Public Act 100-1023
 
SB0682 EnrolledLRB100 06022 SMS 16052 b


  
    AN ACT concerning regulation.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  


 
    Section 1. This Act may be referred to as the Emergency 
Opioid and Addiction Treatment Access Act.
 
    Section 3. Findings.  The General Assembly finds and 
declares the following:
        (1) The opioid epidemic is the most significant public 
    health and public safety crisis in Illinois.
        (2) Opioid overdoses have killed nearly 11,000 people 
    since 2008 and have now become the leading cause of death 
    nationwide for people under the age of 50.
        (3) The opioid epidemic has devastated both rural and 
    urban Illinois residents.  Families have lost their loved 
    ones to drug overdoses.  Incidence of suicide are on the 
    rise.  Illinois' criminal justice system is flooded with 
    individuals with critical substance use disorder treatment 
    needs.  
        (4) Speeding access to treatments will ensure that 
    Illinois residents suffering from a substance abuse crisis 
    will obtain the services they need.
 
    Section 5. The Illinois Insurance Code is amended  by 
changing Section 370c as follows:
 



    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)

    Sec. 370c. Mental and emotional disorders. 

    (a)(1) On and after the effective date of this amendatory 
Act of the 97th General Assembly,
every insurer which 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 offer 
to the
applicant or group policyholder subject to the insurer's 
standards of
insurability, coverage for reasonable and 
necessary treatment and services
for mental, emotional or 
nervous disorders or conditions, other than serious
mental 
illnesses as defined in item (2) of subsection (b), 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 Illinois 
Alcoholism and Other Drug Abuse and Dependency Act of
his 
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 Illinois 
Alcoholism and Other Drug Abuse and Dependency 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 Illinois Alcoholism and Other Drug Abuse and 
Dependency Act is
authorized to provide said services under the 
statutes of this State and in
accordance with accepted 
principles of his 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 Illinois 
Alcoholism and Other Drug Abuse and Dependency 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 Illinois Alcoholism and Other Drug Abuse and 
Dependency Act has informed the patient of the
desirability of 
the patient conferring with the patient's primary care

physician and 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 Illinois Alcoholism and Other Drug Abuse and 
Dependency Act has
provided written
notification to the 
patient's primary care physician, if any, that services
are 
being provided to the patient.  That notification may, however, 
be
waived by the patient on a written form.  Those forms shall 
be retained by
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 Illinois Alcoholism and Other Drug Abuse and 
Dependency Act
for a period of not less than 5 years.

    (b)(1) An insurer that provides coverage for hospital or 
medical
expenses under a group or individual policy of accident 
and health insurance or
health care plan amended, delivered, 
issued, or renewed on or after the effective
date of this 
amendatory Act of the 100th General Assembly shall provide 
coverage
under the policy for treatment of serious mental 
illness and substance use disorders consistent with the parity 
requirements of Section 370c.1 of this Code.  This subsection 
does not apply to any group policy of accident and health 
insurance or health care plan for any plan year of a small 
employer as defined in Section 5 of the Illinois Health 
Insurance Portability and Accountability Act.

    (2) "Serious mental illness" means the following 
psychiatric illnesses as
defined in the most current edition of 
the Diagnostic and Statistical Manual
(DSM) published by the 
American Psychiatric Association:

        (A) schizophrenia;

        (B) paranoid and other psychotic disorders;

        (C) bipolar disorders (hypomanic, manic, depressive, 
    and mixed);

        (D) major depressive disorders (single episode or 
    recurrent);

        (E) schizoaffective disorders (bipolar or depressive);

        (F) pervasive developmental disorders;

        (G) obsessive-compulsive disorders;

        (H) depression in childhood and adolescence;

        (I) panic disorder;
        (J) post-traumatic stress disorders (acute, chronic, 
    or with delayed onset); and

        (K) eating disorders, including, but not limited to, 
    anorexia nervosa, bulimia nervosa, pica, rumination 
    disorder, avoidant/restrictive food intake disorder, other 
    specified feeding or eating disorder (OSFED), and any other 
    eating disorder contained in the most recent version of the 
    Diagnostic and Statistical Manual of Mental Disorders 
    published by the American Psychiatric Association.
    (2.5) "Substance use disorder" means the following mental 
disorders as defined in the most current edition of the 
Diagnostic and Statistical Manual (DSM) published by the 
American Psychiatric Association: 
        (A) substance abuse disorders;
        (B) substance dependence disorders; and
        (C) substance induced disorders.
    (3) Unless otherwise prohibited by federal law and 
consistent with the parity requirements of Section 370c.1 of 
this Code, the reimbursing insurer, a provider of treatment of

serious mental illness or  substance use disorder 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 serious 
mental illness or  substance use disorder, 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 the effective date of this amendatory 
Act of the 97th General Assembly:

        (A) shall provide coverage based upon medical 
    necessity for the
treatment of mental illness and substance 
    use disorders 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:

            (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
            (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


        (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.

        (C) (Blank).

    (5) An issuer of a group health benefit plan 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 the effective date of 
this amendatory Act of the 99th General Assembly 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 American Society of Addiction 
Medicine Patient Placement Criteria.
    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.

    (7) (Blank).



    (8)
(Blank).

    (9) With respect to substance use disorders, coverage for 
inpatient treatment shall include coverage for treatment in a 
residential treatment center 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)  The Department shall enforce the requirements of State 
and federal parity law, which includes ensuring compliance by 
individual and group policies; detecting violations of the law 
by individual and group policies proactively monitoring 
discriminatory practices; accepting, evaluating, and 
responding to complaints regarding such violations; and 
ensuring violations are appropriately remedied and deterred.
    (e) Availability of plan information. 
        (1) The criteria for medical necessity determinations 
    made under a group health plan 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. 
        (2) The reason for any denial under a group health plan 
    (or health insurance coverage offered in connection with 
    such plan) of reimbursement or payment for services with 
    respect to mental health or substance use disorder benefits 
    in the case of any participant or beneficiary must be made 
    available within a reasonable time and in a reasonable 
    manner by the plan administrator (or the health insurance 
    issuer offering such coverage) to the participant or 
    beneficiary upon request. 
    (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 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 the 
effective date of this amendatory Act of the 100th General 
Assembly 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. Under this subsection, a request for expedited 
external review must be initiated within 24 hours following the 
adverse determination notification by the insurer.  Failure to 
request an expedited external review within 24 hours shall 
preclude a covered person or a covered person's authorized 
representative from requesting an expedited external review. 
    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. 
(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
 

    Section 99. Effective date. This Act takes effect January 
1, 2019.