HB5557 104TH GENERAL ASSEMBLY

LRB104 20200 BAB 33651 b

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB5557

Introduced 2/13/2026, by Rep. Maura Hirschauer

SYNOPSIS AS INTRODUCED:

215 ILCS 5/355.8 new

Amends the Illinois Insurance Code. Contains findings. Requires each health carrier to annually submit completed templates with both plan-level and carrier-level data to the Director of Insurance in the form, manner, and time prescribed by the Director by no later than July 1 of each year for data from the previous calendar year. Provides that data must be sufficient to support independent technical evaluation and to enable meaningful public understanding of access to and coverage for each facility type and specified professional provider type. Requires each health carrier to report, disaggregated by facility type, professional provider type, youth, adult, in-person, and telehealth, the specified data elements. Requires the Director to post, in an easily accessible, consumer-friendly manner, on a public website, all underlying data and data files reported no later than 3 months after receipt. Sets forth provisions concerning certification of health carriers and administration and enforcement of the provisions. Provides that the data submission requirements apply to health benefit plans issued or renewed on or after January 1, 2027. Effective immediately.

A BILL FOR

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 Truth in Mental Health Coverage Act.

Section 2. Findings. The General Assembly finds that:

(1) Analyses by Milliman (2017, 2019) and RTI International (2024) demonstrate that, over multiple years, Illinois residents have experienced substantially greater difficulty accessing in-network mental health and substance use disorder services than accessing medical or surgical services.

(2) In 2021, Illinois residents were 90% more likely to receive outpatient behavioral health services out of network than outpatient medical or surgical services; 190% percent more likely to receive outpatient facility behavioral health services out of network; and 350% more likely to receive inpatient behavioral health services out of network.

(3) In Illinois, average in-network reimbursement in 2021 for medical or surgical clinicians was 21%higher than for behavioral health clinicians, indexed to Medicare reimbursement. This gap discourages behavioral health clinicians from joining insurance networks and further limits access to care for enrollees. More recent Illinois-specific data are unavailable due to the absence of standardized public reporting requirements.

(4) Federal regulators have cited the RTI International data as evidence of the need for greater accountability and transparency by health plans and issuers.

(5) Youth face even greater barriers to access due to health benefit plans' narrow networks that lack sufficient child and adolescent behavioral health providers.

(6) Independent economic analyses by McKinsey & Company show that individuals with behavioral health diagnoses incur between 2 times and 4 times higher total medical costs than those without such diagnoses, largely because untreated behavioral health conditions worsen physical health outcomes. Analyses by Milliman show that individuals with behavioral health diagnoses incur between 3.2 times and 6.2 times higher medical costs. Earlier access to effective treatment reduces these downstream costs.

(7) Transparent, comparable information on coverage and access, including information maintained on a public dashboard, is an essential regulatory function necessary to effectuate compliance with State insurance laws, protect consumers and employers as informed purchasers, and reduce the higher downstream medical costs associated with untreated mental health and substance use disorders.

Section 5. The Illinois Insurance Code is amended by adding Section 355.8 as follows:

(215 ILCS 5/355.8 new)

Sec. 355.8. Truth in mental health coverage reporting requirements.

(a) In this Section:

"Adult" means an individual 18 years of age or older.

"Facility type" means categories of facilities and levels of care in which mental health disorder services, substance use disorder services, behavioral health services, or medical or surgical services are delivered, including outpatient facilities such as intensive outpatient programs, partial hospitalization programs, and outpatient surgery facilities, acute inpatient facilities, and subacute inpatient facilities such as residential and skilled nursing facilities.

"Health benefit plan" has the meaning given to that term in Section 370c of this Code.

"Health carrier" has the meaning given to that term in Section 370c of this Code.

"Mental health and substance use disorders" means mental, emotional, nervous, or substance use disorders, as that term is used in Section 370c of this Code.

"Mental health disorders" means mental, emotional, or nervous disorders other than substance use disorders, as classified in the mental and behavioral disorders chapters of the most current version of the International Classification of Diseases and the mental disorder diagnostic categories of the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Medical or surgical disorders" means all physical health conditions or diseases that are not mental health disorders or substance use disorders.

"Medical or surgical services" means health care services or benefits for the diagnosis or treatment of medical or surgical disorders.

"Out-of-network allowed claims" means claims allowed at the out-of-network benefit level, with corresponding enrollee cost-sharing, rather than the in-network benefit level.

"Plan level" means a carrier's product or health benefit plan, as defined by the Director for purposes of public comparison.

"Professional provider type" means categories of health care professionals that furnish mental health disorder services, substance use disorder services, behavioral health services, or medical or surgical services in an office setting, including, but not limited to, psychiatrists, psychologists, psychiatric nurse practitioners, other independently licensed behavioral health clinicians, primary care physicians, medical or surgical specialist physicians, physician assistants, and medical or surgical nurse practitioners, and includes youth-serving providers.

"Substance use disorders" means disorders classified in the substance-related and addictive disorders chapters of the most current version of the International Classification of Diseases and the substance-related and addictive disorders diagnostic categories of the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

"Templates" means Microsoft Excel or similar documents containing embedded formulas for quantitative data using definitions and instructions specified by the Director.

"Utilization review" has the meaning given to that term in Section 370c of this Code.

"Youth" means an individual under 18 years of age.

(b)(1) Each health carrier shall annually submit completed templates with both plan-level and carrier-level data to the Director in the form, manner, and time prescribed by the Director by no later than July 1 of each year for data from the previous calendar year.

(2) Data must be sufficient to support independent technical evaluation and to enable meaningful public understanding of access to and coverage for each facility type and professional provider type of:

(A) mental health disorder services;

(B) substance use disorder services;

(C) behavioral health services;

(D) medical or surgical services;

(E) youth and adult services, separately and combined;

(F) in-person and telehealth services, separately and combined;

(G) geographic area, as specified by the Director; and

(H) whether the facility or professional provider is affiliated with, owned by, or under common control with the health carrier.

(3) Any data cell containing fewer than 11 enrollees must be suppressed consistent with Centers for Medicare and Medicaid Services cell-suppression standards.

(c) Each health carrier shall report, disaggregated by facility type, professional provider type, youth, adult, in-person, and telehealth:

(1) utilization review, including the number and percentage of approvals, modified approvals, denials, and partial denials, average decision timeframes, top denial reasons, and other measures specified by the Director to assess the effects of utilization review on access to timely, clinically appropriate care;

(2) out-of-network utilization rates using allowed claims data;

(3) in-network reimbursement, including average allowed amounts and allowed amounts at the 50th, 75th, and 95th percentiles, each indexed to Medicare;

(4) the number of unique enrollees served by listed in-network professional providers, including youth-serving providers;

(5) the percentage of listed in-network providers relative to State-licensed providers of the same type, including youth-serving providers;

(6) network admission evaluation, including the average time from completed application to network admission for each facility and professional provider type, including youth-serving facilities and professional providers;

(7) psychiatric Collaborative Care Model data, including the number of enrollees, pediatric and adult collaborative care separately, penetration rate per 100,000 covered lives with a behavioral health diagnosis, and reimbursement indexed to Medicare;

(8) appeals and external review, including counts and outcomes of adverse benefit determinations and independent review decisions; and

(9) additional metrics the Director determines necessary for public comparison or oversight.

(d) In specifying the templates, the Director shall review formats that are:

(1) used by state insurance regulators;

(2) endorsed and used by one or more employer coalitions, human resources associations, or mental health nonprofit organizations; and

(3) cited by the United States Department of Labor or the United States Department of Health and Human Services.

(e)(1) The Director shall post, in an easily accessible, consumer-friendly manner, on a public website, all underlying data and data files reported under this Section no later than 3 months after receipt.

(2) The posting must include raw data and downloadable files in a machine-readable format to permit public analysis, research, and independent comparison.

(3) Data must be posted separately for the plan level and aggregated at the carrier level.

(4) Information collected under this Section is not proprietary or confidential and must be publicly disclosed, subject only to cell-suppression standards.

(f)(1) The Director shall maintain an interactive public dashboard that visually presents the posted data, including separate display of youth and adult outcomes, and allows comparison across plans and carriers.

(2) The dashboard must allow users to view metrics for mental health disorder services, substance use disorder services, behavioral health services, and medical or surgical services, separately and combined.

(3) The dashboard must be updated no later than 3 months after receipt of the data.

(g) Each health carrier shall submit a certification, in a form and manner specified by the Director, signed under penalty of perjury by the chief financial officer of the carrier, stating that the reported data are complete and accurate and follow template definitions and instructions.

(h)(1) The Director shall adopt uniform templates, definitions, audit procedures, and correction protocols to ensure comparability across carriers and over time. The Director may satisfy reporting requirements under this Section by using data already collected or maintained by the Department for any regulatory, oversight, or enforcement purpose. Data used or incorporated for purposes of this Section is deemed collected for public reporting and must be made available in accordance with this Section.

(2) The Director may adopt rules to carry out this Section.

(3) Each health carrier must retain all data underlying the reported information for at least 3 years and make such records available to the Director upon request.

(i) A health carrier's failure to comply with this Section constitutes an unfair or deceptive act or practice under this Code and is subject to enforcement by the Director, including referral to the Attorney General.

(j) The costs of implementing and administering this Act shall be paid from the Insurance Producer Administration Fund or another appropriate regulatory fund administered by the Department, and such costs shall reflect the actual and reasonable costs incurred by the Department in administering, overseeing, and enforcing this Section with respect to health carriers subject to this Section.

(k) This Section applies to health benefit plans issued or renewed on or after January 1, 2027.

(l) The provisions of this Section are severable under Section 1.31 of the Statute on Statutes.

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