Illinois General Assembly - Full Text of HB2595
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Full Text of HB2595  102nd General Assembly

HB2595enr 102ND GENERAL ASSEMBLY

  
  
  

 


 
HB2595 EnrolledLRB102 10633 BMS 15962 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. This Act may be referred to as the Generally
5Accepted Standards of Behavioral Health Care Act of 2021.
 
6    Section 2. The General Assembly finds and declares the
7following:
8    (a) The State of Illinois and the entire country faces a
9mental health and addiction crisis.
10        (1) One in 5 adults experience a mental health
11    disorder, and data from 2017 shows that one in 12 had a
12    substance use disorder. The COVID-19 pandemic has
13    exacerbated the nation's mental health and addiction
14    crisis. According the U.S. Center for Disease Control and
15    Prevention, since the start of the COVID-19 pandemic,
16    Americans have experienced higher rates of depression,
17    anxiety, and trauma, and rates of substance use and
18    suicidal ideation have increased.
19        (2) Nationally, the suicide rate has increased 35% in
20    the past 20 years. According to the Illinois Department of
21    Public Health, more than 1,000 Illinoisans die by suicide
22    every year, including 1,439 deaths in 2019, and it is the
23    third leading cause of death among young adults aged 15 to

 

 

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1    34.
2        (3) Between 2013 and 2019, Illinois saw a 1,861%
3    increase in synthetic opioid overdose deaths and a 68%
4    increase in heroin overdose deaths. In 2019 alone, there
5    were 2.3 and 2 times as many opioid deaths as homicides and
6    car crash deaths, respectively.
7        (4) Communities of color are disproportionately
8    impacted by lack of access to and inequities in mental
9    health and substance use disorder care.
10            (A) According to the Substance Abuse and Mental
11        Health Services Administration, two-thirds of Black
12        and Hispanic Americans with a mental illness and
13        nearly 90% with a substance use disorder do not
14        receive medically necessary treatment.
15            (B) Data from the U.S. Census Bureau demonstrates
16        that Black Americans saw the highest increases in
17        rates of anxiety and depression in 2020.
18            (C) Data from the Illinois Department of Public
19        Health reveals that Black Illinoisans are hospitalized
20        for opioid overdoses at a rate 6 times higher than
21        white Illinoisans.
22            (D) In the first half of 2020, the number of
23        suicides among Black Chicagoans had increased 106%
24        from the previous year. Nationally, from 2001 to 2017,
25        suicide rates doubled among Black girls aged 13 to 19
26        and increased 60% for Black boys of the same age.

 

 

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1            (E) According to the Substance Abuse and Mental
2        Health Services Administration, between 2008 and 2018
3        there were significant increases in serious mental
4        illness and suicide ideation in Hispanics aged 18 to
5        25 and there remains a large gap in treatment need
6        among Hispanics.
7        (5) According to the U.S. Center for Disease Control
8    and Prevention, children with adverse childhood
9    experiences are more likely to experience negative
10    outcomes like post-traumatic stress disorder, increased
11    anxiety and depression, suicide, and substance use. A 2020
12    report from Mental Health America shows that 62.1% of
13    Illinois youth with severe depression do not receive any
14    mental health treatment. Survey results found that 80% of
15    college students report that COVID-19 has negatively
16    impacted their mental health.
17        (6) In rural communities, between 2001 and 2015, the
18    suicide rate increased by 27%, and between 1999 and 2015
19    the overdose rate increased 325%.
20        (7) According to the U.S. Department of Veterans
21    Affairs, 154 veterans died by suicide in 2018, which
22    accounts for more than 10% of all suicide deaths reported
23    by the Illinois Department of Public Health in the same
24    year, despite only accounting for approximately 5.7% of
25    the State's total population. Nationally, between 2008 and
26    2017, more than 6,000 veterans died by suicide each year.

 

 

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1        (8) According to the National Alliance on Mental
2    Illness, 2,000,000 people with mental illness are
3    incarcerated every year, where they do not receive the
4    treatment they need.
5    (b) A recent landmark federal court ruling offers a
6concrete demonstration of how the mental health and addiction
7crisis described in subsection (a) is worsened through the
8denial of medically necessary mental health and substance use
9disorder treatment.
10        (1) In March 2019, the United States District Court of
11    the Northern District of California ruled in Wit v. United
12    Behavioral Health, 2019 WL 1033730 (Wit; N.D.CA Mar. 5,
13    2019), that United Behavioral Health created flawed level
14    of care placement criteria that were inconsistent with
15    generally accepted standards of mental health and
16    substance use disorder care in order to "mitigate" the
17    requirements of the federal Mental Health Parity and
18    Addiction Equity Act of 2008.
19        (2) As described by the federal court in Wit, the 8
20    generally accepted standards of mental health and
21    substance use disorder care require all of the following:
22            (A) Effective treatment of underlying conditions,
23        rather than mere amelioration of current symptoms,
24        such as suicidality or psychosis.
25            (B) Treatment of co-occurring behavioral health
26        disorders or medical conditions in a coordinated

 

 

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1        manner.
2            (C) Treatment at the least intensive and
3        restrictive level of care that is safe and effective
4        and meets the needs of the patient's condition; a
5        lower level or less intensive care is appropriate only
6        if it is safe and just as effective as treatment at a
7        higher level or service intensity.
8            (D) Erring on the side of caution, by placing
9        patients in higher levels of care when there is
10        ambiguity as to the appropriate level of care, or when
11        the recommended level of care is not available.
12            (E) Treatment to maintain functioning or prevent
13        deterioration.
14            (F) Treatment of mental health and substance use
15        disorders for an appropriate duration based on
16        individual patient needs rather than on specific time
17        limits.
18            (G) Accounting for the unique needs of children
19        and adolescents when making level of care decisions.
20            (H) Applying multidimensional assessments of
21        patient needs when making determinations regarding the
22        appropriate level of care.
23        (3) The court in Wit found that all parties' expert
24    witnesses regarded the American Society of Addiction
25    Medicine (ASAM) criteria for substance use disorders and
26    Level of Care Utilization System (LOCUS), Child and

 

 

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1    Adolescent Level of Care Utilization System (CALOCUS),
2    Child and Adolescent Service Intensity Instrument (CASII),
3    and Early Childhood Service Intensity Instrument (ECSII)
4    criteria for mental health disorders as prime examples of
5    level of care criteria that are fully consistent with
6    generally accepted standards of mental health and
7    substance use care.
8        (4) In particular, the coverage of intermediate levels
9    of care, such as residential treatment, which are
10    essential components of the level of care continuum called
11    for by nonprofit, and clinical specialty associations such
12    as the American Society of Addiction Medicine, are often
13    denied through overly restrictive medical necessity
14    determinations.
15        (5) On November 3, 2020, the court issued a remedies
16    order requiring United Behavioral Health to reprocess
17    67,000 mental health and substance use disorder claims and
18    mandating that, for the next decade, United Behavioral
19    Health must use the relevant nonprofit clinical society
20    guidelines for its medical necessity determinations.
21        (6) The court's findings also demonstrated how United
22    Behavioral Health was in violation of Section 370c of the
23    Illinois Insurance Code for its failure to use the
24    American Society of Addiction Medicine Criteria for
25    substance use disorders. The results of market conduct
26    examinations released by the Illinois Department of

 

 

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1    Insurance on July 15, 2020 confirmed these findings citing
2    United Healthcare and CIGNA for their failure to use the
3    American Society of Addiction Medicine Criteria when
4    making medical necessity determinations for substance use
5    disorders as required by Illinois law.
6    (c) Insurers should not be permitted to deny medically
7necessary mental health and substance use disorder care
8through the use of utilization review practices and criteria
9that are inconsistent with generally accepted standards of
10mental health and substance use disorder care.
11        (1) Illinois parity law (Sections 370c and 370c.1 of
12    the Illinois Insurance Code) requires that health plans
13    treat illnesses of the brain, such as addiction and
14    depression, the same way they treat illness of other parts
15    of the body, such as cancer and diabetes. The Illinois
16    General Assembly significantly strengthened Illinois'
17    parity law, which incorporates provisions of the federal
18    Paul Wellstone and Pete Domenici Mental Health Parity and
19    Addiction Equity Act of 2008, in both 2015 and 2018.
20        (2) While the federal Patient Protection and
21    Affordable Care Act includes mental health and addiction
22    coverage as one of the 10 essential health benefits, it
23    does not contain a definition for medical necessity, and
24    despite the Patient Protection and Affordable Care Act,
25    needed mental health and addiction coverage can be denied
26    through overly restrictive medical necessity

 

 

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1    determinations.
2        (3) Despite the strong actions taken by the Illinois
3    General Assembly, the court in Wit v. United Behavioral
4    Health demonstrated how insurers can mitigate compliance
5    with parity laws due by denying medically necessary mental
6    health and treatment by using flawed medical necessity
7    criteria.
8        (4) When medically necessary mental health and
9    substance use disorder care is denied, the manifestations
10    of the mental health and addiction crisis described in
11    subsection (a) are severely exacerbated. Individuals with
12    mental health and substance use disorders often have their
13    conditions worsen, sometimes ending up in the criminal
14    justice system or on the streets, resulting in increased
15    emergency hospitalizations, harm to individuals and
16    communities, and higher costs to taxpayers.
17        (5) In order to realize the promise of mental health
18    and addiction parity and remove barriers to mental health
19    and substance use disorder care for all Illinoisans,
20    insurers must be required to cover medically necessary
21    mental health and substance use disorder care and follow
22    generally accepted standards of mental health and
23    substance use disorder care.
 
24    Section 5. The Illinois Insurance Code is amended by
25changing Sections 370c and 370c.1 as follows:
 

 

 

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1    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
2    Sec. 370c. Mental and emotional disorders.
3    (a)(1) On and after the effective date of this amendatory
4Act of the 102nd General Assembly January 1, 2019 (the
5effective date of this amendatory Act of the 101st General
6Assembly Public Act 100-1024), every insurer that amends,
7delivers, issues, or renews group accident and health policies
8providing coverage for hospital or medical treatment or
9services for illness on an expense-incurred basis shall
10provide coverage for the medically necessary treatment of
11reasonable and necessary treatment and services for mental,
12emotional, nervous, or substance use disorders or conditions
13consistent with the parity requirements of Section 370c.1 of
14this Code.
15    (2) Each insured that is covered for mental, emotional,
16nervous, or substance use disorders or conditions shall be
17free to select the physician licensed to practice medicine in
18all its branches, licensed clinical psychologist, licensed
19clinical social worker, licensed clinical professional
20counselor, licensed marriage and family therapist, licensed
21speech-language pathologist, or other licensed or certified
22professional at a program licensed pursuant to the Substance
23Use Disorder Act of his or her choice to treat such disorders,
24and the insurer shall pay the covered charges of such
25physician licensed to practice medicine in all its branches,

 

 

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1licensed clinical psychologist, licensed clinical social
2worker, licensed clinical professional counselor, licensed
3marriage and family therapist, licensed speech-language
4pathologist, or other licensed or certified professional at a
5program licensed pursuant to the Substance Use Disorder Act up
6to the limits of coverage, provided (i) the disorder or
7condition treated is covered by the policy, and (ii) the
8physician, licensed psychologist, licensed clinical social
9worker, licensed clinical professional counselor, licensed
10marriage and family therapist, licensed speech-language
11pathologist, or other licensed or certified professional at a
12program licensed pursuant to the Substance Use Disorder Act is
13authorized to provide said services under the statutes of this
14State and in accordance with accepted principles of his or her
15profession.
16    (3) Insofar as this Section applies solely to licensed
17clinical social workers, licensed clinical professional
18counselors, licensed marriage and family therapists, licensed
19speech-language pathologists, and other licensed or certified
20professionals at programs licensed pursuant to the Substance
21Use Disorder Act, those persons who may provide services to
22individuals shall do so after the licensed clinical social
23worker, licensed clinical professional counselor, licensed
24marriage and family therapist, licensed speech-language
25pathologist, or other licensed or certified professional at a
26program licensed pursuant to the Substance Use Disorder Act

 

 

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1has informed the patient of the desirability of the patient
2conferring with the patient's primary care physician.
3    (4) "Mental, emotional, nervous, or substance use disorder
4or condition" means a condition or disorder that involves a
5mental health condition or substance use disorder that falls
6under any of the diagnostic categories listed in the mental
7and behavioral disorders chapter of the current edition of the
8World Health Organization's International Classification of
9Disease or that is listed in the most recent version of the
10American Psychiatric Association's Diagnostic and Statistical
11Manual of Mental Disorders. "Mental, emotional, nervous, or
12substance use disorder or condition" includes any mental
13health condition that occurs during pregnancy or during the
14postpartum period and includes, but is not limited to,
15postpartum depression.
16    (5) Medically necessary treatment and medical necessity
17determinations shall be interpreted and made in a manner that
18is consistent with and pursuant to subsections (h) through
19(t).
20    (b)(1) (Blank).
21    (2) (Blank).
22    (2.5) (Blank).
23    (3) Unless otherwise prohibited by federal law and
24consistent with the parity requirements of Section 370c.1 of
25this Code, the reimbursing insurer that amends, delivers,
26issues, or renews a group or individual policy of accident and

 

 

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1health insurance, a qualified health plan offered through the
2health insurance marketplace, or a provider of treatment of
3mental, emotional, nervous, or substance use disorders or
4conditions shall furnish medical records or other necessary
5data that substantiate that initial or continued treatment is
6at all times medically necessary. An insurer shall provide a
7mechanism for the timely review by a provider holding the same
8license and practicing in the same specialty as the patient's
9provider, who is unaffiliated with the insurer, jointly
10selected by the patient (or the patient's next of kin or legal
11representative if the patient is unable to act for himself or
12herself), the patient's provider, and the insurer in the event
13of a dispute between the insurer and patient's provider
14regarding the medical necessity of a treatment proposed by a
15patient's provider. If the reviewing provider determines the
16treatment to be medically necessary, the insurer shall provide
17reimbursement for the treatment. Future contractual or
18employment actions by the insurer regarding the patient's
19provider may not be based on the provider's participation in
20this procedure. Nothing prevents the insured from agreeing in
21writing to continue treatment at his or her expense. When
22making a determination of the medical necessity for a
23treatment modality for mental, emotional, nervous, or
24substance use disorders or conditions, an insurer must make
25the determination in a manner that is consistent with the
26manner used to make that determination with respect to other

 

 

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1diseases or illnesses covered under the policy, including an
2appeals process. Medical necessity determinations for
3substance use disorders shall be made in accordance with
4appropriate patient placement criteria established by the
5American Society of Addiction Medicine. No additional criteria
6may be used to make medical necessity determinations for
7substance use disorders.
8    (4) A group health benefit plan amended, delivered,
9issued, or renewed on or after January 1, 2019 (the effective
10date of Public Act 100-1024) or an individual policy of
11accident and health insurance or a qualified health plan
12offered through the health insurance marketplace amended,
13delivered, issued, or renewed on or after January 1, 2019 (the
14effective date of Public Act 100-1024):
15        (A) shall provide coverage based upon medical
16    necessity for the treatment of a mental, emotional,
17    nervous, or substance use disorder or condition consistent
18    with the parity requirements of Section 370c.1 of this
19    Code; provided, however, that in each calendar year
20    coverage shall not be less than the following:
21            (i) 45 days of inpatient treatment; and
22            (ii) beginning on June 26, 2006 (the effective
23        date of Public Act 94-921), 60 visits for outpatient
24        treatment including group and individual outpatient
25        treatment; and
26            (iii) for plans or policies delivered, issued for

 

 

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1        delivery, renewed, or modified after January 1, 2007
2        (the effective date of Public Act 94-906), 20
3        additional outpatient visits for speech therapy for
4        treatment of pervasive developmental disorders that
5        will be in addition to speech therapy provided
6        pursuant to item (ii) of this subparagraph (A); and
7        (B) may not include a lifetime limit on the number of
8    days of inpatient treatment or the number of outpatient
9    visits covered under the plan.
10        (C) (Blank).
11    (5) An issuer of a group health benefit plan or an
12individual policy of accident and health insurance or a
13qualified health plan offered through the health insurance
14marketplace may not count toward the number of outpatient
15visits required to be covered under this Section an outpatient
16visit for the purpose of medication management and shall cover
17the outpatient visits under the same terms and conditions as
18it covers outpatient visits for the treatment of physical
19illness.
20    (5.5) An individual or group health benefit plan amended,
21delivered, issued, or renewed on or after September 9, 2015
22(the effective date of Public Act 99-480) shall offer coverage
23for medically necessary acute treatment services and medically
24necessary clinical stabilization services. The treating
25provider shall base all treatment recommendations and the
26health benefit plan shall base all medical necessity

 

 

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1determinations for substance use disorders in accordance with
2the most current edition of the Treatment Criteria for
3Addictive, Substance-Related, and Co-Occurring Conditions
4established by the American Society of Addiction Medicine. The
5treating provider shall base all treatment recommendations and
6the health benefit plan shall base all medical necessity
7determinations for medication-assisted treatment in accordance
8with the most current Treatment Criteria for Addictive,
9Substance-Related, and Co-Occurring Conditions established by
10the American Society of Addiction Medicine.
11    As used in this subsection:
12    "Acute treatment services" means 24-hour medically
13supervised addiction treatment that provides evaluation and
14withdrawal management and may include biopsychosocial
15assessment, individual and group counseling, psychoeducational
16groups, and discharge planning.
17    "Clinical stabilization services" means 24-hour treatment,
18usually following acute treatment services for substance
19abuse, which may include intensive education and counseling
20regarding the nature of addiction and its consequences,
21relapse prevention, outreach to families and significant
22others, and aftercare planning for individuals beginning to
23engage in recovery from addiction.
24    (6) An issuer of a group health benefit plan may provide or
25offer coverage required under this Section through a managed
26care plan.

 

 

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1    (6.5) An individual or group health benefit plan amended,
2delivered, issued, or renewed on or after January 1, 2019 (the
3effective date of Public Act 100-1024):
4        (A) shall not impose prior authorization requirements,
5    other than those established under the Treatment Criteria
6    for Addictive, Substance-Related, and Co-Occurring
7    Conditions established by the American Society of
8    Addiction Medicine, on a prescription medication approved
9    by the United States Food and Drug Administration that is
10    prescribed or administered for the treatment of substance
11    use disorders;
12        (B) shall not impose any step therapy requirements,
13    other than those established under the Treatment Criteria
14    for Addictive, Substance-Related, and Co-Occurring
15    Conditions established by the American Society of
16    Addiction Medicine, before authorizing coverage for a
17    prescription medication approved by the United States Food
18    and Drug Administration that is prescribed or administered
19    for the treatment of substance use disorders;
20        (C) shall place all prescription medications approved
21    by the United States Food and Drug Administration
22    prescribed or administered for the treatment of substance
23    use disorders on, for brand medications, the lowest tier
24    of the drug formulary developed and maintained by the
25    individual or group health benefit plan that covers brand
26    medications and, for generic medications, the lowest tier

 

 

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1    of the drug formulary developed and maintained by the
2    individual or group health benefit plan that covers
3    generic medications; and
4        (D) shall not exclude coverage for a prescription
5    medication approved by the United States Food and Drug
6    Administration for the treatment of substance use
7    disorders and any associated counseling or wraparound
8    services on the grounds that such medications and services
9    were court ordered.
10    (7) (Blank).
11    (8) (Blank).
12    (9) With respect to all mental, emotional, nervous, or
13substance use disorders or conditions, coverage for inpatient
14treatment shall include coverage for treatment in a
15residential treatment center certified or licensed by the
16Department of Public Health or the Department of Human
17Services.
18    (c) This Section shall not be interpreted to require
19coverage for speech therapy or other habilitative services for
20those individuals covered under Section 356z.15 of this Code.
21    (d) With respect to a group or individual policy of
22accident and health insurance or a qualified health plan
23offered through the health insurance marketplace, the
24Department and, with respect to medical assistance, the
25Department of Healthcare and Family Services shall each
26enforce the requirements of this Section and Sections 356z.23

 

 

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1and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
2Mental Health Parity and Addiction Equity Act of 2008, 42
3U.S.C. 18031(j), and any amendments to, and federal guidance
4or regulations issued under, those Acts, including, but not
5limited to, final regulations issued under the Paul Wellstone
6and Pete Domenici Mental Health Parity and Addiction Equity
7Act of 2008 and final regulations applying the Paul Wellstone
8and Pete Domenici Mental Health Parity and Addiction Equity
9Act of 2008 to Medicaid managed care organizations, the
10Children's Health Insurance Program, and alternative benefit
11plans. Specifically, the Department and the Department of
12Healthcare and Family Services shall take action:
13        (1) proactively ensuring compliance by individual and
14    group policies, including by requiring that insurers
15    submit comparative analyses, as set forth in paragraph (6)
16    of subsection (k) of Section 370c.1, demonstrating how
17    they design and apply nonquantitative treatment
18    limitations, both as written and in operation, for mental,
19    emotional, nervous, or substance use disorder or condition
20    benefits as compared to how they design and apply
21    nonquantitative treatment limitations, as written and in
22    operation, for medical and surgical benefits;
23        (2) evaluating all consumer or provider complaints
24    regarding mental, emotional, nervous, or substance use
25    disorder or condition coverage for possible parity
26    violations;

 

 

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1        (3) performing parity compliance market conduct
2    examinations or, in the case of the Department of
3    Healthcare and Family Services, parity compliance audits
4    of individual and group plans and policies, including, but
5    not limited to, reviews of:
6            (A) nonquantitative treatment limitations,
7        including, but not limited to, prior authorization
8        requirements, concurrent review, retrospective review,
9        step therapy, network admission standards,
10        reimbursement rates, and geographic restrictions;
11            (B) denials of authorization, payment, and
12        coverage; and
13            (C) other specific criteria as may be determined
14        by the Department.
15    The findings and the conclusions of the parity compliance
16market conduct examinations and audits shall be made public.
17    The Director may adopt rules to effectuate any provisions
18of the Paul Wellstone and Pete Domenici Mental Health Parity
19and Addiction Equity Act of 2008 that relate to the business of
20insurance.
21    (e) Availability of plan information.
22        (1) The criteria for medical necessity determinations
23    made under a group health plan, an individual policy of
24    accident and health insurance, or a qualified health plan
25    offered through the health insurance marketplace with
26    respect to mental health or substance use disorder

 

 

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1    benefits (or health insurance coverage offered in
2    connection with the plan with respect to such benefits)
3    must be made available by the plan administrator (or the
4    health insurance issuer offering such coverage) to any
5    current or potential participant, beneficiary, or
6    contracting provider upon request.
7        (2) The reason for any denial under a group health
8    benefit plan, an individual policy of accident and health
9    insurance, or a qualified health plan offered through the
10    health insurance marketplace (or health insurance coverage
11    offered in connection with such plan or policy) of
12    reimbursement or payment for services with respect to
13    mental, emotional, nervous, or substance use disorders or
14    conditions benefits in the case of any participant or
15    beneficiary must be made available within a reasonable
16    time and in a reasonable manner and in readily
17    understandable language by the plan administrator (or the
18    health insurance issuer offering such coverage) to the
19    participant or beneficiary upon request.
20    (f) As used in this Section, "group policy of accident and
21health insurance" and "group health benefit plan" includes (1)
22State-regulated employer-sponsored group health insurance
23plans written in Illinois or which purport to provide coverage
24for a resident of this State; and (2) State employee health
25plans.
26    (g) (1) As used in this subsection:

 

 

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1    "Benefits", with respect to insurers, means the benefits
2provided for treatment services for inpatient and outpatient
3treatment of substance use disorders or conditions at American
4Society of Addiction Medicine levels of treatment 2.1
5(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
6(Clinically Managed Low-Intensity Residential), 3.3
7(Clinically Managed Population-Specific High-Intensity
8Residential), 3.5 (Clinically Managed High-Intensity
9Residential), and 3.7 (Medically Monitored Intensive
10Inpatient) and OMT (Opioid Maintenance Therapy) services.
11    "Benefits", with respect to managed care organizations,
12means the benefits provided for treatment services for
13inpatient and outpatient treatment of substance use disorders
14or conditions at American Society of Addiction Medicine levels
15of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
16Hospitalization), 3.5 (Clinically Managed High-Intensity
17Residential), and 3.7 (Medically Monitored Intensive
18Inpatient) and OMT (Opioid Maintenance Therapy) services.
19    "Substance use disorder treatment provider or facility"
20means a licensed physician, licensed psychologist, licensed
21psychiatrist, licensed advanced practice registered nurse, or
22licensed, certified, or otherwise State-approved facility or
23provider of substance use disorder treatment.
24    (2) A group health insurance policy, an individual health
25benefit plan, or qualified health plan that is offered through
26the health insurance marketplace, small employer group health

 

 

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1plan, and large employer group health plan that is amended,
2delivered, issued, executed, or renewed in this State, or
3approved for issuance or renewal in this State, on or after
4January 1, 2019 (the effective date of Public Act 100-1023)
5shall comply with the requirements of this Section and Section
6370c.1. The services for the treatment and the ongoing
7assessment of the patient's progress in treatment shall follow
8the requirements of 77 Ill. Adm. Code 2060.
9    (3) Prior authorization shall not be utilized for the
10benefits under this subsection. The substance use disorder
11treatment provider or facility shall notify the insurer of the
12initiation of treatment. For an insurer that is not a managed
13care organization, the substance use disorder treatment
14provider or facility notification shall occur for the
15initiation of treatment of the covered person within 2
16business days. For managed care organizations, the substance
17use disorder treatment provider or facility notification shall
18occur in accordance with the protocol set forth in the
19provider agreement for initiation of treatment within 24
20hours. If the managed care organization is not capable of
21accepting the notification in accordance with the contractual
22protocol during the 24-hour period following admission, the
23substance use disorder treatment provider or facility shall
24have one additional business day to provide the notification
25to the appropriate managed care organization. Treatment plans
26shall be developed in accordance with the requirements and

 

 

HB2595 Enrolled- 23 -LRB102 10633 BMS 15962 b

1timeframes established in 77 Ill. Adm. Code 2060. If the
2substance use disorder treatment provider or facility fails to
3notify the insurer of the initiation of treatment in
4accordance with these provisions, the insurer may follow its
5normal prior authorization processes.
6    (4) For an insurer that is not a managed care
7organization, if an insurer determines that benefits are no
8longer medically necessary, the insurer shall notify the
9covered person, the covered person's authorized
10representative, if any, and the covered person's health care
11provider in writing of the covered person's right to request
12an external review pursuant to the Health Carrier External
13Review Act. The notification shall occur within 24 hours
14following the adverse determination.
15    Pursuant to the requirements of the Health Carrier
16External Review Act, the covered person or the covered
17person's authorized representative may request an expedited
18external review. An expedited external review may not occur if
19the substance use disorder treatment provider or facility
20determines that continued treatment is no longer medically
21necessary. Under this subsection, a request for expedited
22external review must be initiated within 24 hours following
23the adverse determination notification by the insurer. Failure
24to request an expedited external review within 24 hours shall
25preclude a covered person or a covered person's authorized
26representative from requesting an expedited external review.

 

 

HB2595 Enrolled- 24 -LRB102 10633 BMS 15962 b

1    If an expedited external review request meets the criteria
2of the Health Carrier External Review Act, an independent
3review organization shall make a final determination of
4medical necessity within 72 hours. If an independent review
5organization upholds an adverse determination, an insurer
6shall remain responsible to provide coverage of benefits
7through the day following the determination of the independent
8review organization. A decision to reverse an adverse
9determination shall comply with the Health Carrier External
10Review Act.
11    (5) The substance use disorder treatment provider or
12facility shall provide the insurer with 7 business days'
13advance notice of the planned discharge of the patient from
14the substance use disorder treatment provider or facility and
15notice on the day that the patient is discharged from the
16substance use disorder treatment provider or facility.
17    (6) The benefits required by this subsection shall be
18provided to all covered persons with a diagnosis of substance
19use disorder or conditions. The presence of additional related
20or unrelated diagnoses shall not be a basis to reduce or deny
21the benefits required by this subsection.
22    (7) Nothing in this subsection shall be construed to
23require an insurer to provide coverage for any of the benefits
24in this subsection.
25    (h) As used in this Section:
26    "Generally accepted standards of mental, emotional,

 

 

HB2595 Enrolled- 25 -LRB102 10633 BMS 15962 b

1nervous, or substance use disorder or condition care" means
2standards of care and clinical practice that are generally
3recognized by health care providers practicing in relevant
4clinical specialties such as psychiatry, psychology, clinical
5sociology, social work, addiction medicine and counseling, and
6behavioral health treatment. Valid, evidence-based sources
7reflecting generally accepted standards of mental, emotional,
8nervous, or substance use disorder or condition care include
9peer-reviewed scientific studies and medical literature,
10recommendations of nonprofit health care provider professional
11associations and specialty societies, including, but not
12limited to, patient placement criteria and clinical practice
13guidelines, recommendations of federal government agencies,
14and drug labeling approved by the United States Food and Drug
15Administration.
16    "Medically necessary treatment of mental, emotional,
17nervous, or substance use disorders or conditions" means a
18service or product addressing the specific needs of that
19patient, for the purpose of screening, preventing, diagnosing,
20managing, or treating an illness, injury, or condition or its
21symptoms and comorbidities, including minimizing the
22progression of an illness, injury, or condition or its
23symptoms and comorbidities in a manner that is all of the
24following:
25        (1) in accordance with the generally accepted
26    standards of mental, emotional, nervous, or substance use

 

 

HB2595 Enrolled- 26 -LRB102 10633 BMS 15962 b

1    disorder or condition care;
2        (2) clinically appropriate in terms of type,
3    frequency, extent, site, and duration; and
4        (3) not primarily for the economic benefit of the
5    insurer, purchaser, or for the convenience of the patient,
6    treating physician, or other health care provider.
7    "Utilization review" means either of the following:
8        (1) prospectively, retrospectively, or concurrently
9    reviewing and approving, modifying, delaying, or denying,
10    based in whole or in part on medical necessity, requests
11    by health care providers, insureds, or their authorized
12    representatives for coverage of health care services
13    before, retrospectively, or concurrently with the
14    provision of health care services to insureds.
15        (2) evaluating the medical necessity, appropriateness,
16    level of care, service intensity, efficacy, or efficiency
17    of health care services, benefits, procedures, or
18    settings, under any circumstances, to determine whether a
19    health care service or benefit subject to a medical
20    necessity coverage requirement in an insurance policy is
21    covered as medically necessary for an insured.
22    "Utilization review criteria" means patient placement
23criteria or any criteria, standards, protocols, or guidelines
24used by an insurer to conduct utilization review.
25    (i)(1) Every insurer that amends, delivers, issues, or
26renews a group or individual policy of accident and health

 

 

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1insurance or a qualified health plan offered through the
2health insurance marketplace in this State and Medicaid
3managed care organizations providing coverage for hospital or
4medical treatment on or after January 1, 2023 shall, pursuant
5to subsections (h) through (s), provide coverage for medically
6necessary treatment of mental, emotional, nervous, or
7substance use disorders or conditions.
8    (2) An insurer shall not set a specific limit on the
9duration of benefits or coverage of medically necessary
10treatment of mental, emotional, nervous, or substance use
11disorders or conditions or limit coverage only to alleviation
12of the insured's current symptoms.
13    (3) All medical necessity determinations made by the
14insurer concerning service intensity, level of care placement,
15continued stay, and transfer or discharge of insureds
16diagnosed with mental, emotional, nervous, or substance use
17disorders or conditions shall be conducted in accordance with
18the requirements of subsections (k) through (u).
19    (4) An insurer that authorizes a specific type of
20treatment by a provider pursuant to this Section shall not
21rescind or modify the authorization after that provider
22renders the health care service in good faith and pursuant to
23this authorization for any reason, including, but not limited
24to, the insurer's subsequent cancellation or modification of
25the insured's or policyholder's contract, or the insured's or
26policyholder's eligibility. Nothing in this Section shall

 

 

HB2595 Enrolled- 28 -LRB102 10633 BMS 15962 b

1require the insurer to cover a treatment when the
2authorization was granted based on a material
3misrepresentation by the insured, the policyholder, or the
4provider. Nothing in this Section shall require Medicaid
5managed care organizations to pay for services if the
6individual was not eligible for Medicaid at the time the
7service was rendered. Nothing in this Section shall require an
8insurer to pay for services if the individual was not the
9insurer's enrollee at the time services were rendered. As used
10in this paragraph, "material" means a fact or situation that
11is not merely technical in nature and results in or could
12result in a substantial change in the situation.
13    (j) An insurer shall not limit benefits or coverage for
14medically necessary services on the basis that those services
15should be or could be covered by a public entitlement program,
16including, but not limited to, special education or an
17individualized education program, Medicaid, Medicare,
18Supplemental Security Income, or Social Security Disability
19Insurance, and shall not include or enforce a contract term
20that excludes otherwise covered benefits on the basis that
21those services should be or could be covered by a public
22entitlement program. Nothing in this subsection shall be
23construed to require an insurer to cover benefits that have
24been authorized and provided for a covered person by a public
25entitlement program. Medicaid managed care organizations are
26not subject to this subsection.

 

 

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1    (k) An insurer shall base any medical necessity
2determination or the utilization review criteria that the
3insurer, and any entity acting on the insurer's behalf,
4applies to determine the medical necessity of health care
5services and benefits for the diagnosis, prevention, and
6treatment of mental, emotional, nervous, or substance use
7disorders or conditions on current generally accepted
8standards of mental, emotional, nervous, or substance use
9disorder or condition care. All denials and appeals shall be
10reviewed by a professional with experience or expertise
11comparable to the provider requesting the authorization.
12    (l) For medical necessity determinations relating to level
13of care placement, continued stay, and transfer or discharge
14of insureds diagnosed with mental, emotional, and nervous
15disorders or conditions, an insurer shall apply the patient
16placement criteria set forth in the most recent version of the
17treatment criteria developed by an unaffiliated nonprofit
18professional association for the relevant clinical specialty
19or, for Medicaid managed care organizations, patient placement
20criteria determined by the Department of Healthcare and Family
21Services that are consistent with generally accepted standards
22of mental, emotional, nervous or substance use disorder or
23condition care. Pursuant to subsection (b), in conducting
24utilization review of all covered services and benefits for
25the diagnosis, prevention, and treatment of substance use
26disorders an insurer shall use the most recent edition of the

 

 

HB2595 Enrolled- 30 -LRB102 10633 BMS 15962 b

1patient placement criteria established by the American Society
2of Addiction Medicine.
3    (m) For medical necessity determinations relating to level
4of care placement, continued stay, and transfer or discharge
5that are within the scope of the sources specified in
6subsection (l), an insurer shall not apply different,
7additional, conflicting, or more restrictive utilization
8review criteria than the criteria set forth in those sources.
9For all level of care placement decisions, the insurer shall
10authorize placement at the level of care consistent with the
11assessment of the insured using the relevant patient placement
12criteria as specified in subsection (l). If that level of
13placement is not available, the insurer shall authorize the
14next higher level of care. In the event of disagreement, the
15insurer shall provide full detail of its assessment using the
16relevant criteria as specified in subsection (l) to the
17provider of the service and the patient.
18    Nothing in this subsection or subsection (l) prohibits an
19insurer from applying utilization review criteria that were
20developed in accordance with subsection (k) to health care
21services and benefits for mental, emotional, and nervous
22disorders or conditions that are not related to medical
23necessity determinations for level of care placement,
24continued stay, and transfer or discharge. If an insurer
25purchases or licenses utilization review criteria pursuant to
26this subsection, the insurer shall verify and document before

 

 

HB2595 Enrolled- 31 -LRB102 10633 BMS 15962 b

1use that the criteria were developed in accordance with
2subsection (k).
3    (n) In conducting utilization review that is outside the
4scope of the criteria as specified in subsection (l) or
5relates to the advancements in technology or in the types or
6levels of care that are not addressed in the most recent
7versions of the sources specified in subsection (l), an
8insurer shall conduct utilization review in accordance with
9subsection (k).
10    (o) This Section does not in any way limit the rights of a
11patient under the Medical Patient Rights Act.
12    (p) This Section does not in any way limit early and
13periodic screening, diagnostic, and treatment benefits as
14defined under 42 U.S.C. 1396d(r).
15    (q) To ensure the proper use of the criteria described in
16subsection (l), every insurer shall do all of the following:
17        (1) Educate the insurer's staff, including any third
18    parties contracted with the insurer to review claims,
19    conduct utilization reviews, or make medical necessity
20    determinations about the utilization review criteria.
21        (2) Make the educational program available to other
22    stakeholders, including the insurer's participating or
23    contracted providers and potential participants,
24    beneficiaries, or covered lives. The education program
25    must be provided at least once a year, in-person or
26    digitally, or recordings of the education program must be

 

 

HB2595 Enrolled- 32 -LRB102 10633 BMS 15962 b

1    made available to the aforementioned stakeholders.
2        (3) Provide, at no cost, the utilization review
3    criteria and any training material or resources to
4    providers and insured patients upon request. For
5    utilization review criteria not concerning level of care
6    placement, continued stay, and transfer or discharge used
7    by the insurer pursuant to subsection (m), the insurer may
8    place the criteria on a secure, password-protected website
9    so long as the access requirements of the website do not
10    unreasonably restrict access to insureds or their
11    providers. No restrictions shall be placed upon the
12    insured's or treating provider's access right to
13    utilization review criteria obtained under this paragraph
14    at any point in time, including before an initial request
15    for authorization.
16        (4) Track, identify, and analyze how the utilization
17    review criteria are used to certify care, deny care, and
18    support the appeals process.
19        (5) Conduct interrater reliability testing to ensure
20    consistency in utilization review decision making that
21    covers how medical necessity decisions are made; this
22    assessment shall cover all aspects of utilization review
23    as defined in subsection (h).
24        (6) Run interrater reliability reports about how the
25    clinical guidelines are used in conjunction with the
26    utilization review process and parity compliance

 

 

HB2595 Enrolled- 33 -LRB102 10633 BMS 15962 b

1    activities.
2        (7) Achieve interrater reliability pass rates of at
3    least 90% and, if this threshold is not met, immediately
4    provide for the remediation of poor interrater reliability
5    and interrater reliability testing for all new staff
6    before they can conduct utilization review without
7    supervision.
8        (8) Maintain documentation of interrater reliability
9    testing and the remediation actions taken for those with
10    pass rates lower than 90% and submit to the Department of
11    Insurance or, in the case of Medicaid managed care
12    organizations, the Department of Healthcare and Family
13    Services the testing results and a summary of remedial
14    actions as part of parity compliance reporting set forth
15    in subsection (k) of Section 370c.1.
16    (r) This Section applies to all health care services and
17benefits for the diagnosis, prevention, and treatment of
18mental, emotional, nervous, or substance use disorders or
19conditions covered by an insurance policy, including
20prescription drugs.
21    (s) This Section applies to an insurer that amends,
22delivers, issues, or renews a group or individual policy of
23accident and health insurance or a qualified health plan
24offered through the health insurance marketplace in this State
25providing coverage for hospital or medical treatment and
26conducts utilization review as defined in this Section,

 

 

HB2595 Enrolled- 34 -LRB102 10633 BMS 15962 b

1including Medicaid managed care organizations, and any entity
2or contracting provider that performs utilization review or
3utilization management functions on an insurer's behalf.
4    (t) If the Director determines that an insurer has
5violated this Section, the Director may, after appropriate
6notice and opportunity for hearing, by order, assess a civil
7penalty between $1,000 and $5,000 for each violation. Moneys
8collected from penalties shall be deposited into the Parity
9Advancement Fund established in subsection (i) of Section
10370c.1.
11    (u) An insurer shall not adopt, impose, or enforce terms
12in its policies or provider agreements, in writing or in
13operation, that undermine, alter, or conflict with the
14requirements of this Section.
15    (v) The provisions of this Section are severable. If any
16provision of this Section or its application is held invalid,
17that invalidity shall not affect other provisions or
18applications that can be given effect without the invalid
19provision or application.
20(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
21100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
228-16-19; revised 9-20-19.)
 
23    (215 ILCS 5/370c.1)
24    Sec. 370c.1. Mental, emotional, nervous, or substance use
25disorder or condition parity.

 

 

HB2595 Enrolled- 35 -LRB102 10633 BMS 15962 b

1    (a) On and after the effective date of this amendatory Act
2of the 99th General Assembly, every insurer that amends,
3delivers, issues, or renews a group or individual policy of
4accident and health insurance or a qualified health plan
5offered through the Health Insurance Marketplace in this State
6providing coverage for hospital or medical treatment and for
7the treatment of mental, emotional, nervous, or substance use
8disorders or conditions shall ensure that:
9        (1) the financial requirements applicable to such
10    mental, emotional, nervous, or substance use disorder or
11    condition benefits are no more restrictive than the
12    predominant financial requirements applied to
13    substantially all hospital and medical benefits covered by
14    the policy and that there are no separate cost-sharing
15    requirements that are applicable only with respect to
16    mental, emotional, nervous, or substance use disorder or
17    condition benefits; and
18        (2) the treatment limitations applicable to such
19    mental, emotional, nervous, or substance use disorder or
20    condition benefits are no more restrictive than the
21    predominant treatment limitations applied to substantially
22    all hospital and medical benefits covered by the policy
23    and that there are no separate treatment limitations that
24    are applicable only with respect to mental, emotional,
25    nervous, or substance use disorder or condition benefits.
26    (b) The following provisions shall apply concerning

 

 

HB2595 Enrolled- 36 -LRB102 10633 BMS 15962 b

1aggregate lifetime limits:
2        (1) In the case of a group or individual policy of
3    accident and health insurance or a qualified health plan
4    offered through the Health Insurance Marketplace amended,
5    delivered, issued, or renewed in this State on or after
6    the effective date of this amendatory Act of the 99th
7    General Assembly that provides coverage for hospital or
8    medical treatment and for the treatment of mental,
9    emotional, nervous, or substance use disorders or
10    conditions the following provisions shall apply:
11            (A) if the policy does not include an aggregate
12        lifetime limit on substantially all hospital and
13        medical benefits, then the policy may not impose any
14        aggregate lifetime limit on mental, emotional,
15        nervous, or substance use disorder or condition
16        benefits; or
17            (B) if the policy includes an aggregate lifetime
18        limit on substantially all hospital and medical
19        benefits (in this subsection referred to as the
20        "applicable lifetime limit"), then the policy shall
21        either:
22                (i) apply the applicable lifetime limit both
23            to the hospital and medical benefits to which it
24            otherwise would apply and to mental, emotional,
25            nervous, or substance use disorder or condition
26            benefits and not distinguish in the application of

 

 

HB2595 Enrolled- 37 -LRB102 10633 BMS 15962 b

1            the limit between the hospital and medical
2            benefits and mental, emotional, nervous, or
3            substance use disorder or condition benefits; or
4                (ii) not include any aggregate lifetime limit
5            on mental, emotional, nervous, or substance use
6            disorder or condition benefits that is less than
7            the applicable lifetime limit.
8        (2) In the case of a policy that is not described in
9    paragraph (1) of subsection (b) of this Section and that
10    includes no or different aggregate lifetime limits on
11    different categories of hospital and medical benefits, the
12    Director shall establish rules under which subparagraph
13    (B) of paragraph (1) of subsection (b) of this Section is
14    applied to such policy with respect to mental, emotional,
15    nervous, or substance use disorder or condition benefits
16    by substituting for the applicable lifetime limit an
17    average aggregate lifetime limit that is computed taking
18    into account the weighted average of the aggregate
19    lifetime limits applicable to such categories.
20    (c) The following provisions shall apply concerning annual
21limits:
22        (1) In the case of a group or individual policy of
23    accident and health insurance or a qualified health plan
24    offered through the Health Insurance Marketplace amended,
25    delivered, issued, or renewed in this State on or after
26    the effective date of this amendatory Act of the 99th

 

 

HB2595 Enrolled- 38 -LRB102 10633 BMS 15962 b

1    General Assembly that provides coverage for hospital or
2    medical treatment and for the treatment of mental,
3    emotional, nervous, or substance use disorders or
4    conditions the following provisions shall apply:
5            (A) if the policy does not include an annual limit
6        on substantially all hospital and medical benefits,
7        then the policy may not impose any annual limits on
8        mental, emotional, nervous, or substance use disorder
9        or condition benefits; or
10            (B) if the policy includes an annual limit on
11        substantially all hospital and medical benefits (in
12        this subsection referred to as the "applicable annual
13        limit"), then the policy shall either:
14                (i) apply the applicable annual limit both to
15            the hospital and medical benefits to which it
16            otherwise would apply and to mental, emotional,
17            nervous, or substance use disorder or condition
18            benefits and not distinguish in the application of
19            the limit between the hospital and medical
20            benefits and mental, emotional, nervous, or
21            substance use disorder or condition benefits; or
22                (ii) not include any annual limit on mental,
23            emotional, nervous, or substance use disorder or
24            condition benefits that is less than the
25            applicable annual limit.
26        (2) In the case of a policy that is not described in

 

 

HB2595 Enrolled- 39 -LRB102 10633 BMS 15962 b

1    paragraph (1) of subsection (c) of this Section and that
2    includes no or different annual limits on different
3    categories of hospital and medical benefits, the Director
4    shall establish rules under which subparagraph (B) of
5    paragraph (1) of subsection (c) of this Section is applied
6    to such policy with respect to mental, emotional, nervous,
7    or substance use disorder or condition benefits by
8    substituting for the applicable annual limit an average
9    annual limit that is computed taking into account the
10    weighted average of the annual limits applicable to such
11    categories.
12    (d) With respect to mental, emotional, nervous, or
13substance use disorders or conditions, an insurer shall use
14policies and procedures for the election and placement of
15mental, emotional, nervous, or substance use disorder or
16condition treatment drugs on their formulary that are no less
17favorable to the insured as those policies and procedures the
18insurer uses for the selection and placement of drugs for
19medical or surgical conditions and shall follow the expedited
20coverage determination requirements for substance abuse
21treatment drugs set forth in Section 45.2 of the Managed Care
22Reform and Patient Rights Act.
23    (e) This Section shall be interpreted in a manner
24consistent with all applicable federal parity regulations
25including, but not limited to, the Paul Wellstone and Pete
26Domenici Mental Health Parity and Addiction Equity Act of

 

 

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12008, final regulations issued under the Paul Wellstone and
2Pete Domenici Mental Health Parity and Addiction Equity Act of
32008 and final regulations applying the Paul Wellstone and
4Pete Domenici Mental Health Parity and Addiction Equity Act of
52008 to Medicaid managed care organizations, the Children's
6Health Insurance Program, and alternative benefit plans.
7    (f) The provisions of subsections (b) and (c) of this
8Section shall not be interpreted to allow the use of lifetime
9or annual limits otherwise prohibited by State or federal law.
10    (g) As used in this Section:
11    "Financial requirement" includes deductibles, copayments,
12coinsurance, and out-of-pocket maximums, but does not include
13an aggregate lifetime limit or an annual limit subject to
14subsections (b) and (c).
15    "Mental, emotional, nervous, or substance use disorder or
16condition" means a condition or disorder that involves a
17mental health condition or substance use disorder that falls
18under any of the diagnostic categories listed in the mental
19and behavioral disorders chapter of the current edition of the
20International Classification of Disease or that is listed in
21the most recent version of the Diagnostic and Statistical
22Manual of Mental Disorders.
23    "Treatment limitation" includes limits on benefits based
24on the frequency of treatment, number of visits, days of
25coverage, days in a waiting period, or other similar limits on
26the scope or duration of treatment. "Treatment limitation"

 

 

HB2595 Enrolled- 41 -LRB102 10633 BMS 15962 b

1includes both quantitative treatment limitations, which are
2expressed numerically (such as 50 outpatient visits per year),
3and nonquantitative treatment limitations, which otherwise
4limit the scope or duration of treatment. A permanent
5exclusion of all benefits for a particular condition or
6disorder shall not be considered a treatment limitation.
7"Nonquantitative treatment" means those limitations as
8described under federal regulations (26 CFR 54.9812-1).
9"Nonquantitative treatment limitations" include, but are not
10limited to, those limitations described under federal
11regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
12146.136.
13    (h) The Department of Insurance shall implement the
14following education initiatives:
15        (1) By January 1, 2016, the Department shall develop a
16    plan for a Consumer Education Campaign on parity. The
17    Consumer Education Campaign shall focus its efforts
18    throughout the State and include trainings in the
19    northern, southern, and central regions of the State, as
20    defined by the Department, as well as each of the 5 managed
21    care regions of the State as identified by the Department
22    of Healthcare and Family Services. Under this Consumer
23    Education Campaign, the Department shall: (1) by January
24    1, 2017, provide at least one live training in each region
25    on parity for consumers and providers and one webinar
26    training to be posted on the Department website and (2)

 

 

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1    establish a consumer hotline to assist consumers in
2    navigating the parity process by March 1, 2017. By January
3    1, 2018 the Department shall issue a report to the General
4    Assembly on the success of the Consumer Education
5    Campaign, which shall indicate whether additional training
6    is necessary or would be recommended.
7        (2) The Department, in coordination with the
8    Department of Human Services and the Department of
9    Healthcare and Family Services, shall convene a working
10    group of health care insurance carriers, mental health
11    advocacy groups, substance abuse patient advocacy groups,
12    and mental health physician groups for the purpose of
13    discussing issues related to the treatment and coverage of
14    mental, emotional, nervous, or substance use disorders or
15    conditions and compliance with parity obligations under
16    State and federal law. Compliance shall be measured,
17    tracked, and shared during the meetings of the working
18    group. The working group shall meet once before January 1,
19    2016 and shall meet semiannually thereafter. The
20    Department shall issue an annual report to the General
21    Assembly that includes a list of the health care insurance
22    carriers, mental health advocacy groups, substance abuse
23    patient advocacy groups, and mental health physician
24    groups that participated in the working group meetings,
25    details on the issues and topics covered, and any
26    legislative recommendations developed by the working

 

 

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1    group.
2        (3) Not later than January August 1 of each year, the
3    Department, in conjunction with the Department of
4    Healthcare and Family Services, shall issue a joint report
5    to the General Assembly and provide an educational
6    presentation to the General Assembly. The report and
7    presentation shall:
8            (A) Cover the methodology the Departments use to
9        check for compliance with the federal Paul Wellstone
10        and Pete Domenici Mental Health Parity and Addiction
11        Equity Act of 2008, 42 U.S.C. 18031(j), and any
12        federal regulations or guidance relating to the
13        compliance and oversight of the federal Paul Wellstone
14        and Pete Domenici Mental Health Parity and Addiction
15        Equity Act of 2008 and 42 U.S.C. 18031(j).
16            (B) Cover the methodology the Departments use to
17        check for compliance with this Section and Sections
18        356z.23 and 370c of this Code.
19            (C) Identify market conduct examinations or, in
20        the case of the Department of Healthcare and Family
21        Services, audits conducted or completed during the
22        preceding 12-month period regarding compliance with
23        parity in mental, emotional, nervous, and substance
24        use disorder or condition benefits under State and
25        federal laws and summarize the results of such market
26        conduct examinations and audits. This shall include:

 

 

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1                (i) the number of market conduct examinations
2            and audits initiated and completed;
3                (ii) the benefit classifications examined by
4            each market conduct examination and audit;
5                (iii) the subject matter of each market
6            conduct examination and audit, including
7            quantitative and nonquantitative treatment
8            limitations; and
9                (iv) a summary of the basis for the final
10            decision rendered in each market conduct
11            examination and audit.
12            Individually identifiable information shall be
13        excluded from the reports consistent with federal
14        privacy protections.
15            (D) Detail any educational or corrective actions
16        the Departments have taken to ensure compliance with
17        the federal Paul Wellstone and Pete Domenici Mental
18        Health Parity and Addiction Equity Act of 2008, 42
19        U.S.C. 18031(j), this Section, and Sections 356z.23
20        and 370c of this Code.
21            (E) The report must be written in non-technical,
22        readily understandable language and shall be made
23        available to the public by, among such other means as
24        the Departments find appropriate, posting the report
25        on the Departments' websites.
26    (i) The Parity Advancement Fund is created as a special

 

 

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1fund in the State treasury. Moneys from fines and penalties
2collected from insurers for violations of this Section shall
3be deposited into the Fund. Moneys deposited into the Fund for
4appropriation by the General Assembly to the Department shall
5be used for the purpose of providing financial support of the
6Consumer Education Campaign, parity compliance advocacy, and
7other initiatives that support parity implementation and
8enforcement on behalf of consumers.
9    (j) The Department of Insurance and the Department of
10Healthcare and Family Services shall convene and provide
11technical support to a workgroup of 11 members that shall be
12comprised of 3 mental health parity experts recommended by an
13organization advocating on behalf of mental health parity
14appointed by the President of the Senate; 3 behavioral health
15providers recommended by an organization that represents
16behavioral health providers appointed by the Speaker of the
17House of Representatives; 2 representing Medicaid managed care
18organizations recommended by an organization that represents
19Medicaid managed care plans appointed by the Minority Leader
20of the House of Representatives; 2 representing commercial
21insurers recommended by an organization that represents
22insurers appointed by the Minority Leader of the Senate; and a
23representative of an organization that represents Medicaid
24managed care plans appointed by the Governor.
25    The workgroup shall provide recommendations to the General
26Assembly on health plan data reporting requirements that

 

 

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1separately break out data on mental, emotional, nervous, or
2substance use disorder or condition benefits and data on other
3medical benefits, including physical health and related health
4services no later than December 31, 2019. The recommendations
5to the General Assembly shall be filed with the Clerk of the
6House of Representatives and the Secretary of the Senate in
7electronic form only, in the manner that the Clerk and the
8Secretary shall direct. This workgroup shall take into account
9federal requirements and recommendations on mental health
10parity reporting for the Medicaid program. This workgroup
11shall also develop the format and provide any needed
12definitions for reporting requirements in subsection (k). The
13research and evaluation of the working group shall include,
14but not be limited to:
15        (1) claims denials due to benefit limits, if
16    applicable;
17        (2) administrative denials for no prior authorization;
18        (3) denials due to not meeting medical necessity;
19        (4) denials that went to external review and whether
20    they were upheld or overturned for medical necessity;
21        (5) out-of-network claims;
22        (6) emergency care claims;
23        (7) network directory providers in the outpatient
24    benefits classification who filed no claims in the last 6
25    months, if applicable;
26        (8) the impact of existing and pertinent limitations

 

 

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1    and restrictions related to approved services, licensed
2    providers, reimbursement levels, and reimbursement
3    methodologies within the Division of Mental Health, the
4    Division of Substance Use Prevention and Recovery
5    programs, the Department of Healthcare and Family
6    Services, and, to the extent possible, federal regulations
7    and law; and
8        (9) when reporting and publishing should begin.
9    Representatives from the Department of Healthcare and
10Family Services, representatives from the Division of Mental
11Health, and representatives from the Division of Substance Use
12Prevention and Recovery shall provide technical advice to the
13workgroup.
14    (k) An insurer that amends, delivers, issues, or renews a
15group or individual policy of accident and health insurance or
16a qualified health plan offered through the health insurance
17marketplace in this State providing coverage for hospital or
18medical treatment and for the treatment of mental, emotional,
19nervous, or substance use disorders or conditions shall submit
20an annual report, the format and definitions for which will be
21developed by the workgroup in subsection (j), to the
22Department, or, with respect to medical assistance, the
23Department of Healthcare and Family Services starting on or
24before July 1, 2020 that contains the following information
25separately for inpatient in-network benefits, inpatient
26out-of-network benefits, outpatient in-network benefits,

 

 

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1outpatient out-of-network benefits, emergency care benefits,
2and prescription drug benefits in the case of accident and
3health insurance or qualified health plans, or inpatient,
4outpatient, emergency care, and prescription drug benefits in
5the case of medical assistance:
6        (1) A summary of the plan's pharmacy management
7    processes for mental, emotional, nervous, or substance use
8    disorder or condition benefits compared to those for other
9    medical benefits.
10        (2) A summary of the internal processes of review for
11    experimental benefits and unproven technology for mental,
12    emotional, nervous, or substance use disorder or condition
13    benefits and those for other medical benefits.
14        (3) A summary of how the plan's policies and
15    procedures for utilization management for mental,
16    emotional, nervous, or substance use disorder or condition
17    benefits compare to those for other medical benefits.
18        (4) A description of the process used to develop or
19    select the medical necessity criteria for mental,
20    emotional, nervous, or substance use disorder or condition
21    benefits and the process used to develop or select the
22    medical necessity criteria for medical and surgical
23    benefits.
24        (5) Identification of all nonquantitative treatment
25    limitations that are applied to both mental, emotional,
26    nervous, or substance use disorder or condition benefits

 

 

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1    and medical and surgical benefits within each
2    classification of benefits.
3        (6) The results of an analysis that demonstrates that
4    for the medical necessity criteria described in
5    subparagraph (A) and for each nonquantitative treatment
6    limitation identified in subparagraph (B), as written and
7    in operation, the processes, strategies, evidentiary
8    standards, or other factors used in applying the medical
9    necessity criteria and each nonquantitative treatment
10    limitation to mental, emotional, nervous, or substance use
11    disorder or condition benefits within each classification
12    of benefits are comparable to, and are applied no more
13    stringently than, the processes, strategies, evidentiary
14    standards, or other factors used in applying the medical
15    necessity criteria and each nonquantitative treatment
16    limitation to medical and surgical benefits within the
17    corresponding classification of benefits; at a minimum,
18    the results of 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        mental, emotional, nervous, or substance use disorder
6        or condition benefits are comparable to, and are
7        applied no more stringently than, the processes and
8        strategies used to design each nonquantitative
9        treatment limitation, as written, for medical and
10        surgical benefits;
11            (D) provide the comparative analyses, including
12        the results of the analyses, performed to determine
13        that the processes and strategies used to apply each
14        nonquantitative treatment limitation, in operation,
15        for mental, emotional, nervous, or substance use
16        disorder or condition benefits are comparable to, and
17        applied no more stringently than, the processes or
18        strategies used to apply each nonquantitative
19        treatment limitation, in operation, for medical and
20        surgical benefits; and
21            (E) disclose the specific findings and conclusions
22        reached by the insurer that the results of the
23        analyses described in subparagraphs (C) and (D)
24        indicate that the insurer is in compliance with this
25        Section and the Mental Health Parity and Addiction
26        Equity Act of 2008 and its implementing regulations,

 

 

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1        which includes 42 CFR Parts 438, 440, and 457 and 45
2        CFR 146.136 and any other related federal regulations
3        found in the Code of Federal Regulations.
4        (7) Any other information necessary to clarify data
5    provided in accordance with this Section requested by the
6    Director, including information that may be proprietary or
7    have commercial value, under the requirements of Section
8    30 of the Viatical Settlements Act of 2009.
9    (l) An insurer that amends, delivers, issues, or renews a
10group or individual policy of accident and health insurance or
11a qualified health plan offered through the health insurance
12marketplace in this State providing coverage for hospital or
13medical treatment and for the treatment of mental, emotional,
14nervous, or substance use disorders or conditions on or after
15the effective date of this amendatory Act of the 100th General
16Assembly shall, in advance of the plan year, make available to
17the Department or, with respect to medical assistance, the
18Department of Healthcare and Family Services and to all plan
19participants and beneficiaries the information required in
20subparagraphs (C) through (E) of paragraph (6) of subsection
21(k). For plan participants and medical assistance
22beneficiaries, the information required in subparagraphs (C)
23through (E) of paragraph (6) of subsection (k) shall be made
24available on a publicly-available website whose web address is
25prominently displayed in plan and managed care organization
26informational and marketing materials.

 

 

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1    (m) In conjunction with its compliance examination program
2conducted in accordance with the Illinois State Auditing Act,
3the Auditor General shall undertake a review of compliance by
4the Department and the Department of Healthcare and Family
5Services with Section 370c and this Section. Any findings
6resulting from the review conducted under this Section shall
7be included in the applicable State agency's compliance
8examination report. Each compliance examination report shall
9be issued in accordance with Section 3-14 of the Illinois
10State Auditing Act. A copy of each report shall also be
11delivered to the head of the applicable State agency and
12posted on the Auditor General's website.
13(Source: P.A. 99-480, eff. 9-9-15; 100-1024, eff. 1-1-19.)
 
14    Section 10. The Health Carrier External Review Act is
15amended by changing Sections 35 and 40 as follows:
 
16    (215 ILCS 180/35)
17    Sec. 35. Standard external review.
18    (a) Within 4 months after the date of receipt of a notice
19of an adverse determination or final adverse determination, a
20covered person or the covered person's authorized
21representative may file a request for an external review with
22the Director. Within one business day after the date of
23receipt of a request for external review, the Director shall
24send a copy of the request to the health carrier.

 

 

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1    (b) Within 5 business days following the date of receipt
2of the external review request, the health carrier shall
3complete a preliminary review of the request to determine
4whether:
5        (1) the individual is or was a covered person in the
6    health benefit plan at the time the health care service
7    was requested or at the time the health care service was
8    provided;
9        (2) the health care service that is the subject of the
10    adverse determination or the final adverse determination
11    is a covered service under the covered person's health
12    benefit plan, but the health carrier has determined that
13    the health care service is not covered;
14        (3) the covered person has exhausted the health
15    carrier's internal appeal process unless the covered
16    person is not required to exhaust the health carrier's
17    internal appeal process pursuant to this Act;
18        (4) (blank); and
19        (5) the covered person has provided all the
20    information and forms required to process an external
21    review, as specified in this Act.
22    (c) Within one business day after completion of the
23preliminary review, the health carrier shall notify the
24Director and covered person and, if applicable, the covered
25person's authorized representative in writing whether the
26request is complete and eligible for external review. If the

 

 

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1request:
2        (1) is not complete, the health carrier shall inform
3    the Director and covered person and, if applicable, the
4    covered person's authorized representative in writing and
5    include in the notice what information or materials are
6    required by this Act to make the request complete; or
7        (2) is not eligible for external review, the health
8    carrier shall inform the Director and covered person and,
9    if applicable, the covered person's authorized
10    representative in writing and include in the notice the
11    reasons for its ineligibility.
12    The Department may specify the form for the health
13carrier's notice of initial determination under this
14subsection (c) and any supporting information to be included
15in the notice.
16    The notice of initial determination of ineligibility shall
17include a statement informing the covered person and, if
18applicable, the covered person's authorized representative
19that a health carrier's initial determination that the
20external review request is ineligible for review may be
21appealed to the Director by filing a complaint with the
22Director.
23    Notwithstanding a health carrier's initial determination
24that the request is ineligible for external review, the
25Director may determine that a request is eligible for external
26review and require that it be referred for external review. In

 

 

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1making such determination, the Director's decision shall be in
2accordance with the terms of the covered person's health
3benefit plan, unless such terms are inconsistent with
4applicable law, and shall be subject to all applicable
5provisions of this Act.
6    (d) Whenever the Director receives notice that a request
7is eligible for external review following the preliminary
8review conducted pursuant to this Section, within one business
9day after the date of receipt of the notice, the Director
10shall:
11        (1) assign an independent review organization from the
12    list of approved independent review organizations compiled
13    and maintained by the Director pursuant to this Act and
14    notify the health carrier of the name of the assigned
15    independent review organization; and
16        (2) notify in writing the covered person and, if
17    applicable, the covered person's authorized representative
18    of the request's eligibility and acceptance for external
19    review and the name of the independent review
20    organization.
21    The Director shall include in the notice provided to the
22covered person and, if applicable, the covered person's
23authorized representative a statement that the covered person
24or the covered person's authorized representative may, within
255 business days following the date of receipt of the notice
26provided pursuant to item (2) of this subsection (d), submit

 

 

HB2595 Enrolled- 56 -LRB102 10633 BMS 15962 b

1in writing to the assigned independent review organization
2additional information that the independent review
3organization shall consider when conducting the external
4review. The independent review organization is not required
5to, but may, accept and consider additional information
6submitted after 5 business days.
7    (e) The assignment by the Director of an approved
8independent review organization to conduct an external review
9in accordance with this Section shall be done on a random basis
10among those independent review organizations approved by the
11Director pursuant to this Act.
12    (f) Within 5 business days after the date of receipt of the
13notice provided pursuant to item (1) of subsection (d) of this
14Section, the health carrier or its designee utilization review
15organization shall provide to the assigned independent review
16organization the documents and any information considered in
17making the adverse determination or final adverse
18determination; in such cases, the following provisions shall
19apply:
20        (1) Except as provided in item (2) of this subsection
21    (f), failure by the health carrier or its utilization
22    review organization to provide the documents and
23    information within the specified time frame shall not
24    delay the conduct of the external review.
25        (2) If the health carrier or its utilization review
26    organization fails to provide the documents and

 

 

HB2595 Enrolled- 57 -LRB102 10633 BMS 15962 b

1    information within the specified time frame, the assigned
2    independent review organization may terminate the external
3    review and make a decision to reverse the adverse
4    determination or final adverse determination.
5        (3) Within one business day after making the decision
6    to terminate the external review and make a decision to
7    reverse the adverse determination or final adverse
8    determination under item (2) of this subsection (f), the
9    independent review organization shall notify the Director,
10    the health carrier, the covered person and, if applicable,
11    the covered person's authorized representative, of its
12    decision to reverse the adverse determination.
13    (g) Upon receipt of the information from the health
14carrier or its utilization review organization, the assigned
15independent review organization shall review all of the
16information and documents and any other information submitted
17in writing to the independent review organization by the
18covered person and the covered person's authorized
19representative.
20    (h) Upon receipt of any information submitted by the
21covered person or the covered person's authorized
22representative, the independent review organization shall
23forward the information to the health carrier within 1
24business day.
25        (1) Upon receipt of the information, if any, the
26    health carrier may reconsider its adverse determination or

 

 

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1    final adverse determination that is the subject of the
2    external review.
3        (2) Reconsideration by the health carrier of its
4    adverse determination or final adverse determination shall
5    not delay or terminate the external review.
6        (3) The external review may only be terminated if the
7    health carrier decides, upon completion of its
8    reconsideration, to reverse its adverse determination or
9    final adverse determination and provide coverage or
10    payment for the health care service that is the subject of
11    the adverse determination or final adverse determination.
12    In such cases, the following provisions shall apply:
13            (A) Within one business day after making the
14        decision to reverse its adverse determination or final
15        adverse determination, the health carrier shall notify
16        the Director, the covered person and, if applicable,
17        the covered person's authorized representative, and
18        the assigned independent review organization in
19        writing of its decision.
20            (B) Upon notice from the health carrier that the
21        health carrier has made a decision to reverse its
22        adverse determination or final adverse determination,
23        the assigned independent review organization shall
24        terminate the external review.
25    (i) In addition to the documents and information provided
26by the health carrier or its utilization review organization

 

 

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1and the covered person and the covered person's authorized
2representative, if any, the independent review organization,
3to the extent the information or documents are available and
4the independent review organization considers them
5appropriate, shall consider the following in reaching a
6decision:
7        (1) the covered person's pertinent medical records;
8        (2) the covered person's health care provider's
9    recommendation;
10        (3) consulting reports from appropriate health care
11    providers and other documents submitted by the health
12    carrier or its designee utilization review organization,
13    the covered person, the covered person's authorized
14    representative, or the covered person's treating provider;
15        (4) the terms of coverage under the covered person's
16    health benefit plan with the health carrier to ensure that
17    the independent review organization's decision is not
18    contrary to the terms of coverage under the covered
19    person's health benefit plan with the health carrier,
20    unless the terms are inconsistent with applicable law;
21        (5) the most appropriate practice guidelines, which
22    shall include applicable evidence-based standards and may
23    include any other practice guidelines developed by the
24    federal government, national or professional medical
25    societies, boards, and associations;
26        (6) any applicable clinical review criteria developed

 

 

HB2595 Enrolled- 60 -LRB102 10633 BMS 15962 b

1    and used by the health carrier or its designee utilization
2    review organization;
3        (7) the opinion of the independent review
4    organization's clinical reviewer or reviewers after
5    considering items (1) through (6) of this subsection (i)
6    to the extent the information or documents are available
7    and the clinical reviewer or reviewers considers the
8    information or documents appropriate;
9        (8) (blank); and
10        (9) in the case of medically necessary determinations
11    for substance use disorders, the patient placement
12    criteria established by the American Society of Addiction
13    Medicine.
14    (i-5) For an adverse determination or final adverse
15determination involving mental, emotional, nervous, or
16substance use disorders or conditions, the independent review
17organization shall:
18        (1) consider the documents and information as set
19    forth in subsection (i), except that all practice
20    guidelines and clinical review criteria must be consistent
21    with the requirements set forth in Section 370c of the
22    Illinois Insurance Code; and
23        (2) make its decision, pursuant to subsection (j),
24    whether to uphold or reverse the adverse determination or
25    final adverse determination based on whether the service
26    constitutes medically necessary treatment of a mental,

 

 

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1    emotional, nervous, or substance use disorders or
2    condition as defined in Section 370c of the Illinois
3    Insurance Code.
4    (j) Within 5 days after the date of receipt of all
5necessary information, but in no event more than 45 days after
6the date of receipt of the request for an external review, the
7assigned independent review organization shall provide written
8notice of its decision to uphold or reverse the adverse
9determination or the final adverse determination to the
10Director, the health carrier, the covered person, and, if
11applicable, the covered person's authorized representative. In
12reaching a decision, the assigned independent review
13organization is not bound by any claim determinations reached
14prior to the submission of information to the independent
15review organization. In such cases, the following provisions
16shall apply:
17        (1) The independent review organization shall include
18    in the notice:
19            (A) a general description of the reason for the
20        request for external review;
21            (B) the date the independent review organization
22        received the assignment from the Director to conduct
23        the external review;
24            (C) the time period during which the external
25        review was conducted;
26            (D) references to the evidence or documentation,

 

 

HB2595 Enrolled- 62 -LRB102 10633 BMS 15962 b

1        including the evidence-based standards, considered in
2        reaching its decision;
3            (E) the date of its decision;
4            (F) the principal reason or reasons for its
5        decision, including what applicable, if any,
6        evidence-based standards that were a basis for its
7        decision; and
8            (G) the rationale for its decision.
9        (2) (Blank).
10        (3) (Blank).
11        (4) Upon receipt of a notice of a decision reversing
12    the adverse determination or final adverse determination,
13    the health carrier immediately shall approve the coverage
14    that was the subject of the adverse determination or final
15    adverse determination.
16(Source: P.A. 99-480, eff. 9-9-15.)
 
17    (215 ILCS 180/40)
18    Sec. 40. Expedited external review.
19    (a) A covered person or a covered person's authorized
20representative may file a request for an expedited external
21review with the Director either orally or in writing:
22        (1) immediately after the date of receipt of a notice
23    prior to a final adverse determination as provided by
24    subsection (b) of Section 20 of this Act;
25        (2) immediately after the date of receipt of a notice

 

 

HB2595 Enrolled- 63 -LRB102 10633 BMS 15962 b

1    upon final adverse determination as provided by subsection
2    (c) of Section 20 of this Act; or
3        (3) if a health carrier fails to provide a decision on
4    request for an expedited internal appeal within 48 hours
5    as provided by item (2) of Section 30 of this Act.
6    (b) Upon receipt of a request for an expedited external
7review, the Director shall immediately send a copy of the
8request to the health carrier. Immediately upon receipt of the
9request for an expedited external review, the health carrier
10shall determine whether the request meets the reviewability
11requirements set forth in subsection (b) of Section 35. In
12such cases, the following provisions shall apply:
13        (1) The health carrier shall immediately notify the
14    Director, the covered person, and, if applicable, the
15    covered person's authorized representative of its
16    eligibility determination.
17        (2) The notice of initial determination shall include
18    a statement informing the covered person and, if
19    applicable, the covered person's authorized representative
20    that a health carrier's initial determination that an
21    external review request is ineligible for review may be
22    appealed to the Director.
23        (3) The Director may determine that a request is
24    eligible for expedited external review notwithstanding a
25    health carrier's initial determination that the request is
26    ineligible and require that it be referred for external

 

 

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1    review.
2        (4) In making a determination under item (3) of this
3    subsection (b), the Director's decision shall be made in
4    accordance with the terms of the covered person's health
5    benefit plan, unless such terms are inconsistent with
6    applicable law, and shall be subject to all applicable
7    provisions of this Act.
8        (5) The Director may specify the form for the health
9    carrier's notice of initial determination under this
10    subsection (b) and any supporting information to be
11    included in the notice.
12    (c) Upon receipt of the notice that the request meets the
13reviewability requirements, the Director shall immediately
14assign an independent review organization from the list of
15approved independent review organizations compiled and
16maintained by the Director to conduct the expedited review. In
17such cases, the following provisions shall apply:
18        (1) The assignment of an approved independent review
19    organization to conduct an external review in accordance
20    with this Section shall be made from those approved
21    independent review organizations qualified to conduct
22    external review as required by Sections 50 and 55 of this
23    Act.
24        (2) The Director shall immediately notify the health
25    carrier of the name of the assigned independent review
26    organization. Immediately upon receipt from the Director

 

 

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1    of the name of the independent review organization
2    assigned to conduct the external review, but in no case
3    more than 24 hours after receiving such notice, the health
4    carrier or its designee utilization review organization
5    shall provide or transmit all necessary documents and
6    information considered in making the adverse determination
7    or final adverse determination to the assigned independent
8    review organization electronically or by telephone or
9    facsimile or any other available expeditious method.
10        (3) If the health carrier or its utilization review
11    organization fails to provide the documents and
12    information within the specified timeframe, the assigned
13    independent review organization may terminate the external
14    review and make a decision to reverse the adverse
15    determination or final adverse determination.
16        (4) Within one business day after making the decision
17    to terminate the external review and make a decision to
18    reverse the adverse determination or final adverse
19    determination under item (3) of this subsection (c), the
20    independent review organization shall notify the Director,
21    the health carrier, the covered person, and, if
22    applicable, the covered person's authorized representative
23    of its decision to reverse the adverse determination or
24    final adverse determination.
25    (d) In addition to the documents and information provided
26by the health carrier or its utilization review organization

 

 

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1and any documents and information provided by the covered
2person and the covered person's authorized representative, the
3independent review organization, to the extent the information
4or documents are available and the independent review
5organization considers them appropriate, shall consider
6information as required by subsection (i) of Section 35 of
7this Act in reaching a decision.
8    (d-5) For expedited external reviews involving mental,
9emotional, nervous, or substance use disorders or conditions,
10the independent review organization shall consider documents
11and information and shall make a decision to uphold or reverse
12the adverse determination or final adverse determination
13pursuant to subsection (i-5) of Section 35.
14    (e) As expeditiously as the covered person's medical
15condition or circumstances requires, but in no event more than
1672 hours after the date of receipt of the request for an
17expedited external review, the assigned independent review
18organization shall:
19        (1) make a decision to uphold or reverse the final
20    adverse determination; and
21        (2) notify the Director, the health carrier, the
22    covered person, the covered person's health care provider,
23    and, if applicable, the covered person's authorized
24    representative, of the decision.
25    (f) In reaching a decision, the assigned independent
26review organization is not bound by any decisions or

 

 

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1conclusions reached during the health carrier's utilization
2review process or the health carrier's internal appeal
3process.
4    (g) Upon receipt of notice of a decision reversing the
5adverse determination or final adverse determination, the
6health carrier shall immediately approve the coverage that was
7the subject of the adverse determination or final adverse
8determination.
9    (h) If the notice provided pursuant to subsection (e) of
10this Section was not in writing, then within 48 hours after the
11date of providing that notice, the assigned independent review
12organization shall provide written confirmation of the
13decision to the Director, the health carrier, the covered
14person, and, if applicable, the covered person's authorized
15representative including the information set forth in
16subsection (j) of Section 35 of this Act as applicable.
17    (i) An expedited external review may not be provided for
18retrospective adverse or final adverse determinations.
19    (j) The assignment by the Director of an approved
20independent review organization to conduct an external review
21in accordance with this Section shall be done on a random basis
22among those independent review organizations approved by the
23Director pursuant to this Act.
24(Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11;
2597-574, eff. 8-26-11.)
 
26    Section 99. Effective date. This Act takes effect January

 

 

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11, 2022, except that this Section and the changes to Section
2370c.1 of the Illinois Insurance Code take effect upon
3becoming law.