Public Act 101-0386
 
HB2438 EnrolledLRB101 08404 RAB 53474 b


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


 
    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 101st General Assembly this amendatory Act of the 
100th General Assembly,
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 
reasonable and necessary treatment and services
for 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 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 Substance Use Disorder 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 Substance Use Disorder 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 Substance 
Use Disorder 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 Substance Use Disorder 
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.

    (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 
International Classification of Disease or that is listed in 
the most recent version of the 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. 
    (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) this amendatory Act of the 100th General 
Assembly 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) this amendatory Act of the 100th General Assembly:

        (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:

            (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 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) 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 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) this amendatory Act of 
the 100th General Assembly: 
        (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;
        (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;
        (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
        (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.
    (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;
        (2) evaluating all consumer or provider complaints 
    regarding mental, emotional, nervous, or substance use 
    disorder or condition coverage for possible parity 
    violations;
        (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:
            (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;
            (B) denials of authorization, payment, and 
        coverage; and
            (C) other specific criteria as may be determined by 
        the Department.
    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. 
        (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. 
    (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) 
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; 
100-1023, eff. 1-1-19;  100-1024, eff. 1-1-19; revised 
10-18-18.)
 

    Section 99. Effective date. This Act takes effect upon 
becoming law.