrators, independent practice associations, and physician-hospital
organizations (hereinafter referred to as "payors") that
provide
periodic payments, which are payments not requiring a claim, bill, capitation
encounter
data, or capitation reconciliation reports, such as
prospective capitation payments, to
health care professionals and health care facilities
to provide medical or health care services for insureds or enrollees.
(1) A payor shall make periodic payments in | | accordance with item (3). Failure to make periodic payments within the period of time specified in item (3) shall entitle the health care professional or health care facility to interest at the rate of 9% per year from the date payment was required to be made to the date of the late payment, provided that interest amounting to less than $1 need not be paid. Any required interest payments shall be made within 30 days after the payment.
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(2) When a payor requires selection of a health care
| | professional or health care facility, the selection shall be completed by the insured or enrollee no later than 30 days after enrollment. The payor shall provide written notice of this requirement to all insureds and enrollees. Nothing in this Section shall be construed to require a payor to select a health care professional or health care facility for an insured or enrollee.
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(3) A payor shall provide the health care
| | professional or health care facility with notice of the selection as a health care professional or health care facility by an insured or enrollee and the effective date of the selection within 60 calendar days after the selection. No later than the 60th day following the date an insured or enrollee has selected a health care professional or health care facility or the date that selection becomes effective, whichever is later, or in cases of retrospective enrollment only, 30 days after notice by an employer to the payor of the selection, a payor shall begin periodic payment of the required amounts to the insured's or enrollee's health care professional or health care facility, or the designee of either, calculated from the date of selection or the date the selection becomes effective, whichever is later. All subsequent payments shall be made in accordance with a monthly periodic cycle.
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(b) Notwithstanding any other provision of this Section,
independent practice associations and physician-hospital organizations shall
make periodic payment of the required amounts in
accordance with a monthly periodic schedule after
an insured or enrollee has selected a health care professional or health care
facility or after that selection becomes effective, whichever
is later.
Notwithstanding any other provision of this Section, independent
practice associations and physician-hospital organizations shall make all
other payments for health services within 30 days after receipt of
due proof
of loss. Independent
practice associations and physician-hospital organizations shall notify the
insured, insured's assignee, health care professional, or health care facility
of any failure to provide sufficient documentation for a due proof of
loss within 30 days after receipt of the claim for health services.
Failure to pay within the required time period shall entitle the payee to
interest at the rate of 9% per year from the date the payment is due to the
date of the late payment, provided that interest amounting to less than $1
need not be paid. Any required interest payments shall be made within 30
days after the payment.
(c) All insurers, health maintenance
organizations, managed care plans, health care plans, preferred provider
organizations, and third party administrators
shall ensure that all claims and indemnities
concerning health care services
other than for
any periodic payment shall be paid within 30 days after receipt of due
written proof of such loss. An insured, insured's assignee, health care
professional, or health care facility shall be
notified of any known failure to provide sufficient documentation for a
due proof of
loss within 30 days after receipt of the claim for health care
services.
Failure to pay
within such period shall entitle the payee
to interest at the rate of 9% per year from the 30th day after
receipt of such proof of loss to
the date of late payment, provided that interest amounting to less than one
dollar need not be paid. Any
required interest payments shall be made within 30 days after the payment.
(d) The Department shall enforce the provisions of this Section pursuant to
the enforcement powers granted to it by law.
(e) The Department is hereby granted specific authority to issue a
cease and desist order, fine, or otherwise penalize independent practice
associations and physician-hospital organizations that violate this Section.
The Department shall adopt reasonable rules to enforce compliance with this
Section by
independent practice associations and physician-hospital organizations.
(Source: P.A. 97-813, eff. 7-13-12.)
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215 ILCS 5/368b
(215 ILCS 5/368b)
Sec. 368b. Contracting procedures.
(a) A health care professional or health care provider offered a contract by
an
insurer, health maintenance organization,
independent practice association, or physician
hospital organization for signature after the effective date of this amendatory
Act of the
93rd General Assembly shall be provided with a proposed health care
professional or
health care provider
services contract including, if any, exhibits and attachments that the contract
indicates are
to be attached. Within 35 days after a written request, the health care
professional or health
care provider offered a contract shall be given the opportunity to review and
obtain a
copy of the following: a specialty-specific fee schedule sample based on a
minimum of
the 50 highest volume fee schedule codes with the rates applicable to the
health care
professional or health care provider to whom the contract is offered, the
network
provider
administration manual, and a summary capitation schedule, if payment is made on
a
capitation basis. If 50 codes do not exist for a particular specialty, the
health care
professional or health care provider offered a contract shall be given the
opportunity to
review or obtain a copy of a fee schedule sample with the codes applicable to
that
particular specialty. This information may be provided electronically. An
insurer, health
maintenance organization, independent practice
association, or physician hospital
organization may substitute the fee schedule sample with a document providing
reference
to the information needed to calculate the fee schedule that is available to
the public at no
charge and the percentage or conversion factor at which the insurer, health
maintenance
organization, preferred provider organization, independent practice
association, or physician hospital organization sets its rates.
(b) The fee schedule, the capitation schedule, and
the network provider
administration manual constitute confidential, proprietary, and trade secret
information and are subject to the provisions of the Illinois Trade Secrets
Act.
The health
care professional or health care provider receiving such protected information
may disclose
the information on a need to know basis and only to individuals and entities
that provide
services directly related to the health care professional's or health care
provider's decision
to enter into the contract or keep the contract in force. Any person or entity
receiving or
reviewing such protected information pursuant to this Section shall not
disclose
the
information to any other person, organization, or entity, unless the disclosure
is requested
pursuant to a valid court order or required by a state or federal government
agency.
Individuals or entities receiving such information from a health care
professional
or health care provider as delineated in this subsection are subject to the
provisions of the
Illinois Trade Secrets Act.
(c) The health care professional or health care provider shall be allowed at
least
30 days to review the health care professional or health care provider services
contract, including
exhibits and
attachments, if any, before signing. The 30-day review period begins upon
receipt of the
health care
professional or health care provider services contract, unless the information
available
upon request
in subsection (a) is not included. If information is not included in the
professional
services contract and is requested pursuant to subsection (a), the 30-day
review period
begins on the date of receipt of the information. Nothing in this subsection
shall prohibit
a health care professional or health care provider from signing a contract
prior to the
expiration of the 30-day review period.
(d) As used in this subsection: "Change" means an increase or decrease in the fee schedule referred to in subsection (a). "Nonroutine change" means any proposed change to the fee schedule except a change that is otherwise required by law, regulation, or an applicable regulatory authority or that is required as a result of changes in fee schedules, reimbursement methodology, or payment policies established by a government agency or by the American Medical Association's current procedural terminology codes, reporting guidelines, and conventions, or a change that is expressly provided for under the terms of the contract by the inclusion of or reference to a specific fee or fee schedule, reimbursement methodology, or payment policy indexing mechanism. The insurer, health maintenance organization,
independent practice
association, or physician hospital organization shall provide all contracted
health care
professionals or health care providers with any changes to the fee schedule
provided
under subsection (a) not later than 35 days after the effective date of the
changes,
unless such
changes are specified in the contract and the health care professional or
health care
provider is able to calculate the changed rates based on information in the
contract and
information available to the public at no charge. Beginning January 1, 2023, with respect to nonroutine changes to the fee schedule, the insurer, health maintenance organization, independent practice association, or physician hospital organization shall provide all contracted health care professionals or health care providers impacted by the nonroutine change with notice of the change at least 60 days before the effective date of the change. The right to advance notice of nonroutine changes to the fee schedule may not be waived by the health care professional or health care provider. For the purposes of this subsection (d), health maintenance organizations that provide or arrange for and pay or reimburse for the cost of any health care services for persons who are enrolled in the medical assistance programs under the Illinois Public Aid Code shall comply with provider notification requirements established by the Department of Healthcare and Family Services.
This information may be made available by mail, e-mail, newsletter, website
listing, or
other reasonable method. For nonroutine changes, the information directing the health care professional or health care provider to the information provided by newsletter, website listing, or other reasonable method shall be provided by email or, if requested by the health care professional or health care provider, by mail. Upon request, a health care professional or health
care provider
may request an updated copy of the fee schedule referred to in subsection (a)
every
calendar quarter. (e) Upon termination of a contract with an insurer, health maintenance
organization, independent practice
association, or physician hospital
organization and at
the request of the patient, a health care professional or health care provider
shall transfer
copies of the patient's medical records. Any other provision of law
notwithstanding, the
costs for copying and transferring copies of medical records shall be assigned
per the
arrangements agreed upon, if any, in the health care professional or health
care provider services
contract.
(Source: P.A. 102-957, eff. 1-1-23 .)
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215 ILCS 5/368c
(215 ILCS 5/368c)
Sec. 368c.
Remittance advice and procedures.
(a) A remittance advice shall be furnished to a health care professional or
health
care provider that identifies the disposition of each claim. The remittance
advice shall identify the services billed; the patient responsibility, if any;
the actual payment, if any, for the services billed; and the reason for any
reduction to the amount for
which the claim was submitted. For any reductions to the amount for which the
claim was submitted, the remittance shall identify any withholds and the reason
for any denial or reduction.
A remittance advice for capitation or prospective payment arrangements shall
be
furnished to a health care professional or health care provider pursuant to a
contract with
an insurer, health maintenance organization,
independent practice association,
or
physician hospital organization in accordance with the terms of the contract.
(b) When health care services are provided by a non-participating
health care
professional or health care provider, an insurer, health maintenance
organization,
independent practice association, or physician hospital organization may pay
for covered
services either to a patient directly or to the non-participating health care
professional or
health care provider.
(c) When a person presents a
benefits information card,
a health care professional or health care provider shall make a good faith
effort
to inform the
person if the
health care professional or health care provider has a participation contract
with the
insurer,
health maintenance organization, or other
entity identified on the card.
(Source: P.A. 93-261, eff. 1-1-04.)
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215 ILCS 5/368d
(215 ILCS 5/368d)
Sec. 368d. Recoupments.
(a) A health care professional or health care provider shall be provided a
remittance advice, which must include an explanation of a
recoupment or
offset taken by an insurer, health maintenance organization,
independent practice association, or physician hospital
organization, if any. The recoupment explanation shall, at a minimum, include
the name
of the patient; the date of service; the service code or if no service code is
available a service description;
the recoupment amount; and the reason for the recoupment or offset. In
addition,
an insurer,
health maintenance organization, independent
practice association, or physician
hospital organization shall provide with the remittance advice, or with any demand for recoupment or offset, a telephone
number or mailing address to initiate an appeal of the recoupment or offset together with the deadline for initiating an appeal. Such information shall be prominently displayed on the remittance advice or written document containing the demand for recoupment or offset. Any appeal of a recoupment or offset by a health care professional or health care provider must be made within 60 days after receipt of the remittance advice.
(b) It is not a recoupment when a health care professional or health care
provider
is paid an amount prospectively or concurrently under a contract with an
insurer, health
maintenance organization, independent practice
association, or physician
hospital
organization that requires a retrospective reconciliation based upon specific
conditions
outlined in the contract.
(c) No recoupment or offset may be requested or withheld from future payments 12 months or more after the original payment is made, except in cases in which: (1) a court, government administrative agency, other | | tribunal, or independent third-party arbitrator makes or has made a formal finding of fraud or material misrepresentation;
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| (2) an insurer is acting as a plan administrator for
| | the Comprehensive Health Insurance Plan under the Comprehensive Health Insurance Plan Act;
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| (3) the provider has already been paid in full by any
| | other payer, third party, or workers' compensation insurer; or
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| (4) an insurer contracted with the Department of
| | Healthcare and Family Services is required by the Department of Healthcare and Family Services to recoup or offset payments due to a federal Medicaid requirement.
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| No contract between an insurer and a health care professional or health care provider may provide for recoupments in violation of this Section. Nothing in this Section shall be construed to preclude insurers, health maintenance organizations, independent practice associations, or physician hospital organizations from resolving coordination of benefits between or among each other, including, but not limited to, resolution of workers' compensation and third-party liability cases, without recouping payment from the provider beyond the 18-month time limit provided in this subsection (c).
(Source: P.A. 102-632, eff. 1-1-22 .)
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215 ILCS 5/368e
(215 ILCS 5/368e)
Sec. 368e.
Administration and enforcement.
(a) Other than the duties specifically created in Sections 368b, 368c, and
368d,
nothing in those Sections is intended to preclude, prevent, or require the
adoption,
modification, or termination of any utilization management, quality management,
or
claims processing methodologies or other provisions of a contract applicable to
services provided under a
contract
between an insurer, health maintenance organization,
independent practice
association, or
physician hospital organization and a health care professional or health care
provider.
(b) Nothing in Sections 368b, 368c, and 368d precludes, prevents, or
requires
the
adoption, modification, or termination of any health plan term, benefit,
coverage or
eligibility provision, or payment methodology.
(c) The provisions of Sections 368b, 368c, and 368d are deemed incorporated
into health care professional and health care provider service contracts
entered into on or before the
effective date of
this amendatory Act of the 93rd General Assembly and do not require an insurer,
health
maintenance organization, independent practice
association, or physician
hospital
organization to renew or renegotiate the contracts with a health care
professional or health
care provider.
(d) The Department shall enforce the provisions of this Section and
Sections 368b, 368c, and 368d pursuant to the enforcement powers granted to it
by law.
(e) The Department is hereby granted specific authority to issue a cease and
desist order against, fine, or otherwise penalize independent practice
associations and
physician-hospital organizations for violations.
(f) The Department shall adopt reasonable rules to enforce compliance with
this Section and Sections 368b, 368c, and 368d.
(Source: P.A. 93-261, eff. 1-1-04.)
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215 ILCS 5/368f (215 ILCS 5/368f) (Text of Section before amendment by P.A. 103-649 ) Sec. 368f. Military service member insurance reinstatement. (a) No Illinois resident activated for military service and no spouse or dependent of the resident who becomes eligible for a federal government-sponsored health insurance program, including the TriCare program providing coverage for civilian dependents of military personnel, as a result of the activation shall be denied reinstatement into the same individual health insurance coverage with the health insurer that the resident lapsed as a result of activation or becoming covered by the federal government-sponsored health insurance program. The resident shall have the right to reinstatement in the same individual health insurance coverage without medical underwriting, subject to payment of the current premium charged to other persons of the same age and gender that are covered under the same individual health coverage. Except in the case of birth or adoption that occurs during the period of activation, reinstatement must be into the same coverage type as the resident held prior to lapsing the individual health insurance coverage and at the same or, at the option of the resident, higher deductible level. The reinstatement rights provided under this subsection (a) are not available to a resident or dependents if the activated person is discharged from the military under other than honorable conditions. (b) The health insurer with which the reinstatement is being requested must receive a request for reinstatement no later than 63 days following the later of (i) deactivation or (ii) loss of coverage under the federal government-sponsored health insurance program. The health insurer may request proof of loss of coverage and the timing of the loss of coverage of the government-sponsored coverage in order to determine eligibility for reinstatement into the individual coverage. The effective date of the reinstatement of individual health coverage shall be the first of the month following receipt of the notice requesting reinstatement. (c) All insurers must provide written notice to the policyholder of individual health coverage of the rights described in subsection (a) of this Section. In lieu of the inclusion of the notice in the individual health insurance policy, an insurance company may satisfy the notification requirement by providing a single written notice: (1) in conjunction with the enrollment process for a | | policyholder initially enrolling in the individual coverage on or after the effective date of this amendatory Act of the 94th General Assembly; or
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| (2) by mailing written notice to policyholders whose
| | coverage was effective prior to the effective date of this amendatory Act of the 94th General Assembly no later than 90 days following the effective date of this amendatory Act of the 94th General Assembly.
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| (d) The provisions of subsection (a) of this Section do not apply to any policy or certificate providing coverage for any specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care, Medicare supplement, vision care, or short-term nonrenewable health policy or other limited-benefit supplemental insurance, or any coverage issued as a supplement to any liability insurance, workers' compensation or similar insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket, or individual basis.
(e) Nothing in this Section shall require an insurer to reinstate the resident if the insurer requires residency in an enrollment area and those residency requirements are not met after deactivation or loss of coverage under the government-sponsored health insurance program.
(f) All terms, conditions, and limitations of the individual coverage into which reinstatement is made apply equally to all insureds enrolled in the coverage.
(g) The Secretary may adopt rules as may be necessary to carry out the provisions of this Section.
(Source: P.A. 94-1037, eff. 7-20-06.)
(Text of Section after amendment by P.A. 103-649 )
Sec. 368f. Military service member insurance reinstatement.
(a) No Illinois resident activated for military service and no spouse or dependent of the resident who becomes eligible for a federal government-sponsored health insurance program, including the TriCare program providing coverage for civilian dependents of military personnel, as a result of the activation shall be denied reinstatement into the same individual health insurance coverage with the health insurer that the resident lapsed as a result of activation or becoming covered by the federal government-sponsored health insurance program. The resident shall have the right to reinstatement in the same individual health insurance coverage without medical underwriting, subject to payment of the current premium charged to other persons of the same age and gender that are covered under the same individual health coverage. Except in the case of birth or adoption that occurs during the period of activation, reinstatement must be into the same coverage type as the resident held prior to lapsing the individual health insurance coverage and at the same or, at the option of the resident, higher deductible level. The reinstatement rights provided under this subsection (a) are not available to a resident or dependents if the activated person is discharged from the military under other than honorable conditions.
(b) The health insurer with which the reinstatement is being requested must receive a request for reinstatement no later than 63 days following the later of (i) deactivation or (ii) loss of coverage under the federal government-sponsored health insurance program. The health insurer may request proof of loss of coverage and the timing of the loss of coverage of the government-sponsored coverage in order to determine eligibility for reinstatement into the individual coverage. The effective date of the reinstatement of individual health coverage shall be the first of the month following receipt of the notice requesting reinstatement.
(c) All insurers must provide written notice to the policyholder of individual health coverage of the rights described in subsection (a) of this Section. In lieu of the inclusion of the notice in the individual health insurance policy, an insurance company may satisfy the notification requirement by providing a single written notice:
(1) in conjunction with the enrollment process for a
| | policyholder initially enrolling in the individual coverage on or after the effective date of this amendatory Act of the 94th General Assembly; or
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| (2) by mailing written notice to policyholders whose
| | coverage was effective prior to the effective date of this amendatory Act of the 94th General Assembly no later than 90 days following the effective date of this amendatory Act of the 94th General Assembly.
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| (d) The provisions of subsection (a) of this Section do not apply to any policy or certificate providing coverage for any specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity or other fixed indemnity, long-term care, Medicare supplement, vision care, or short-term travel or other limited-benefit supplemental insurance, or any coverage issued as a supplement to any liability insurance, workers' compensation or similar insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket, or individual basis.
(e) Nothing in this Section shall require an insurer to reinstate the resident if the insurer requires residency in an enrollment area and those residency requirements are not met after deactivation or loss of coverage under the government-sponsored health insurance program.
(f) All terms, conditions, and limitations of the individual coverage into which reinstatement is made apply equally to all insureds enrolled in the coverage.
(g) The Secretary may adopt rules as may be necessary to carry out the provisions of this Section.
(Source: P.A. 103-649, eff. 1-1-25.)
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215 ILCS 5/368g (215 ILCS 5/368g) Sec. 368g. Time-based billing. (a) As used in this Section, "CPT code" means the medical billing code set contained in the most recent version of the Current Procedural Terminology code book published by the American Medical Association. (b) A health care plan requiring a health care provider to use a time-based CPT code to bill for health care services shall not apply a time measurement standard that results in fewer units billed than allowed by the CPT code book, except as required by federal law for federally funded patients.
(Source: P.A. 101-119, eff. 7-22-19; 102-558, eff. 8-20-21.) |
215 ILCS 5/369
(215 ILCS 5/369) (from Ch. 73, par. 981)
Sec. 369.
Rights of
minors.
Any minor of the age of fifteen years or more may, notwithstanding such
minority, contract for health and accident insurance on his own life for
his own benefit or for the benefit of his father, mother, husband, wife,
child, brother or sister, and may exercise all such contractual rights and
powers with respect to any such contract of insurance as might be exercised
by a person of full legal age, and may exercise with like effect all rights
and privileges under such contract, including the surrender of his interest
therein and the giving of a valid discharge for any benefit accruing or
money payable thereunder. Such minor shall not, by reason of his minority,
be entitled to rescind, avoid, or repudiate such contract, or any exercise
of a right or privilege thereunder.
(Source: Laws 1937, p. 696.)
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215 ILCS 5/370
(215 ILCS 5/370) (from Ch. 73, par. 982)
Sec. 370.
Policies
issued in violation of article-Penalty.
(1) Any company, or any officer or agent thereof, issuing or delivering
to any person in this State any policy in wilful violation of the provision
of this article shall be guilty of a petty offense.
(2) The Director may revoke the license of any foreign or alien company,
or of the agent thereof wilfully violating any provision of this article or
suspend such license for any period of time up to, but not to exceed, two
years; or may by order require such insurance company or agent to pay to
the people of the State of Illinois a penalty in a sum not exceeding $1,000,
and upon the failure of such insurance company or agent to
pay such penalty within twenty days after the mailing of such order,
postage prepaid, registered, and addressed to the last known place of
business of such insurance company or agent, unless such order is stayed by
an order of a court of competent jurisdiction, the Director of Insurance
may revoke or suspend the license of such insurance company or agent for
any period of time up to, but not exceeding a period of, two years.
(Source: P.A. 93-32, eff. 7-1-03.)
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215 ILCS 5/370a
(215 ILCS 5/370a) (from Ch. 73, par. 982a)
Sec. 370a.
Assignability of Accident and Health Insurance.
No provision of the Illinois Insurance Code, or any other law, prohibits
an insured under any policy of accident and health insurance or any other
person who may be the owner of any rights under such policy from making an
assignment of all or any part of his rights and privileges under the policy
including but not limited to the right to designate a beneficiary and to
have an individual policy issued in accordance with its terms. Subject to
the terms of the policy or any contract relating thereto, an assignment by
an insured or by any other owner of rights under the policy, made before or
after the effective date of this amendatory Act of 1969 is valid for the
purpose of vesting in the assignee, in accordance with any provisions
included therein as to the time at which it is effective, all rights and
privileges so assigned. However, such assignment is without prejudice to
the company on account of any payment it makes or individual policy it
issues before receipt of notice of the assignment. This amendatory Act of
1969 acknowledges, declares and codifies the existing right of assignment
of interests under accident and health insurance policies.
If an enrollee or insured of an insurer, health maintenance organization,
managed care plan, health care plan, preferred provider organization, or third
party administrator assigns a claim to a health care professional or health
care facility, then payment
shall be made directly to the health care professional or health care facility
including any interest
required under Section 368a, of this Code for failure to pay
claims
within 30
days after receipt by the insurer of due proof of loss. Nothing in this
Section shall be construed to prevent any parties from reconciling duplicate
payments.
(Source: P.A. 91-605, eff. 12-14-99; 91-788, eff. 6-9-00.)
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215 ILCS 5/370b
(215 ILCS 5/370b) (from Ch. 73, par. 982b)
Sec. 370b.
Reimbursement on equal basis.
Notwithstanding any provision
of any individual or group
policy of accident and health insurance, or any provision of a policy,
contract, plan or agreement for hospital or medical service or indemnity,
wherever such policy, contract, plan or agreement provides for
reimbursement for any service provided by persons licensed under the Medical Practice Act of 1987 or the Podiatric Medical
Practice
Act of 1987, the person entitled to benefits or person performing services
under such policy, contract, plan or agreement is entitled to reimbursement
on an equal basis for such service, when the service is performed by a
person licensed under the Medical Practice Act of 1987 or the
Podiatric Medical Practice Act of 1987. The provisions of this Section do
not apply to any policy, contract, plan or agreement in effect prior to
September 19, 1969 or to
preferred provider arrangements or benefit agreements.
(Source: P.A. 90-14, eff. 7-1-97.)
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215 ILCS 5/370b.1 (215 ILCS 5/370b.1) Sec. 370b.1. Surgical assistant payments. Payment for services rendered by a registered surgical assistant, as defined in the Registered Surgical Assistant and Registered Surgical Technologist Title Protection Act, who is neither an employee of an ambulatory surgical treatment center, as defined in the Ambulatory Surgical Treatment Center Act, nor an employee of a hospital shall be paid at the appropriate non-physician modifier rate if the payor would have made payment had the same services been provided by a physician.
(Source: P.A. 99-100, eff. 1-1-16 .) |
215 ILCS 5/370c
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after January 1, 2022 (the effective date of Public Act 102-579),
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 medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions consistent with the parity requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional, nervous, or substance use
disorders or conditions shall be free to select the physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapist, licensed speech-language pathologist, or other licensed or certified professional at a program licensed pursuant to the Substance Use Disorder Act of
his or her choice to treat such disorders, and
the insurer shall pay the covered charges of such physician licensed to
practice medicine in all its branches, licensed clinical psychologist,
licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapist, licensed speech-language pathologist, or other licensed or certified professional at a program licensed pursuant to the Substance Use Disorder Act up
to the limits of coverage, provided (i)
the disorder or condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family therapist, licensed speech-language pathologist, or other licensed or certified professional at a program licensed pursuant to the Substance Use Disorder Act is
authorized to provide said services under the statutes of this State and in
accordance with accepted principles of his or her profession.
(3) Insofar as this Section applies solely to licensed clinical social
workers, licensed clinical professional counselors, licensed marriage and family therapists, licensed speech-language pathologists, and other licensed or certified professionals at programs licensed pursuant to the Substance Use Disorder Act, those persons who may
provide services to individuals shall do so
after the licensed clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed speech-language pathologist, or other licensed or certified professional at a program licensed pursuant to the Substance Use Disorder Act has informed the patient of the
desirability of the patient conferring with the patient's primary care
physician.
(4) "Mental, emotional, nervous, or substance use disorder or condition" means a condition or disorder that involves a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the current edition of the World Health Organization's International Classification of Disease or that is listed in the most recent version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. "Mental, emotional, nervous, or substance use disorder or condition" includes any mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression. (5) Medically necessary treatment and medical necessity determinations shall be interpreted and made in a manner that is consistent with and pursuant to subsections (h) through (t). (b)(1) (Blank).
(2) (Blank).
(2.5) (Blank). (3) Unless otherwise prohibited by federal law and consistent with the parity requirements of Section 370c.1 of this Code, the reimbursing insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance, a qualified health plan offered through the health insurance marketplace, or a provider of treatment of mental, emotional, nervous,
or substance use disorders or conditions shall furnish medical records or other necessary data
that substantiate that initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the timely review by a
provider holding the same license and practicing in the same specialty as the
patient's provider, who is unaffiliated with the insurer, jointly selected by
the patient (or the patient's next of kin or legal representative if the
patient is unable to act for himself or herself), the patient's provider, and
the insurer in the event of a dispute between the insurer and patient's
provider regarding the medical necessity of a treatment proposed by a patient's
provider. If the reviewing provider determines the treatment to be medically
necessary, the insurer shall provide reimbursement for the treatment. Future
contractual or employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in this procedure.
Nothing prevents
the insured from agreeing in writing to continue treatment at his or her
expense. When making a determination of the medical necessity for a treatment
modality for mental, emotional, nervous, or substance use disorders or conditions, an insurer must make the determination in a
manner that is consistent with the manner used to make that determination with
respect to other diseases or illnesses covered under the policy, including an
appeals process. Medical necessity determinations for substance use disorders shall be made in accordance with appropriate patient placement criteria established by the American Society of Addiction Medicine. No additional criteria may be used to make medical necessity determinations for substance use disorders.
(4) A group health benefit plan amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1024) or an individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1024):
(A) shall provide coverage based upon medical | | necessity for the treatment of a mental, emotional, nervous, or substance use disorder or condition consistent with the parity requirements of Section 370c.1 of this Code; provided, however, that in each calendar year coverage shall not be less than the following:
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(i) 45 days of inpatient treatment; and
(ii) beginning on June 26, 2006 (the effective
| | date of Public Act 94-921), 60 visits for outpatient treatment including group and individual outpatient treatment; and
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| (iii) for plans or policies delivered, issued for
| | delivery, renewed, or modified after January 1, 2007 (the effective date of Public Act 94-906), 20 additional outpatient visits for speech therapy for treatment of pervasive developmental disorders that will be in addition to speech therapy provided pursuant to item (ii) of this subparagraph (A); and
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(B) may not include a lifetime limit on the number of
| | days of inpatient treatment or the number of outpatient visits covered under the plan.
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(C) (Blank).
(5) An issuer of a group health benefit plan or an individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace may not count toward the number
of outpatient visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover the outpatient
visits under the same terms and conditions as it covers outpatient visits for
the treatment of physical illness.
(5.5) An individual or group health benefit plan amended, delivered, issued, or renewed on or after September 9, 2015 (the effective date of Public Act 99-480) shall offer coverage for medically necessary acute treatment services and medically necessary clinical stabilization services. The treating provider shall base all treatment recommendations and the health benefit plan shall base all medical necessity determinations for substance use disorders in accordance with the most current edition of the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine. The treating provider shall base all treatment recommendations and the health benefit plan shall base all medical necessity determinations for medication-assisted treatment in accordance with the most current Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically supervised addiction treatment that provides evaluation and withdrawal management and may include biopsychosocial assessment, individual and group counseling, psychoeducational groups, and discharge planning.
"Clinical stabilization services" means 24-hour treatment, usually following acute treatment services for substance abuse, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others, and aftercare planning for individuals beginning to engage in recovery from addiction.
(6) An issuer of a group health benefit
plan may provide or offer coverage required under this Section through a
managed care plan.
(6.5) An individual or group health benefit plan amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1024):
(A) shall not impose prior authorization
| | requirements, other than those established under the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine, on a prescription medication approved by the United States Food and Drug Administration that is prescribed or administered for the treatment of substance use disorders;
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| (B) shall not impose any step therapy requirements,
| | other than those established under the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine, before authorizing coverage for a prescription medication approved by the United States Food and Drug Administration that is prescribed or administered for the treatment of substance use disorders;
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| (C) shall place all prescription medications approved
| | by the United States Food and Drug Administration prescribed or administered for the treatment of substance use disorders on, for brand medications, the lowest tier of the drug formulary developed and maintained by the individual or group health benefit plan that covers brand medications and, for generic medications, the lowest tier of the drug formulary developed and maintained by the individual or group health benefit plan that covers generic medications; and
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| (D) shall not exclude coverage for a prescription
| | medication approved by the United States Food and Drug Administration for the treatment of substance use disorders and any associated counseling or wraparound services on the grounds that such medications and services were court ordered.
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| (7) (Blank).
(8)
(Blank).
(9) With respect to all mental, emotional, nervous, or substance use disorders or conditions, coverage for inpatient treatment shall include coverage for treatment in a residential treatment center certified or licensed by the Department of Public Health or the Department of Human Services.
(c) This Section shall not be interpreted to require coverage for speech therapy or other habilitative services for those individuals covered under Section 356z.15
of this Code.
(d) With respect to a group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace, the Department and, with respect to medical assistance, the Department of Healthcare and Family Services shall each enforce the requirements of this Section and Sections 356z.23 and 370c.1 of this Code, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. 18031(j), and any amendments to, and federal guidance or regulations issued under, those Acts, including, but not limited to, final regulations issued under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and final regulations applying the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 to Medicaid managed care organizations, the Children's Health Insurance Program, and alternative benefit plans. Specifically, the Department and the Department of Healthcare and Family Services shall take action:
(1) proactively ensuring compliance by individual and
| | group policies, including by requiring that insurers submit comparative analyses, as set forth in paragraph (6) of subsection (k) of Section 370c.1, demonstrating how they design and apply nonquantitative treatment limitations, both as written and in operation, for mental, emotional, nervous, or substance use disorder or condition benefits as compared to how they design and apply nonquantitative treatment limitations, as written and in operation, for medical and surgical benefits;
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| (2) evaluating all consumer or provider complaints
| | regarding mental, emotional, nervous, or substance use disorder or condition coverage for possible parity violations;
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| (3) performing parity compliance market conduct
| | examinations or, in the case of the Department of Healthcare and Family Services, parity compliance audits of individual and group plans and policies, including, but not limited to, reviews of:
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| (A) nonquantitative treatment limitations,
| | including, but not limited to, prior authorization requirements, concurrent review, retrospective review, step therapy, network admission standards, reimbursement rates, and geographic restrictions;
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| (B) denials of authorization, payment, and
| | (C) other specific criteria as may be determined
| | The findings and the conclusions of the parity compliance market conduct examinations and audits shall be made public.
The Director may adopt rules to effectuate any provisions of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that relate to the business of insurance.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
| | made under a group health plan, an individual policy of accident and health insurance, or a qualified health plan offered through the health insurance marketplace with respect to mental health or substance use disorder benefits (or health insurance coverage offered in connection with the plan with respect to such benefits) must be made available by the plan administrator (or the health insurance issuer offering such coverage) to any current or potential participant, beneficiary, or contracting provider upon request.
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| (2) The reason for any denial under a group health
| | benefit plan, an individual policy of accident and health insurance, or a qualified health plan offered through the health insurance marketplace (or health insurance coverage offered in connection with such plan or policy) of reimbursement or payment for services with respect to mental, emotional, nervous, or substance use disorders or conditions benefits in the case of any participant or beneficiary must be made available within a reasonable time and in a reasonable manner and in readily understandable language by the plan administrator (or the health insurance issuer offering such coverage) to the participant or beneficiary upon request.
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| (f) As used in this Section, "group policy of accident and health insurance" and "group health benefit plan" includes (1) State-regulated employer-sponsored group health insurance plans written in Illinois or which purport to provide coverage for a resident of this State; and (2) State employee health plans.
(g) (1) As used in this subsection:
"Benefits", with respect to insurers, means
the benefits provided for treatment services for inpatient and outpatient treatment of substance use disorders or conditions at American Society of Addiction Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 (Clinically Managed Low-Intensity Residential), 3.3 (Clinically Managed Population-Specific High-Intensity Residential), 3.5 (Clinically Managed High-Intensity Residential), and 3.7 (Medically Monitored Intensive Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Benefits", with respect to managed care organizations, means the benefits provided for treatment services for inpatient and outpatient treatment of substance use disorders or conditions at American Society of Addiction Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.5 (Clinically Managed High-Intensity Residential), and 3.7 (Medically Monitored Intensive Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Substance use disorder treatment provider or facility" means a licensed physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed, certified, or otherwise State-approved facility or provider of substance use disorder treatment.
(2) A group health insurance policy, an individual health benefit plan, or qualified health plan that is offered through the health insurance marketplace, small employer group health plan, and large employer group health plan that is amended, delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State, on or after January 1, 2019 (the effective date of Public Act 100-1023) shall comply with the requirements of this Section and Section 370c.1. The services for the treatment and the ongoing assessment of the patient's progress in treatment shall follow the requirements of 77 Ill. Adm. Code 2060.
(3) Prior authorization shall not be utilized for the benefits under this subsection. The substance use disorder treatment provider or facility shall notify the insurer of the initiation of treatment. For an insurer that is not a managed care organization, the substance use disorder treatment provider or facility notification shall occur for the initiation of treatment of the covered person within 2 business days. For managed care organizations, the substance use disorder treatment provider or facility notification shall occur in accordance with the protocol set forth in the provider agreement for initiation of treatment within 24 hours. If the managed care organization is not capable of accepting the notification in accordance with the contractual protocol during the 24-hour period following admission, the substance use disorder treatment provider or facility shall have one additional business day to provide the notification to the appropriate managed care organization. Treatment plans shall be developed in accordance with the requirements and timeframes established in 77 Ill. Adm. Code 2060. If the substance use disorder treatment provider or facility fails to notify the insurer of the initiation of treatment in accordance with these provisions, the insurer may follow its normal prior authorization processes.
(4) For an insurer that is not a managed care organization, if an insurer determines that benefits are no longer medically necessary, the insurer shall notify the covered person, the covered person's authorized representative, if any, and the covered person's health care provider in writing of the covered person's right to request an external review pursuant to the Health Carrier External Review Act. The notification shall occur within 24 hours following the adverse determination.
Pursuant to the requirements of the Health Carrier External Review Act, the covered person or the covered person's authorized representative may request an expedited external review.
An expedited external review may not occur if the substance use disorder treatment provider or facility determines that continued treatment is no longer medically necessary.
If an expedited external review request meets the criteria of the Health Carrier External Review Act, an independent review organization shall make a final determination of medical necessity within 72 hours. If an independent review organization upholds an adverse determination, an insurer shall remain responsible to provide coverage of benefits through the day following the determination of the independent review organization. A decision to reverse an adverse determination shall comply with the Health Carrier External Review Act.
(5) The substance use disorder treatment provider or facility shall provide the insurer with 7 business days' advance notice of the planned discharge of the patient from the substance use disorder treatment provider or facility and notice on the day that the patient is discharged from the substance use disorder treatment provider or facility.
(6) The benefits required by this subsection shall be provided to all covered persons with a diagnosis of substance use disorder or conditions. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this subsection.
(7) Nothing in this subsection shall be construed to require an insurer to provide coverage for any of the benefits in this subsection.
(h) As used in this Section:
"Generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care" means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, social work, addiction medicine and counseling, and behavioral health treatment. Valid, evidence-based sources reflecting generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care include peer-reviewed scientific studies and medical literature, recommendations of nonprofit health care provider professional associations and specialty societies, including, but not limited to, patient placement criteria and clinical practice guidelines, recommendations of federal government agencies, and drug labeling approved by the United States Food and Drug Administration.
"Medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions" means a service or product addressing the specific needs of that patient, for the purpose of screening, preventing, diagnosing, managing, or treating an illness, injury, or condition or its symptoms and comorbidities, including minimizing the progression of an illness, injury, or condition or its symptoms and comorbidities in a manner that is all of the following:
(1) in accordance with the generally accepted
| | standards of mental, emotional, nervous, or substance use disorder or condition care;
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| (2) clinically appropriate in terms of type,
| | frequency, extent, site, and duration; and
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| (3) not primarily for the economic benefit of the
| | insurer, purchaser, or for the convenience of the patient, treating physician, or other health care provider.
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| "Utilization review" means either of the following:
(1) prospectively, retrospectively, or concurrently
| | reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests by health care providers, insureds, or their authorized representatives for coverage of health care services before, retrospectively, or concurrently with the provision of health care services to insureds.
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| (2) evaluating the medical necessity,
| | appropriateness, level of care, service intensity, efficacy, or efficiency of health care services, benefits, procedures, or settings, under any circumstances, to determine whether a health care service or benefit subject to a medical necessity coverage requirement in an insurance policy is covered as medically necessary for an insured.
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| "Utilization review criteria" means patient placement criteria or any criteria, standards, protocols, or guidelines used by an insurer to conduct utilization review.
(i)(1) 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 this State and Medicaid managed care organizations providing coverage for hospital or medical treatment on or after January 1, 2023 shall, pursuant to subsections (h) through (s), provide coverage for medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions.
(2) An insurer shall not set a specific limit on the duration of benefits or coverage of medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions or limit coverage only to alleviation of the insured's current symptoms.
(3) All medical necessity determinations made by the insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental, emotional, nervous, or substance use disorders or conditions shall be conducted in accordance with the requirements of subsections (k) through (u).
(4) An insurer that authorizes a specific type of treatment by a provider pursuant to this Section shall not rescind or modify the authorization after that provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurer's subsequent cancellation or modification of the insured's or policyholder's contract, or the insured's or policyholder's eligibility. Nothing in this Section shall require the insurer to cover a treatment when the authorization was granted based on a material misrepresentation by the insured, the policyholder, or the provider. Nothing in this Section shall require Medicaid managed care organizations to pay for services if the individual was not eligible for Medicaid at the time the service was rendered. Nothing in this Section shall require an insurer to pay for services if the individual was not the insurer's enrollee at the time services were rendered. As used in this paragraph, "material" means a fact or situation that is not merely technical in nature and results in or could result in a substantial change in the situation.
(j) 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, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program. Nothing in this subsection shall be construed to require an insurer to cover benefits that have been authorized and provided for a covered person by a public entitlement program. Medicaid managed care organizations are not subject to this subsection.
(k) An insurer shall base any medical necessity determination or the utilization review criteria that the insurer, and any entity acting on the insurer's behalf, applies to determine the medical necessity of health care services and benefits for the diagnosis, prevention, and treatment of mental, emotional, nervous, or substance use disorders or conditions on current generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care. All denials and appeals shall be reviewed by a professional with experience or expertise comparable to the provider requesting the authorization.
(l) For medical necessity determinations relating to level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental, emotional, and nervous disorders or conditions, an insurer shall apply the patient placement criteria set forth in the most recent version of the treatment criteria developed by an unaffiliated nonprofit professional association for the relevant clinical specialty or, for Medicaid managed care organizations, patient placement criteria determined by the Department of Healthcare and Family Services that are consistent with generally accepted standards of mental, emotional, nervous or substance use disorder or condition care. Pursuant to subsection (b), in conducting utilization review of all covered services and benefits for the diagnosis, prevention, and treatment of substance use disorders an insurer shall use the most recent edition of the patient placement criteria established by the American Society of Addiction Medicine.
(m) For medical necessity determinations relating to level of care placement, continued stay, and transfer or discharge that are within the scope of the sources specified in subsection (l), an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria set forth in those sources. For all level of care placement decisions, the insurer shall authorize placement at the level of care consistent with the assessment of the insured using the relevant patient placement criteria as specified in subsection (l). If that level of placement is not available, the insurer shall authorize the next higher level of care. In the event of disagreement, the insurer shall provide full detail of its assessment using the relevant criteria as specified in subsection (l) to the provider of the service and the patient.
Nothing in this subsection or subsection (l) prohibits an insurer from applying utilization review criteria that were developed in accordance with subsection (k) to health care services and benefits for mental, emotional, and nervous disorders or conditions that are not related to medical necessity determinations for level of care placement, continued stay, and transfer or discharge. If an insurer purchases or licenses utilization review criteria pursuant to this subsection, the insurer shall verify and document before use that the criteria were developed in accordance with subsection (k).
(n) In conducting utilization review that is outside the scope of the criteria as specified in subsection (l) or relates to the advancements in technology or in the types or levels of care that are not addressed in the most recent versions of the sources specified in subsection (l), an insurer shall conduct utilization review in accordance with subsection (k).
(o) This Section does not in any way limit the rights of a patient under the Medical Patient Rights Act.
(p) This Section does not in any way limit early and periodic screening, diagnostic, and treatment benefits as defined under 42 U.S.C. 1396d(r).
(q) To ensure the proper use of the criteria described in subsection (l), every insurer shall do all of the following:
(1) Educate the insurer's staff, including any
| | third parties contracted with the insurer to review claims, conduct utilization reviews, or make medical necessity determinations about the utilization review criteria.
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| (2) Make the educational program available to other
| | stakeholders, including the insurer's participating or contracted providers and potential participants, beneficiaries, or covered lives. The education program must be provided at least once a year, in-person or digitally, or recordings of the education program must be made available to the aforementioned stakeholders.
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| (3) Provide, at no cost, the utilization review
| | criteria and any training material or resources to providers and insured patients upon request. For utilization review criteria not concerning level of care placement, continued stay, and transfer or discharge used by the insurer pursuant to subsection (m), the insurer may place the criteria on a secure, password-protected website so long as the access requirements of the website do not unreasonably restrict access to insureds or their providers. No restrictions shall be placed upon the insured's or treating provider's access right to utilization review criteria obtained under this paragraph at any point in time, including before an initial request for authorization.
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| (4) Track, identify, and analyze how the
| | utilization review criteria are used to certify care, deny care, and support the appeals process.
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| (5) Conduct interrater reliability testing to
| | ensure consistency in utilization review decision making that covers how medical necessity decisions are made; this assessment shall cover all aspects of utilization review as defined in subsection (h).
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| (6) Run interrater reliability reports about how
| | the clinical guidelines are used in conjunction with the utilization review process and parity compliance activities.
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| (7) Achieve interrater reliability pass rates of at
| | least 90% and, if this threshold is not met, immediately provide for the remediation of poor interrater reliability and interrater reliability testing for all new staff before they can conduct utilization review without supervision.
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| (8) Maintain documentation of interrater
| | reliability testing and the remediation actions taken for those with pass rates lower than 90% and submit to the Department of Insurance or, in the case of Medicaid managed care organizations, the Department of Healthcare and Family Services the testing results and a summary of remedial actions as part of parity compliance reporting set forth in subsection (k) of Section 370c.1.
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| (r) This Section applies to all health care services and benefits for the diagnosis, prevention, and treatment of mental, emotional, nervous, or substance use disorders or conditions covered by an insurance policy, including prescription drugs.
(s) This Section applies to an 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 this State providing coverage for hospital or medical treatment and conducts utilization review as defined in this Section, including Medicaid managed care organizations, and any entity or contracting provider that performs utilization review or utilization management functions on an insurer's behalf.
(t) If the Director determines that an insurer has violated this Section, the Director may, after appropriate notice and opportunity for hearing, by order, assess a civil penalty between $1,000 and $5,000 for each violation. Moneys collected from penalties shall be deposited into the Parity Advancement Fund established in subsection (i) of Section 370c.1.
(u) An insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this Section.
(v) The provisions of this Section are severable. If any provision of this Section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; 102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)
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