Illinois General Assembly - Full Text of SB1707
Illinois General Assembly

Previous General Assemblies

Full Text of SB1707  100th General Assembly

SB1707enr 100TH GENERAL ASSEMBLY

  
  
  

 


 
SB1707 EnrolledLRB100 11322 MJP 21693 b

1    AN ACT concerning health.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, and 356z.26 of
16the Illinois Insurance Code. The program of health benefits
17must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c,
18and 370c.1 of the Illinois Insurance Code. The Department of
19Insurance shall enforce the requirements of this Section.
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on

 

 

SB1707 Enrolled- 2 -LRB100 11322 MJP 21693 b

1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
4100-138, eff. 8-18-17; revised 10-3-17.)
 
5    Section 10. The State Finance Act is amended by changing
6Section 5.872 as follows:
 
7    (30 ILCS 105/5.872)
8    Sec. 5.872. The Parity Advancement Education Fund.
9(Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
 
10    Section 15. The Counties Code is amended by changing
11Section 5-1069.3 as follows:
 
12    (55 ILCS 5/5-1069.3)
13    Sec. 5-1069.3. Required health benefits. If a county,
14including a home rule county, is a self-insurer for purposes of
15providing health insurance coverage for its employees, the
16coverage shall include coverage for the post-mastectomy care
17benefits required to be covered by a policy of accident and
18health insurance under Section 356t and the coverage required
19under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
20356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
21356z.14, 356z.15, 356z.22, and 356z.25, and 356z.26 of the
22Illinois Insurance Code. The coverage shall comply with

 

 

SB1707 Enrolled- 3 -LRB100 11322 MJP 21693 b

1Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
2Insurance Code. The Department of Insurance shall enforce the
3requirements of this Section. The requirement that health
4benefits be covered as provided in this Section is an exclusive
5power and function of the State and is a denial and limitation
6under Article VII, Section 6, subsection (h) of the Illinois
7Constitution. A home rule county to which this Section applies
8must comply with every provision of this Section.
9    Rulemaking authority to implement Public Act 95-1045, if
10any, is conditioned on the rules being adopted in accordance
11with all provisions of the Illinois Administrative Procedure
12Act and all rules and procedures of the Joint Committee on
13Administrative Rules; any purported rule not so adopted, for
14whatever reason, is unauthorized.
15(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
16100-138, eff. 8-18-17; revised 10-5-17.)
 
17    Section 20. The Illinois Municipal Code is amended by
18changing Section 10-4-2.3 as follows:
 
19    (65 ILCS 5/10-4-2.3)
20    Sec. 10-4-2.3. Required health benefits. If a
21municipality, including a home rule municipality, is a
22self-insurer for purposes of providing health insurance
23coverage for its employees, the coverage shall include coverage
24for the post-mastectomy care benefits required to be covered by

 

 

SB1707 Enrolled- 4 -LRB100 11322 MJP 21693 b

1a policy of accident and health insurance under Section 356t
2and the coverage required under Sections 356g, 356g.5,
3356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
4356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and
5356z.25, and 356z.26 of the Illinois Insurance Code. The
6coverage shall comply with Sections 155.22a, 355b, 356z.19, and
7370c of the Illinois Insurance Code. The Department of
8Insurance shall enforce the requirements of this Section. The
9requirement that health benefits be covered as provided in this
10is an exclusive power and function of the State and is a denial
11and limitation under Article VII, Section 6, subsection (h) of
12the Illinois Constitution. A home rule municipality to which
13this Section applies must comply with every provision of this
14Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
22100-138, eff. 8-18-17; revised 10-5-17.)
 
23    Section 25. The School Code is amended by changing Section
2410-22.3f as follows:
 

 

 

SB1707 Enrolled- 5 -LRB100 11322 MJP 21693 b

1    (105 ILCS 5/10-22.3f)
2    Sec. 10-22.3f. Required health benefits. Insurance
3protection and benefits for employees shall provide the
4post-mastectomy care benefits required to be covered by a
5policy of accident and health insurance under Section 356t and
6the coverage required under Sections 356g, 356g.5, 356g.5-1,
7356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
8356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, and 356z.26 of
9the Illinois Insurance Code. Insurance policies shall comply
10with Section 356z.19 of the Illinois Insurance Code. The
11coverage shall comply with Sections 155.22a, and 355b, and 370c
12of the Illinois Insurance Code. The Department of Insurance
13shall enforce the requirements of this Section.
14    Rulemaking authority to implement Public Act 95-1045, if
15any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
21revised 9-25-17.)
 
22    Section 30. The Illinois Insurance Code is amended by
23changing Sections 370c and 370c.1 as follows:
 
24    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)

 

 

SB1707 Enrolled- 6 -LRB100 11322 MJP 21693 b

1    Sec. 370c. Mental and emotional disorders.
2    (a)(1) On and after the effective date of this amendatory
3Act of the 100th General Assembly the effective date of this
4amendatory Act of the 97th General Assembly, every insurer that
5which amends, delivers, issues, or renews group accident and
6health policies providing coverage for hospital or medical
7treatment or services for illness on an expense-incurred basis
8shall provide offer to the applicant or group policyholder
9subject to the insurer's standards of insurability, coverage
10for reasonable and necessary treatment and services for mental,
11emotional, or nervous, or substance use disorders or
12conditions, other than serious mental illnesses as defined in
13item (2) of subsection (b), consistent with the parity
14requirements of Section 370c.1 of this Code.
15    (2) Each insured that is covered for mental, emotional,
16nervous, or substance use disorders or conditions shall be free
17to select the physician licensed to practice medicine in all
18its 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 Illinois
23Alcoholism and Other Drug Abuse and Dependency Act of his
24choice to treat such disorders, and the insurer shall pay the
25covered charges of such physician licensed to practice medicine
26in all its branches, licensed clinical psychologist, licensed

 

 

SB1707 Enrolled- 7 -LRB100 11322 MJP 21693 b

1clinical social worker, licensed clinical professional
2counselor, licensed marriage and family therapist, licensed
3speech-language pathologist, or other licensed or certified
4professional at a program licensed pursuant to the Illinois
5Alcoholism and Other Drug Abuse and Dependency Act up to the
6limits of coverage, provided (i) the disorder or condition
7treated is covered by the policy, and (ii) the physician,
8licensed psychologist, licensed clinical social worker,
9licensed clinical professional counselor, licensed marriage
10and family therapist, licensed speech-language pathologist, or
11other licensed or certified professional at a program licensed
12pursuant to the Illinois Alcoholism and Other Drug Abuse and
13Dependency Act is authorized to provide said services under the
14statutes of this State and in accordance with accepted
15principles of his profession.
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 Illinois
21Alcoholism and Other Drug Abuse and Dependency Act, those
22persons who may provide services to individuals shall do so
23after the licensed clinical social worker, licensed clinical
24professional counselor, licensed marriage and family
25therapist, licensed speech-language pathologist, or other
26licensed or certified professional at a program licensed

 

 

SB1707 Enrolled- 8 -LRB100 11322 MJP 21693 b

1pursuant to the Illinois Alcoholism and Other Drug Abuse and
2Dependency Act has informed the patient of the desirability of
3the patient conferring with the patient's primary care
4physician and the licensed clinical social worker, licensed
5clinical professional counselor, licensed marriage and family
6therapist, licensed speech-language pathologist, or other
7licensed or certified professional at a program licensed
8pursuant to the Illinois Alcoholism and Other Drug Abuse and
9Dependency Act has provided written notification to the
10patient's primary care physician, if any, that services are
11being provided to the patient. That notification may, however,
12be waived by the patient on a written form. Those forms shall
13be retained by the licensed clinical social worker, licensed
14clinical professional counselor, licensed marriage and family
15therapist, licensed speech-language pathologist, or other
16licensed or certified professional at a program licensed
17pursuant to the Illinois Alcoholism and Other Drug Abuse and
18Dependency Act for a period of not less than 5 years.
19    (4) "Mental, emotional, nervous, or substance use disorder
20or condition" means a condition or disorder that involves a
21mental health condition or substance use disorder that falls
22under any of the diagnostic categories listed in the mental and
23behavioral disorders chapter of the current edition of the
24International Classification of Disease or that is listed in
25the most recent version of the Diagnostic and Statistical
26Manual of Mental Disorders.

 

 

SB1707 Enrolled- 9 -LRB100 11322 MJP 21693 b

1    (b)(1) (Blank). An insurer that provides coverage for
2hospital or medical expenses under a group or individual policy
3of accident and health insurance or health care plan amended,
4delivered, issued, or renewed on or after the effective date of
5this amendatory Act of the 100th General Assembly shall provide
6coverage under the policy for treatment of serious mental
7illness and substance use disorders consistent with the parity
8requirements of Section 370c.1 of this Code. This subsection
9does not apply to any group policy of accident and health
10insurance or health care plan for any plan year of a small
11employer as defined in Section 5 of the Illinois Health
12Insurance Portability and Accountability Act.
13    (2) (Blank). "Serious mental illness" means the following
14psychiatric illnesses as defined in the most current edition of
15the Diagnostic and Statistical Manual (DSM) published by the
16American Psychiatric Association:
17        (A) schizophrenia;
18        (B) paranoid and other psychotic disorders;
19        (C) bipolar disorders (hypomanic, manic, depressive,
20    and mixed);
21        (D) major depressive disorders (single episode or
22    recurrent);
23        (E) schizoaffective disorders (bipolar or depressive);
24        (F) pervasive developmental disorders;
25        (G) obsessive-compulsive disorders;
26        (H) depression in childhood and adolescence;

 

 

SB1707 Enrolled- 10 -LRB100 11322 MJP 21693 b

1        (I) panic disorder;
2        (J) post-traumatic stress disorders (acute, chronic,
3    or with delayed onset); and
4        (K) eating disorders, including, but not limited to,
5    anorexia nervosa, bulimia nervosa, pica, rumination
6    disorder, avoidant/restrictive food intake disorder, other
7    specified feeding or eating disorder (OSFED), and any other
8    eating disorder contained in the most recent version of the
9    Diagnostic and Statistical Manual of Mental Disorders
10    published by the American Psychiatric Association.
11    (2.5) (Blank). "Substance use disorder" means the
12following mental disorders as defined in the most current
13edition of the Diagnostic and Statistical Manual (DSM)
14published by the American Psychiatric Association:
15        (A) substance abuse disorders;
16        (B) substance dependence disorders; and
17        (C) substance induced disorders.
18    (3) Unless otherwise prohibited by federal law and
19consistent with the parity requirements of Section 370c.1 of
20this Code, the reimbursing insurer that amends, delivers,
21issues, or renews a group or individual policy of accident and
22health insurance, a qualified health plan offered through the
23health insurance marketplace, or , a provider of treatment of
24mental, emotional, nervous, serious mental illness or
25substance use disorders or conditions disorder shall furnish
26medical records or other necessary data that substantiate that

 

 

SB1707 Enrolled- 11 -LRB100 11322 MJP 21693 b

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

 

 

SB1707 Enrolled- 12 -LRB100 11322 MJP 21693 b

1Addiction Medicine. No additional criteria may be used to make
2medical necessity determinations for substance use disorders.
3    (4) A group health benefit plan amended, delivered, issued,
4or renewed on or after the effective date of this amendatory
5Act of the 100th General Assembly or an individual policy of
6accident and health insurance or a qualified health plan
7offered through the health insurance marketplace amended,
8delivered, issued, or renewed on or after the effective date of
9this amendatory Act of the 100th General Assembly the effective
10date of this amendatory Act of the 97th General Assembly:
11        (A) shall provide coverage based upon medical
12    necessity for the treatment of a mental, emotional,
13    nervous, or mental illness and substance use disorder or
14    condition disorders consistent with the parity
15    requirements of Section 370c.1 of this Code; provided,
16    however, that in each calendar year coverage shall not be
17    less than the following:
18            (i) 45 days of inpatient treatment; and
19            (ii) beginning on June 26, 2006 (the effective date
20        of Public Act 94-921), 60 visits for outpatient
21        treatment including group and individual outpatient
22        treatment; and
23            (iii) for plans or policies delivered, issued for
24        delivery, renewed, or modified after January 1, 2007
25        (the effective date of Public Act 94-906), 20
26        additional outpatient visits for speech therapy for

 

 

SB1707 Enrolled- 13 -LRB100 11322 MJP 21693 b

1        treatment of pervasive developmental disorders that
2        will be in addition to speech therapy provided pursuant
3        to item (ii) of this subparagraph (A); and
4        (B) may not include a lifetime limit on the number of
5    days of inpatient treatment or the number of outpatient
6    visits covered under the plan.
7        (C) (Blank).
8    (5) An issuer of a group health benefit plan or an
9individual policy of accident and health insurance or a
10qualified health plan offered through the health insurance
11marketplace may not count toward the number of outpatient
12visits required to be covered under this Section an outpatient
13visit for the purpose of medication management and shall cover
14the outpatient visits under the same terms and conditions as it
15covers outpatient visits for the treatment of physical illness.
16    (5.5) An individual or group health benefit plan amended,
17delivered, issued, or renewed on or after the effective date of
18this amendatory Act of the 99th General Assembly shall offer
19coverage for medically necessary acute treatment services and
20medically necessary clinical stabilization services. The
21treating provider shall base all treatment recommendations and
22the health benefit plan shall base all medical necessity
23determinations for substance use disorders in accordance with
24the most current edition of the Treatment Criteria for
25Addictive, Substance-Related, and Co-Occurring Conditions
26established by the American Society of Addiction Medicine

 

 

SB1707 Enrolled- 14 -LRB100 11322 MJP 21693 b

1Patient Placement Criteria. The treating provider shall base
2all treatment recommendations and the health benefit plan shall
3base all medical necessity determinations for
4medication-assisted treatment in accordance with the most
5current Treatment Criteria for Addictive, Substance-Related,
6and Co-Occurring Conditions established by the American
7Society of Addiction Medicine.
8    As used in this subsection:
9    "Acute treatment services" means 24-hour medically
10supervised addiction treatment that provides evaluation and
11withdrawal management and may include biopsychosocial
12assessment, individual and group counseling, psychoeducational
13groups, and discharge planning.
14    "Clinical stabilization services" means 24-hour treatment,
15usually following acute treatment services for substance
16abuse, which may include intensive education and counseling
17regarding the nature of addiction and its consequences, relapse
18prevention, outreach to families and significant others, and
19aftercare planning for individuals beginning to engage in
20recovery from addiction.
21    (6) An issuer of a group health benefit plan may provide or
22offer coverage required under this Section through a managed
23care plan.
24    (6.5) An individual or group health benefit plan amended,
25delivered, issued, or renewed on or after the effective date of
26this amendatory Act of the 100th General Assembly:

 

 

SB1707 Enrolled- 15 -LRB100 11322 MJP 21693 b

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

 

 

SB1707 Enrolled- 16 -LRB100 11322 MJP 21693 b

1        (D) shall not exclude coverage for a prescription
2    medication approved by the United States Food and Drug
3    Administration for the treatment of substance use
4    disorders and any associated counseling or wraparound
5    services on the grounds that such medications and services
6    were court ordered.
7    (7) (Blank).
8    (8) (Blank).
9    (9) With respect to all mental, emotional, nervous, or
10substance use disorders or conditions, coverage for inpatient
11treatment shall include coverage for treatment in a residential
12treatment center certified or licensed by the Department of
13Public Health or the Department of Human Services.
14    (c) This Section shall not be interpreted to require
15coverage for speech therapy or other habilitative services for
16those individuals covered under Section 356z.15 of this Code.
17    (d) With respect to a group or individual policy of
18accident and health insurance or a qualified health plan
19offered through the health insurance marketplace, the
20Department and, with respect to medical assistance, the
21Department of Healthcare and Family Services shall each enforce
22the requirements of this Section and Sections 356z.23 and
23370c.1 of this Code, the Paul Wellstone and Pete Domenici
24Mental Health Parity and Addiction Equity Act of 2008, 42
25U.S.C. 18031(j), and any amendments to, and federal guidance or
26regulations issued under, those Acts, including, but not

 

 

SB1707 Enrolled- 17 -LRB100 11322 MJP 21693 b

1limited to, final regulations issued under the Paul Wellstone
2and Pete Domenici Mental Health Parity and Addiction Equity Act
3of 2008 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.
7Specifically, the Department and the Department of Healthcare
8and Family Services shall take action:
9        (1) proactively ensuring compliance by individual and
10    group policies, including by requiring that insurers
11    submit comparative analyses, as set forth in paragraph (6)
12    of subsection (k) of Section 370c.1, demonstrating how they
13    design and apply nonquantitative treatment limitations,
14    both as written and in operation, for mental, emotional,
15    nervous, or substance use disorder or condition benefits as
16    compared to how they design and apply nonquantitative
17    treatment limitations, as written and in operation, for
18    medical and surgical benefits;
19        (2) evaluating all consumer or provider complaints
20    regarding mental, emotional, nervous, or substance use
21    disorder or condition coverage for possible parity
22    violations;
23        (3) performing parity compliance market conduct
24    examinations or, in the case of the Department of
25    Healthcare and Family Services, parity compliance audits
26    of individual and group plans and policies, including, but

 

 

SB1707 Enrolled- 18 -LRB100 11322 MJP 21693 b

1    not limited to, reviews of:
2            (A) nonquantitative treatment limitations,
3        including, but not limited to, prior authorization
4        requirements, concurrent review, retrospective review,
5        step therapy, network admission standards,
6        reimbursement rates, and geographic restrictions;
7            (B) denials of authorization, payment, and
8        coverage; and
9            (C) other specific criteria as may be determined by
10        the Department.
11    The findings and the conclusions of the parity compliance
12market conduct examinations and audits shall be made public.
13    The Director may adopt rules to effectuate any provisions
14of the Paul Wellstone and Pete Domenici Mental Health Parity
15and Addiction Equity Act of 2008 that relate to the business of
16insurance.
17    (d) The Department shall enforce the requirements of State
18and federal parity law, which includes ensuring compliance by
19individual and group policies; detecting violations of the law
20by individual and group policies proactively monitoring
21discriminatory practices; accepting, evaluating, and
22responding to complaints regarding such violations; and
23ensuring violations are appropriately remedied and deterred.
24    (e) Availability of plan information.
25        (1) The criteria for medical necessity determinations
26    made under a group health plan, an individual policy of

 

 

SB1707 Enrolled- 19 -LRB100 11322 MJP 21693 b

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

 

 

SB1707 Enrolled- 20 -LRB100 11322 MJP 21693 b

1for a resident of this State; and (2) State employee health
2plans.
3(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
 
4    (215 ILCS 5/370c.1)
5    Sec. 370c.1. Mental, emotional, nervous, or substance use
6disorder or condition health and addiction parity.
7    (a) On and after the effective date of this amendatory Act
8of the 99th General Assembly, every insurer that amends,
9delivers, issues, or renews a group or individual policy of
10accident and health insurance or a qualified health plan
11offered through the Health Insurance Marketplace in this State
12providing coverage for hospital or medical treatment and for
13the treatment of mental, emotional, nervous, or substance use
14disorders or conditions shall ensure that:
15        (1) the financial requirements applicable to such
16    mental, emotional, nervous, or substance use disorder or
17    condition benefits are no more restrictive than the
18    predominant financial requirements applied to
19    substantially all hospital and medical benefits covered by
20    the policy and that there are no separate cost-sharing
21    requirements that are applicable only with respect to
22    mental, emotional, nervous, or substance use disorder or
23    condition benefits; and
24        (2) the treatment limitations applicable to such
25    mental, emotional, nervous, or substance use disorder or

 

 

SB1707 Enrolled- 21 -LRB100 11322 MJP 21693 b

1    condition benefits are no more restrictive than the
2    predominant treatment limitations applied to substantially
3    all hospital and medical benefits covered by the policy and
4    that there are no separate treatment limitations that are
5    applicable only with respect to mental, emotional,
6    nervous, or substance use disorder or condition benefits.
7    (b) The following provisions shall apply concerning
8aggregate lifetime limits:
9        (1) In the case of a group or individual policy of
10    accident and health insurance or a qualified health plan
11    offered through the Health Insurance Marketplace amended,
12    delivered, issued, or renewed in this State on or after the
13    effective date of this amendatory Act of the 99th General
14    Assembly that provides coverage for hospital or medical
15    treatment and for the treatment of mental, emotional,
16    nervous, or substance use disorders or conditions the
17    following provisions shall apply:
18            (A) if the policy does not include an aggregate
19        lifetime limit on substantially all hospital and
20        medical benefits, then the policy may not impose any
21        aggregate lifetime limit on mental, emotional,
22        nervous, or substance use disorder or condition
23        benefits; or
24            (B) if the policy includes an aggregate lifetime
25        limit on substantially all hospital and medical
26        benefits (in this subsection referred to as the

 

 

SB1707 Enrolled- 22 -LRB100 11322 MJP 21693 b

1        "applicable lifetime limit"), then the policy shall
2        either:
3                (i) apply the applicable lifetime limit both
4            to the hospital and medical benefits to which it
5            otherwise would apply and to mental, emotional,
6            nervous, or substance use disorder or condition
7            benefits and not distinguish in the application of
8            the limit between the hospital and medical
9            benefits and mental, emotional, nervous, or
10            substance use disorder or condition benefits; or
11                (ii) not include any aggregate lifetime limit
12            on mental, emotional, nervous, or substance use
13            disorder or condition benefits that is less than
14            the applicable lifetime limit.
15        (2) In the case of a policy that is not described in
16    paragraph (1) of subsection (b) of this Section and that
17    includes no or different aggregate lifetime limits on
18    different categories of hospital and medical benefits, the
19    Director shall establish rules under which subparagraph
20    (B) of paragraph (1) of subsection (b) of this Section is
21    applied to such policy with respect to mental, emotional,
22    nervous, or substance use disorder or condition benefits by
23    substituting for the applicable lifetime limit an average
24    aggregate lifetime limit that is computed taking into
25    account the weighted average of the aggregate lifetime
26    limits applicable to such categories.

 

 

SB1707 Enrolled- 23 -LRB100 11322 MJP 21693 b

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

 

 

SB1707 Enrolled- 24 -LRB100 11322 MJP 21693 b

1            benefits and mental, emotional, nervous, or
2            substance use disorder or condition benefits; or
3                (ii) not include any annual limit on mental,
4            emotional, nervous, or substance use disorder or
5            condition benefits that is less than the
6            applicable annual limit.
7        (2) In the case of a policy that is not described in
8    paragraph (1) of subsection (c) of this Section and that
9    includes no or different annual limits on different
10    categories of hospital and medical benefits, the Director
11    shall establish rules under which subparagraph (B) of
12    paragraph (1) of subsection (c) of this Section is applied
13    to such policy with respect to mental, emotional, nervous,
14    or substance use disorder or condition benefits by
15    substituting for the applicable annual limit an average
16    annual limit that is computed taking into account the
17    weighted average of the annual limits applicable to such
18    categories.
19    (d) With respect to mental, emotional, nervous, or
20substance use disorders or conditions, an insurer shall use
21policies and procedures for the election and placement of
22mental, emotional, nervous, or substance use disorder or
23condition substance abuse treatment drugs on their formulary
24that are no less favorable to the insured as those policies and
25procedures the insurer uses for the selection and placement of
26other drugs for medical or surgical conditions and shall follow

 

 

SB1707 Enrolled- 25 -LRB100 11322 MJP 21693 b

1the expedited coverage determination requirements for
2substance abuse treatment drugs set forth in Section 45.2 of
3the Managed Care Reform and Patient Rights Act.
4    (e) This Section shall be interpreted in a manner
5consistent with all applicable federal parity regulations
6including, but not limited to, the Paul Wellstone and Pete
7Domenici Mental Health Parity and Addiction Equity Act of 2008,
8final regulations issued under the Paul Wellstone and Pete
9Domenici Mental Health Parity and Addiction Equity Act of 2008
10and final regulations applying the Paul Wellstone and Pete
11Domenici Mental Health Parity and Addiction Equity Act of 2008
12to Medicaid managed care organizations, the Children's Health
13Insurance Program, and alternative benefit plans at 78 FR
1468240.
15    (f) The provisions of subsections (b) and (c) of this
16Section shall not be interpreted to allow the use of lifetime
17or annual limits otherwise prohibited by State or federal law.
18    (g) As used in this Section:
19    "Financial requirement" includes deductibles, copayments,
20coinsurance, and out-of-pocket maximums, but does not include
21an aggregate lifetime limit or an annual limit subject to
22subsections (b) and (c).
23    "Mental, emotional, nervous, or substance use disorder or
24condition" means a condition or disorder that involves a mental
25health condition or substance use disorder that falls under any
26of the diagnostic categories listed in the mental and

 

 

SB1707 Enrolled- 26 -LRB100 11322 MJP 21693 b

1behavioral disorders chapter of the current edition of the
2International Classification of Disease or that is listed in
3the most recent version of the Diagnostic and Statistical
4Manual of Mental Disorders.
5    "Treatment limitation" includes limits on benefits based
6on the frequency of treatment, number of visits, days of
7coverage, days in a waiting period, or other similar limits on
8the scope or duration of treatment. "Treatment limitation"
9includes both quantitative treatment limitations, which are
10expressed numerically (such as 50 outpatient visits per year),
11and nonquantitative treatment limitations, which otherwise
12limit the scope or duration of treatment. A permanent exclusion
13of all benefits for a particular condition or disorder shall
14not be considered a treatment limitation. "Nonquantitative
15treatment" means those limitations as described under federal
16regulations (26 CFR 54.9812-1). "Nonquantitative treatment
17limitations" include, but are not limited to, those limitations
18described under federal regulations 26 CFR 54.9812-1, 29 CFR
192590.712, and 45 CFR 146.136.
20    (h) The Department of Insurance shall implement the
21following education initiatives:
22        (1) By January 1, 2016, the Department shall develop a
23    plan for a Consumer Education Campaign on parity. The
24    Consumer Education Campaign shall focus its efforts
25    throughout the State and include trainings in the northern,
26    southern, and central regions of the State, as defined by

 

 

SB1707 Enrolled- 27 -LRB100 11322 MJP 21693 b

1    the Department, as well as each of the 5 managed care
2    regions of the State as identified by the Department of
3    Healthcare and Family Services. Under this Consumer
4    Education Campaign, the Department shall: (1) by January 1,
5    2017, provide at least one live training in each region on
6    parity for consumers and providers and one webinar training
7    to be posted on the Department website and (2) establish a
8    consumer hotline to assist consumers in navigating the
9    parity process by March 1, 2017 2016. By January 1, 2018
10    the Department shall issue a report to the General Assembly
11    on the success of the Consumer Education Campaign, which
12    shall indicate whether additional training is necessary or
13    would be recommended.
14        (2) The Department, in coordination with the
15    Department of Human Services and the Department of
16    Healthcare and Family Services, shall convene a working
17    group of health care insurance carriers, mental health
18    advocacy groups, substance abuse patient advocacy groups,
19    and mental health physician groups for the purpose of
20    discussing issues related to the treatment and coverage of
21    mental, emotional, nervous, or substance use abuse
22    disorders or conditions and compliance with parity
23    obligations under State and federal law. Compliance shall
24    be measured, tracked, and shared during the meetings of the
25    working group and mental illness. The working group shall
26    meet once before January 1, 2016 and shall meet

 

 

SB1707 Enrolled- 28 -LRB100 11322 MJP 21693 b

1    semiannually thereafter. The Department shall issue an
2    annual report to the General Assembly that includes a list
3    of the health care insurance carriers, mental health
4    advocacy groups, substance abuse patient advocacy groups,
5    and mental health physician groups that participated in the
6    working group meetings, details on the issues and topics
7    covered, and any legislative recommendations developed by
8    the working group.
9        (3) Not later than August 1 of each year, the
10    Department, in conjunction with the Department of
11    Healthcare and Family Services, shall issue a joint report
12    to the General Assembly and provide an educational
13    presentation to the General Assembly. The report and
14    presentation shall:
15            (A) Cover the methodology the Departments use to
16        check for compliance with the federal Paul Wellstone
17        and Pete Domenici Mental Health Parity and Addiction
18        Equity Act of 2008, 42 U.S.C. 18031(j), and any federal
19        regulations or guidance relating to the compliance and
20        oversight of the federal Paul Wellstone and Pete
21        Domenici Mental Health Parity and Addiction Equity Act
22        of 2008 and 42 U.S.C. 18031(j).
23            (B) Cover the methodology the Departments use to
24        check for compliance with this Section and Sections
25        356z.23 and 370c of this Code.
26            (C) Identify market conduct examinations or, in

 

 

SB1707 Enrolled- 29 -LRB100 11322 MJP 21693 b

1        the case of the Department of Healthcare and Family
2        Services, audits conducted or completed during the
3        preceding 12-month period regarding compliance with
4        parity in mental, emotional, nervous, and substance
5        use disorder or condition benefits under State and
6        federal laws and summarize the results of such market
7        conduct examinations and audits. This shall include:
8                (i) the number of market conduct examinations
9            and audits initiated and completed;
10                (ii) the benefit classifications examined by
11            each market conduct examination and audit;
12                (iii) the subject matter of each market
13            conduct examination and audit, including
14            quantitative and nonquantitative treatment
15            limitations; and
16                (iv) a summary of the basis for the final
17            decision rendered in each market conduct
18            examination and audit.
19            Individually identifiable information shall be
20        excluded from the reports consistent with federal
21        privacy protections.
22            (D) Detail any educational or corrective actions
23        the Departments have taken to ensure compliance with
24        the federal Paul Wellstone and Pete Domenici Mental
25        Health Parity and Addiction Equity Act of 2008, 42
26        U.S.C. 18031(j), this Section, and Sections 356z.23

 

 

SB1707 Enrolled- 30 -LRB100 11322 MJP 21693 b

1        and 370c of this Code.
2            (E) The report must be written in non-technical,
3        readily understandable language and shall be made
4        available to the public by, among such other means as
5        the Departments find appropriate, posting the report
6        on the Departments' websites.
7    (i) The Parity Advancement Education Fund is created as a
8special fund in the State treasury. Moneys from fines and
9penalties collected from insurers for violations of this
10Section shall be deposited into the Fund. Moneys deposited into
11the Fund for appropriation by the General Assembly to the
12Department of Insurance shall be used for the purpose of
13providing financial support of the Consumer Education
14Campaign, parity compliance advocacy, and other initiatives
15that support parity implementation and enforcement on behalf of
16consumers.
17    (j) The Department of Insurance and the Department of
18Healthcare and Family Services shall convene and provide
19technical support to a workgroup of 11 members that shall be
20comprised of 3 mental health parity experts recommended by an
21organization advocating on behalf of mental health parity
22appointed by the President of the Senate; 3 behavioral health
23providers recommended by an organization that represents
24behavioral health providers appointed by the Speaker of the
25House of Representatives; 2 representing Medicaid managed care
26organizations recommended by an organization that represents

 

 

SB1707 Enrolled- 31 -LRB100 11322 MJP 21693 b

1Medicaid managed care plans appointed by the Minority Leader of
2the House of Representatives; 2 representing commercial
3insurers recommended by an organization that represents
4insurers appointed by the Minority Leader of the Senate; and a
5representative of an organization that represents Medicaid
6managed care plans appointed by the Governor.
7    The workgroup shall provide recommendations to the General
8Assembly on health plan data reporting requirements that
9separately break out data on mental, emotional, nervous, or
10substance use disorder or condition benefits and data on other
11medical benefits, including physical health and related health
12services no later than December 31, 2019. The recommendations
13to the General Assembly shall be filed with the Clerk of the
14House of Representatives and the Secretary of the Senate in
15electronic form only, in the manner that the Clerk and the
16Secretary shall direct. This workgroup shall take into account
17federal requirements and recommendations on mental health
18parity reporting for the Medicaid program. This workgroup shall
19also develop the format and provide any needed definitions for
20reporting requirements in subsection (k). The research and
21evaluation of the working group shall include, but not be
22limited to:
23        (1) claims denials due to benefit limits, if
24    applicable;
25        (2) administrative denials for no prior authorization;
26        (3) denials due to not meeting medical necessity;

 

 

SB1707 Enrolled- 32 -LRB100 11322 MJP 21693 b

1        (4) denials that went to external review and whether
2    they were upheld or overturned for medical necessity;
3        (5) out-of-network claims;
4        (6) emergency care claims;
5        (7) network directory providers in the outpatient
6    benefits classification who filed no claims in the last 6
7    months, if applicable;
8        (8) the impact of existing and pertinent limitations
9    and restrictions related to approved services, licensed
10    providers, reimbursement levels, and reimbursement
11    methodologies within the Division of Mental Health, the
12    Division of Substance Use Prevention and Recovery
13    programs, the Department of Healthcare and Family
14    Services, and, to the extent possible, federal regulations
15    and law; and
16        (9) when reporting and publishing should begin.
17    Representatives from the Department of Healthcare and
18Family Services, representatives from the Division of Mental
19Health, and representatives from the Division of Substance Use
20Prevention and Recovery shall provide technical advice to the
21workgroup.
22    (k) An insurer that amends, delivers, issues, or renews a
23group or individual policy of accident and health insurance or
24a qualified health plan offered through the health insurance
25marketplace in this State providing coverage for hospital or
26medical treatment and for the treatment of mental, emotional,

 

 

SB1707 Enrolled- 33 -LRB100 11322 MJP 21693 b

1nervous, or substance use disorders or conditions shall submit
2an annual report, the format and definitions for which will be
3developed by the workgroup in subsection (j), to the
4Department, or, with respect to medical assistance, the
5Department of Healthcare and Family Services starting on or
6before July 1, 2020 that contains the following information
7separately for inpatient in-network benefits, inpatient
8out-of-network benefits, outpatient in-network benefits,
9outpatient out-of-network benefits, emergency care benefits,
10and prescription drug benefits in the case of accident and
11health insurance or qualified health plans, or inpatient,
12outpatient, emergency care, and prescription drug benefits in
13the case of medical assistance:
14        (1) A summary of the plan's pharmacy management
15    processes for mental, emotional, nervous, or substance use
16    disorder or condition benefits compared to those for other
17    medical benefits.
18        (2) A summary of the internal processes of review for
19    experimental benefits and unproven technology for mental,
20    emotional, nervous, or substance use disorder or condition
21    benefits and those for other medical benefits.
22        (3) A summary of how the plan's policies and procedures
23    for utilization management for mental, emotional, nervous,
24    or substance use disorder or condition benefits compare to
25    those for other medical benefits.
26        (4) A description of the process used to develop or

 

 

SB1707 Enrolled- 34 -LRB100 11322 MJP 21693 b

1    select the medical necessity criteria for mental,
2    emotional, nervous, or substance use disorder or condition
3    benefits and the process used to develop or select the
4    medical necessity criteria for medical and surgical
5    benefits.
6        (5) Identification of all nonquantitative treatment
7    limitations that are applied to both mental, emotional,
8    nervous, or substance use disorder or condition benefits
9    and medical and surgical benefits within each
10    classification of benefits.
11        (6) The results of an analysis that demonstrates that
12    for the medical necessity criteria described in
13    subparagraph (A) and for each nonquantitative treatment
14    limitation identified in subparagraph (B), as written and
15    in operation, the processes, strategies, evidentiary
16    standards, or other factors used in applying the medical
17    necessity criteria and each nonquantitative treatment
18    limitation to mental, emotional, nervous, or substance use
19    disorder or condition benefits within each classification
20    of benefits are comparable to, and are applied no more
21    stringently than, the processes, strategies, evidentiary
22    standards, or other factors used in applying the medical
23    necessity criteria and each nonquantitative treatment
24    limitation to medical and surgical benefits within the
25    corresponding classification of benefits; at a minimum,
26    the results of the analysis shall:

 

 

SB1707 Enrolled- 35 -LRB100 11322 MJP 21693 b

1            (A) identify the factors used to determine that a
2        nonquantitative treatment limitation applies to a
3        benefit, including factors that were considered but
4        rejected;
5            (B) identify and define the specific evidentiary
6        standards used to define the factors and any other
7        evidence relied upon in designing each nonquantitative
8        treatment limitation;
9            (C) provide the comparative analyses, including
10        the results of the analyses, performed to determine
11        that the processes and strategies used to design each
12        nonquantitative treatment limitation, as written, for
13        mental, emotional, nervous, or substance use disorder
14        or condition benefits are comparable to, and are
15        applied no more stringently than, the processes and
16        strategies used to design each nonquantitative
17        treatment limitation, as written, for medical and
18        surgical benefits;
19            (D) provide the comparative analyses, including
20        the results of the analyses, performed to determine
21        that the processes and strategies used to apply each
22        nonquantitative treatment limitation, in operation,
23        for mental, emotional, nervous, or substance use
24        disorder or condition benefits are comparable to, and
25        applied no more stringently than, the processes or
26        strategies used to apply each nonquantitative

 

 

SB1707 Enrolled- 36 -LRB100 11322 MJP 21693 b

1        treatment limitation, in operation, for medical and
2        surgical benefits; and
3            (E) disclose the specific findings and conclusions
4        reached by the insurer that the results of the analyses
5        described in subparagraphs (C) and (D) indicate that
6        the insurer is in compliance with this Section and the
7        Mental Health Parity and Addiction Equity Act of 2008
8        and its implementing regulations, which includes 42
9        CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any
10        other related federal regulations found in the Code of
11        Federal Regulations.
12        (7) Any other information necessary to clarify data
13    provided in accordance with this Section requested by the
14    Director, including information that may be proprietary or
15    have commercial value, under the requirements of Section 30
16    of the Viatical Settlements Act of 2009.
17    (l) An insurer that amends, delivers, issues, or renews a
18group or individual policy of accident and health insurance or
19a qualified health plan offered through the health insurance
20marketplace in this State providing coverage for hospital or
21medical treatment and for the treatment of mental, emotional,
22nervous, or substance use disorders or conditions on or after
23the effective date of this amendatory Act of the 100th General
24Assembly shall, in advance of the plan year, make available to
25the Department or, with respect to medical assistance, the
26Department of Healthcare and Family Services and to all plan

 

 

SB1707 Enrolled- 37 -LRB100 11322 MJP 21693 b

1participants and beneficiaries the information required in
2subparagraphs (C) through (E) of paragraph (6) of subsection
3(k). For plan participants and medical assistance
4beneficiaries, the information required in subparagraphs (C)
5through (E) of paragraph (6) of subsection (k) shall be made
6available on a publicly-available website whose web address is
7prominently displayed in plan and managed care organization
8informational and marketing materials.
9    (m) In conjunction with its compliance examination program
10conducted in accordance with the Illinois State Auditing Act,
11the Auditor General shall undertake a review of compliance by
12the Department and the Department of Healthcare and Family
13Services with Section 370c and this Section. Any findings
14resulting from the review conducted under this Section shall be
15included in the applicable State agency's compliance
16examination report. Each compliance examination report shall
17be issued in accordance with Section 3-14 of the Illinois State
18Auditing Act. A copy of each report shall also be delivered to
19the head of the applicable State agency and posted on the
20Auditor General's website.
21(Source: P.A. 99-480, eff. 9-9-15.)
 
22    Section 99. Effective date. This Act takes effect January
231, 2019.