102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB2381

 

Introduced 2/26/2021, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.36

    Amends the Illinois Insurance Code. In provisions concerning development of medical necessity criteria for coverage of treatment models for early treatment of serious mental illnesses, provides that the rule adopted by the Department of Insurance that defines medical necessity for each of the treatment models shall be updated during calendar year 2021 to include nationally recognized, generally acceptable clinical criteria sourced to evidence-based medicine and to avoid unnecessary anti-competitive impacts.


LRB102 12039 BMS 17375 b

 

 

A BILL FOR

 

SB2381LRB102 12039 BMS 17375 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5renumbering and changing Section 356z.33 as added by Public
6Act 101-461 as follows:
 
7    (215 ILCS 5/356z.36)
8    Sec. 356z.36 356z.33. Coverage of treatment models for
9early treatment of serious mental illnesses.
10    (a) For purposes of early treatment of a serious mental
11illness in a child or young adult under age 26, a group or
12individual policy of accident and health insurance, or managed
13care plan, that is amended, delivered, issued, or renewed
14after December 31, 2020 shall provide coverage of the
15following bundled, evidence-based treatment:
16        (1) Coordinated specialty care for first episode
17    psychosis treatment, covering the elements of the
18    treatment model included in the most recent national
19    research trials conducted by the National Institute of
20    Mental Health in the Recovery After an Initial
21    Schizophrenia Episode (RAISE) trials for psychosis
22    resulting from a serious mental illness, but excluding the
23    components of the treatment model related to education and

 

 

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1    employment support.
2        (2) Assertive community treatment (ACT) and community
3    support team (CST) treatment. The elements of ACT and CST
4    to be covered shall include those covered under Article V
5    of the Illinois Public Aid Code, through 89 Ill. Adm. Code
6    140.453(d)(4).
7    (b) Adherence to the clinical models. For purposes of
8ensuring adherence to the coordinated specialty care for first
9episode psychosis treatment model, only providers contracted
10with the Department of Human Services' Division of Mental
11Health to be FIRST.IL providers to deliver coordinated
12specialty care for first episode psychosis treatment shall be
13permitted to provide such treatment in accordance with this
14Section and such providers must adhere to the fidelity of the
15treatment model. For purposes of ensuring fidelity to ACT and
16CST, only providers certified to provide ACT and CST by the
17Department of Human Services' Division of Mental Health and
18approved to provide ACT and CST by the Department of
19Healthcare and Family Services, or its designee, in accordance
20with 89 Ill. Adm. Code 140, shall be permitted to provide such
21services under this Section and such providers shall be
22required to adhere to the fidelity of the models.
23    (c) Development of medical necessity criteria for
24coverage. Within 6 months after January 1, 2020 (the effective
25date of Public Act 101-461) this amendatory Act of the 101st
26General Assembly, the Department of Insurance shall lead and

 

 

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1convene a workgroup that includes the Department of Human
2Services' Division of Mental Health, the Department of
3Healthcare and Family Services, providers of the treatment
4models listed in this Section, and insurers operating in
5Illinois to develop medical necessity criteria for such
6treatment models for purposes of coverage under this Section.
7The workgroup shall use the medical necessity criteria the
8State and other states use as guidance for establishing
9medical necessity for insurance coverage. The Department of
10Insurance shall adopt a rule that defines medical necessity
11for each of the 3 treatment models listed in this Section by no
12later than June 30, 2020 based on the workgroup's
13recommendations. The rule shall be updated during calendar
14year 2021 to include nationally recognized, generally
15acceptable clinical criteria sourced to evidence-based
16medicine and to avoid unnecessary anti-competitive impacts.
17    (d) For purposes of credentialing the mental health
18professionals and other medical professionals that are part of
19a coordinated specialty care for first episode psychosis
20treatment team, an ACT team, or a CST team, the credentialing
21of the psychiatrist or the licensed clinical leader of the
22treatment team shall qualify all members of the treatment team
23to be credentialed with the insurer.
24    (e) Payment for the services performed under the treatment
25models listed in this Section shall be based on a bundled
26treatment model or payment, rather than payment for each

 

 

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1separate service delivered by a treatment team member. By no
2later than 6 months after January 1, 2020 (the effective date
3of Public Act 101-461) this amendatory Act of the 101st
4General Assembly, the Department of Insurance shall convene a
5workgroup of Illinois insurance companies and Illinois mental
6health treatment providers that deliver the bundled treatment
7approaches listed in this Section to determine a coding
8solution that allows for these bundled treatment models to be
9coded and paid for as a bundle of services, similar to
10intensive outpatient treatment where multiple services are
11covered under one billing code or a bundled set of billing
12codes. The coding solution shall ensure that services
13delivered using coordinated specialty care for first episode
14psychosis treatment, ACT, or CST are provided and billed as a
15bundled service, rather than for each individual service
16provided by a treatment team member, which would deconstruct
17the evidence-based practice. The coding solution shall be
18reached prior to coverage, which shall begin for plans
19amended, delivered, issued, or renewed after December 31,
202020, to ensure coverage of the treatment team approaches as
21intended by this Section.
22    (f) If, at any time, the Secretary of the United States
23Department of Health and Human Services, or its successor
24agency, adopts rules or regulations to be published in the
25Federal Register or publishes a comment in the Federal
26Register or issues an opinion, guidance, or other action that

 

 

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1would require the State, under any provision of the Patient
2Protection and Affordable Care Act (P.L. 111-148), including,
3but not limited to, 42 U.S.C. 18031(d)(3)(b), or any successor
4provision, to defray the cost of any coverage for serious
5mental illnesses or serious emotional disturbances outlined in
6this Section, then the requirement that a group or individual
7policy of accident and health insurance or managed care plan
8cover the bundled treatment approaches listed in this Section
9is inoperative other than any such coverage authorized under
10Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
11the State shall not assume any obligation for the cost of the
12coverage.
13    (g) After 5 years following full implementation of this
14Section, if requested by an insurer, the Department of
15Insurance shall contract with an independent third party with
16expertise in analyzing health insurance premiums and costs to
17perform an independent analysis of the impact coverage of the
18team-based treatment models listed in this Section has had on
19insurance premiums in Illinois. If premiums increased by more
20than 1% annually solely due to coverage of these treatment
21models, coverage of these models shall no longer be required.
22    (h) The Department of Insurance shall adopt any rules
23necessary to implement the provisions of this Section by no
24later than June 30, 2020.
25(Source: P.A. 101-461, eff. 1-1-20; revised 10-16-19.)