SB2440 100TH GENERAL ASSEMBLY

LRB100 16053 SMS 31172 b

100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB2440

Introduced 1/30/2018, by Sen. Julie A. Morrison

SYNOPSIS AS INTRODUCED:

215 ILCS 5/370c.1

Amends the Illinois Insurance Code. Provides than an insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan that provides coverage for hospital or medical treatment and for treatment of a mental, emotional, nervous, or substance use disorder or condition shall submit an annual report to the Department of Insurance or, with respect to medical assistance, the Department of Healthcare and Family Services on or before March 1 containing specific information. Provides that the Director of Insurance cannot certify an insurer's policy if the insurer fails to submit all specific information required.

A BILL FOR

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.1 as follows:

(215 ILCS 5/370c.1)

Sec. 370c.1. Mental health and addiction parity.

(a) On and after the effective date of this amendatory Act of the 99th General Assembly, 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 providing coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions shall ensure that:

(1) the financial requirements applicable to such mental, emotional, nervous, or substance use disorder or condition benefits are no more restrictive than the predominant financial requirements applied to substantially all hospital and medical benefits covered by the policy and that there are no separate cost-sharing requirements that are applicable only with respect to mental, emotional, nervous, or substance use disorder or condition benefits; and

(2) the treatment limitations applicable to such mental, emotional, nervous, or substance use disorder or condition benefits are no more restrictive than the predominant treatment limitations applied to substantially all hospital and medical benefits covered by the policy and that there are no separate treatment limitations that are applicable only with respect to mental, emotional, nervous, or substance use disorder or condition benefits.

(b) The following provisions shall apply concerning aggregate lifetime limits:

(1) In the case of a group or individual policy of accident and health insurance or a qualified health plan offered through the Health Insurance Marketplace amended, delivered, issued, or renewed in this State on or after the effective date of this amendatory Act of the 99th General Assembly that provides coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions the following provisions shall apply:

(A) if the policy does not include an aggregate lifetime limit on substantially all hospital and medical benefits, then the policy may not impose any aggregate lifetime limit on mental, emotional, nervous, or substance use disorder or condition benefits; or

(B) if the policy includes an aggregate lifetime limit on substantially all hospital and medical benefits (in this subsection referred to as the "applicable lifetime limit"), then the policy shall either:

(i) apply the applicable lifetime limit both to the hospital and medical benefits to which it otherwise would apply and to mental, emotional, nervous, or substance use disorder or condition benefits and not distinguish in the application of the limit between the hospital and medical benefits and mental, emotional, nervous, or substance use disorder or condition benefits; or

(ii) not include any aggregate lifetime limit on mental, emotional, nervous, or substance use disorder or condition benefits that is less than the applicable lifetime limit.

(2) In the case of a policy that is not described in paragraph (1) of subsection (b) of this Section and that includes no or different aggregate lifetime limits on different categories of hospital and medical benefits, the Director shall establish rules under which subparagraph (B) of paragraph (1) of subsection (b) of this Section is applied to such policy with respect to mental, emotional, nervous, or substance use disorder or condition benefits by substituting for the applicable lifetime limit an average aggregate lifetime limit that is computed taking into account the weighted average of the aggregate lifetime limits applicable to such categories.

(c) The following provisions shall apply concerning annual limits:

(1) In the case of a group or individual policy of accident and health insurance or a qualified health plan offered through the Health Insurance Marketplace amended, delivered, issued, or renewed in this State on or after the effective date of this amendatory Act of the 99th General Assembly that provides coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions the following provisions shall apply:

(A) if the policy does not include an annual limit on substantially all hospital and medical benefits, then the policy may not impose any annual limits on mental, emotional, nervous, or substance use disorder or condition benefits; or

(B) if the policy includes an annual limit on substantially all hospital and medical benefits (in this subsection referred to as the "applicable annual limit"), then the policy shall either:

(i) apply the applicable annual limit both to the hospital and medical benefits to which it otherwise would apply and to mental, emotional, nervous, or substance use disorder or condition benefits and not distinguish in the application of the limit between the hospital and medical benefits and mental, emotional, nervous, or substance use disorder or condition benefits; or

(ii) not include any annual limit on mental, emotional, nervous, or substance use disorder or condition benefits that is less than the applicable annual limit.

(2) In the case of a policy that is not described in paragraph (1) of subsection (c) of this Section and that includes no or different annual limits on different categories of hospital and medical benefits, the Director shall establish rules under which subparagraph (B) of paragraph (1) of subsection (c) of this Section is applied to such policy with respect to mental, emotional, nervous, or substance use disorder or condition benefits by substituting for the applicable annual limit an average annual limit that is computed taking into account the weighted average of the annual limits applicable to such categories.

(d) With respect to substance use disorders, an insurer shall use policies and procedures for the election and placement of substance abuse treatment drugs on their formulary that are no less favorable to the insured as those policies and procedures the insurer uses for the selection and placement of other drugs and shall follow the expedited coverage determination requirements for substance abuse treatment drugs set forth in Section 45.2 of the Managed Care Reform and Patient Rights Act.

(e) This Section shall be interpreted in a manner consistent with all applicable federal parity regulations including, but not limited to, the Mental Health Parity and Addiction Equity Act of 2008 at 78 FR 68240.

(f) The provisions of subsections (b) and (c) of this Section shall not be interpreted to allow the use of lifetime or annual limits otherwise prohibited by State or federal law.

(g) As used in this Section:

"Financial requirement" includes deductibles, copayments, coinsurance, and out-of-pocket maximums, but does not include an aggregate lifetime limit or an annual limit subject to subsections (b) and (c).

"Treatment limitation" includes limits on benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment. "Treatment limitation" includes both quantitative treatment limitations, which are expressed numerically (such as 50 outpatient visits per year), and nonquantitative treatment limitations, which otherwise limit the scope or duration of treatment. A permanent exclusion of all benefits for a particular condition or disorder shall not be considered a treatment limitation. "Nonquantitative treatment" means those limitations as described under federal regulations (26 CFR 54.9812-1).

(h) The Department of Insurance shall implement the following education initiatives:

(1) By January 1, 2016, the Department shall develop a plan for a Consumer Education Campaign on parity. The Consumer Education Campaign shall focus its efforts throughout the State and include trainings in the northern, southern, and central regions of the State, as defined by the Department, as well as each of the 5 managed care regions of the State as identified by the Department of Healthcare and Family Services. Under this Consumer Education Campaign, the Department shall: (1) by January 1, 2017, provide at least one live training in each region on parity for consumers and providers and one webinar training to be posted on the Department website and (2) establish a consumer hotline to assist consumers in navigating the parity process by March 1, 2016. By January 1, 2018 the Department shall issue a report to the General Assembly on the success of the Consumer Education Campaign, which shall indicate whether additional training is necessary or would be recommended.

(2) The Department, in coordination with the Department of Human Services and the Department of Healthcare and Family Services, shall convene a working group of health care insurance carriers, mental health advocacy groups, substance abuse patient advocacy groups, and mental health physician groups for the purpose of discussing issues related to the treatment and coverage of substance abuse disorders and mental illness. The working group shall meet once before January 1, 2016 and shall meet semiannually thereafter. The Department shall issue an annual report to the General Assembly that includes a list of the health care insurance carriers, mental health advocacy groups, substance abuse patient advocacy groups, and mental health physician groups that participated in the working group meetings, details on the issues and topics covered, and any legislative recommendations.

(i) The Parity Education Fund is created as a special fund in the State treasury. Moneys deposited into the Fund for appropriation by the General Assembly to the Department of Insurance shall be used for the purpose of providing financial support of the Consumer Education Campaign.

(j) 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 for the treatment of mental, emotional, nervous, or substance use disorders or conditions shall submit an annual report to the Department or, with respect to medical assistance, the Department of Healthcare and Family Services on or before March 1 that contains the following information separately for inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, emergency care benefits, and prescription drug benefits in the case of accident and health insurance or qualified health plans, or inpatient, outpatient, emergency care, and prescription drug benefits in the case of medical assistance:

(1) The number and percentage of times a benefit limit is exceeded for a mental, emotional, nervous, or substance use disorder or condition benefit and the number and percentage of times a benefit limit is exceeded for other medical benefits.

(2) The number and percentage of times a co-pay or co-insurance limit for a mental, emotional, nervous, or substance use disorder or condition benefit is different from other medical benefits.

(3) The number and percentage of claim denials for mental, emotional, nervous, or substance use disorder or condition benefits due to benefit limits and the number and percentage of claim denials for other medical benefits due to benefit limits.

(4) The number and percentage of denials for experimental benefits or the use of unproven technology for a mental, emotional, nervous, or substance use disorder or condition benefit and the number and percentage of denials for experimental benefits or the use of unproven technology for other medical benefits.

(5) The number and percentage of administrative denials for no prior authorization for a mental, emotional, nervous, or substance use disorder or condition benefit and the number and percentage of administrative denials for no prior authorization for other medical benefits.

(6) The number and percentage of denials due to a mental, emotional, nervous, or substance use disorder or condition benefit not being a covered benefit and the number and percentage of denials for other medical benefits not being a covered benefit.

(7) The number and percentage of denials due to a mental, emotional, nervous, or substance use disorder or condition benefit not meeting medical necessity and the number and percentage of denials for other medical benefits not meeting medical necessity.

(8) The number and percentage of denials upheld on appeal for a mental, emotional, nervous, or substance use disorder or condition benefit for not meeting medical necessity and the number and percentage of those for other medical benefits.

(9) The number and percentage of denials due to a mental, emotional, nervous, or substance use disorder or condition benefit being denied administratively or any reason other than medical necessity.

(10) The number and percentage of denials of mental, emotional, nervous, or substance use disorder or condition benefits that went to the plan's external quality review organization, or similar reviewing body and were upheld and those that were overturned for medical necessity.

(11) The number and percentage of continued stay review denials for mental, emotional, nervous, or substance use disorder or condition benefits.

(12) The number and percentage of out-of-network claims for mental, emotional, nervous, or substance use disorder or condition benefits in each classification of benefits and the number and percentage of out-of-network claims for other medical benefits in each classification of benefits.

(13) The number and percentage of emergency care claims for mental, emotional, nervous, or substance use disorder or condition benefits in each classification of benefits and the number and percentage of emergency care claims for other medical benefits in each classification of benefits.

(14) The number and percentage of network directory providers in the outpatient benefits classification who filed no claims in the last 6 months of the plan's claims reporting period and all pertinent summary information and results respecting the tests and metrics the insurer used to assess the availability of each of the following types of mental, emotional, nervous, or substance use disorder or condition providers: MD/DO; doctoral level non-MD/DO and non-doctoral level non-MD/DO practitioners; and inpatient, residential, and ambulatory provider organizations.

(15) A summary of the plan's pharmacy management processes for mental, emotional, nervous, or substance use disorder or condition benefits compared to those for other medical benefits.

(16) A summary of the internal processes of review for experimental benefits and unproven technology for mental, emotional, nervous, or substance use disorder or condition benefits and those for other medical benefits.

(17) A summary of how the plan's policies and procedures for utilization management for mental, emotional, nervous, or substance use disorder or condition benefits compare to those for other medical benefits.

(18) The results of an analysis that demonstrates that for each nonquantitative treatment limitation, as written and in operation, the processes, strategies, evidentiary standards, or other factors used to apply each nonquantitative treatment limitation to mental, emotional, nervous, or substance use disorder or condition benefits are comparable to, and are applied no more stringently than the processes, strategies, evidentiary standards, or other factors used to apply each nonquantitative treatment limitation, as written and in operation, to medical and surgical benefits; at a minimum, the results of the analysis shall:

(A) identify the factors used to determine that a nonquantitative treatment limitation will apply to a benefit, including factors that were considered but rejected;

(B) identify and define the specific evidentiary standards used to define the factors and any other evidentiary standards relied upon in designing each nonquantitative treatment limitation;

(C) identify and describe the methods and analyses used, including the results of the analyses, to determine that the processes and strategies used to design each nonquantitative treatment limitation as written for mental, emotional, nervous, or substance use disorders or conditions benefits are comparable to and no more stringent than the processes and strategies used to design each nonquantitative treatment limitation as written for medical and surgical benefits;

(D) identify and describe the methods and analyses used, including the results of the analyses, to determine that the processes and strategies used to apply each nonquantitative treatment limitation in operation for mental, emotional, nervous, or substance use disorders or conditions benefits are comparable to and no more stringent than the processes or strategies used to apply each nonquantitative treatment limitation in operation for medical and surgical benefits; and

(E) disclose the specific findings and conclusions reached by the insurer that the results of the analyses above indicate that the insurer is in compliance with this Section and the Mental Health Parity and Addiction Equity Act of 2008 and its implementing regulations, which includes 45 CFR 146.136 and any other relevant current or future regulations.

(19) A certification signed by the insurer's chief executive officer and chief medical officer that states that the insurer has completed a comprehensive review of the administrative practices of the insurer for the prior calendar year for compliance with the necessary provisions of this Section and Sections 356z.23 and 370c of this Code, the federal 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.

(20) Any other information necessary to clarify data provided in accordance with this Section requested by the Director, including information that may be proprietary or have commercial value.

The Director shall not certify any policy of an insurer that fails to submit all data as required by this Section.

(Source: P.A. 99-480, eff. 9-9-15.)