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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The State Employees Group Insurance Act of 1971 | |||||||||||||||||||||||||||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | (Text of Section before amendment by P.A. 102-768 ) | |||||||||||||||||||||||||||||||
8 | Sec. 6.11. Required health benefits; Illinois Insurance | |||||||||||||||||||||||||||||||
9 | Code
requirements. The program of health
benefits shall | |||||||||||||||||||||||||||||||
10 | provide the post-mastectomy care benefits required to be | |||||||||||||||||||||||||||||||
11 | covered
by a policy of accident and health insurance under | |||||||||||||||||||||||||||||||
12 | Section 356t of the Illinois
Insurance Code. The program of | |||||||||||||||||||||||||||||||
13 | health benefits shall provide the coverage
required under | |||||||||||||||||||||||||||||||
14 | Sections 356g, 356g.5, 356g.5-1, 356m, 356q,
356u, 356w, 356x, | |||||||||||||||||||||||||||||||
15 | 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | |||||||||||||||||||||||||||||||
16 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, | |||||||||||||||||||||||||||||||
17 | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | |||||||||||||||||||||||||||||||
18 | 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | |||||||||||||||||||||||||||||||
19 | 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, and 356z.60 of | |||||||||||||||||||||||||||||||
20 | the
Illinois Insurance Code.
The program of health benefits | |||||||||||||||||||||||||||||||
21 | must comply with Sections 155.22a, 155.37, 355b, 356z.19, | |||||||||||||||||||||||||||||||
22 | 370c, and 370c.1 and Article XXXIIB of the
Illinois Insurance | |||||||||||||||||||||||||||||||
23 | Code. The Department of Insurance shall enforce the |
| |||||||
| |||||||
1 | requirements of this Section with respect to Sections 370c and | ||||||
2 | 370c.1 of the Illinois Insurance Code; all other requirements | ||||||
3 | of this Section shall be enforced by the Department of Central | ||||||
4 | Management Services.
| ||||||
5 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
6 | any, is conditioned on the rules being adopted in accordance | ||||||
7 | with all provisions of the Illinois Administrative Procedure | ||||||
8 | Act and all rules and procedures of the Joint Committee on | ||||||
9 | Administrative Rules; any purported rule not so adopted, for | ||||||
10 | whatever reason, is unauthorized. | ||||||
11 | (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20; | ||||||
12 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
13 | 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103, | ||||||
14 | eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; | ||||||
15 | 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. | ||||||
16 | 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, | ||||||
17 | eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; | ||||||
18 | revised 12-13-22.) | ||||||
19 | (Text of Section after amendment by P.A. 102-768 ) | ||||||
20 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
21 | Code
requirements. The program of health
benefits shall | ||||||
22 | provide the post-mastectomy care benefits required to be | ||||||
23 | covered
by a policy of accident and health insurance under | ||||||
24 | Section 356t of the Illinois
Insurance Code. The program of | ||||||
25 | health benefits shall provide the coverage
required under |
| |||||||
| |||||||
1 | Sections 356g, 356g.5, 356g.5-1, 356m, 356q,
356u, 356w, 356x, | ||||||
2 | 356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
3 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, | ||||||
4 | 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33, | ||||||
5 | 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, | ||||||
6 | 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, and | ||||||
7 | 356z.60 , and 356z.61 of the
Illinois Insurance Code.
The | ||||||
8 | program of health benefits must comply with Sections 155.22a, | ||||||
9 | 155.37, 355b, 356z.19, 370c, and 370c.1 , and 370c.3 and | ||||||
10 | Article XXXIIB of the
Illinois Insurance Code. The Department | ||||||
11 | of Insurance shall enforce the requirements of this Section | ||||||
12 | with respect to Sections 370c and 370c.1 of the Illinois | ||||||
13 | Insurance Code; all other requirements of this Section shall | ||||||
14 | be enforced by the Department of Central Management Services.
| ||||||
15 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
16 | any, is conditioned on the rules being adopted in accordance | ||||||
17 | with all provisions of the Illinois Administrative Procedure | ||||||
18 | Act and all rules and procedures of the Joint Committee on | ||||||
19 | Administrative Rules; any purported rule not so adopted, for | ||||||
20 | whatever reason, is unauthorized. | ||||||
21 | (Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20; | ||||||
22 | 101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff. | ||||||
23 | 1-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103, | ||||||
24 | eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; | ||||||
25 | 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. | ||||||
26 | 1-1-23; 102-768, eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, |
| |||||||
| |||||||
1 | eff. 5-13-22; 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; | ||||||
2 | 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.) | ||||||
3 | Section 10. The Illinois Insurance Code is amended by | ||||||
4 | changing Sections 370c and 370c.1 and by adding Sections | ||||||
5 | 356z.61 and 370c.3 as follows: | ||||||
6 | (215 ILCS 5/356z.61 new) | ||||||
7 | Sec. 356z.61. Vision, hearing, and dental disorders. | ||||||
8 | (a) As used in this Section: | ||||||
9 | "Group policy of accident and health insurance" and "group | ||||||
10 | health benefit plan" includes (1) State-regulated | ||||||
11 | employer-sponsored group health insurance plans written in | ||||||
12 | Illinois or which purport to provide coverage for a resident | ||||||
13 | of this State; and (2) State employee health plans. | ||||||
14 | "Medically necessary treatment of vision, hearing, and | ||||||
15 | dental disorders or conditions" means a service or product | ||||||
16 | addressing the specific needs of that patient for the purpose | ||||||
17 | of screening, preventing, diagnosing, managing, or treating an | ||||||
18 | illness, injury, or condition or its symptoms and | ||||||
19 | comorbidities, including minimizing the progression of an | ||||||
20 | illness, injury, or condition or its symptoms and | ||||||
21 | comorbidities in a manner that is all of the following: | ||||||
22 | (1) in accordance with the generally accepted | ||||||
23 | standards of care; and | ||||||
24 | (2) not primarily for the economic benefit of the |
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| |||||||
1 | insurer, purchaser, or for the convenience of the patient, | ||||||
2 | treating physician, or other health care provider. | ||||||
3 | "Utilization review" means either of the following: | ||||||
4 | (1) Prospectively, retrospectively, or concurrently | ||||||
5 | reviewing and approving, modifying, delaying, or denying, | ||||||
6 | based in whole or in part on medical necessity, requests | ||||||
7 | by health care providers, insureds, or their authorized | ||||||
8 | representatives for coverage of health care services | ||||||
9 | before, retrospectively, or concurrently with the | ||||||
10 | provision of health care services to insureds. | ||||||
11 | (2) Evaluating the medical necessity, appropriateness, | ||||||
12 | level of care, service intensity, efficacy, or efficiency | ||||||
13 | of health care services, benefits, procedures, or | ||||||
14 | settings, under any circumstances, to determine whether a | ||||||
15 | health care service or benefit subject to a medical | ||||||
16 | necessity coverage requirement in an insurance policy is | ||||||
17 | covered as medically necessary for an insured. | ||||||
18 | "Utilization review criteria" means patient placement | ||||||
19 | criteria or any criteria, standards, protocols, or guidelines | ||||||
20 | used by an insurer to conduct utilization review. | ||||||
21 | (b)(1) On and after the effective date of this amendatory | ||||||
22 | Act of the 103rd General Assembly, every insurer that amends, | ||||||
23 | delivers, issues, or renews group accident and health policies | ||||||
24 | providing coverage for hospital or medical treatment or | ||||||
25 | services for illness on an expense-incurred basis shall | ||||||
26 | provide coverage for the medically necessary treatment of |
| |||||||
| |||||||
1 | vision, hearing, and dental disorders or conditions consistent | ||||||
2 | with the parity requirements of Section 370c.3. | ||||||
3 | (2) Each insured that is covered for vision, hearing, | ||||||
4 | and dental disorders or conditions shall be free to select | ||||||
5 | the physician licensed to practice medicine in all of its | ||||||
6 | branches of his or her choice to treat such disorders or | ||||||
7 | conditions, and the insurer shall pay the covered charges | ||||||
8 | of such physician licensed to practice medicine in all of | ||||||
9 | its branches up to the limits of coverage, so long as (i) | ||||||
10 | the disorder or condition treated is covered by the | ||||||
11 | policy, and (ii) the physician is authorized to provide | ||||||
12 | said services under the laws of this State and in | ||||||
13 | accordance with accepted principles of his or her | ||||||
14 | profession. | ||||||
15 | (c)(1) Unless otherwise prohibited by federal law and | ||||||
16 | consistent with the parity requirements of Section 370c.3, the | ||||||
17 | reimbursing insurer that amends, delivers, issues, or renews a | ||||||
18 | group or individual policy of accident and health insurance, a | ||||||
19 | qualified health plan offered through the health insurance | ||||||
20 | marketplace, or a provider of treatment of vision, hearing, | ||||||
21 | and dental disorders or conditions shall furnish medical | ||||||
22 | records or other necessary data that substantiate that initial | ||||||
23 | or continued treatment is at all times medically necessary. An | ||||||
24 | insurer shall provide a mechanism for the timely review by a | ||||||
25 | provider holding the same license and practicing in the same | ||||||
26 | specialty as the patient's provider who is unaffiliated with |
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1 | the insurer, jointly selected by the patient or the patient's | ||||||
2 | next of kin or legal representative if the patient is unable to | ||||||
3 | act for himself or herself, the patient's provider, and the | ||||||
4 | insurer if there is a dispute between the insurer and | ||||||
5 | patient's provider regarding the medical necessity of a | ||||||
6 | treatment proposed by a patient's provider. If the reviewing | ||||||
7 | provider determines the treatment to be medically necessary, | ||||||
8 | then the insurer shall provide reimbursement for the | ||||||
9 | treatment. Future contractual or employment actions by the | ||||||
10 | insurer regarding the patient's provider may not be based on | ||||||
11 | the provider's participation in this procedure. Nothing | ||||||
12 | prevents the insured from agreeing in writing to continue | ||||||
13 | treatment at his or her expense. When making a determination | ||||||
14 | of the medical necessity for a treatment modality for vision, | ||||||
15 | hearing, and dental disorders or conditions an insurer must | ||||||
16 | make the determination in a manner that is consistent with the | ||||||
17 | manner used to make that determination with respect to other | ||||||
18 | diseases or illnesses covered under the policy, including an | ||||||
19 | appeals process. | ||||||
20 | (2) A group health benefit plan, an individual policy | ||||||
21 | of accident and health insurance, or a qualified health | ||||||
22 | plan offered through the health insurance marketplace that | ||||||
23 | is amended, delivered, issued, or renewed on or after the | ||||||
24 | effective date of this amendatory Act of the 103rd General | ||||||
25 | Assembly shall provide coverage based upon medical | ||||||
26 | necessity for the treatment of vision, hearing, and dental |
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| |||||||
1 | disorders or conditions consistent with the parity | ||||||
2 | requirements of Section 370c.3. | ||||||
3 | (3) An issuer of a group health benefit plan, an | ||||||
4 | individual policy of accident and health insurance, or a | ||||||
5 | qualified health plan offered through the health insurance | ||||||
6 | marketplace shall cover the outpatient visits for vision, | ||||||
7 | hearing, and dental disorders or conditions under the same | ||||||
8 | terms and conditions as it covers outpatient visits for | ||||||
9 | the treatment of other physical illness. | ||||||
10 | (4) An issuer of a group health benefit plan may | ||||||
11 | provide or offer coverage required under this Section | ||||||
12 | through a managed care plan. | ||||||
13 | (d) Availability of plan information. | ||||||
14 | (1) The criteria for medical necessity determinations | ||||||
15 | made under a group health plan, an individual policy of | ||||||
16 | accident and health insurance, or a qualified health plan | ||||||
17 | offered through the health insurance marketplace with | ||||||
18 | respect to vision, hearing, and dental disorders or | ||||||
19 | conditions, or health insurance coverage offered in | ||||||
20 | connection with the plan, with respect to such benefits | ||||||
21 | must be made available by the plan administrator, or the | ||||||
22 | health insurance issuer offering such coverage, to any | ||||||
23 | current or potential participant, beneficiary, or | ||||||
24 | contracting provider upon request. | ||||||
25 | (2) The reason for any denial under a group health | ||||||
26 | benefit plan, an individual policy of accident and health |
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1 | insurance, or a qualified health plan offered through the | ||||||
2 | health insurance marketplace, or health insurance coverage | ||||||
3 | offered in connection with such plan or policy, of | ||||||
4 | reimbursement or payment for services with respect to | ||||||
5 | vision, hearing, and dental disorders or conditions | ||||||
6 | benefits in the case of any participant or beneficiary | ||||||
7 | must be made available within a reasonable time and in a | ||||||
8 | reasonable manner and in readily understandable language | ||||||
9 | by the plan administrator, or the health insurance issuer | ||||||
10 | offering such coverage, to the participant or beneficiary | ||||||
11 | upon request. | ||||||
12 | (e)(1) If an insurer determines that treatment is no | ||||||
13 | longer medically necessary, the insurer shall notify the | ||||||
14 | covered person, the covered person's authorized | ||||||
15 | representative, if any, and the covered person's health care | ||||||
16 | provider in writing of the covered person's right to request | ||||||
17 | an external review pursuant to the Health Carrier External | ||||||
18 | Review Act. The notification shall occur within 24 hours | ||||||
19 | following the adverse determination. | ||||||
20 | (2) Pursuant to the requirements of the Health Carrier | ||||||
21 | External Review Act, the covered person or the covered | ||||||
22 | person's authorized representative may request an | ||||||
23 | expedited external review. Under this subsection, a | ||||||
24 | request for expedited external review must be initiated | ||||||
25 | within 24 hours following the adverse determination | ||||||
26 | notification by the insurer. Failure to request an |
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| |||||||
1 | expedited external review within 24 hours shall preclude a | ||||||
2 | covered person or a covered person's authorized | ||||||
3 | representative from requesting an expedited external | ||||||
4 | review. | ||||||
5 | (3) If an expedited external review request meets the | ||||||
6 | criteria of the Health Carrier External Review Act, an | ||||||
7 | independent review organization shall make a final | ||||||
8 | determination of medical necessity within 72 hours. If an | ||||||
9 | independent review organization upholds an adverse | ||||||
10 | determination, an insurer shall remain responsible to | ||||||
11 | provide coverage of benefits through the day following the | ||||||
12 | determination of the independent review organization. A | ||||||
13 | decision to reverse an adverse determination shall comply | ||||||
14 | with the Health Carrier External Review Act. | ||||||
15 | (f)(1) Every insurer that amends, delivers, issues, or | ||||||
16 | renews a group or individual policy of accident and health | ||||||
17 | insurance or a qualified health plan offered through the | ||||||
18 | health insurance marketplace in this State and Medicaid | ||||||
19 | managed care organizations providing coverage for hospital or | ||||||
20 | medical treatment on or after January 1, 2024 shall provide | ||||||
21 | coverage for medically necessary treatment of vision, hearing, | ||||||
22 | and dental disorders or conditions. | ||||||
23 | (2) An insurer shall not set a specific limit on the | ||||||
24 | duration of benefits or coverage of medically necessary | ||||||
25 | treatment of vision, hearing, and dental disorders or | ||||||
26 | conditions or limit coverage only to alleviation of the |
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| |||||||
1 | insured's current symptoms. | ||||||
2 | (3) An insurer that authorizes a specific type of | ||||||
3 | treatment by a provider pursuant to this Section shall not | ||||||
4 | rescind or modify the authorization after that provider | ||||||
5 | renders the health care service in good faith and pursuant | ||||||
6 | to this authorization for any reason, including, but not | ||||||
7 | limited to, the insurer's subsequent cancellation or | ||||||
8 | modification of the insured's or policyholder's contract | ||||||
9 | or the insured's or policyholder's eligibility. Nothing in | ||||||
10 | this Section shall require the insurer to cover a | ||||||
11 | treatment when the authorization was granted based on a | ||||||
12 | material misrepresentation by the insured, the | ||||||
13 | policyholder, or the provider. Nothing in this Section | ||||||
14 | shall require Medicaid managed care organizations to pay | ||||||
15 | for services if the individual was not eligible for | ||||||
16 | Medicaid at the time the service was rendered. Nothing in | ||||||
17 | this Section shall require an insurer to pay for services | ||||||
18 | if the individual was not the insurer's enrollee at the | ||||||
19 | time services were rendered. As used in this paragraph, | ||||||
20 | "material" means a fact or situation that is not merely | ||||||
21 | technical in nature and results in or could result in a | ||||||
22 | substantial change in the situation. | ||||||
23 | (g) An insurer shall not limit benefits or coverage for | ||||||
24 | medically necessary services on the basis that those services | ||||||
25 | should be or could be covered by a public entitlement program, | ||||||
26 | including, but not limited to, special education or an |
| |||||||
| |||||||
1 | individualized education program, Medicaid, Medicare, | ||||||
2 | supplemental security income, or social security disability | ||||||
3 | insurance, and shall not include or enforce a contract term | ||||||
4 | that excludes otherwise covered benefits on the basis that | ||||||
5 | those services should be or could be covered by a public | ||||||
6 | entitlement program. Nothing in this subsection shall be | ||||||
7 | construed to require an insurer to cover benefits that have | ||||||
8 | been authorized and provided for a covered person by a public | ||||||
9 | entitlement program. Medicaid managed care organizations are | ||||||
10 | not subject to this subsection. | ||||||
11 | (h) An insurer shall base any medical necessity | ||||||
12 | determination or the utilization review criteria that the | ||||||
13 | insurer and any entity acting on the insurer's behalf applies | ||||||
14 | to determine the medical necessity of health care services and | ||||||
15 | benefits for the diagnosis, prevention, and treatment of | ||||||
16 | vision, hearing, and dental disorders or conditions on current | ||||||
17 | generally accepted standards of vision, hearing, and dental | ||||||
18 | disorders or conditions care. All denials and appeals shall be | ||||||
19 | reviewed by a professional with experience or expertise | ||||||
20 | comparable to the provider requesting the authorization. | ||||||
21 | (i) This Section does not in any way limit the rights of a | ||||||
22 | patient under the Medical Patient Rights Act. | ||||||
23 | (j) This Section does not in any way limit early and | ||||||
24 | periodic screening, diagnostic, and treatment benefits as | ||||||
25 | defined under 42 U.S.C. 1396d(r). | ||||||
26 | (k) Every insurer shall do all of the following: |
| |||||||
| |||||||
1 | (1) Educate the insurer's staff, including any third | ||||||
2 | parties contracted with the insurer to review claims, | ||||||
3 | conduct utilization reviews, or make medical necessity | ||||||
4 | determinations about the utilization review criteria. | ||||||
5 | (2) Make the educational program available to other | ||||||
6 | stakeholders, including the insurer's participating or | ||||||
7 | contracted providers and potential participants, | ||||||
8 | beneficiaries, or covered lives. The education program | ||||||
9 | must be provided at least once a year, in-person or | ||||||
10 | digitally, or recordings of the education program must be | ||||||
11 | made available to the aforementioned stakeholders. | ||||||
12 | (3) Provide, at no cost, the utilization review | ||||||
13 | criteria and any training material or resources to | ||||||
14 | providers and insured patients upon request. No | ||||||
15 | restrictions shall be placed upon the insured's or | ||||||
16 | treating provider's access right to utilization review | ||||||
17 | criteria obtained under this paragraph at any point in | ||||||
18 | time, including before an initial request for | ||||||
19 | authorization. | ||||||
20 | (4) Track, identify, and analyze how the utilization | ||||||
21 | review criteria are used to certify care, deny care, and | ||||||
22 | support the appeals process. | ||||||
23 | (5) Conduct interrater reliability testing to ensure | ||||||
24 | consistency in utilization review decision making that | ||||||
25 | covers how medical necessity decisions are made; this | ||||||
26 | assessment shall cover all aspects of utilization review. |
| |||||||
| |||||||
1 | (6) Run interrater reliability reports about how the | ||||||
2 | clinical guidelines are used in conjunction with the | ||||||
3 | utilization review process and parity compliance | ||||||
4 | activities. | ||||||
5 | (7) Achieve interrater reliability pass rates of at | ||||||
6 | least 90%, and if this threshold is not met, immediately | ||||||
7 | provide for the remediation of poor interrater reliability | ||||||
8 | and interrater reliability testing for all new staff | ||||||
9 | before they can conduct utilization review without | ||||||
10 | supervision. | ||||||
11 | (8) Maintain documentation of interrater reliability | ||||||
12 | testing and the remediation actions taken for those with | ||||||
13 | pass rates lower than 90% and submit to the Department or, | ||||||
14 | in the case of Medicaid managed care organizations, the | ||||||
15 | Department of Healthcare and Family Services the testing | ||||||
16 | results and a summary of remedial actions as part of | ||||||
17 | parity compliance reporting set forth in Section 370c.3. | ||||||
18 | (l) This Section applies to all health care services and | ||||||
19 | benefits for the diagnosis, prevention, and treatment of | ||||||
20 | vision, hearing, and dental disorders or conditions covered by | ||||||
21 | an insurance policy, including prescription drugs. | ||||||
22 | (m) This Section applies to an insurer that amends, | ||||||
23 | delivers, issues, or renews a group or individual policy of | ||||||
24 | accident and health insurance or a qualified health plan | ||||||
25 | offered through the health insurance marketplace in this State | ||||||
26 | providing coverage for hospital or medical treatment that |
| |||||||
| |||||||
1 | conducts utilization review as defined in this Section, | ||||||
2 | including Medicaid managed care organizations and any entity | ||||||
3 | or contracting provider that performs utilization review or | ||||||
4 | utilization management functions on an insurer's behalf. | ||||||
5 | (n) If the Director determines that an insurer has | ||||||
6 | violated this Section, the Director may, after appropriate | ||||||
7 | notice and opportunity for hearing, by order, assess a civil | ||||||
8 | penalty between $1,000 and $5,000 for each violation. Moneys | ||||||
9 | collected from penalties shall be deposited into the Parity | ||||||
10 | Advancement Fund. Nothing in this Section shall be construed | ||||||
11 | to limit criminal liability. | ||||||
12 | (o) If an insurer commits a violation of this Section, the | ||||||
13 | insurer shall be given 30 days' notice to rectify that | ||||||
14 | violation. Failure to rectify the violation within the 30-day | ||||||
15 | notice period and any subsequent violation of this Section by | ||||||
16 | the insurer shall constitute a Class A misdemeanor and result | ||||||
17 | in criminal liability pursuant to Section 49-7 of the Criminal | ||||||
18 | Code of 2012. | ||||||
19 | (p) An insurer shall not adopt, impose, or enforce terms | ||||||
20 | in its policies or provider agreements, in writing or in | ||||||
21 | operation, that undermine, alter, or conflict with the | ||||||
22 | requirements of this Section. | ||||||
23 | (q) The provisions of this Section are severable. If any | ||||||
24 | provision of this Section or its application to any person or | ||||||
25 | circumstance is held invalid, the invalidity of that provision | ||||||
26 | or application does not affect other provisions or |
| |||||||
| |||||||
1 | applications of this Section that can be given effect without | ||||||
2 | the invalid provision or application.
| ||||||
3 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| ||||||
4 | Sec. 370c. Mental and emotional disorders.
| ||||||
5 | (a)(1) On and after January 1, 2022 (the effective date of | ||||||
6 | Public Act 102-579),
every insurer that amends, delivers, | ||||||
7 | issues, or renews
group accident and health policies providing | ||||||
8 | coverage for hospital or medical treatment or
services for | ||||||
9 | illness on an expense-incurred basis shall provide coverage | ||||||
10 | for the medically necessary treatment of mental, emotional, | ||||||
11 | nervous, or substance use disorders or conditions consistent | ||||||
12 | with the parity requirements of Section 370c.1 of this Code.
| ||||||
13 | (2) Each insured that is covered for mental, emotional, | ||||||
14 | nervous, or substance use
disorders or conditions shall be | ||||||
15 | free to select the physician licensed to
practice medicine in | ||||||
16 | all its branches, licensed clinical psychologist,
licensed | ||||||
17 | clinical social worker, licensed clinical professional | ||||||
18 | counselor, licensed marriage and family therapist, licensed | ||||||
19 | speech-language pathologist, or other licensed or certified | ||||||
20 | professional at a program licensed pursuant to the Substance | ||||||
21 | Use Disorder Act of
his or her choice to treat such disorders, | ||||||
22 | and
the insurer shall pay the covered charges of such | ||||||
23 | physician licensed to
practice medicine in all its branches, | ||||||
24 | licensed clinical psychologist,
licensed clinical social | ||||||
25 | worker, licensed clinical professional counselor, licensed |
| |||||||
| |||||||
1 | marriage and family therapist, licensed speech-language | ||||||
2 | pathologist, or other licensed or certified professional at a | ||||||
3 | program licensed pursuant to the Substance Use Disorder Act up
| ||||||
4 | to the limits of coverage, provided (i)
the disorder or | ||||||
5 | condition treated is covered by the policy, and (ii) the
| ||||||
6 | physician, licensed psychologist, licensed clinical social | ||||||
7 | worker, licensed
clinical professional counselor, licensed | ||||||
8 | marriage and family therapist, licensed speech-language | ||||||
9 | pathologist, or other licensed or certified professional at a | ||||||
10 | program licensed pursuant to the Substance Use Disorder Act is
| ||||||
11 | authorized to provide said services under the statutes of this | ||||||
12 | State and in
accordance with accepted principles of his or her | ||||||
13 | profession.
| ||||||
14 | (3) Insofar as this Section applies solely to licensed | ||||||
15 | clinical social
workers, licensed clinical professional | ||||||
16 | counselors, licensed marriage and family therapists, licensed | ||||||
17 | speech-language pathologists, and other licensed or certified | ||||||
18 | professionals at programs licensed pursuant to the Substance | ||||||
19 | Use Disorder Act, those persons who may
provide services to | ||||||
20 | individuals shall do so
after the licensed clinical social | ||||||
21 | worker, licensed clinical professional
counselor, licensed | ||||||
22 | marriage and family therapist, licensed speech-language | ||||||
23 | pathologist, or other licensed or certified professional at a | ||||||
24 | program licensed pursuant to the Substance Use Disorder Act | ||||||
25 | has informed the patient of the
desirability of the patient | ||||||
26 | conferring with the patient's primary care
physician.
|
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| |||||||
1 | (4) "Mental, emotional, nervous, or substance use disorder | ||||||
2 | or condition" means a condition or disorder that involves a | ||||||
3 | mental health condition or substance use disorder that falls | ||||||
4 | under any of the diagnostic categories listed in the mental | ||||||
5 | and behavioral disorders chapter of the current edition of the | ||||||
6 | World Health Organization's International Classification of | ||||||
7 | Disease or that is listed in the most recent version of the | ||||||
8 | American Psychiatric Association's Diagnostic and Statistical | ||||||
9 | Manual of Mental Disorders. "Mental, emotional, nervous, or | ||||||
10 | substance use disorder or condition" includes any mental | ||||||
11 | health condition that occurs during pregnancy or during the | ||||||
12 | postpartum period and includes, but is not limited to, | ||||||
13 | postpartum depression. | ||||||
14 | (5) Medically necessary treatment and medical necessity | ||||||
15 | determinations shall be interpreted and made in a manner that | ||||||
16 | is consistent with and pursuant to subsections (h) through | ||||||
17 | (t). | ||||||
18 | (b)(1) (Blank).
| ||||||
19 | (2) (Blank).
| ||||||
20 | (2.5) (Blank). | ||||||
21 | (3) Unless otherwise prohibited by federal law and | ||||||
22 | consistent with the parity requirements of Section 370c.1 of | ||||||
23 | this Code, the reimbursing insurer that amends, delivers, | ||||||
24 | issues, or renews a group or individual policy of accident and | ||||||
25 | health insurance, a qualified health plan offered through the | ||||||
26 | health insurance marketplace, or a provider of treatment of |
| |||||||
| |||||||
1 | mental, emotional, nervous,
or substance use disorders or | ||||||
2 | conditions shall furnish medical records or other necessary | ||||||
3 | data
that substantiate that initial or continued treatment is | ||||||
4 | at all times medically
necessary. An insurer shall provide a | ||||||
5 | mechanism for the timely review by a
provider holding the same | ||||||
6 | license and practicing in the same specialty as the
patient's | ||||||
7 | provider, who is unaffiliated with the insurer, jointly | ||||||
8 | selected by
the patient (or the patient's next of kin or legal | ||||||
9 | representative if the
patient is unable to act for himself or | ||||||
10 | herself), the patient's provider, and
the insurer in the event | ||||||
11 | of a dispute between the insurer and patient's
provider | ||||||
12 | regarding the medical necessity of a treatment proposed by a | ||||||
13 | patient's
provider. If the reviewing provider determines the | ||||||
14 | treatment to be medically
necessary, the insurer shall provide | ||||||
15 | reimbursement for the treatment. Future
contractual or | ||||||
16 | employment actions by the insurer regarding the patient's
| ||||||
17 | provider may not be based on the provider's participation in | ||||||
18 | this procedure.
Nothing prevents
the insured from agreeing in | ||||||
19 | writing to continue treatment at his or her
expense. When | ||||||
20 | making a determination of the medical necessity for a | ||||||
21 | treatment
modality for mental, emotional, nervous, or | ||||||
22 | substance use disorders or conditions, an insurer must make | ||||||
23 | the determination in a
manner that is consistent with the | ||||||
24 | manner used to make that determination with
respect to other | ||||||
25 | diseases or illnesses covered under the policy, including an
| ||||||
26 | appeals process. Medical necessity determinations for |
| |||||||
| |||||||
1 | substance use disorders shall be made in accordance with | ||||||
2 | appropriate patient placement criteria established by the | ||||||
3 | American Society of Addiction Medicine. No additional criteria | ||||||
4 | may be used to make medical necessity determinations for | ||||||
5 | substance use disorders.
| ||||||
6 | (4) A group health benefit plan amended, delivered, | ||||||
7 | issued, or renewed on or after January 1, 2019 (the effective | ||||||
8 | date of Public Act 100-1024) or an individual policy of | ||||||
9 | accident and health insurance or a qualified health plan | ||||||
10 | offered through the health insurance marketplace amended, | ||||||
11 | delivered, issued, or renewed on or after January 1, 2019 (the | ||||||
12 | effective date of Public Act 100-1024):
| ||||||
13 | (A) shall provide coverage based upon medical | ||||||
14 | necessity for the
treatment of a mental, emotional, | ||||||
15 | nervous, or substance use disorder or condition consistent | ||||||
16 | with the parity requirements of Section 370c.1 of this | ||||||
17 | Code; provided, however, that in each calendar year | ||||||
18 | coverage shall not be less than the following:
| ||||||
19 | (i) 45 days of inpatient treatment; and
| ||||||
20 | (ii) beginning on June 26, 2006 (the effective | ||||||
21 | date of Public Act 94-921), 60 visits for outpatient | ||||||
22 | treatment including group and individual
outpatient | ||||||
23 | treatment; and | ||||||
24 | (iii) for plans or policies delivered, issued for | ||||||
25 | delivery, renewed, or modified after January 1, 2007 | ||||||
26 | (the effective date of Public Act 94-906),
20 |
| |||||||
| |||||||
1 | additional outpatient visits for speech therapy for | ||||||
2 | treatment of pervasive developmental disorders that | ||||||
3 | will be in addition to speech therapy provided | ||||||
4 | pursuant to item (ii) of this subparagraph (A); and
| ||||||
5 | (B) may not include a lifetime limit on the number of | ||||||
6 | days of inpatient
treatment or the number of outpatient | ||||||
7 | visits covered under the plan.
| ||||||
8 | (C) (Blank).
| ||||||
9 | (5) An issuer of a group health benefit plan or an | ||||||
10 | individual policy of accident and health insurance or a | ||||||
11 | qualified health plan offered through the health insurance | ||||||
12 | marketplace may not count toward the number
of outpatient | ||||||
13 | visits required to be covered under this Section an outpatient
| ||||||
14 | visit for the purpose of medication management and shall cover | ||||||
15 | the outpatient
visits under the same terms and conditions as | ||||||
16 | it covers outpatient visits for
the treatment of physical | ||||||
17 | illness.
| ||||||
18 | (5.5) An individual or group health benefit plan amended, | ||||||
19 | delivered, issued, or renewed on or after September 9, 2015 | ||||||
20 | (the effective date of Public Act 99-480) shall offer coverage | ||||||
21 | for medically necessary acute treatment services and medically | ||||||
22 | necessary clinical stabilization services. The treating | ||||||
23 | provider shall base all treatment recommendations and the | ||||||
24 | health benefit plan shall base all medical necessity | ||||||
25 | determinations for substance use disorders in accordance with | ||||||
26 | the most current edition of the Treatment Criteria for |
| |||||||
| |||||||
1 | Addictive, Substance-Related, and Co-Occurring Conditions | ||||||
2 | established by the American Society of Addiction Medicine. The | ||||||
3 | treating provider shall base all treatment recommendations and | ||||||
4 | the health benefit plan shall base all medical necessity | ||||||
5 | determinations for medication-assisted treatment in accordance | ||||||
6 | with the most current Treatment Criteria for Addictive, | ||||||
7 | Substance-Related, and Co-Occurring Conditions established by | ||||||
8 | the American Society of Addiction Medicine. | ||||||
9 | As used in this subsection: | ||||||
10 | "Acute treatment services" means 24-hour medically | ||||||
11 | supervised addiction treatment that provides evaluation and | ||||||
12 | withdrawal management and may include biopsychosocial | ||||||
13 | assessment, individual and group counseling, psychoeducational | ||||||
14 | groups, and discharge planning. | ||||||
15 | "Clinical stabilization services" means 24-hour treatment, | ||||||
16 | usually following acute treatment services for substance | ||||||
17 | abuse, which may include intensive education and counseling | ||||||
18 | regarding the nature of addiction and its consequences, | ||||||
19 | relapse prevention, outreach to families and significant | ||||||
20 | others, and aftercare planning for individuals beginning to | ||||||
21 | engage in recovery from addiction. | ||||||
22 | (6) An issuer of a group health benefit
plan may provide or | ||||||
23 | offer coverage required under this Section through a
managed | ||||||
24 | care plan.
| ||||||
25 | (6.5) An individual or group health benefit plan amended, | ||||||
26 | delivered, issued, or renewed on or after January 1, 2019 (the |
| |||||||
| |||||||
1 | effective date of Public Act 100-1024): | ||||||
2 | (A) shall not impose prior authorization requirements, | ||||||
3 | other than those established under the Treatment Criteria | ||||||
4 | for Addictive, Substance-Related, and Co-Occurring | ||||||
5 | Conditions established by the American Society of | ||||||
6 | Addiction Medicine, on a prescription medication approved | ||||||
7 | by the United States Food and Drug Administration that is | ||||||
8 | prescribed or administered for the treatment of substance | ||||||
9 | use disorders; | ||||||
10 | (B) shall not impose any step therapy requirements, | ||||||
11 | other than those established under the Treatment Criteria | ||||||
12 | for Addictive, Substance-Related, and Co-Occurring | ||||||
13 | Conditions established by the American Society of | ||||||
14 | Addiction Medicine, before authorizing coverage for a | ||||||
15 | prescription medication approved by the United States Food | ||||||
16 | and Drug Administration that is prescribed or administered | ||||||
17 | for the treatment of substance use disorders; | ||||||
18 | (C) shall place all prescription medications approved | ||||||
19 | by the United States Food and Drug Administration | ||||||
20 | prescribed or administered for the treatment of substance | ||||||
21 | use disorders on, for brand medications, the lowest tier | ||||||
22 | of the drug formulary developed and maintained by the | ||||||
23 | individual or group health benefit plan that covers brand | ||||||
24 | medications and, for generic medications, the lowest tier | ||||||
25 | of the drug formulary developed and maintained by the | ||||||
26 | individual or group health benefit plan that covers |
| |||||||
| |||||||
1 | generic medications; and | ||||||
2 | (D) shall not exclude coverage for a prescription | ||||||
3 | medication approved by the United States Food and Drug | ||||||
4 | Administration for the treatment of substance use | ||||||
5 | disorders and any associated counseling or wraparound | ||||||
6 | services on the grounds that such medications and services | ||||||
7 | were court ordered. | ||||||
8 | (7) (Blank).
| ||||||
9 | (8)
(Blank).
| ||||||
10 | (9) With respect to all mental, emotional, nervous, or | ||||||
11 | substance use disorders or conditions, coverage for inpatient | ||||||
12 | treatment shall include coverage for treatment in a | ||||||
13 | residential treatment center certified or licensed by the | ||||||
14 | Department of Public Health or the Department of Human | ||||||
15 | Services. | ||||||
16 | (c) This Section shall not be interpreted to require | ||||||
17 | coverage for speech therapy or other habilitative services for | ||||||
18 | those individuals covered under Section 356z.15
of this Code. | ||||||
19 | (d) With respect to a group or individual policy of | ||||||
20 | accident and health insurance or a qualified health plan | ||||||
21 | offered through the health insurance marketplace, the | ||||||
22 | Department and, with respect to medical assistance, the | ||||||
23 | Department of Healthcare and Family Services shall each | ||||||
24 | enforce the requirements of this Section and Sections 356z.23 | ||||||
25 | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | ||||||
26 | Mental Health Parity and Addiction Equity Act of 2008, 42 |
| |||||||
| |||||||
1 | U.S.C. 18031(j), and any amendments to, and federal guidance | ||||||
2 | or regulations issued under, those Acts, including, but not | ||||||
3 | limited to, final regulations issued under the Paul Wellstone | ||||||
4 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
5 | Act of 2008 and final regulations applying the Paul Wellstone | ||||||
6 | and Pete Domenici Mental Health Parity and Addiction Equity | ||||||
7 | Act of 2008 to Medicaid managed care organizations, the | ||||||
8 | Children's Health Insurance Program, and alternative benefit | ||||||
9 | plans. Specifically, the Department and the Department of | ||||||
10 | Healthcare and Family Services shall take action: | ||||||
11 | (1) proactively ensuring compliance by individual and | ||||||
12 | group policies, including by requiring that insurers | ||||||
13 | submit comparative analyses, as set forth in paragraph (6) | ||||||
14 | of subsection (k) of Section 370c.1, demonstrating how | ||||||
15 | they design and apply nonquantitative treatment | ||||||
16 | limitations, both as written and in operation, for mental, | ||||||
17 | emotional, nervous, or substance use disorder or condition | ||||||
18 | benefits as compared to how they design and apply | ||||||
19 | nonquantitative treatment limitations, as written and in | ||||||
20 | operation, for medical and surgical benefits; | ||||||
21 | (2) evaluating all consumer or provider complaints | ||||||
22 | regarding mental, emotional, nervous, or substance use | ||||||
23 | disorder or condition coverage for possible parity | ||||||
24 | violations; | ||||||
25 | (3) performing parity compliance market conduct | ||||||
26 | examinations or, in the case of the Department of |
| |||||||
| |||||||
1 | Healthcare and Family Services, parity compliance audits | ||||||
2 | of individual and group plans and policies, including, but | ||||||
3 | not limited to, reviews of: | ||||||
4 | (A) nonquantitative treatment limitations, | ||||||
5 | including, but not limited to, prior authorization | ||||||
6 | requirements, concurrent review, retrospective review, | ||||||
7 | step therapy, network admission standards, | ||||||
8 | reimbursement rates, and geographic restrictions; | ||||||
9 | (B) denials of authorization, payment, and | ||||||
10 | coverage; and | ||||||
11 | (C) other specific criteria as may be determined | ||||||
12 | by the Department. | ||||||
13 | The findings and the conclusions of the parity compliance | ||||||
14 | market conduct examinations and audits shall be made public. | ||||||
15 | The Director may adopt rules to effectuate any provisions | ||||||
16 | of the Paul Wellstone and Pete Domenici Mental Health Parity | ||||||
17 | and Addiction Equity Act of 2008 that relate to the business of | ||||||
18 | insurance. | ||||||
19 | (e) Availability of plan information. | ||||||
20 | (1) The criteria for medical necessity determinations | ||||||
21 | made under a group health plan, an individual policy of | ||||||
22 | accident and health insurance, or a qualified health plan | ||||||
23 | offered through the health insurance marketplace with | ||||||
24 | respect to mental health or substance use disorder | ||||||
25 | benefits (or health insurance coverage offered in | ||||||
26 | connection with the plan with respect to such benefits) |
| |||||||
| |||||||
1 | must be made available by the plan administrator (or the | ||||||
2 | health insurance issuer offering such coverage) to any | ||||||
3 | current or potential participant, beneficiary, or | ||||||
4 | contracting provider upon request. | ||||||
5 | (2) The reason for any denial under a group health | ||||||
6 | benefit plan, an individual policy of accident and health | ||||||
7 | insurance, or a qualified health plan offered through the | ||||||
8 | health insurance marketplace (or health insurance coverage | ||||||
9 | offered in connection with such plan or policy) of | ||||||
10 | reimbursement or payment for services with respect to | ||||||
11 | mental, emotional, nervous, or substance use disorders or | ||||||
12 | conditions benefits in the case of any participant or | ||||||
13 | beneficiary must be made available within a reasonable | ||||||
14 | time and in a reasonable manner and in readily | ||||||
15 | understandable language by the plan administrator (or the | ||||||
16 | health insurance issuer offering such coverage) to the | ||||||
17 | participant or beneficiary upon request. | ||||||
18 | (f) As used in this Section, "group policy of accident and | ||||||
19 | health insurance" and "group health benefit plan" includes (1) | ||||||
20 | State-regulated employer-sponsored group health insurance | ||||||
21 | plans written in Illinois or which purport to provide coverage | ||||||
22 | for a resident of this State; and (2) State employee health | ||||||
23 | plans. | ||||||
24 | (g) (1) As used in this subsection: | ||||||
25 | "Benefits", with respect to insurers, means
the benefits | ||||||
26 | provided for treatment services for inpatient and outpatient |
| |||||||
| |||||||
1 | treatment of substance use disorders or conditions at American | ||||||
2 | Society of Addiction Medicine levels of treatment 2.1 | ||||||
3 | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | ||||||
4 | (Clinically Managed Low-Intensity Residential), 3.3 | ||||||
5 | (Clinically Managed Population-Specific High-Intensity | ||||||
6 | Residential), 3.5 (Clinically Managed High-Intensity | ||||||
7 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
8 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
9 | "Benefits", with respect to managed care organizations, | ||||||
10 | means the benefits provided for treatment services for | ||||||
11 | inpatient and outpatient treatment of substance use disorders | ||||||
12 | or conditions at American Society of Addiction Medicine levels | ||||||
13 | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | ||||||
14 | Hospitalization), 3.5 (Clinically Managed High-Intensity | ||||||
15 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
16 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
17 | "Substance use disorder treatment provider or facility" | ||||||
18 | means a licensed physician, licensed psychologist, licensed | ||||||
19 | psychiatrist, licensed advanced practice registered nurse, or | ||||||
20 | licensed, certified, or otherwise State-approved facility or | ||||||
21 | provider of substance use disorder treatment. | ||||||
22 | (2) A group health insurance policy, an individual health | ||||||
23 | benefit plan, or qualified health plan that is offered through | ||||||
24 | the health insurance marketplace, small employer group health | ||||||
25 | plan, and large employer group health plan that is amended, | ||||||
26 | delivered, issued, executed, or renewed in this State, or |
| |||||||
| |||||||
1 | approved for issuance or renewal in this State, on or after | ||||||
2 | January 1, 2019 (the effective date of Public Act 100-1023) | ||||||
3 | shall comply with the requirements of this Section and Section | ||||||
4 | 370c.1. The services for the treatment and the ongoing | ||||||
5 | assessment of the patient's progress in treatment shall follow | ||||||
6 | the requirements of 77 Ill. Adm. Code 2060. | ||||||
7 | (3) Prior authorization shall not be utilized for the | ||||||
8 | benefits under this subsection. The substance use disorder | ||||||
9 | treatment provider or facility shall notify the insurer of the | ||||||
10 | initiation of treatment. For an insurer that is not a managed | ||||||
11 | care organization, the substance use disorder treatment | ||||||
12 | provider or facility notification shall occur for the | ||||||
13 | initiation of treatment of the covered person within 2 | ||||||
14 | business days. For managed care organizations, the substance | ||||||
15 | use disorder treatment provider or facility notification shall | ||||||
16 | occur in accordance with the protocol set forth in the | ||||||
17 | provider agreement for initiation of treatment within 24 | ||||||
18 | hours. If the managed care organization is not capable of | ||||||
19 | accepting the notification in accordance with the contractual | ||||||
20 | protocol during the 24-hour period following admission, the | ||||||
21 | substance use disorder treatment provider or facility shall | ||||||
22 | have one additional business day to provide the notification | ||||||
23 | to the appropriate managed care organization. Treatment plans | ||||||
24 | shall be developed in accordance with the requirements and | ||||||
25 | timeframes established in 77 Ill. Adm. Code 2060. If the | ||||||
26 | substance use disorder treatment provider or facility fails to |
| |||||||
| |||||||
1 | notify the insurer of the initiation of treatment in | ||||||
2 | accordance with these provisions, the insurer may follow its | ||||||
3 | normal prior authorization processes. | ||||||
4 | (4) For an insurer that is not a managed care | ||||||
5 | organization, if an insurer determines that benefits are no | ||||||
6 | longer medically necessary, the insurer shall notify the | ||||||
7 | covered person, the covered person's authorized | ||||||
8 | representative, if any, and the covered person's health care | ||||||
9 | provider in writing of the covered person's right to request | ||||||
10 | an external review pursuant to the Health Carrier External | ||||||
11 | Review Act. The notification shall occur within 24 hours | ||||||
12 | following the adverse determination. | ||||||
13 | Pursuant to the requirements of the Health Carrier | ||||||
14 | External Review Act, the covered person or the covered | ||||||
15 | person's authorized representative may request an expedited | ||||||
16 | external review.
An expedited external review may not occur if | ||||||
17 | the substance use disorder treatment provider or facility | ||||||
18 | determines that continued treatment is no longer medically | ||||||
19 | necessary. Under this subsection, a request for expedited | ||||||
20 | external review must be initiated within 24 hours following | ||||||
21 | the adverse determination notification by the insurer. Failure | ||||||
22 | to request an expedited external review within 24 hours shall | ||||||
23 | preclude a covered person or a covered person's authorized | ||||||
24 | representative from requesting an expedited external review. | ||||||
25 | If an expedited external review request meets the criteria | ||||||
26 | of the Health Carrier External Review Act, an independent |
| |||||||
| |||||||
1 | review organization shall make a final determination of | ||||||
2 | medical necessity within 72 hours. If an independent review | ||||||
3 | organization upholds an adverse determination, an insurer | ||||||
4 | shall remain responsible to provide coverage of benefits | ||||||
5 | through the day following the determination of the independent | ||||||
6 | review organization. A decision to reverse an adverse | ||||||
7 | determination shall comply with the Health Carrier External | ||||||
8 | Review Act. | ||||||
9 | (5) The substance use disorder treatment provider or | ||||||
10 | facility shall provide the insurer with 7 business days' | ||||||
11 | advance notice of the planned discharge of the patient from | ||||||
12 | the substance use disorder treatment provider or facility and | ||||||
13 | notice on the day that the patient is discharged from the | ||||||
14 | substance use disorder treatment provider or facility. | ||||||
15 | (6) The benefits required by this subsection shall be | ||||||
16 | provided to all covered persons with a diagnosis of substance | ||||||
17 | use disorder or conditions. The presence of additional related | ||||||
18 | or unrelated diagnoses shall not be a basis to reduce or deny | ||||||
19 | the benefits required by this subsection. | ||||||
20 | (7) Nothing in this subsection shall be construed to | ||||||
21 | require an insurer to provide coverage for any of the benefits | ||||||
22 | in this subsection. | ||||||
23 | (h) As used in this Section: | ||||||
24 | "Generally accepted standards of mental, emotional, | ||||||
25 | nervous, or substance use disorder or condition care" means | ||||||
26 | standards of care and clinical practice that are generally |
| |||||||
| |||||||
1 | recognized by health care providers practicing in relevant | ||||||
2 | clinical specialties such as psychiatry, psychology, clinical | ||||||
3 | sociology, social work, addiction medicine and counseling, and | ||||||
4 | behavioral health treatment. Valid, evidence-based sources | ||||||
5 | reflecting generally accepted standards of mental, emotional, | ||||||
6 | nervous, or substance use disorder or condition care include | ||||||
7 | peer-reviewed scientific studies and medical literature, | ||||||
8 | recommendations of nonprofit health care provider professional | ||||||
9 | associations and specialty societies, including, but not | ||||||
10 | limited to, patient placement criteria and clinical practice | ||||||
11 | guidelines, recommendations of federal government agencies, | ||||||
12 | and drug labeling approved by the United States Food and Drug | ||||||
13 | Administration. | ||||||
14 | "Medically necessary treatment of mental, emotional, | ||||||
15 | nervous, or substance use disorders or conditions" means a | ||||||
16 | service or product addressing the specific needs of that | ||||||
17 | patient, for the purpose of screening, preventing, diagnosing, | ||||||
18 | managing, or treating an illness, injury, or condition or its | ||||||
19 | symptoms and comorbidities, including minimizing the | ||||||
20 | progression of an illness, injury, or condition or its | ||||||
21 | symptoms and comorbidities in a manner that is all of the | ||||||
22 | following: | ||||||
23 | (1) in accordance with the generally accepted | ||||||
24 | standards of mental, emotional, nervous, or substance use | ||||||
25 | disorder or condition care; | ||||||
26 | (2) clinically appropriate in terms of type, |
| |||||||
| |||||||
1 | frequency, extent, site, and duration; and | ||||||
2 | (3) not primarily for the economic benefit of the | ||||||
3 | insurer, purchaser, or for the convenience of the patient, | ||||||
4 | treating physician, or other health care provider. | ||||||
5 | "Utilization review" means either of the following: | ||||||
6 | (1) prospectively, retrospectively, or concurrently | ||||||
7 | reviewing and approving, modifying, delaying, or denying, | ||||||
8 | based in whole or in part on medical necessity, requests | ||||||
9 | by health care providers, insureds, or their authorized | ||||||
10 | representatives for coverage of health care services | ||||||
11 | before, retrospectively, or concurrently with the | ||||||
12 | provision of health care services to insureds. | ||||||
13 | (2) evaluating the medical necessity, appropriateness, | ||||||
14 | level of care, service intensity, efficacy, or efficiency | ||||||
15 | of health care services, benefits, procedures, or | ||||||
16 | settings, under any circumstances, to determine whether a | ||||||
17 | health care service or benefit subject to a medical | ||||||
18 | necessity coverage requirement in an insurance policy is | ||||||
19 | covered as medically necessary for an insured. | ||||||
20 | "Utilization review criteria" means patient placement | ||||||
21 | criteria or any criteria, standards, protocols, or guidelines | ||||||
22 | used by an insurer to conduct utilization review. | ||||||
23 | (i)(1) Every insurer that amends, delivers, issues, or | ||||||
24 | renews a group or individual policy of accident and health | ||||||
25 | insurance or a qualified health plan offered through the | ||||||
26 | health insurance marketplace in this State and Medicaid |
| |||||||
| |||||||
1 | managed care organizations providing coverage for hospital or | ||||||
2 | medical treatment on or after January 1, 2023 shall, pursuant | ||||||
3 | to subsections (h) through (s), provide coverage for medically | ||||||
4 | necessary treatment of mental, emotional, nervous, or | ||||||
5 | substance use disorders or conditions. | ||||||
6 | (2) An insurer shall not set a specific limit on the | ||||||
7 | duration of benefits or coverage of medically necessary | ||||||
8 | treatment of mental, emotional, nervous, or substance use | ||||||
9 | disorders or conditions or limit coverage only to alleviation | ||||||
10 | of the insured's current symptoms. | ||||||
11 | (3) All medical necessity determinations made by the | ||||||
12 | insurer concerning service intensity, level of care placement, | ||||||
13 | continued stay, and transfer or discharge of insureds | ||||||
14 | diagnosed with mental, emotional, nervous, or substance use | ||||||
15 | disorders or conditions shall be conducted in accordance with | ||||||
16 | the requirements of subsections (k) through (u). | ||||||
17 | (4) An insurer that authorizes a specific type of | ||||||
18 | treatment by a provider pursuant to this Section shall not | ||||||
19 | rescind or modify the authorization after that provider | ||||||
20 | renders the health care service in good faith and pursuant to | ||||||
21 | this authorization for any reason, including, but not limited | ||||||
22 | to, the insurer's subsequent cancellation or modification of | ||||||
23 | the insured's or policyholder's contract, or the insured's or | ||||||
24 | policyholder's eligibility. Nothing in this Section shall | ||||||
25 | require the insurer to cover a treatment when the | ||||||
26 | authorization was granted based on a material |
| |||||||
| |||||||
1 | misrepresentation by the insured, the policyholder, or the | ||||||
2 | provider. Nothing in this Section shall require Medicaid | ||||||
3 | managed care organizations to pay for services if the | ||||||
4 | individual was not eligible for Medicaid at the time the | ||||||
5 | service was rendered. Nothing in this Section shall require an | ||||||
6 | insurer to pay for services if the individual was not the | ||||||
7 | insurer's enrollee at the time services were rendered. As used | ||||||
8 | in this paragraph, "material" means a fact or situation that | ||||||
9 | is not merely technical in nature and results in or could | ||||||
10 | result in a substantial change in the situation. | ||||||
11 | (j) An insurer shall not limit benefits or coverage for | ||||||
12 | medically necessary services on the basis that those services | ||||||
13 | should be or could be covered by a public entitlement program, | ||||||
14 | including, but not limited to, special education or an | ||||||
15 | individualized education program, Medicaid, Medicare, | ||||||
16 | Supplemental Security Income, or Social Security Disability | ||||||
17 | Insurance, and shall not include or enforce a contract term | ||||||
18 | that excludes otherwise covered benefits on the basis that | ||||||
19 | those services should be or could be covered by a public | ||||||
20 | entitlement program. Nothing in this subsection shall be | ||||||
21 | construed to require an insurer to cover benefits that have | ||||||
22 | been authorized and provided for a covered person by a public | ||||||
23 | entitlement program. Medicaid managed care organizations are | ||||||
24 | not subject to this subsection. | ||||||
25 | (k) An insurer shall base any medical necessity | ||||||
26 | determination or the utilization review criteria that the |
| |||||||
| |||||||
1 | insurer, and any entity acting on the insurer's behalf, | ||||||
2 | applies to determine the medical necessity of health care | ||||||
3 | services and benefits for the diagnosis, prevention, and | ||||||
4 | treatment of mental, emotional, nervous, or substance use | ||||||
5 | disorders or conditions on current generally accepted | ||||||
6 | standards of mental, emotional, nervous, or substance use | ||||||
7 | disorder or condition care. All denials and appeals shall be | ||||||
8 | reviewed by a professional with experience or expertise | ||||||
9 | comparable to the provider requesting the authorization. | ||||||
10 | (l) For medical necessity determinations relating to level | ||||||
11 | of care placement, continued stay, and transfer or discharge | ||||||
12 | of insureds diagnosed with mental, emotional, and nervous | ||||||
13 | disorders or conditions, an insurer shall apply the patient | ||||||
14 | placement criteria set forth in the most recent version of the | ||||||
15 | treatment criteria developed by an unaffiliated nonprofit | ||||||
16 | professional association for the relevant clinical specialty | ||||||
17 | or, for Medicaid managed care organizations, patient placement | ||||||
18 | criteria determined by the Department of Healthcare and Family | ||||||
19 | Services that are consistent with generally accepted standards | ||||||
20 | of mental, emotional, nervous or substance use disorder or | ||||||
21 | condition care. Pursuant to subsection (b), in conducting | ||||||
22 | utilization review of all covered services and benefits for | ||||||
23 | the diagnosis, prevention, and treatment of substance use | ||||||
24 | disorders an insurer shall use the most recent edition of the | ||||||
25 | patient placement criteria established by the American Society | ||||||
26 | of Addiction Medicine. |
| |||||||
| |||||||
1 | (m) For medical necessity determinations relating to level | ||||||
2 | of care placement, continued stay, and transfer or discharge | ||||||
3 | that are within the scope of the sources specified in | ||||||
4 | subsection (l), an insurer shall not apply different, | ||||||
5 | additional, conflicting, or more restrictive utilization | ||||||
6 | review criteria than the criteria set forth in those sources. | ||||||
7 | For all level of care placement decisions, the insurer shall | ||||||
8 | authorize placement at the level of care consistent with the | ||||||
9 | assessment of the insured using the relevant patient placement | ||||||
10 | criteria as specified in subsection (l). If that level of | ||||||
11 | placement is not available, the insurer shall authorize the | ||||||
12 | next higher level of care. In the event of disagreement, the | ||||||
13 | insurer shall provide full detail of its assessment using the | ||||||
14 | relevant criteria as specified in subsection (l) to the | ||||||
15 | provider of the service and the patient. | ||||||
16 | Nothing in this subsection or subsection (l) prohibits an | ||||||
17 | insurer from applying utilization review criteria that were | ||||||
18 | developed in accordance with subsection (k) to health care | ||||||
19 | services and benefits for mental, emotional, and nervous | ||||||
20 | disorders or conditions that are not related to medical | ||||||
21 | necessity determinations for level of care placement, | ||||||
22 | continued stay, and transfer or discharge. If an insurer | ||||||
23 | purchases or licenses utilization review criteria pursuant to | ||||||
24 | this subsection, the insurer shall verify and document before | ||||||
25 | use that the criteria were developed in accordance with | ||||||
26 | subsection (k). |
| |||||||
| |||||||
1 | (n) In conducting utilization review that is outside the | ||||||
2 | scope of the criteria as specified in subsection (l) or | ||||||
3 | relates to the advancements in technology or in the types or | ||||||
4 | levels of care that are not addressed in the most recent | ||||||
5 | versions of the sources specified in subsection (l), an | ||||||
6 | insurer shall conduct utilization review in accordance with | ||||||
7 | subsection (k). | ||||||
8 | (o) This Section does not in any way limit the rights of a | ||||||
9 | patient under the Medical Patient Rights Act. | ||||||
10 | (p) This Section does not in any way limit early and | ||||||
11 | periodic screening, diagnostic, and treatment benefits as | ||||||
12 | defined under 42 U.S.C. 1396d(r). | ||||||
13 | (q) To ensure the proper use of the criteria described in | ||||||
14 | subsection (l), every insurer shall do all of the following: | ||||||
15 | (1) Educate the insurer's staff, including any third | ||||||
16 | parties contracted with the insurer to review claims, | ||||||
17 | conduct utilization reviews, or make medical necessity | ||||||
18 | determinations about the utilization review criteria. | ||||||
19 | (2) Make the educational program available to other | ||||||
20 | stakeholders, including the insurer's participating or | ||||||
21 | contracted providers and potential participants, | ||||||
22 | beneficiaries, or covered lives. The education program | ||||||
23 | must be provided at least once a year, in-person or | ||||||
24 | digitally, or recordings of the education program must be | ||||||
25 | made available to the aforementioned stakeholders. | ||||||
26 | (3) Provide, at no cost, the utilization review |
| |||||||
| |||||||
1 | criteria and any training material or resources to | ||||||
2 | providers and insured patients upon request. For | ||||||
3 | utilization review criteria not concerning level of care | ||||||
4 | placement, continued stay, and transfer or discharge used | ||||||
5 | by the insurer pursuant to subsection (m), the insurer may | ||||||
6 | place the criteria on a secure, password-protected website | ||||||
7 | so long as the access requirements of the website do not | ||||||
8 | unreasonably restrict access to insureds or their | ||||||
9 | providers. No restrictions shall be placed upon the | ||||||
10 | insured's or treating provider's access right to | ||||||
11 | utilization review criteria obtained under this paragraph | ||||||
12 | at any point in time, including before an initial request | ||||||
13 | for authorization. | ||||||
14 | (4) Track, identify, and analyze how the utilization | ||||||
15 | review criteria are used to certify care, deny care, and | ||||||
16 | support the appeals process. | ||||||
17 | (5) Conduct interrater reliability testing to ensure | ||||||
18 | consistency in utilization review decision making that | ||||||
19 | covers how medical necessity decisions are made; this | ||||||
20 | assessment shall cover all aspects of utilization review | ||||||
21 | as defined in subsection (h). | ||||||
22 | (6) Run interrater reliability reports about how the | ||||||
23 | clinical guidelines are used in conjunction with the | ||||||
24 | utilization review process and parity compliance | ||||||
25 | activities. | ||||||
26 | (7) Achieve interrater reliability pass rates of at |
| |||||||
| |||||||
1 | least 90% and, if this threshold is not met, immediately | ||||||
2 | provide for the remediation of poor interrater reliability | ||||||
3 | and interrater reliability testing for all new staff | ||||||
4 | before they can conduct utilization review without | ||||||
5 | supervision. | ||||||
6 | (8) Maintain documentation of interrater reliability | ||||||
7 | testing and the remediation actions taken for those with | ||||||
8 | pass rates lower than 90% and submit to the Department of | ||||||
9 | Insurance or, in the case of Medicaid managed care | ||||||
10 | organizations, the Department of Healthcare and Family | ||||||
11 | Services the testing results and a summary of remedial | ||||||
12 | actions as part of parity compliance reporting set forth | ||||||
13 | in subsection (k) of Section 370c.1. | ||||||
14 | (r) This Section applies to all health care services and | ||||||
15 | benefits for the diagnosis, prevention, and treatment of | ||||||
16 | mental, emotional, nervous, or substance use disorders or | ||||||
17 | conditions covered by an insurance policy, including | ||||||
18 | prescription drugs. | ||||||
19 | (s) This Section applies to an insurer that amends, | ||||||
20 | delivers, issues, or renews a group or individual policy of | ||||||
21 | accident and health insurance or a qualified health plan | ||||||
22 | offered through the health insurance marketplace in this State | ||||||
23 | providing coverage for hospital or medical treatment and | ||||||
24 | conducts utilization review as defined in this Section, | ||||||
25 | including Medicaid managed care organizations, and any entity | ||||||
26 | or contracting provider that performs utilization review or |
| |||||||
| |||||||
1 | utilization management functions on an insurer's behalf. | ||||||
2 | (t) If the Director determines that an insurer has | ||||||
3 | violated this Section, the Director may, after appropriate | ||||||
4 | notice and opportunity for hearing, by order, assess a civil | ||||||
5 | penalty between $1,000 and $5,000 for each violation. Moneys | ||||||
6 | collected from penalties shall be deposited into the Parity | ||||||
7 | Advancement Fund established in subsection (i) of Section | ||||||
8 | 370c.1. Nothing in this Section shall be construed to limit | ||||||
9 | criminal liability. | ||||||
10 | (u) If an insurer commits a violation of this Section, the | ||||||
11 | insurer shall be given 30 days' notice to rectify that | ||||||
12 | violation. Failure to rectify the violation within the 30-day | ||||||
13 | notice period and any subsequent violation of this Section by | ||||||
14 | the insurer shall constitute a Class A misdemeanor and shall | ||||||
15 | result in criminal liability pursuant to Section 49-7 of the | ||||||
16 | Criminal Code of 2012. | ||||||
17 | (v) (u) An insurer shall not adopt, impose, or enforce | ||||||
18 | terms in its policies or provider agreements, in writing or in | ||||||
19 | operation, that undermine, alter, or conflict with the | ||||||
20 | requirements of this Section. | ||||||
21 | (w) (v) The provisions of this Section are severable. If | ||||||
22 | any provision of this Section or its application is held | ||||||
23 | invalid, that invalidity shall not affect other provisions or | ||||||
24 | applications that can be given effect without the invalid | ||||||
25 | provision or application. | ||||||
26 | (Source: P.A. 101-81, eff. 7-12-19; 101-386, eff. 8-16-19; |
| |||||||
| |||||||
1 | 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; 102-813, eff. | ||||||
2 | 5-13-22.) | ||||||
3 | (215 ILCS 5/370c.1) | ||||||
4 | Sec. 370c.1. Mental, emotional, nervous, or substance use | ||||||
5 | disorder or condition parity. | ||||||
6 | (a) On and after July 23, 2021 (the effective date of | ||||||
7 | Public Act 102-135), every insurer that amends, delivers, | ||||||
8 | issues, or renews a group or individual policy of accident and | ||||||
9 | health insurance or a qualified health plan offered through | ||||||
10 | the Health Insurance Marketplace in this State providing | ||||||
11 | coverage for hospital or medical treatment and for the | ||||||
12 | treatment of mental, emotional, nervous, or substance use | ||||||
13 | disorders or conditions shall ensure prior to policy issuance | ||||||
14 | that: | ||||||
15 | (1) the financial requirements applicable to such | ||||||
16 | mental, emotional, nervous, or substance use disorder or | ||||||
17 | condition benefits are no more restrictive than the | ||||||
18 | predominant financial requirements applied to | ||||||
19 | substantially all hospital and medical benefits covered by | ||||||
20 | the policy and that there are no separate cost-sharing | ||||||
21 | requirements that are applicable only with respect to | ||||||
22 | mental, emotional, nervous, or substance use disorder or | ||||||
23 | condition benefits; and | ||||||
24 | (2) the treatment limitations applicable to such | ||||||
25 | mental, emotional, nervous, or substance use disorder or |
| |||||||
| |||||||
1 | condition benefits are no more restrictive than the | ||||||
2 | predominant treatment limitations applied to substantially | ||||||
3 | all hospital and medical benefits covered by the policy | ||||||
4 | and that there are no separate treatment limitations that | ||||||
5 | are applicable only with respect to mental, emotional, | ||||||
6 | nervous, or substance use disorder or condition benefits. | ||||||
7 | (b) The following provisions shall apply concerning | ||||||
8 | aggregate lifetime limits: | ||||||
9 | (1) In the case of a group or individual policy of | ||||||
10 | accident and health insurance or a qualified health plan | ||||||
11 | offered through the Health Insurance Marketplace amended, | ||||||
12 | delivered, issued, or renewed in this State on or after | ||||||
13 | September 9, 2015 (the effective date of Public Act | ||||||
14 | 99-480) that provides coverage for hospital or medical | ||||||
15 | treatment and for the treatment of mental, emotional, | ||||||
16 | nervous, or substance use disorders or conditions the | ||||||
17 | following provisions shall apply: | ||||||
18 | (A) if the policy does not include an aggregate | ||||||
19 | lifetime limit on substantially all hospital and | ||||||
20 | medical benefits, then the policy may not impose any | ||||||
21 | aggregate lifetime limit on mental, emotional, | ||||||
22 | nervous, or substance use disorder or condition | ||||||
23 | benefits; or | ||||||
24 | (B) if the policy includes an aggregate lifetime | ||||||
25 | limit on substantially all hospital and medical | ||||||
26 | benefits (in this subsection referred to as the |
| |||||||
| |||||||
1 | "applicable lifetime limit"), then the policy shall | ||||||
2 | either: | ||||||
3 | (i) apply the applicable lifetime limit both | ||||||
4 | to the hospital and medical benefits to which it | ||||||
5 | otherwise would apply and to mental, emotional, | ||||||
6 | nervous, or substance use disorder or condition | ||||||
7 | benefits and not distinguish in the application of | ||||||
8 | the limit between the hospital and medical | ||||||
9 | benefits and mental, emotional, nervous, or | ||||||
10 | substance use disorder or condition benefits; or | ||||||
11 | (ii) not include any aggregate lifetime limit | ||||||
12 | on mental, emotional, nervous, or substance use | ||||||
13 | disorder or condition benefits that is less than | ||||||
14 | the applicable lifetime limit. | ||||||
15 | (2) In the case of a policy that is not described in | ||||||
16 | paragraph (1) of subsection (b) of this Section and that | ||||||
17 | includes no or different aggregate lifetime limits on | ||||||
18 | different categories of hospital and medical benefits, the | ||||||
19 | Director shall establish rules under which subparagraph | ||||||
20 | (B) of paragraph (1) of subsection (b) of this Section is | ||||||
21 | applied to such policy with respect to mental, emotional, | ||||||
22 | nervous, or substance use disorder or condition benefits | ||||||
23 | by substituting for the applicable lifetime limit an | ||||||
24 | average aggregate lifetime limit that is computed taking | ||||||
25 | into account the weighted average of the aggregate | ||||||
26 | lifetime limits applicable to such categories. |
| |||||||
| |||||||
1 | (c) The following provisions shall apply concerning annual | ||||||
2 | limits: | ||||||
3 | (1) In the case of a group or individual policy of | ||||||
4 | accident and health insurance or a qualified health plan | ||||||
5 | offered through the Health Insurance Marketplace amended, | ||||||
6 | delivered, issued, or renewed in this State on or after | ||||||
7 | September 9, 2015 (the effective date of Public Act | ||||||
8 | 99-480) that provides coverage for hospital or medical | ||||||
9 | treatment and for the treatment of mental, emotional, | ||||||
10 | nervous, or substance use disorders or conditions the | ||||||
11 | following provisions shall apply: | ||||||
12 | (A) if the policy does not include an annual limit | ||||||
13 | on substantially all hospital and medical benefits, | ||||||
14 | then the policy may not impose any annual limits on | ||||||
15 | mental, emotional, nervous, or substance use disorder | ||||||
16 | or condition benefits; or | ||||||
17 | (B) if the policy includes an annual limit on | ||||||
18 | substantially all hospital and medical benefits (in | ||||||
19 | this subsection referred to as the "applicable annual | ||||||
20 | limit"), then the policy shall either: | ||||||
21 | (i) apply the applicable annual limit both to | ||||||
22 | the hospital and medical benefits to which it | ||||||
23 | otherwise would apply and to mental, emotional, | ||||||
24 | nervous, or substance use disorder or condition | ||||||
25 | benefits and not distinguish in the application of | ||||||
26 | the limit between the hospital and medical |
| |||||||
| |||||||
1 | benefits and mental, emotional, nervous, or | ||||||
2 | substance use disorder or condition benefits; or | ||||||
3 | (ii) not include any annual limit on mental, | ||||||
4 | emotional, nervous, or substance use disorder or | ||||||
5 | condition benefits that is less than the | ||||||
6 | applicable annual limit. | ||||||
7 | (2) In the case of a policy that is not described in | ||||||
8 | paragraph (1) of subsection (c) of this Section and that | ||||||
9 | includes no or different annual limits on different | ||||||
10 | categories of hospital and medical benefits, the Director | ||||||
11 | shall establish rules under which subparagraph (B) of | ||||||
12 | paragraph (1) of subsection (c) of this Section is applied | ||||||
13 | to such policy with respect to mental, emotional, nervous, | ||||||
14 | or substance use disorder or condition benefits by | ||||||
15 | substituting for the applicable annual limit an average | ||||||
16 | annual limit that is computed taking into account the | ||||||
17 | weighted average of the annual limits applicable to such | ||||||
18 | categories. | ||||||
19 | (d) With respect to mental, emotional, nervous, or | ||||||
20 | substance use disorders or conditions, an insurer shall use | ||||||
21 | policies and procedures for the election and placement of | ||||||
22 | mental, emotional, nervous, or substance use disorder or | ||||||
23 | condition treatment drugs on their formulary that are no less | ||||||
24 | favorable to the insured as those policies and procedures the | ||||||
25 | insurer uses for the selection and placement of drugs for | ||||||
26 | medical or surgical conditions and shall follow the expedited |
| |||||||
| |||||||
1 | coverage determination requirements for substance abuse | ||||||
2 | treatment drugs set forth in Section 45.2 of the Managed Care | ||||||
3 | Reform and Patient Rights Act. | ||||||
4 | (e) This Section shall be interpreted in a manner | ||||||
5 | consistent with all applicable federal parity regulations | ||||||
6 | including, but not limited to, the Paul Wellstone and Pete | ||||||
7 | Domenici Mental Health Parity and Addiction Equity Act of | ||||||
8 | 2008, final regulations issued under the Paul Wellstone and | ||||||
9 | Pete Domenici Mental Health Parity and Addiction Equity Act of | ||||||
10 | 2008 and final regulations applying the Paul Wellstone and | ||||||
11 | Pete Domenici Mental Health Parity and Addiction Equity Act of | ||||||
12 | 2008 to Medicaid managed care organizations, the Children's | ||||||
13 | Health Insurance Program, and alternative benefit plans. | ||||||
14 | (f) The provisions of subsections (b) and (c) of this | ||||||
15 | Section shall not be interpreted to allow the use of lifetime | ||||||
16 | or annual limits otherwise prohibited by State or federal law. | ||||||
17 | (g) As used in this Section: | ||||||
18 | "Financial requirement" includes deductibles, copayments, | ||||||
19 | coinsurance, and out-of-pocket maximums, but does not include | ||||||
20 | an aggregate lifetime limit or an annual limit subject to | ||||||
21 | subsections (b) and (c). | ||||||
22 | "Mental, emotional, nervous, or substance use disorder or | ||||||
23 | condition" means a condition or disorder that involves a | ||||||
24 | mental health condition or substance use disorder that falls | ||||||
25 | under any of the diagnostic categories listed in the mental | ||||||
26 | and behavioral disorders chapter of the current edition of the |
| |||||||
| |||||||
1 | International Classification of Disease or that is listed in | ||||||
2 | the most recent version of the Diagnostic and Statistical | ||||||
3 | Manual of Mental Disorders. | ||||||
4 | "Treatment limitation" includes limits on benefits based | ||||||
5 | on the frequency of treatment, number of visits, days of | ||||||
6 | coverage, days in a waiting period, or other similar limits on | ||||||
7 | the scope or duration of treatment. "Treatment limitation" | ||||||
8 | includes both quantitative treatment limitations, which are | ||||||
9 | expressed numerically (such as 50 outpatient visits per year), | ||||||
10 | and nonquantitative treatment limitations, which otherwise | ||||||
11 | limit the scope or duration of treatment. A permanent | ||||||
12 | exclusion of all benefits for a particular condition or | ||||||
13 | disorder shall not be considered a treatment limitation. | ||||||
14 | "Nonquantitative treatment" means those limitations as | ||||||
15 | described under federal regulations (26 CFR 54.9812-1). | ||||||
16 | "Nonquantitative treatment limitations" include, but are not | ||||||
17 | limited to, those limitations described under federal | ||||||
18 | regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR | ||||||
19 | 146.136.
| ||||||
20 | (h) The Department of Insurance shall implement the | ||||||
21 | following education initiatives: | ||||||
22 | (1) By January 1, 2016, the Department shall develop a | ||||||
23 | plan for a Consumer Education Campaign on parity. The | ||||||
24 | Consumer Education Campaign shall focus its efforts | ||||||
25 | throughout the State and include trainings in the | ||||||
26 | northern, southern, and central regions of the State, as |
| |||||||
| |||||||
1 | defined by the Department, as well as each of the 5 managed | ||||||
2 | care regions of the State as identified by the Department | ||||||
3 | of Healthcare and Family Services. Under this Consumer | ||||||
4 | Education Campaign, the Department shall: (1) by January | ||||||
5 | 1, 2017, provide at least one live training in each region | ||||||
6 | on parity for consumers and providers and one webinar | ||||||
7 | training to be posted on the Department website and (2) | ||||||
8 | establish a consumer hotline to assist consumers in | ||||||
9 | navigating the parity process by March 1, 2017. By January | ||||||
10 | 1, 2018 the Department shall issue a report to the General | ||||||
11 | Assembly on the success of the Consumer Education | ||||||
12 | Campaign, which shall indicate whether additional training | ||||||
13 | is necessary or would be recommended. | ||||||
14 | (2) The Department, in coordination with the | ||||||
15 | Department of Human Services and the Department of | ||||||
16 | Healthcare and Family Services, shall convene a working | ||||||
17 | group of health care insurance carriers, mental health | ||||||
18 | advocacy groups, substance abuse patient advocacy groups, | ||||||
19 | and mental health physician groups for the purpose of | ||||||
20 | discussing issues related to the treatment and coverage of | ||||||
21 | mental, emotional, nervous, or substance use disorders or | ||||||
22 | conditions and compliance with parity obligations under | ||||||
23 | State and federal law. Compliance shall be measured, | ||||||
24 | tracked, and shared during the meetings of the working | ||||||
25 | group. The working group shall meet once before January 1, | ||||||
26 | 2016 and shall meet semiannually thereafter. The |
| |||||||
| |||||||
1 | Department shall issue an annual report to the General | ||||||
2 | Assembly that includes a list of the health care insurance | ||||||
3 | carriers, mental health advocacy groups, substance abuse | ||||||
4 | patient advocacy groups, and mental health physician | ||||||
5 | groups that participated in the working group meetings, | ||||||
6 | details on the issues and topics covered, and any | ||||||
7 | legislative recommendations developed by the working | ||||||
8 | group. | ||||||
9 | (3) Not later than January 1 of each year, the | ||||||
10 | Department, in conjunction with the Department of | ||||||
11 | Healthcare and Family Services, shall issue a joint report | ||||||
12 | to the General Assembly and provide an educational | ||||||
13 | presentation to the General Assembly. The report and | ||||||
14 | presentation shall: | ||||||
15 | (A) Cover the methodology the Departments use to | ||||||
16 | check for compliance with the federal Paul Wellstone | ||||||
17 | and Pete Domenici Mental Health Parity and Addiction | ||||||
18 | Equity Act of 2008, 42 U.S.C. 18031(j), and any | ||||||
19 | federal regulations or guidance relating to the | ||||||
20 | compliance and oversight of the federal Paul Wellstone | ||||||
21 | and Pete Domenici Mental Health Parity and Addiction | ||||||
22 | Equity Act of 2008 and 42 U.S.C. 18031(j). | ||||||
23 | (B) Cover the methodology the Departments use to | ||||||
24 | check for compliance with this Section and Sections | ||||||
25 | 356z.23 , and 370c , and 370c.3 of this Code. | ||||||
26 | (C) Identify market conduct examinations or, in |
| |||||||
| |||||||
1 | the case of the Department of Healthcare and Family | ||||||
2 | Services, audits conducted or completed during the | ||||||
3 | preceding 12-month period regarding compliance with | ||||||
4 | parity in mental, emotional, nervous, and substance | ||||||
5 | use disorder or condition benefits and parity in | ||||||
6 | vision, hearing, and dental disorder or condition | ||||||
7 | benefits under State and federal laws and summarize | ||||||
8 | the results of such market conduct examinations and | ||||||
9 | audits. This shall include: | ||||||
10 | (i) the number of market conduct examinations | ||||||
11 | and audits initiated and completed; | ||||||
12 | (ii) the benefit classifications examined by | ||||||
13 | each market conduct examination and audit; | ||||||
14 | (iii) the subject matter of each market | ||||||
15 | conduct examination and audit, including | ||||||
16 | quantitative and nonquantitative treatment | ||||||
17 | limitations; and | ||||||
18 | (iv) a summary of the basis for the final | ||||||
19 | decision rendered in each market conduct | ||||||
20 | examination and audit. | ||||||
21 | Individually identifiable information shall be | ||||||
22 | excluded from the reports consistent with federal | ||||||
23 | privacy protections. | ||||||
24 | (D) Detail any educational or corrective actions | ||||||
25 | the Departments have taken to ensure compliance with | ||||||
26 | the federal Paul Wellstone and Pete Domenici Mental |
| |||||||
| |||||||
1 | Health Parity and Addiction Equity Act of 2008, 42 | ||||||
2 | U.S.C. 18031(j), this Section, and Sections 356z.23 , | ||||||
3 | and 370c , and 370c.3 of this Code. | ||||||
4 | (E) The report must be written in non-technical, | ||||||
5 | readily understandable language and shall be made | ||||||
6 | available to the public by, among such other means as | ||||||
7 | the Departments find appropriate, posting the report | ||||||
8 | on the Departments' websites. | ||||||
9 | (i) The Parity Advancement Fund is created as a special | ||||||
10 | fund in the State treasury. Moneys from fines and penalties | ||||||
11 | collected from insurers for violations of this Section shall | ||||||
12 | be deposited into the Fund. Moneys deposited into the Fund for | ||||||
13 | appropriation by the General Assembly to the Department shall | ||||||
14 | be used for the purpose of providing financial support of the | ||||||
15 | Consumer Education Campaign, parity compliance advocacy, and | ||||||
16 | other initiatives that support parity implementation and | ||||||
17 | enforcement on behalf of consumers. | ||||||
18 | (j) The Department of Insurance and the Department of | ||||||
19 | Healthcare and Family Services shall convene and provide | ||||||
20 | technical support to a workgroup of 11 members that shall be | ||||||
21 | comprised of 3 mental health parity experts recommended by an | ||||||
22 | organization advocating on behalf of mental health parity | ||||||
23 | appointed by the President of the Senate; 3 behavioral health | ||||||
24 | providers recommended by an organization that represents | ||||||
25 | behavioral health providers appointed by the Speaker of the | ||||||
26 | House of Representatives; 2 representing Medicaid managed care |
| |||||||
| |||||||
1 | organizations recommended by an organization that represents | ||||||
2 | Medicaid managed care plans appointed by the Minority Leader | ||||||
3 | of the House of Representatives; 2 representing commercial | ||||||
4 | insurers recommended by an organization that represents | ||||||
5 | insurers appointed by the Minority Leader of the Senate; and a | ||||||
6 | representative of an organization that represents Medicaid | ||||||
7 | managed care plans appointed by the Governor. | ||||||
8 | The workgroup shall provide recommendations to the General | ||||||
9 | Assembly on health plan data reporting requirements that | ||||||
10 | separately break out data on mental, emotional, nervous, or | ||||||
11 | substance use disorder or condition benefits and data on other | ||||||
12 | medical benefits, including physical health and related health | ||||||
13 | services no later than December 31, 2019. The recommendations | ||||||
14 | to the General Assembly shall be filed with the Clerk of the | ||||||
15 | House of Representatives and the Secretary of the Senate in | ||||||
16 | electronic form only, in the manner that the Clerk and the | ||||||
17 | Secretary shall direct. This workgroup shall take into account | ||||||
18 | federal requirements and recommendations on mental health | ||||||
19 | parity reporting for the Medicaid program. This workgroup | ||||||
20 | shall also develop the format and provide any needed | ||||||
21 | definitions for reporting requirements in subsection (k). The | ||||||
22 | research and evaluation of the working group shall include, | ||||||
23 | but not be limited to: | ||||||
24 | (1) claims denials due to benefit limits, if | ||||||
25 | applicable; | ||||||
26 | (2) administrative denials for no prior authorization; |
| |||||||
| |||||||
1 | (3) denials due to not meeting medical necessity; | ||||||
2 | (4) denials that went to external review and whether | ||||||
3 | they were upheld or overturned for medical necessity; | ||||||
4 | (5) out-of-network claims; | ||||||
5 | (6) emergency care claims; | ||||||
6 | (7) network directory providers in the outpatient | ||||||
7 | benefits classification who filed no claims in the last 6 | ||||||
8 | months, if applicable; | ||||||
9 | (8) the impact of existing and pertinent limitations | ||||||
10 | and restrictions related to approved services, licensed | ||||||
11 | providers, reimbursement levels, and reimbursement | ||||||
12 | methodologies within the Division of Mental Health, the | ||||||
13 | Division of Substance Use Prevention and Recovery | ||||||
14 | programs, the Department of Healthcare and Family | ||||||
15 | Services, and, to the extent possible, federal regulations | ||||||
16 | and law; and | ||||||
17 | (9) when reporting and publishing should begin. | ||||||
18 | Representatives from the Department of Healthcare and | ||||||
19 | Family Services, representatives from the Division of Mental | ||||||
20 | Health, and representatives from the Division of Substance Use | ||||||
21 | Prevention and Recovery shall provide technical advice to the | ||||||
22 | workgroup. | ||||||
23 | (k) An insurer that amends, delivers, issues, or renews a | ||||||
24 | group or individual policy of accident and health insurance or | ||||||
25 | a qualified health plan offered through the health insurance | ||||||
26 | marketplace in this State providing coverage for hospital or |
| |||||||
| |||||||
1 | medical treatment and for the treatment of mental, emotional, | ||||||
2 | nervous, or substance use disorders or conditions shall submit | ||||||
3 | an annual report, the format and definitions for which will be | ||||||
4 | developed by the workgroup in subsection (j), to the | ||||||
5 | Department, or, with respect to medical assistance, the | ||||||
6 | Department of Healthcare and Family Services starting on or | ||||||
7 | before July 1, 2020 that contains the following information | ||||||
8 | separately for inpatient in-network benefits, inpatient | ||||||
9 | out-of-network benefits, outpatient in-network benefits, | ||||||
10 | outpatient out-of-network benefits, emergency care benefits, | ||||||
11 | and prescription drug benefits in the case of accident and | ||||||
12 | health insurance or qualified health plans, or inpatient, | ||||||
13 | outpatient, emergency care, and prescription drug benefits in | ||||||
14 | the case of medical assistance: | ||||||
15 | (1) A summary of the plan's pharmacy management | ||||||
16 | processes for mental, emotional, nervous, or substance use | ||||||
17 | disorder or condition benefits compared to those for other | ||||||
18 | medical benefits. | ||||||
19 | (2) A summary of the internal processes of review for | ||||||
20 | experimental benefits and unproven technology for mental, | ||||||
21 | emotional, nervous, or substance use disorder or condition | ||||||
22 | benefits and those for
other medical benefits. | ||||||
23 | (3) A summary of how the plan's policies and | ||||||
24 | procedures for utilization management for mental, | ||||||
25 | emotional, nervous, or substance use disorder or condition | ||||||
26 | benefits compare to those for other medical benefits. |
| |||||||
| |||||||
1 | (4) A description of the process used to develop or | ||||||
2 | select the medical necessity criteria for mental, | ||||||
3 | emotional, nervous, or substance use disorder or condition | ||||||
4 | benefits and the process used to develop or select the | ||||||
5 | medical necessity criteria for medical and surgical | ||||||
6 | benefits. | ||||||
7 | (5) Identification of all nonquantitative treatment | ||||||
8 | limitations that are applied to both mental, emotional, | ||||||
9 | nervous, or substance use disorder or condition benefits | ||||||
10 | and medical and surgical benefits within each | ||||||
11 | classification of benefits. | ||||||
12 | (6) The results of an analysis that demonstrates that | ||||||
13 | for the medical necessity criteria described in | ||||||
14 | subparagraph (A) and for each nonquantitative treatment | ||||||
15 | limitation identified in subparagraph (B), as written and | ||||||
16 | in operation, the processes, strategies, evidentiary | ||||||
17 | standards, or other factors used in applying the medical | ||||||
18 | necessity criteria and each nonquantitative treatment | ||||||
19 | limitation to mental, emotional, nervous, or substance use | ||||||
20 | disorder or condition benefits within each classification | ||||||
21 | of benefits are comparable to, and are applied no more | ||||||
22 | stringently than, the processes, strategies, evidentiary | ||||||
23 | standards, or other factors used in applying the medical | ||||||
24 | necessity criteria and each nonquantitative treatment | ||||||
25 | limitation to medical and surgical benefits within the | ||||||
26 | corresponding classification of benefits; at a minimum, |
| |||||||
| |||||||
1 | the results of the analysis shall: | ||||||
2 | (A) identify the factors used to determine that a | ||||||
3 | nonquantitative treatment limitation applies to a | ||||||
4 | benefit, including factors that were considered but | ||||||
5 | rejected; | ||||||
6 | (B) identify and define the specific evidentiary | ||||||
7 | standards used to define the factors and any other | ||||||
8 | evidence relied upon in designing each nonquantitative | ||||||
9 | treatment limitation; | ||||||
10 | (C) provide the comparative analyses, including | ||||||
11 | the results of the analyses, performed to determine | ||||||
12 | that the processes and strategies used to design each | ||||||
13 | nonquantitative treatment limitation, as written, for | ||||||
14 | mental, emotional, nervous, or substance use disorder | ||||||
15 | or condition benefits are comparable to, and are | ||||||
16 | applied no more stringently than, the processes and | ||||||
17 | strategies used to design each nonquantitative | ||||||
18 | treatment limitation, as written, for medical and | ||||||
19 | surgical benefits; | ||||||
20 | (D) provide the comparative analyses, including | ||||||
21 | the results of the analyses, performed to determine | ||||||
22 | that the processes and strategies used to apply each | ||||||
23 | nonquantitative treatment limitation, in operation, | ||||||
24 | for mental, emotional, nervous, or substance use | ||||||
25 | disorder or condition benefits are comparable to, and | ||||||
26 | applied no more stringently than, the processes or |
| |||||||
| |||||||
1 | strategies used to apply each nonquantitative | ||||||
2 | treatment limitation, in operation, for medical and | ||||||
3 | surgical benefits; and | ||||||
4 | (E) disclose the specific findings and conclusions | ||||||
5 | reached by the insurer that the results of the | ||||||
6 | analyses described in subparagraphs (C) and (D) | ||||||
7 | indicate that the insurer is in compliance with this | ||||||
8 | Section and the Mental Health Parity and Addiction | ||||||
9 | Equity Act of 2008 and its implementing regulations, | ||||||
10 | which includes 42 CFR Parts 438, 440, and 457 and 45 | ||||||
11 | CFR 146.136 and any other related federal regulations | ||||||
12 | found in the Code of Federal Regulations. | ||||||
13 | (7) Any other information necessary to clarify data | ||||||
14 | provided in accordance with this Section requested by the | ||||||
15 | Director, including information that may be proprietary or | ||||||
16 | have commercial value, under the requirements of Section | ||||||
17 | 30 of the Viatical Settlements Act of 2009. | ||||||
18 | (l) An insurer that amends, delivers, issues, or renews a | ||||||
19 | group or individual policy of accident and health insurance or | ||||||
20 | a qualified health plan offered through the health insurance | ||||||
21 | marketplace in this State providing coverage for hospital or | ||||||
22 | medical treatment and for the treatment of mental, emotional, | ||||||
23 | nervous, or substance use disorders or conditions on or after | ||||||
24 | January 1, 2019 (the effective date of Public Act 100-1024) | ||||||
25 | shall, in advance of the plan year, make available to the | ||||||
26 | Department or, with respect to medical assistance, the |
| |||||||
| |||||||
1 | Department of Healthcare and Family Services and to all plan | ||||||
2 | participants and beneficiaries the information required in | ||||||
3 | subparagraphs (C) through (E) of paragraph (6) of subsection | ||||||
4 | (k). For plan participants and medical assistance | ||||||
5 | beneficiaries, the information required in subparagraphs (C) | ||||||
6 | through (E) of paragraph (6) of subsection (k) shall be made | ||||||
7 | available on a publicly-available website whose web address is | ||||||
8 | prominently displayed in plan and managed care organization | ||||||
9 | informational and marketing materials. | ||||||
10 | (m) In conjunction with its compliance examination program | ||||||
11 | conducted in accordance with the Illinois State Auditing Act, | ||||||
12 | the Auditor General shall undertake a review of
compliance by | ||||||
13 | the Department and the Department of Healthcare and Family | ||||||
14 | Services with Section 370c and this Section. Any
findings | ||||||
15 | resulting from the review conducted under this Section shall | ||||||
16 | be included in the applicable State agency's compliance | ||||||
17 | examination report. Each compliance examination report shall | ||||||
18 | be issued in accordance with Section 3-14 of the Illinois | ||||||
19 | State
Auditing Act. A copy of each report shall also be | ||||||
20 | delivered to
the head of the applicable State agency and | ||||||
21 | posted on the Auditor General's website. | ||||||
22 | (Source: P.A. 102-135, eff. 7-23-21; 102-579, eff. 8-25-21; | ||||||
23 | 102-813, eff. 5-13-22.) | ||||||
24 | (215 ILCS 5/370c.3 new) | ||||||
25 | Sec. 370c.3. Vision, hearing, and dental disorder or |
| |||||||
| |||||||
1 | condition parity. | ||||||
2 | (a) As used in this Section: | ||||||
3 | "Financial requirement" includes deductibles, copayments, | ||||||
4 | coinsurance, and out-of-pocket maximums, but does not include | ||||||
5 | an aggregate lifetime limit or an annual limit subject to | ||||||
6 | subsections (b) and (c). | ||||||
7 | "Treatment limitation" includes limits on benefits based | ||||||
8 | on the frequency of treatment, number of visits, days of | ||||||
9 | coverage, days in a waiting period, or other similar limits on | ||||||
10 | the scope or duration of treatment. "Treatment limitation" | ||||||
11 | includes both quantitative treatment limitations, which are | ||||||
12 | expressed numerically (such as 50 outpatient visits per year), | ||||||
13 | and nonquantitative treatment limitations, which otherwise | ||||||
14 | limit the scope or duration of treatment. A permanent | ||||||
15 | exclusion of all benefits for a particular condition or | ||||||
16 | disorder shall not be considered a treatment limitation. | ||||||
17 | "Nonquantitative treatment" means those limitations as | ||||||
18 | described under federal regulations (26 CFR 54.9812-1). | ||||||
19 | "Nonquantitative treatment limitations" include, but are not | ||||||
20 | limited to, those limitations described under federal | ||||||
21 | regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR | ||||||
22 | 146.136. | ||||||
23 | (b) On and after the effective date of this amendatory Act | ||||||
24 | of the 103rd General Assembly, every insurer that amends, | ||||||
25 | delivers, issues, or renews a group or individual policy of | ||||||
26 | accident and health insurance or a qualified health plan |
| |||||||
| |||||||
1 | offered through the health insurance marketplace in this State | ||||||
2 | providing coverage for hospital or medical treatment and for | ||||||
3 | the treatment of a vision, hearing, or dental disorder or | ||||||
4 | condition shall ensure before policy issuance that: | ||||||
5 | (1) the financial requirements applicable to such | ||||||
6 | vision, hearing, or dental disorder or condition benefits | ||||||
7 | are no more restrictive than the predominant financial | ||||||
8 | requirements applied to substantially all hospital and | ||||||
9 | medical benefits covered by the policy and that there are | ||||||
10 | no separate cost-sharing requirements that are applicable | ||||||
11 | only with respect to vision, hearing, or dental disorder | ||||||
12 | or condition benefits; and | ||||||
13 | (2) the treatment limitations applicable to such | ||||||
14 | vision, hearing, or dental disorder or condition benefits | ||||||
15 | are no more restrictive than the predominant treatment | ||||||
16 | limitations applied to substantially all hospital and | ||||||
17 | medical benefits covered by the policy and that there are | ||||||
18 | no separate treatment limitations that are applicable only | ||||||
19 | with respect to vision, hearing, or dental disorder or | ||||||
20 | condition benefits. | ||||||
21 | (c) The following provisions shall apply concerning | ||||||
22 | aggregate lifetime limits: | ||||||
23 | (1) In the case of a group or individual policy of | ||||||
24 | accident and health insurance or a qualified health plan | ||||||
25 | offered through the health insurance marketplace amended, | ||||||
26 | delivered, issued, or renewed in this State on or after |
| |||||||
| |||||||
1 | the effective date of this amendatory Act of the 103rd | ||||||
2 | General Assembly that provides coverage for hospital or | ||||||
3 | medical treatment and for the treatment of a vision, | ||||||
4 | hearing, or dental disorder or condition, the following | ||||||
5 | provisions shall apply: | ||||||
6 | (A) if the policy does not include an aggregate | ||||||
7 | lifetime limit on substantially all hospital and | ||||||
8 | medical benefits, then the policy may not impose any | ||||||
9 | aggregate lifetime limit on vision, hearing, dental | ||||||
10 | disorder or condition benefits; or | ||||||
11 | (B) if the policy includes an aggregate lifetime | ||||||
12 | limit on substantially all hospital and medical | ||||||
13 | benefits, then the policy shall either: | ||||||
14 | (i) apply the aggregate lifetime limit both to | ||||||
15 | the hospital and medical benefits to which it | ||||||
16 | otherwise would apply and to vision, hearing, and | ||||||
17 | dental disorder or condition benefits and not | ||||||
18 | distinguish in the application of the limit | ||||||
19 | between the hospital and medical benefits and | ||||||
20 | vision, hearing, and dental disorder or condition | ||||||
21 | benefits; or | ||||||
22 | (ii) not include any aggregate lifetime limit | ||||||
23 | on vision, hearing, and dental disorder or | ||||||
24 | condition benefits that is less than the aggregate | ||||||
25 | lifetime limit on substantially all hospital and | ||||||
26 | medical benefits. |
| |||||||
| |||||||
1 | (2) In the case of a policy that is not described in | ||||||
2 | paragraph (1) of subsection (b) and that includes no or | ||||||
3 | different aggregate lifetime limits on different | ||||||
4 | categories of hospital and medical benefits, the | ||||||
5 | Department shall adopt rules under which subparagraph (B) | ||||||
6 | of paragraph (1) of subsection (b) is applied to such | ||||||
7 | policy with respect to vision, hearing, and dental | ||||||
8 | disorder or condition benefits by substituting the | ||||||
9 | aggregate lifetime limit on substantially all hospital and | ||||||
10 | medical benefits with an average aggregate lifetime limit | ||||||
11 | that is computed taking into account the weighted average | ||||||
12 | of the aggregate lifetime limits applicable to such | ||||||
13 | categories. | ||||||
14 | (d) The following provisions shall apply concerning annual | ||||||
15 | limits: | ||||||
16 | (1) In the case of a group or individual policy of | ||||||
17 | accident and health insurance or a qualified health plan | ||||||
18 | offered through the health insurance marketplace amended, | ||||||
19 | delivered, issued, or renewed in this State on or after | ||||||
20 | the effective date of this amendatory Act of the 103rd | ||||||
21 | General Assembly that provides coverage for hospital or | ||||||
22 | medical treatment and for the treatment of a vision, | ||||||
23 | hearing, or dental disorder or condition, the following | ||||||
24 | provisions shall apply: | ||||||
25 | (A) if the policy does not include an annual limit | ||||||
26 | on substantially all hospital and medical benefits, |
| |||||||
| |||||||
1 | then the policy may not impose any annual limits on | ||||||
2 | vision, hearing, or dental disorder or condition | ||||||
3 | benefits; or | ||||||
4 | (B) if the policy includes an annual limit on | ||||||
5 | substantially all hospital and medical benefits, then | ||||||
6 | the policy shall either: | ||||||
7 | (i) apply the annual limit on substantially | ||||||
8 | all hospital and medical benefits both to the | ||||||
9 | hospital and medical benefits to which it | ||||||
10 | otherwise would apply and to mental, emotional, | ||||||
11 | nervous, or substance use disorder or condition | ||||||
12 | benefits and not distinguish in the application of | ||||||
13 | the limit between the hospital and medical | ||||||
14 | benefits and vision, hearing, and dental disorder | ||||||
15 | or condition benefits; or | ||||||
16 | (ii) not include any annual limit on vision, | ||||||
17 | hearing, and dental disorder or condition benefits | ||||||
18 | that is less than the annual limit on | ||||||
19 | substantially all hospital and medical benefits. | ||||||
20 | (2) In the case of a policy that is not described in | ||||||
21 | paragraph (1) of subsection (c) and that includes no or | ||||||
22 | different annual limits on different categories of | ||||||
23 | hospital and medical benefits, the Director shall | ||||||
24 | establish rules under which subparagraph (B) of paragraph | ||||||
25 | (1) of subsection (c) is applied to such policy with | ||||||
26 | respect to vision, hearing, and dental disorder or |
| |||||||
| |||||||
1 | condition benefits by substituting the annual limit on | ||||||
2 | substantially all hospital and medical benefits with an | ||||||
3 | average annual limit that is computed taking into account | ||||||
4 | the weighted average of the annual limits applicable to | ||||||
5 | such categories. | ||||||
6 | (e) With respect to a vision, hearing, and dental disorder | ||||||
7 | or condition, an insurer shall use policies and procedures for | ||||||
8 | the election and placement of vision, hearing, and dental | ||||||
9 | disorder or condition treatment drugs on their formulary that | ||||||
10 | are no less favorable to the insured as those policies and | ||||||
11 | procedures the insurer uses for the selection and placement of | ||||||
12 | drugs for medical or surgical conditions and shall follow the | ||||||
13 | expedited coverage determination requirements for substance | ||||||
14 | abuse treatment drugs set forth in Section 45.2 of the Managed | ||||||
15 | Care Reform and Patient Rights Act. | ||||||
16 | (f) The provisions of subsections (c) and (d) shall not be | ||||||
17 | interpreted to allow the use of lifetime or annual limits | ||||||
18 | otherwise prohibited by State or federal law. | ||||||
19 | (g) An insurer that amends, delivers, issues, or renews a | ||||||
20 | group or individual policy of accident and health insurance or | ||||||
21 | a qualified health plan offered through the health insurance | ||||||
22 | marketplace in this State providing coverage for hospital or | ||||||
23 | medical treatment and for the treatment of vision, hearing, or | ||||||
24 | dental disorders or conditions shall submit an annual report | ||||||
25 | that contains the following information separately for | ||||||
26 | inpatient in-network benefits, inpatient out-of-network |
| |||||||
| |||||||
1 | benefits, outpatient in-network benefits, outpatient | ||||||
2 | out-of-network benefits, emergency care benefits, and | ||||||
3 | prescription drug benefits in the case of accident and health | ||||||
4 | insurance or qualified health plans, or inpatient, outpatient, | ||||||
5 | emergency care, and prescription drug benefits in the case of | ||||||
6 | medical assistance: | ||||||
7 | (1) A summary of the plan's pharmacy management | ||||||
8 | processes for vision, hearing, and dental disorder or | ||||||
9 | condition benefits compared to those for other medical | ||||||
10 | benefits. | ||||||
11 | (2) A summary of the internal processes of review for | ||||||
12 | experimental benefits and unproven technology for vision, | ||||||
13 | hearing, and dental disorder or condition benefits and | ||||||
14 | those for other medical benefits. | ||||||
15 | (3) A summary of how the plan's policies and | ||||||
16 | procedures for utilization management for vision, hearing, | ||||||
17 | and dental disorder or condition benefits compare to those | ||||||
18 | for other medical benefits. | ||||||
19 | (4) A description of the process used to develop or | ||||||
20 | select the medical necessity criteria for vision, hearing, | ||||||
21 | and dental disorder or condition benefits and the process | ||||||
22 | used to develop or select the medical necessity criteria | ||||||
23 | for medical and surgical benefits. | ||||||
24 | (5) Identification of all nonquantitative treatment | ||||||
25 | limitations that are applied to vision, hearing, and | ||||||
26 | dental disorder or condition benefits and medical and |
| |||||||
| |||||||
1 | surgical benefits within each classification of benefits. | ||||||
2 | (6) The results of an analysis that demonstrates that | ||||||
3 | for the medical necessity criteria described in | ||||||
4 | subparagraph (A) of this paragraph and for each | ||||||
5 | nonquantitative treatment limitation identified in | ||||||
6 | subparagraph (B) of this paragraph, as written and in | ||||||
7 | operation, the processes, strategies, evidentiary | ||||||
8 | standards, or other factors used in applying the medical | ||||||
9 | necessity criteria and each nonquantitative treatment | ||||||
10 | limitation for vision, hearing, and dental disorder or | ||||||
11 | condition benefits within each classification of benefits | ||||||
12 | are comparable to, and are applied no more stringently | ||||||
13 | than, the processes, strategies, evidentiary standards, or | ||||||
14 | other factors used in applying the medical necessity | ||||||
15 | criteria and each nonquantitative treatment limitation to | ||||||
16 | medical and surgical benefits within the corresponding | ||||||
17 | classification of benefits; at a minimum, the results of | ||||||
18 | the analysis shall: | ||||||
19 | (A) identify the factors used to determine that a | ||||||
20 | nonquantitative treatment limitation applies to a | ||||||
21 | benefit, including factors that were considered but | ||||||
22 | rejected; | ||||||
23 | (B) identify and define the specific evidentiary | ||||||
24 | standards used to define the factors and any other | ||||||
25 | evidence relied upon in designing each nonquantitative | ||||||
26 | treatment limitation; |
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1 | (C) provide the comparative analyses, including | ||||||
2 | the results of the analyses, performed to determine | ||||||
3 | that the processes and strategies used to design each | ||||||
4 | nonquantitative treatment limitation, as written, for | ||||||
5 | vision, hearing, and dental disorder or condition | ||||||
6 | benefits are comparable to, and are applied no more | ||||||
7 | stringently than, the processes and strategies used to | ||||||
8 | design each nonquantitative treatment limitation, as | ||||||
9 | written, for medical and surgical benefits; | ||||||
10 | (D) provide the comparative analyses, including | ||||||
11 | the results of the analyses, performed to determine | ||||||
12 | that the processes and strategies used to apply each | ||||||
13 | nonquantitative treatment limitation, in operation, | ||||||
14 | for vision, hearing, and dental disorder or condition | ||||||
15 | benefits are comparable to, and applied no more | ||||||
16 | stringently than, the processes or strategies used to | ||||||
17 | apply each nonquantitative treatment limitation, in | ||||||
18 | operation, for medical and surgical benefits; and | ||||||
19 | (E) disclose the specific findings and conclusions | ||||||
20 | reached by the insurer that the results of the | ||||||
21 | analyses described in subparagraphs (C) and (D) of | ||||||
22 | this paragraph indicate that the insurer is in | ||||||
23 | compliance with this Section. | ||||||
24 | (7) Any other information necessary to clarify data | ||||||
25 | provided in accordance with this Section requested by the | ||||||
26 | Director, including information that may be proprietary or |
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1 | have commercial value, under the requirements of Section | ||||||
2 | 30 of the Viatical Settlements Act of 2009. | ||||||
3 | (h) An insurer that amends, delivers, issues, or renews a | ||||||
4 | group or individual policy of accident and health insurance or | ||||||
5 | a qualified health plan offered through the health insurance | ||||||
6 | marketplace in this State providing coverage for hospital or | ||||||
7 | medical treatment and for the treatment of vision, hearing, or | ||||||
8 | dental disorder or condition on or after the effective date of | ||||||
9 | this amendatory Act of the 103rd General Assembly shall, in | ||||||
10 | advance of the plan year, make available to the Department or, | ||||||
11 | with respect to medical assistance, the Department of | ||||||
12 | Healthcare and Family Services and to all plan participants | ||||||
13 | and beneficiaries the information required in subparagraphs | ||||||
14 | (C) through (E) of paragraph (6) of subsection (g). For plan | ||||||
15 | participants and medical assistance beneficiaries, the | ||||||
16 | information required in subparagraphs (C) through (E) of | ||||||
17 | paragraph (6) of subsection (g) shall be made available on a | ||||||
18 | publicly available website with a web address that is | ||||||
19 | prominently displayed in plan and managed care organization | ||||||
20 | informational and marketing materials. | ||||||
21 | (i) In conjunction with its compliance examination program | ||||||
22 | conducted in accordance with the Illinois State Auditing Act, | ||||||
23 | the Auditor General shall undertake a review of compliance by | ||||||
24 | the Department and the Department of Healthcare and Family | ||||||
25 | Services with Section 370c and this Section. Any findings | ||||||
26 | resulting from the review conducted under this Section shall |
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1 | be included in the applicable State agency's compliance | ||||||
2 | examination report. Each compliance examination report shall | ||||||
3 | be issued in accordance with Section 3-14 of the Illinois | ||||||
4 | State Auditing Act. A copy of each report shall also be | ||||||
5 | delivered to the head of the applicable State agency and | ||||||
6 | posted on the Auditor General's website.
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7 | Section 15. The Illinois Public Aid Code is amended by | ||||||
8 | changing Section 5-16.8 as follows:
| ||||||
9 | (305 ILCS 5/5-16.8)
| ||||||
10 | Sec. 5-16.8. Required health benefits. The medical | ||||||
11 | assistance program
shall
(i) provide the post-mastectomy care | ||||||
12 | benefits required to be covered by a policy of
accident and | ||||||
13 | health insurance under Section 356t and the coverage required
| ||||||
14 | under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, | ||||||
15 | 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, | ||||||
16 | 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60 , and | ||||||
17 | 356z.61 of the Illinois
Insurance Code, (ii) be subject to the | ||||||
18 | provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, | ||||||
19 | 370c, and 370c.1 , and 370c.3 of the Illinois
Insurance Code, | ||||||
20 | and (iii) be subject to the provisions of subsection (d-5) of | ||||||
21 | Section 10 of the Network Adequacy and Transparency Act.
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22 | The Department, by rule, shall adopt a model similar to | ||||||
23 | the requirements of Section 356z.39 of the Illinois Insurance | ||||||
24 | Code. |
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1 | On and after July 1, 2012, the Department shall reduce any | ||||||
2 | rate of reimbursement for services or other payments or alter | ||||||
3 | any methodologies authorized by this Code to reduce any rate | ||||||
4 | of reimbursement for services or other payments in accordance | ||||||
5 | with Section 5-5e. | ||||||
6 | To ensure full access to the benefits set forth in this | ||||||
7 | Section, on and after January 1, 2016, the Department shall | ||||||
8 | ensure that provider and hospital reimbursement for | ||||||
9 | post-mastectomy care benefits required under this Section are | ||||||
10 | no lower than the Medicare reimbursement rate. | ||||||
11 | (Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20; | ||||||
12 | 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff. | ||||||
13 | 1-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144, | ||||||
14 | eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; | ||||||
15 | 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. | ||||||
16 | 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, | ||||||
17 | eff. 1-1-23; 102-1117, eff. 1-13-23.)
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18 | Section 20. The Criminal Code of 2012 is amended by adding | ||||||
19 | Section 49-7 as follows: | ||||||
20 | (720 ILCS 5/49-7 new) | ||||||
21 | Sec. 49-7. Criminal violation of health benefit parity. | ||||||
22 | (a) A person commits a criminal violation of health | ||||||
23 | benefit parity if he or she knowingly and without legal | ||||||
24 | justification, by any means, causes Sections 356z.61, 370c, or |
| |||||||
| |||||||
1 | 370c.3 of the Illinois Insurance Code to be violated. | ||||||
2 | (b) Criminal violation of health benefit parity is a Class | ||||||
3 | A misdemeanor. | ||||||
4 | (c) Nothing in this Section shall be construed to limit | ||||||
5 | further liability for civil damages or penalties resulting | ||||||
6 | from other negligent conduct or intentional misconduct by any | ||||||
7 | person. | ||||||
8 | Section 95. No acceleration or delay. Where this Act makes | ||||||
9 | changes in a statute that is represented in this Act by text | ||||||
10 | that is not yet or no longer in effect (for example, a Section | ||||||
11 | represented by multiple versions), the use of that text does | ||||||
12 | not accelerate or delay the taking effect of (i) the changes | ||||||
13 | made by this Act or (ii) provisions derived from any other | ||||||
14 | Public Act.
|