Full Text of HB5498 101st General Assembly
HB5498 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB5498 Introduced , by Rep. Deb Conroy SYNOPSIS AS INTRODUCED: |
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215 ILCS 5/370c | from Ch. 73, par. 982c |
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Amends the Illinois Insurance Code. Provides that the Department of Insurance and the Department of Healthcare and Family Services shall each appoint a Mental Health and Substance Use Disorder Parity Compliance Officer to assist with the responsibilities of enforcing the requirements of the Illinois Insurance Code. Provides that group accident and health policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis shall provide specified coverage for the diagnosis and medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions. Provides criteria and standards for the types of treatment that constitute medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions. Provides that an insurer shall not limit benefits or coverage for chronic or pervasive mental, emotional, nervous, or substance use disorders or conditions to short-term treatment or to alleviating current symptoms. Provides that insurers shall perform specified actions to ensure the proper use of medical necessity criteria. Provides that if medically necessary services for mental, emotional, nervous, or substance use disorders or conditions are not available in-network within the geography and timeliness standards, the insurer must cover out-of-network services. Provides that if the Department of Insurance determines that an insurer has failed to meet the requirements of the amendatory Act, it shall impose a penalty per product line with respect to each beneficiary. Makes other changes.
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| | FISCAL NOTE ACT MAY APPLY | | STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT |
| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Reference to Act. This Act may be referred to as | 5 | | the Ensuring Coverage of Mental Health and Substance Use | 6 | | Disorder Care Act. | 7 | | Section 2. Intent; purposes; findings. | 8 | | (a) The General Assembly intends by this Act to ensure that | 9 | | all health plan medical necessity determinations concerning | 10 | | mental health and substance use disorder services are fully | 11 | | consistent with the generally accepted standards of behavioral | 12 | | healthcare. | 13 | | (b) The U.S. District Court of the Northern District of | 14 | | California in Wit v. United Behavioral Health, 2019 WL 1033730 | 15 | | (N.D.CA Mar. 5, 2019), a class-action case representing over | 16 | | 50,000 people wrongly and systematically denied coverage of | 17 | | mental health and substance use disorder services they sought, | 18 | | found that generally accepted standards of care require: | 19 | | (1) effective treatment of underlying conditions, | 20 | | rather than mere amelioration of current symptoms (such as | 21 | | suicidality or psychosis); | 22 | | (2) treatment of co-occurring behavioral health | 23 | | disorders and medical conditions in a coordinated manner; |
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| 1 | | (3) treatment of the least intensive and restrictive | 2 | | level of care that is safe and effective; a lower level or | 3 | | less intensive care is appropriate only if it is safe and | 4 | | just as effective as treatment at a higher level of service | 5 | | intensity; | 6 | | (4) erring on the side of caution by placing patients | 7 | | in higher levels of care when there is ambiguity as to the | 8 | | appropriate level of care or when the recommended level of | 9 | | care is not available; | 10 | | (5) treatment to maintain functioning or prevent | 11 | | deterioration; | 12 | | (6) treatment of mental health and substance use | 13 | | disorders for an appropriate duration based on individual | 14 | | patient needs rather than on specific time limits; | 15 | | (7) accounting for the unique needs of children and | 16 | | adolescents when making level of care decisions; and | 17 | | (8) applying multidimensional assessments of patient | 18 | | needs when making determinations regarding the appropriate | 19 | | level of care. | 20 | | (c) In Wit v. United Behavioral Health, the U.S. District | 21 | | Court concluded that all parties' experts agreed that the | 22 | | following standardized assessment tools, used for medical | 23 | | necessity determinations and placement decisions, reflect | 24 | | generally accepted standards of care: | 25 | | (1) the Treatment Criteria for Addictive, | 26 | | Substance-Related, and Co-Occurring Conditions (ASAM |
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| 1 | | Criteria) developed by the American Society of Addiction | 2 | | Medicine; | 3 | | (2) the Level of Care Utilization System (LOCUS) | 4 | | criteria developed by the American Association of | 5 | | Community Psychiatrists; | 6 | | (3) the Child and Adolescent Level of Care Utilization | 7 | | System (CALOCUS) developed by the American Association of | 8 | | Community Psychiatrists; | 9 | | (4) the Child and Adolescent Services Intensity | 10 | | Instrument (CASII) developed by the American Academy of | 11 | | Child & Adolescent Psychiatry; and | 12 | | (5) the Early Childhood Service Intensity Instrument | 13 | | (ECSII) developed by the American Academy Child & | 14 | | Adolescent Psychiatry. | 15 | | (d) Nothing in this Act is intended to be interpreted in | 16 | | such a manner that it undermines patient self determination or | 17 | | in a manner that limits a patient's right to choose his or her | 18 | | preferred course of care or that is inconsistent with the | 19 | | Medical Patient Rights Act. | 20 | | Section 5. The Illinois Insurance Code is amended by | 21 | | changing Section 370c as follows:
| 22 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 23 | | Sec. 370c. Mental and emotional disorders.
| 24 | | (a)(1) On and after August 16, 2019 January 1, 2019 (the |
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| 1 | | effective date of Public Act 101-386 this amendatory Act of the | 2 | | 101st General Assembly Public Act 100-1024 ),
every insurer that | 3 | | amends, delivers, issues, or renews
group accident and health | 4 | | policies providing coverage for hospital or medical treatment | 5 | | or
services for illness on an expense-incurred basis shall , | 6 | | pursuant to subsections (h) through (m), provide coverage for | 7 | | the diagnosis and medically necessary treatment of reasonable | 8 | | and necessary treatment and services
for mental, emotional, | 9 | | nervous, or substance use disorders or conditions consistent | 10 | | with the parity requirements of Section 370c.1 of this Code.
| 11 | | (2) Each insured that is covered for mental, emotional, | 12 | | nervous, or substance use
disorders or conditions shall be free | 13 | | to select the physician licensed to
practice medicine in all | 14 | | its branches, licensed clinical psychologist,
licensed | 15 | | clinical social worker, licensed clinical professional | 16 | | counselor, licensed marriage and family therapist, licensed | 17 | | speech-language pathologist, or other licensed or certified | 18 | | professional at a program licensed pursuant to the Substance | 19 | | Use Disorder Act of
his choice to treat such disorders, and
the | 20 | | insurer shall pay the covered charges of such physician | 21 | | licensed to
practice medicine in all its branches, licensed | 22 | | clinical psychologist,
licensed clinical social worker, | 23 | | licensed clinical professional counselor, licensed marriage | 24 | | and family therapist, licensed speech-language pathologist, or | 25 | | other licensed or certified professional at a program licensed | 26 | | pursuant to the Substance Use Disorder Act up
to the limits of |
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| 1 | | coverage, provided (i)
the disorder or condition treated is | 2 | | covered by the policy, and (ii) the
physician, licensed | 3 | | psychologist, licensed clinical social worker, licensed
| 4 | | clinical professional counselor, licensed marriage and family | 5 | | therapist, licensed speech-language pathologist, or other | 6 | | licensed or certified professional at a program licensed | 7 | | pursuant to the Substance Use Disorder Act is
authorized to | 8 | | provide said services under the statutes of this State and in
| 9 | | accordance with accepted principles of his profession.
| 10 | | (3) Insofar as this Section applies solely to licensed | 11 | | clinical social
workers, licensed clinical professional | 12 | | counselors, licensed marriage and family therapists, licensed | 13 | | speech-language pathologists, and other licensed or certified | 14 | | professionals at programs licensed pursuant to the Substance | 15 | | Use Disorder Act, those persons who may
provide services to | 16 | | individuals shall do so
after the licensed clinical social | 17 | | worker, licensed clinical professional
counselor, licensed | 18 | | marriage and family therapist, licensed speech-language | 19 | | pathologist, or other licensed or certified professional at a | 20 | | program licensed pursuant to the Substance Use Disorder Act has | 21 | | informed the patient of the
desirability of the patient | 22 | | conferring with the patient's primary care
physician.
| 23 | | (4) "Mental, emotional, nervous, or substance use disorder | 24 | | or condition" means a condition or disorder that involves a | 25 | | mental health condition or substance use disorder that falls | 26 | | under any of the diagnostic categories listed in the mental and |
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| 1 | | behavioral disorders chapter of the current edition of the | 2 | | International Classification of Disease or that is listed in | 3 | | the most recent version of the Diagnostic and Statistical | 4 | | Manual of Mental Disorders. "Mental, emotional, nervous, or | 5 | | substance use disorder or condition" includes any mental health | 6 | | condition that occurs during pregnancy or during the postpartum | 7 | | period and includes, but is not limited to, postpartum | 8 | | depression. | 9 | | (b)(1) (Blank).
| 10 | | (2) (Blank).
| 11 | | (2.5) (Blank). | 12 | | (3) Unless otherwise prohibited by federal law and | 13 | | consistent with the parity requirements of Section 370c.1 of | 14 | | this Code, the reimbursing insurer that amends, delivers, | 15 | | issues, or renews a group or individual policy of accident and | 16 | | health insurance, a qualified health plan offered through the | 17 | | health insurance marketplace, or a provider of treatment of | 18 | | mental, emotional, nervous,
or substance use disorders or | 19 | | conditions shall furnish medical records or other necessary | 20 | | data
that substantiate that initial or continued treatment is | 21 | | at all times medically
necessary. An insurer shall provide a | 22 | | mechanism for the timely review by a
provider holding the same | 23 | | license and practicing in the same specialty as the
patient's | 24 | | provider, who is unaffiliated with the insurer, jointly | 25 | | selected by
the patient (or the patient's next of kin or legal | 26 | | representative if the
patient is unable to act for himself or |
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| 1 | | herself), the patient's provider, and
the insurer in the event | 2 | | of a dispute between the insurer and patient's
provider | 3 | | regarding the medical necessity , made pursuant to subsections | 4 | | (h) through (m), of a treatment proposed by a patient's
| 5 | | provider. If the reviewing provider determines the treatment to | 6 | | be medically
necessary, the insurer shall provide | 7 | | reimbursement for the treatment. Future
contractual or | 8 | | employment actions by the insurer regarding the patient's
| 9 | | provider may not be based on the provider's participation in | 10 | | this procedure.
Nothing prevents
the insured from agreeing in | 11 | | writing to continue treatment at his or her
expense. When | 12 | | making a determination of the medical necessity pursuant to | 13 | | subsections (h) through (m) for a treatment
modality for | 14 | | mental, emotional, nervous, or substance use disorders or | 15 | | conditions, an insurer must make the determination in a
manner | 16 | | that is consistent with the manner used to make that | 17 | | determination with
respect to other diseases or illnesses | 18 | | covered under the policy, including an
appeals process. Medical | 19 | | necessity determinations made pursuant to subsections (h) | 20 | | through (m) for substance use disorders shall be made in | 21 | | accordance with appropriate patient placement criteria | 22 | | established by the American Society of Addiction Medicine. No | 23 | | additional criteria may be used to make medical necessity | 24 | | determinations , pursuant to subsections (h) through (m), for | 25 | | substance use disorders.
| 26 | | (4) A group health benefit plan amended, delivered, issued, |
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| 1 | | or renewed on or after January 1, 2019 (the effective date of | 2 | | Public Act 100-1024) or an individual policy of accident and | 3 | | health insurance or a qualified health plan offered through the | 4 | | health insurance marketplace amended, delivered, issued, or | 5 | | renewed on or after January 1, 2019 (the effective date of | 6 | | Public Act 100-1024):
| 7 | | (A) shall provide coverage based upon medical | 8 | | necessity , pursuant to subsections (h) through (m), for the
| 9 | | treatment of a mental, emotional, nervous, or substance use | 10 | | disorder or condition consistent with the parity | 11 | | requirements of Section 370c.1 of this Code; provided, | 12 | | however, that in each calendar year coverage shall not be | 13 | | less than the following:
| 14 | | (i) 45 days of inpatient treatment; and
| 15 | | (ii) beginning on June 26, 2006 (the effective date | 16 | | of Public Act 94-921), 60 visits for outpatient | 17 | | treatment including group and individual
outpatient | 18 | | treatment; and | 19 | | (iii) for plans or policies delivered, issued for | 20 | | delivery, renewed, or modified after January 1, 2007 | 21 | | (the effective date of Public Act 94-906),
20 | 22 | | additional outpatient visits for speech therapy for | 23 | | treatment of pervasive developmental disorders that | 24 | | will be in addition to speech therapy provided pursuant | 25 | | to item (ii) of this subparagraph (A); and
| 26 | | (B) may not include a lifetime limit on the number of |
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| 1 | | days of inpatient
treatment or the number of outpatient | 2 | | visits covered under the plan.
| 3 | | (C) (Blank).
| 4 | | (5) An issuer of a group health benefit plan or an | 5 | | individual policy of accident and health insurance or a | 6 | | qualified health plan offered through the health insurance | 7 | | marketplace may not count toward the number
of outpatient | 8 | | visits required to be covered under this Section an outpatient
| 9 | | visit for the purpose of medication management and shall cover | 10 | | the outpatient
visits under the same terms and conditions as it | 11 | | covers outpatient visits for
the treatment of physical illness.
| 12 | | (5.5) An individual or group health benefit plan amended, | 13 | | delivered, issued, or renewed on or after September 9, 2015 | 14 | | (the effective date of Public Act 99-480) shall offer coverage | 15 | | for medically necessary acute treatment services and medically | 16 | | necessary clinical stabilization services. The treating | 17 | | provider shall base all treatment recommendations and the | 18 | | health benefit plan shall base all medical necessity | 19 | | determinations , pursuant to subsections (h) through (m), for | 20 | | substance use disorders in accordance with the most current | 21 | | edition of the Treatment Criteria for Addictive, | 22 | | Substance-Related, and Co-Occurring Conditions established by | 23 | | the American Society of Addiction Medicine. The treating | 24 | | provider shall base all treatment recommendations and the | 25 | | health benefit plan shall base all medical necessity | 26 | | determinations , pursuant to subsections (h) through (m), for |
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| 1 | | medication-assisted treatment in accordance with the most | 2 | | current Treatment Criteria for Addictive, Substance-Related, | 3 | | and Co-Occurring Conditions established by the American | 4 | | Society of Addiction Medicine. | 5 | | As used in this subsection: | 6 | | "Acute treatment services" means 24-hour medically | 7 | | supervised addiction treatment that provides evaluation and | 8 | | withdrawal management and may include biopsychosocial | 9 | | assessment, individual and group counseling, psychoeducational | 10 | | groups, and discharge planning. | 11 | | "Clinical stabilization services" means 24-hour treatment, | 12 | | usually following acute treatment services for substance | 13 | | abuse, which may include intensive education and counseling | 14 | | regarding the nature of addiction and its consequences, relapse | 15 | | prevention, outreach to families and significant others, and | 16 | | aftercare planning for individuals beginning to engage in | 17 | | recovery from addiction. | 18 | | (6) An issuer of a group health benefit
plan may provide or | 19 | | offer coverage required under this Section through a
managed | 20 | | care plan.
| 21 | | (6.5) An individual or group health benefit plan amended, | 22 | | delivered, issued, or renewed on or after January 1, 2019 (the | 23 | | effective date of Public Act 100-1024): | 24 | | (A) shall not impose prior authorization requirements, | 25 | | other than those established under the Treatment Criteria | 26 | | for Addictive, Substance-Related, and Co-Occurring |
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| 1 | | Conditions established by the American Society of | 2 | | Addiction Medicine, on a prescription medication approved | 3 | | by the United States Food and Drug Administration that is | 4 | | prescribed or administered for the treatment of substance | 5 | | use disorders; | 6 | | (B) shall not impose any step therapy requirements, | 7 | | other than those established under the Treatment Criteria | 8 | | for Addictive, Substance-Related, and Co-Occurring | 9 | | Conditions established by the American Society of | 10 | | Addiction Medicine, before authorizing coverage for a | 11 | | prescription medication approved by the United States Food | 12 | | and Drug Administration that is prescribed or administered | 13 | | for the treatment of substance use disorders; | 14 | | (C) shall place all prescription medications approved | 15 | | by the United States Food and Drug Administration | 16 | | prescribed or administered for the treatment of substance | 17 | | use disorders on, for brand medications, the lowest tier of | 18 | | the drug formulary developed and maintained by the | 19 | | individual or group health benefit plan that covers brand | 20 | | medications and, for generic medications, the lowest tier | 21 | | of the drug formulary developed and maintained by the | 22 | | individual or group health benefit plan that covers generic | 23 | | medications; and | 24 | | (D) shall not exclude coverage for a prescription | 25 | | medication approved by the United States Food and Drug | 26 | | Administration for the treatment of substance use |
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| 1 | | disorders and any associated counseling or wraparound | 2 | | services on the grounds that such medications and services | 3 | | were court ordered. | 4 | | (7) (Blank).
| 5 | | (8)
(Blank).
| 6 | | (9) With respect to all mental, emotional, nervous, or | 7 | | substance use disorders or conditions, coverage for inpatient | 8 | | treatment shall include coverage for treatment in a residential | 9 | | treatment center certified or licensed by the Department of | 10 | | Public Health or the Department of Human Services. | 11 | | (c) This Section shall not be interpreted to require | 12 | | coverage for speech therapy or other habilitative services for | 13 | | those individuals covered under Section 356z.15
of this Code. | 14 | | (d) With respect to a group or individual policy of | 15 | | accident and health insurance or a qualified health plan | 16 | | offered through the health insurance marketplace, the | 17 | | Department and, with respect to medical assistance, the | 18 | | Department of Healthcare and Family Services shall each enforce | 19 | | the requirements of this Section and Sections 356z.23 and | 20 | | 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 21 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 22 | | U.S.C. 18031(j), and any amendments to, and federal guidance or | 23 | | regulations issued under, those Acts, including, but not | 24 | | limited to, final regulations issued under the Paul Wellstone | 25 | | and Pete Domenici Mental Health Parity and Addiction Equity Act | 26 | | of 2008 and final regulations applying the Paul Wellstone and |
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| 1 | | Pete Domenici Mental Health Parity and Addiction Equity Act of | 2 | | 2008 to Medicaid managed care organizations, the Children's | 3 | | Health Insurance Program, and alternative benefit plans. | 4 | | Specifically, the Department and the Department of Healthcare | 5 | | and Family Services shall take action: | 6 | | (1) proactively ensuring compliance by individual and | 7 | | group policies, including by requiring that insurers | 8 | | submit comparative analyses, as set forth in paragraph (6) | 9 | | of subsection (k) of Section 370c.1, demonstrating how they | 10 | | design and apply nonquantitative treatment limitations, | 11 | | both as written and in operation, for mental, emotional, | 12 | | nervous, or substance use disorder or condition benefits as | 13 | | compared to how they design and apply nonquantitative | 14 | | treatment limitations, as written and in operation, for | 15 | | medical and surgical benefits; | 16 | | (2) evaluating all consumer or provider complaints | 17 | | regarding mental, emotional, nervous, or substance use | 18 | | disorder or condition coverage for possible parity | 19 | | violations; | 20 | | (3) performing parity compliance market conduct | 21 | | examinations or, in the case of the Department of | 22 | | Healthcare and Family Services, parity compliance audits | 23 | | of individual and group plans and policies, including, but | 24 | | not limited to, reviews of: | 25 | | (A) nonquantitative treatment limitations, | 26 | | including, but not limited to, prior authorization |
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| 1 | | requirements, concurrent review, retrospective review, | 2 | | step therapy, network admission standards, | 3 | | reimbursement rates, and geographic restrictions; | 4 | | (B) denials of authorization, payment, and | 5 | | coverage; and | 6 | | (C) other specific criteria as may be determined by | 7 | | the Department. | 8 | | The findings and the conclusions of the parity compliance | 9 | | market conduct examinations and audits shall be made public. | 10 | | The Director may adopt rules to effectuate any provisions | 11 | | of the Paul Wellstone and Pete Domenici Mental Health Parity | 12 | | and Addiction Equity Act of 2008 that relate to the business of | 13 | | insurance. | 14 | | (d-1) The Department of Insurance and the Department of | 15 | | Healthcare and Family Services shall each appoint a Mental | 16 | | Health and Substance Use Disorder Parity Compliance Officer to | 17 | | assist the departments with the responsibilities of enforcing | 18 | | the requirements of this Section and Section 370c.1. | 19 | | (e) Availability of plan information. | 20 | | (1) The criteria for medical necessity determinations , | 21 | | pursuant to subsections (h) through (m), made under a group | 22 | | health plan, an individual policy of accident and health | 23 | | insurance, or a qualified health plan offered through the | 24 | | health insurance marketplace with respect to mental health | 25 | | or substance use disorder benefits (or health insurance | 26 | | coverage offered in connection with the plan with respect |
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| 1 | | to such benefits) must be made available by the plan | 2 | | administrator (or the health insurance issuer offering | 3 | | such coverage) to any current or potential participant, | 4 | | beneficiary, or 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 time | 14 | | and in a reasonable manner and in readily understandable | 15 | | language by the plan administrator (or the health insurance | 16 | | issuer offering such coverage) to the participant or | 17 | | 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 |
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| 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 |
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| 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 business | 14 | | days. For managed care organizations, the substance use | 15 | | disorder treatment provider or facility notification shall | 16 | | occur in accordance with the protocol set forth in the provider | 17 | | agreement for initiation of treatment within 24 hours. If the | 18 | | managed care organization is not capable of accepting the | 19 | | notification in accordance with the contractual protocol | 20 | | during the 24-hour period following admission, the substance | 21 | | use disorder treatment provider or facility shall have one | 22 | | additional business day to provide the notification to the | 23 | | appropriate managed care organization. Treatment plans shall | 24 | | be developed in accordance with the requirements and timeframes | 25 | | established in 77 Ill. Adm. Code 2060. If the substance use | 26 | | disorder treatment provider or facility fails to notify the |
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| 1 | | insurer of the initiation of treatment in accordance with these | 2 | | provisions, the insurer may follow its normal prior | 3 | | authorization processes. | 4 | | (4) For an insurer that is not a managed care organization, | 5 | | if an insurer determines that benefits are no longer medically | 6 | | necessary, the insurer shall notify the covered person, the | 7 | | covered person's authorized representative, if any, and the | 8 | | covered person's health care provider in writing of the covered | 9 | | person's right to request an external review pursuant to the | 10 | | Health Carrier External Review Act. The notification shall | 11 | | occur within 24 hours following the adverse determination. | 12 | | Pursuant to the requirements of the Health Carrier External | 13 | | Review Act, the covered person or the covered person's | 14 | | authorized representative may request an expedited external | 15 | | review.
An expedited external review may not occur if the | 16 | | substance use disorder treatment provider or facility | 17 | | determines that continued treatment is no longer medically | 18 | | necessary. Under this subsection, a request for expedited | 19 | | external review must be initiated within 24 hours following the | 20 | | adverse determination notification by the insurer. Failure to | 21 | | request an expedited external review within 24 hours shall | 22 | | preclude a covered person or a covered person's authorized | 23 | | representative from requesting an expedited external review. | 24 | | If an expedited external review request meets the criteria | 25 | | of the Health Carrier External Review Act, an independent | 26 | | review organization shall make a final determination of medical |
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| 1 | | necessity , pursuant to subsections (h) through (m), within 72 | 2 | | hours. If an independent review organization upholds an adverse | 3 | | determination, an insurer shall remain responsible to provide | 4 | | coverage of benefits through the day following the | 5 | | determination of the independent review organization. A | 6 | | decision to reverse an adverse determination shall comply with | 7 | | the Health Carrier External Review Act. | 8 | | (5) The substance use disorder treatment provider or | 9 | | facility shall provide the insurer with 7 business days' | 10 | | advance notice of the planned discharge of the patient from the | 11 | | substance use disorder treatment provider or facility and | 12 | | notice on the day that the patient is discharged from the | 13 | | substance use disorder treatment provider or facility. | 14 | | (6) The benefits required by this subsection shall be | 15 | | provided to all covered persons with a diagnosis of substance | 16 | | use disorder or conditions. The presence of additional related | 17 | | or unrelated diagnoses shall not be a basis to reduce or deny | 18 | | the benefits required by this subsection. | 19 | | (7) Nothing in this subsection shall be construed to | 20 | | require an insurer to provide coverage for any of the benefits | 21 | | in this subsection. | 22 | | (h)(1) Every insurer that amends, delivers, issues, or | 23 | | renews group accident and health policies providing coverage | 24 | | for hospital or medical treatment or services for illness on an | 25 | | expense-incurred basis on or after July 1, 2020 shall, pursuant | 26 | | to this Section, provide coverage for the diagnosis and |
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| 1 | | medically necessary treatment of mental, emotional, nervous, | 2 | | or substance use disorders or conditions. | 3 | | (2) Medically necessary treatment of mental, emotional, | 4 | | nervous, or substance use disorders or conditions shall be an | 5 | | item or service that is: | 6 | | (A) recommended by the patient's treatment provider; | 7 | | (B) furnished in the manner and setting that can most | 8 | | effectively and comprehensively address patients' | 9 | | conditions, including, but not limited to, functional | 10 | | impairments, lack of coping skills, symptoms, and the | 11 | | underlying bio-psycho-social determinants of mental | 12 | | health, substance use, medical disorders, and any | 13 | | combination thereof; | 14 | | (C) provided in sufficient amount, duration, and scope | 15 | | to: | 16 | | (i) prevent, diagnose, or treat a disorder; | 17 | | (ii) achieve age-appropriate growth and | 18 | | development; | 19 | | (iii) manage the progression of disability; or | 20 | | (iv) attain, maintain, or regain full functional | 21 | | capacity. | 22 | | (D) consistent with generally accepted standards of | 23 | | practice, which shall be based on: | 24 | | (i) scientific evidence published in peer-reviewed | 25 | | medical or scientific literature generally recognized | 26 | | by the relevant clinical community; or |
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| 1 | | (ii) clinical specialty society recommendations, | 2 | | professional standards, or consensus statements. | 3 | | (3) An insurer shall not limit benefits or coverage for | 4 | | chronic or pervasive mental, emotional, nervous, or substance | 5 | | use disorders or conditions to short-term treatment or to | 6 | | alleviating current symptoms. | 7 | | (4) Consistent with paragraph (2), for all medical | 8 | | necessity determinations concerning level of care placement, | 9 | | continued stay, and transfer and discharge, to the extent | 10 | | applicable services are described therein, an insurer must | 11 | | exclusively rely on the most recent editions of: | 12 | | (A) the Treatment Criteria for Addictive, | 13 | | Substance-Related, and Co-Occurring Conditions (ASAM | 14 | | Criteria) developed by the American Society of Addiction | 15 | | Medicine for substance use disorders for patients of any | 16 | | age; | 17 | | (B) the Level of Care Utilization System (LOCUS) | 18 | | criteria developed by the American Association of | 19 | | Community Psychiatrists for mental health disorders for | 20 | | patients ages 18 years and over; | 21 | | (C) the Child and Adolescent Level of Care Utilization | 22 | | System (CALOCUS) developed by the American Association of | 23 | | Community Psychiatrists or the Child and Adolescent | 24 | | Services Intensity Instrument (CASII) developed by the | 25 | | American Academy of Child & Adolescent Psychiatry for | 26 | | mental health disorders for patients ages 6 to 17; |
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| 1 | | (D) the Early Childhood Service Intensity Instrument | 2 | | (ECSII) developed by the American Academy Child & | 3 | | Adolescent Psychiatry for mental health disorders for | 4 | | patients ages 0 to 5 years; or | 5 | | (E) the American Psychiatric Association criteria for | 6 | | eating disorders for a primary diagnosis of an eating | 7 | | disorder for patients of any age. | 8 | | (5) To ensure the proper use of criteria described in | 9 | | paragraph (4), insurers shall: | 10 | | (A) track, identify, and analyze how the clinical | 11 | | guidelines are used to certify care, deny care, and support | 12 | | the appeals process and submit the results of this analysis | 13 | | to the Department or, in the case of Medicaid managed care | 14 | | organizations, to the Department of Healthcare and Family | 15 | | Services on July 1 of every year. The Departments are to | 16 | | submit a joint report summarizing the submitted analyses to | 17 | | the General Assembly by January 1 of every year; | 18 | | (B) apply the criteria to the level of treatment | 19 | | proposed by the insured patient's treatment provider and | 20 | | not impose criteria for a different or higher level of | 21 | | treatment; | 22 | | (C) run inter-rater reliability reports about how the | 23 | | clinical guidelines are used in conjunction with the | 24 | | utilization management process and parity compliance | 25 | | activities; | 26 | | (D) achieve inter-rater reliability pass rates of at |
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| 1 | | least 90% and, whenever this threshold is not met, | 2 | | immediately provide for the remediation of poor | 3 | | inter-rater reliability and inter-reliability testing for | 4 | | all new staff before they can conduct utilization review | 5 | | without supervision; and | 6 | | (E) report the activities in this subsection to the | 7 | | plan's quality assurance committee. | 8 | | (i) Every insurer that amends, delivers, issues, or renews | 9 | | group accident and health policies providing coverage for | 10 | | hospital or medical treatment or services for illness on an | 11 | | expense-incurred basis shall, at minimum, include the | 12 | | following services as covered benefits for mental, emotional, | 13 | | nervous, or substance use disorders or conditions: | 14 | | (1) outpatient services; | 15 | | (2) inpatient services; | 16 | | (3) intermediate services, including the full range of | 17 | | levels of care in the most recent edition of the ASAM | 18 | | criteria, LOCUS, CALOCUS, ECSII, and CASII (including, but | 19 | | not limited to, partial hospitalization, intensive | 20 | | outpatient, psycho-social treatment models, and | 21 | | coordinated specialty care); | 22 | | (4) emergency and urgent care services, both inpatient | 23 | | and outpatient; | 24 | | (5) all medications approved by the United States Food | 25 | | and Drug Administration for the treatment of substance use | 26 | | disorders; and |
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| 1 | | (6) emergency medication without prior authorization. | 2 | | (j) If any medically necessary services for mental, | 3 | | emotional, nervous, or substance use disorders or conditions | 4 | | are not available in-network within the geography and | 5 | | timeliness standards set by law or regulation, the insurer must | 6 | | immediately cover out-of-network services, whether secured by | 7 | | the patient or insurer, at an in-network benefit level and | 8 | | reimburse out-of-network providers for such services at full | 9 | | billed charges. An insurer may not interrupt a course of | 10 | | treatment initiated out-of-network due to inadequacy if | 11 | | in-network services subsequently become available. | 12 | | (k) An insurer shall not limit the benefits or coverage for | 13 | | medically necessary services on the basis that those services | 14 | | should be or could be covered by a public entitlement program, | 15 | | including, but not limited to, special education or an | 16 | | individualized education program, Medicaid, Medicare, | 17 | | Supplemental Security Income, or Social Security Disability | 18 | | Insurance, and shall not include or enforce a contract term | 19 | | that excludes otherwise covered benefits on the basis that | 20 | | those services should be or could be covered by a public | 21 | | entitlement program. | 22 | | (l) An insurer shall only engage applicable qualified | 23 | | physicians who specialize in the treatment of mental, | 24 | | emotional, nervous, or substance use disorders or conditions or | 25 | | the appropriate subspecialty therein and who possess an active | 26 | | professional license or certificate, to review, approve, or |
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| 1 | | deny services. | 2 | | (m) An insurer shall not adopt, impose, or enforce any | 3 | | terms in its policies or provider agreements, in writing or in | 4 | | operation, that undermine or alter the requirements in this | 5 | | Section. | 6 | | (n) If the Department determines that an insurer has failed | 7 | | to meet any requirement of this Section or Section 370c.1, the | 8 | | Department shall impose a penalty per product line with respect | 9 | | to each participant or beneficiary to whom such failure | 10 | | relates. | 11 | | (1) The amount of the penalty imposed shall be as | 12 | | follows: | 13 | | (A) for violations in which it is established that | 14 | | the insurer did not know and, by exercising reasonable | 15 | | diligence, would not have known that the insurer | 16 | | violated a provision, an amount not less than $100 or | 17 | | more than $50,000 for each violation; | 18 | | (B) for a violation in which it is established that | 19 | | the violation was due to reasonable cause and not to | 20 | | willful neglect, an amount not less than $1,000 or more | 21 | | than $50,000 for each violation; | 22 | | (C) for a violation in which it is established that | 23 | | the violation was due to willful neglect and was timely | 24 | | corrected, an amount not less than $10,000 or more than | 25 | | $50,000 for each violation; and | 26 | | (D) for a violation in which it is established that |
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| 1 | | the violation was due to willful neglect and was not | 2 | | timely corrected, an amount not less than $50,000 for | 3 | | each violation. | 4 | | (2) Except that a penalty for violations of the same | 5 | | requirement or prohibition under any of these categories | 6 | | may not exceed $3,000,000 in a calendar year. | 7 | | (3) With respect to parity, violations of different | 8 | | State or federal requirements or prohibitions shall be | 9 | | considered a unique violation for the purposes of paragraph | 10 | | (2). | 11 | | (4) The amounts in this subsection shall be annually | 12 | | adjusted for inflation in accordance with 26 U.S.C. | 13 | | 1(f)(3). | 14 | | (5) Notwithstanding paragraph (3) of Section 403A, | 15 | | penalties under this Section and Section 370c.1 shall not | 16 | | be subject to time limits. | 17 | | (Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19; | 18 | | 100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff. | 19 | | 8-16-19; revised 9-20-19.)
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