Illinois General Assembly - Full Text of HB5498
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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:
 
215 ILCS 5/370c  from Ch. 73, par. 982c

    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.


LRB101 20368 BMS 69914 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB5498LRB101 20368 BMS 69914 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Reference to Act. This Act may be referred to as
5the Ensuring Coverage of Mental Health and Substance Use
6Disorder Care Act.
 
7    Section 2. Intent; purposes; findings.
8    (a) The General Assembly intends by this Act to ensure that
9all health plan medical necessity determinations concerning
10mental health and substance use disorder services are fully
11consistent with the generally accepted standards of behavioral
12healthcare.
13    (b) The U.S. District Court of the Northern District of
14California in Wit v. United Behavioral Health, 2019 WL 1033730
15(N.D.CA Mar. 5, 2019), a class-action case representing over
1650,000 people wrongly and systematically denied coverage of
17mental health and substance use disorder services they sought,
18found 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
21Court concluded that all parties' experts agreed that the
22following standardized assessment tools, used for medical
23necessity determinations and placement decisions, reflect
24generally 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
16such a manner that it undermines patient self determination or
17in a manner that limits a patient's right to choose his or her
18preferred course of care or that is inconsistent with the
19Medical Patient Rights Act.
 
20    Section 5. The Illinois Insurance Code is amended by
21changing 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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1effective date of Public Act 101-386 this amendatory Act of the
2101st General Assembly Public Act 100-1024), every insurer that
3amends, delivers, issues, or renews group accident and health
4policies providing coverage for hospital or medical treatment
5or services for illness on an expense-incurred basis shall,
6pursuant to subsections (h) through (m), provide coverage for
7the diagnosis and medically necessary treatment of reasonable
8and necessary treatment and services for mental, emotional,
9nervous, or substance use disorders or conditions consistent
10with the parity requirements of Section 370c.1 of this Code.
11    (2) Each insured that is covered for mental, emotional,
12nervous, or substance use disorders or conditions shall be free
13to select the physician licensed to practice medicine in all
14its branches, licensed clinical psychologist, licensed
15clinical social worker, licensed clinical professional
16counselor, licensed marriage and family therapist, licensed
17speech-language pathologist, or other licensed or certified
18professional at a program licensed pursuant to the Substance
19Use Disorder Act of his choice to treat such disorders, and the
20insurer shall pay the covered charges of such physician
21licensed to practice medicine in all its branches, licensed
22clinical psychologist, licensed clinical social worker,
23licensed clinical professional counselor, licensed marriage
24and family therapist, licensed speech-language pathologist, or
25other licensed or certified professional at a program licensed
26pursuant to the Substance Use Disorder Act up to the limits of

 

 

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1coverage, provided (i) the disorder or condition treated is
2covered by the policy, and (ii) the physician, licensed
3psychologist, licensed clinical social worker, licensed
4clinical professional counselor, licensed marriage and family
5therapist, licensed speech-language pathologist, or other
6licensed or certified professional at a program licensed
7pursuant to the Substance Use Disorder Act is authorized to
8provide said services under the statutes of this State and in
9accordance with accepted principles of his profession.
10    (3) Insofar as this Section applies solely to licensed
11clinical social workers, licensed clinical professional
12counselors, licensed marriage and family therapists, licensed
13speech-language pathologists, and other licensed or certified
14professionals at programs licensed pursuant to the Substance
15Use Disorder Act, those persons who may provide services to
16individuals shall do so after the licensed clinical social
17worker, licensed clinical professional counselor, licensed
18marriage and family therapist, licensed speech-language
19pathologist, or other licensed or certified professional at a
20program licensed pursuant to the Substance Use Disorder Act has
21informed the patient of the desirability of the patient
22conferring with the patient's primary care physician.
23    (4) "Mental, emotional, nervous, or substance use disorder
24or condition" means a condition or disorder that involves a
25mental health condition or substance use disorder that falls
26under any of the diagnostic categories listed in the mental and

 

 

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1behavioral disorders chapter of the current edition of the
2International Classification of Disease or that is listed in
3the most recent version of the Diagnostic and Statistical
4Manual of Mental Disorders. "Mental, emotional, nervous, or
5substance use disorder or condition" includes any mental health
6condition that occurs during pregnancy or during the postpartum
7period and includes, but is not limited to, postpartum
8depression.
9    (b)(1) (Blank).
10    (2) (Blank).
11    (2.5) (Blank).
12    (3) Unless otherwise prohibited by federal law and
13consistent with the parity requirements of Section 370c.1 of
14this Code, the reimbursing insurer that amends, delivers,
15issues, or renews a group or individual policy of accident and
16health insurance, a qualified health plan offered through the
17health insurance marketplace, or a provider of treatment of
18mental, emotional, nervous, or substance use disorders or
19conditions shall furnish medical records or other necessary
20data that substantiate that initial or continued treatment is
21at all times medically necessary. An insurer shall provide a
22mechanism for the timely review by a provider holding the same
23license and practicing in the same specialty as the patient's
24provider, who is unaffiliated with the insurer, jointly
25selected by the patient (or the patient's next of kin or legal
26representative if the patient is unable to act for himself or

 

 

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1herself), the patient's provider, and the insurer in the event
2of a dispute between the insurer and patient's provider
3regarding the medical necessity, made pursuant to subsections
4(h) through (m), of a treatment proposed by a patient's
5provider. If the reviewing provider determines the treatment to
6be medically necessary, the insurer shall provide
7reimbursement for the treatment. Future contractual or
8employment actions by the insurer regarding the patient's
9provider may not be based on the provider's participation in
10this procedure. Nothing prevents the insured from agreeing in
11writing to continue treatment at his or her expense. When
12making a determination of the medical necessity pursuant to
13subsections (h) through (m) for a treatment modality for
14mental, emotional, nervous, or substance use disorders or
15conditions, an insurer must make the determination in a manner
16that is consistent with the manner used to make that
17determination with respect to other diseases or illnesses
18covered under the policy, including an appeals process. Medical
19necessity determinations made pursuant to subsections (h)
20through (m) for substance use disorders shall be made in
21accordance with appropriate patient placement criteria
22established by the American Society of Addiction Medicine. No
23additional criteria may be used to make medical necessity
24determinations, pursuant to subsections (h) through (m), for
25substance use disorders.
26    (4) A group health benefit plan amended, delivered, issued,

 

 

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1or renewed on or after January 1, 2019 (the effective date of
2Public Act 100-1024) or an individual policy of accident and
3health insurance or a qualified health plan offered through the
4health insurance marketplace amended, delivered, issued, or
5renewed on or after January 1, 2019 (the effective date of
6Public 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
5individual policy of accident and health insurance or a
6qualified health plan offered through the health insurance
7marketplace may not count toward the number of outpatient
8visits required to be covered under this Section an outpatient
9visit for the purpose of medication management and shall cover
10the outpatient visits under the same terms and conditions as it
11covers outpatient visits for the treatment of physical illness.
12    (5.5) An individual or group health benefit plan amended,
13delivered, issued, or renewed on or after September 9, 2015
14(the effective date of Public Act 99-480) shall offer coverage
15for medically necessary acute treatment services and medically
16necessary clinical stabilization services. The treating
17provider shall base all treatment recommendations and the
18health benefit plan shall base all medical necessity
19determinations, pursuant to subsections (h) through (m), for
20substance use disorders in accordance with the most current
21edition of the Treatment Criteria for Addictive,
22Substance-Related, and Co-Occurring Conditions established by
23the American Society of Addiction Medicine. The treating
24provider shall base all treatment recommendations and the
25health benefit plan shall base all medical necessity
26determinations, pursuant to subsections (h) through (m), for

 

 

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1medication-assisted treatment in accordance with the most
2current Treatment Criteria for Addictive, Substance-Related,
3and Co-Occurring Conditions established by the American
4Society of Addiction Medicine.
5    As used in this subsection:
6    "Acute treatment services" means 24-hour medically
7supervised addiction treatment that provides evaluation and
8withdrawal management and may include biopsychosocial
9assessment, individual and group counseling, psychoeducational
10groups, and discharge planning.
11    "Clinical stabilization services" means 24-hour treatment,
12usually following acute treatment services for substance
13abuse, which may include intensive education and counseling
14regarding the nature of addiction and its consequences, relapse
15prevention, outreach to families and significant others, and
16aftercare planning for individuals beginning to engage in
17recovery from addiction.
18    (6) An issuer of a group health benefit plan may provide or
19offer coverage required under this Section through a managed
20care plan.
21    (6.5) An individual or group health benefit plan amended,
22delivered, issued, or renewed on or after January 1, 2019 (the
23effective 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
7substance use disorders or conditions, coverage for inpatient
8treatment shall include coverage for treatment in a residential
9treatment center certified or licensed by the Department of
10Public Health or the Department of Human Services.
11    (c) This Section shall not be interpreted to require
12coverage for speech therapy or other habilitative services for
13those individuals covered under Section 356z.15 of this Code.
14    (d) With respect to a group or individual policy of
15accident and health insurance or a qualified health plan
16offered through the health insurance marketplace, the
17Department and, with respect to medical assistance, the
18Department of Healthcare and Family Services shall each enforce
19the requirements of this Section and Sections 356z.23 and
20370c.1 of this Code, the Paul Wellstone and Pete Domenici
21Mental Health Parity and Addiction Equity Act of 2008, 42
22U.S.C. 18031(j), and any amendments to, and federal guidance or
23regulations issued under, those Acts, including, but not
24limited to, final regulations issued under the Paul Wellstone
25and Pete Domenici Mental Health Parity and Addiction Equity Act
26of 2008 and final regulations applying the Paul Wellstone and

 

 

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1Pete Domenici Mental Health Parity and Addiction Equity Act of
22008 to Medicaid managed care organizations, the Children's
3Health Insurance Program, and alternative benefit plans.
4Specifically, the Department and the Department of Healthcare
5and 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
9market conduct examinations and audits shall be made public.
10    The Director may adopt rules to effectuate any provisions
11of the Paul Wellstone and Pete Domenici Mental Health Parity
12and Addiction Equity Act of 2008 that relate to the business of
13insurance.
14    (d-1) The Department of Insurance and the Department of
15Healthcare and Family Services shall each appoint a Mental
16Health and Substance Use Disorder Parity Compliance Officer to
17assist the departments with the responsibilities of enforcing
18the 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
19health insurance" and "group health benefit plan" includes (1)
20State-regulated employer-sponsored group health insurance
21plans written in Illinois or which purport to provide coverage
22for a resident of this State; and (2) State employee health
23plans.
24    (g) (1) As used in this subsection:
25    "Benefits", with respect to insurers, means the benefits
26provided for treatment services for inpatient and outpatient

 

 

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1treatment of substance use disorders or conditions at American
2Society 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
6Residential), 3.5 (Clinically Managed High-Intensity
7Residential), and 3.7 (Medically Monitored Intensive
8Inpatient) and OMT (Opioid Maintenance Therapy) services.
9    "Benefits", with respect to managed care organizations,
10means the benefits provided for treatment services for
11inpatient and outpatient treatment of substance use disorders
12or conditions at American Society of Addiction Medicine levels
13of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
14Hospitalization), 3.5 (Clinically Managed High-Intensity
15Residential), and 3.7 (Medically Monitored Intensive
16Inpatient) and OMT (Opioid Maintenance Therapy) services.
17    "Substance use disorder treatment provider or facility"
18means a licensed physician, licensed psychologist, licensed
19psychiatrist, licensed advanced practice registered nurse, or
20licensed, certified, or otherwise State-approved facility or
21provider of substance use disorder treatment.
22    (2) A group health insurance policy, an individual health
23benefit plan, or qualified health plan that is offered through
24the health insurance marketplace, small employer group health
25plan, and large employer group health plan that is amended,
26delivered, issued, executed, or renewed in this State, or

 

 

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1approved for issuance or renewal in this State, on or after
2January 1, 2019 (the effective date of Public Act 100-1023)
3shall comply with the requirements of this Section and Section
4370c.1. The services for the treatment and the ongoing
5assessment of the patient's progress in treatment shall follow
6the requirements of 77 Ill. Adm. Code 2060.
7    (3) Prior authorization shall not be utilized for the
8benefits under this subsection. The substance use disorder
9treatment provider or facility shall notify the insurer of the
10initiation of treatment. For an insurer that is not a managed
11care organization, the substance use disorder treatment
12provider or facility notification shall occur for the
13initiation of treatment of the covered person within 2 business
14days. For managed care organizations, the substance use
15disorder treatment provider or facility notification shall
16occur in accordance with the protocol set forth in the provider
17agreement for initiation of treatment within 24 hours. If the
18managed care organization is not capable of accepting the
19notification in accordance with the contractual protocol
20during the 24-hour period following admission, the substance
21use disorder treatment provider or facility shall have one
22additional business day to provide the notification to the
23appropriate managed care organization. Treatment plans shall
24be developed in accordance with the requirements and timeframes
25established in 77 Ill. Adm. Code 2060. If the substance use
26disorder treatment provider or facility fails to notify the

 

 

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1insurer of the initiation of treatment in accordance with these
2provisions, the insurer may follow its normal prior
3authorization processes.
4    (4) For an insurer that is not a managed care organization,
5if an insurer determines that benefits are no longer medically
6necessary, the insurer shall notify the covered person, the
7covered person's authorized representative, if any, and the
8covered person's health care provider in writing of the covered
9person's right to request an external review pursuant to the
10Health Carrier External Review Act. The notification shall
11occur within 24 hours following the adverse determination.
12    Pursuant to the requirements of the Health Carrier External
13Review Act, the covered person or the covered person's
14authorized representative may request an expedited external
15review. An expedited external review may not occur if the
16substance use disorder treatment provider or facility
17determines that continued treatment is no longer medically
18necessary. Under this subsection, a request for expedited
19external review must be initiated within 24 hours following the
20adverse determination notification by the insurer. Failure to
21request an expedited external review within 24 hours shall
22preclude a covered person or a covered person's authorized
23representative from requesting an expedited external review.
24    If an expedited external review request meets the criteria
25of the Health Carrier External Review Act, an independent
26review organization shall make a final determination of medical

 

 

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1necessity, pursuant to subsections (h) through (m), within 72
2hours. If an independent review organization upholds an adverse
3determination, an insurer shall remain responsible to provide
4coverage of benefits through the day following the
5determination of the independent review organization. A
6decision to reverse an adverse determination shall comply with
7the Health Carrier External Review Act.
8    (5) The substance use disorder treatment provider or
9facility shall provide the insurer with 7 business days'
10advance notice of the planned discharge of the patient from the
11substance use disorder treatment provider or facility and
12notice on the day that the patient is discharged from the
13substance use disorder treatment provider or facility.
14    (6) The benefits required by this subsection shall be
15provided to all covered persons with a diagnosis of substance
16use disorder or conditions. The presence of additional related
17or unrelated diagnoses shall not be a basis to reduce or deny
18the benefits required by this subsection.
19    (7) Nothing in this subsection shall be construed to
20require an insurer to provide coverage for any of the benefits
21in this subsection.
22    (h)(1) Every insurer that amends, delivers, issues, or
23renews group accident and health policies providing coverage
24for hospital or medical treatment or services for illness on an
25expense-incurred basis on or after July 1, 2020 shall, pursuant
26to this Section, provide coverage for the diagnosis and

 

 

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1medically necessary treatment of mental, emotional, nervous,
2or substance use disorders or conditions.
3    (2) Medically necessary treatment of mental, emotional,
4nervous, or substance use disorders or conditions shall be an
5item 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
4chronic or pervasive mental, emotional, nervous, or substance
5use disorders or conditions to short-term treatment or to
6alleviating current symptoms.
7    (4) Consistent with paragraph (2), for all medical
8necessity determinations concerning level of care placement,
9continued stay, and transfer and discharge, to the extent
10applicable services are described therein, an insurer must
11exclusively 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
9paragraph (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
9group accident and health policies providing coverage for
10hospital or medical treatment or services for illness on an
11expense-incurred basis shall, at minimum, include the
12following services as covered benefits for mental, emotional,
13nervous, 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,
3emotional, nervous, or substance use disorders or conditions
4are not available in-network within the geography and
5timeliness standards set by law or regulation, the insurer must
6immediately cover out-of-network services, whether secured by
7the patient or insurer, at an in-network benefit level and
8reimburse out-of-network providers for such services at full
9billed charges. An insurer may not interrupt a course of
10treatment initiated out-of-network due to inadequacy if
11in-network services subsequently become available.
12    (k) An insurer shall not limit the benefits or coverage for
13medically necessary services on the basis that those services
14should be or could be covered by a public entitlement program,
15including, but not limited to, special education or an
16individualized education program, Medicaid, Medicare,
17Supplemental Security Income, or Social Security Disability
18Insurance, and shall not include or enforce a contract term
19that excludes otherwise covered benefits on the basis that
20those services should be or could be covered by a public
21entitlement program.
22    (l) An insurer shall only engage applicable qualified
23physicians who specialize in the treatment of mental,
24emotional, nervous, or substance use disorders or conditions or
25the appropriate subspecialty therein and who possess an active
26professional license or certificate, to review, approve, or

 

 

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1deny services.
2    (m) An insurer shall not adopt, impose, or enforce any
3terms in its policies or provider agreements, in writing or in
4operation, that undermine or alter the requirements in this
5Section.
6    (n) If the Department determines that an insurer has failed
7to meet any requirement of this Section or Section 370c.1, the
8Department shall impose a penalty per product line with respect
9to each participant or beneficiary to whom such failure
10relates.
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;
18100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
198-16-19; revised 9-20-19.)