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

HB2595eng 102ND GENERAL ASSEMBLY

  
  
  

 


 
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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 Section 370c 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 Engrossed- 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.

 

 

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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,

 

 

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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, condition, or its
21symptoms, including minimizing the progression of an illness,
22injury, condition, or its symptoms in a manner that is all of
23the following:
24        (1) in accordance with the generally accepted
25    standards of mental, emotional, nervous, or substance use
26    disorder or condition care;

 

 

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

 

 

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1health insurance marketplace in this State and Medicaid
2managed care organizations providing coverage for hospital or
3medical treatment on or after January 1, 2022 shall, pursuant
4to subsections (h) through (s), provide coverage for medically
5necessary treatment of mental, emotional, nervous, or
6substance use disorders or conditions.
7    (2) An insurer shall not set a specific limit on the
8duration of benefits or coverage of medically necessary
9treatment of mental, emotional, nervous, or substance use
10disorders or conditions or limit coverage only to alleviation
11of the insured's current symptoms; insurers shall base the
12duration of treatment on the insured's individual needs,
13including treating the insured's underlying mental, emotional,
14nervous, or substance use disorders or conditions and
15comorbidities.
16    (3) All medical necessity determinations made by the
17insurer concerning service intensity, level of care placement,
18continued stay, and transfer or discharge of insureds
19diagnosed with mental, emotional, nervous, or substance use
20disorders or conditions shall be conducted in accordance with
21the requirements of subsections (k) through (u).
22    (4) An insurer that authorizes a specific type of
23treatment by a provider pursuant to this Section shall not
24rescind or modify the authorization after that provider
25renders the health care service in good faith and pursuant to
26this authorization for any reason, including, but not limited

 

 

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1to, the insurer's subsequent cancellation or modification of
2the insured's or policyholder's contract, or the insured's or
3policyholder's eligibility. Nothing in this Section shall
4require the insurer to cover a treatment when the
5authorization was granted based on a material
6misrepresentation by the insured, the policyholder, or the
7provider. As used in this paragraph, "material" means a fact
8or situation that is not merely technical in nature and
9results in or could result in a substantial change in the
10situation.
11    (j) An insurer shall not limit benefits or coverage for
12medically necessary services on the basis that those services
13should be or could be covered by a public program, including,
14but not limited to, special education or an individualized
15education program, Medicaid, Medicare, Supplemental Security
16Income, or Social Security Disability Insurance, and shall not
17include or enforce a contract term that excludes otherwise
18covered benefits on the basis that those services should be or
19could be covered by a public program.
20    (k) An insurer shall base any medical necessity
21determination or the utilization review criteria that the
22insurer, and any entity acting on the insurer's behalf,
23applies to determine the medical necessity of health care
24services and benefits for the diagnosis, prevention, and
25treatment of mental, emotional, nervous, or substance use
26disorders or conditions on current generally accepted

 

 

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1standards of mental, emotional, nervous, or substance use
2disorder or condition care. All denials and appeals shall be
3reviewed by a professional with experience or expertise
4comparable to the provider requesting the authorization.
5    (l) In conducting utilization review of all covered health
6care services and benefits for the diagnosis, prevention, and
7treatment of mental, emotional, and nervous disorders or
8conditions in children, adolescents, and adults, an insurer
9shall exclusively apply without modification the criteria and
10guidelines set forth in the most recent version of the
11treatment criteria developed by an unaffiliated nonprofit
12professional association for the relevant clinical specialty.
13Pursuant to subsection (b), in conducting utilization review
14of all covered services and benefits for the diagnosis,
15prevention, and treatment of substance use disorders an
16insurer shall use the most recent edition of the patient
17placement criteria established by the American Society of
18Addiction Medicine.
19    (m) In conducting utilization review involving level of
20care placement decisions or any other patient care decisions
21that are within the scope of the sources specified in
22subsection (l), an insurer shall not apply different,
23additional, conflicting, or more restrictive utilization
24review criteria than the criteria and guidelines set forth in
25those sources. For all level of care placement decisions, the
26insurer shall authorize placement at the level of care

 

 

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1consistent with the assessment of the insured using the
2relevant criteria and guidelines as specified in subsection
3(l). If that level of placement is not available, the insurer
4shall authorize the next higher level of care. In the event of
5disagreement, the insurer shall provide full detail of its
6assessment using the relevant criteria and guidelines as
7specified in subsection (l) to the provider of the service.
8    This subsection does not prohibit an insurer from applying
9utilization review criteria that were developed in accordance
10with subsection (k) to health care services and benefits for
11mental, emotional, and nervous disorders or conditions that:
12        (1) are outside the scope of the criteria and
13    guidelines set forth in the sources specified in
14    subsection (l); or
15        (2) relate to advancements in technology or types of
16    care that are not covered in the most recent versions of
17    the sources specified in subsection (l).
18    (n) An insurer shall only engage applicable qualified
19providers in the treatment of mental, emotional, nervous, or
20substance use disorders or conditions or the appropriate
21subspecialty therein and who possess an active professional
22license or certificate, to review, approve, or deny services.
23    (o) This Section does not in any way limit the rights of a
24patient under the Medical Patient Rights Act.
25    (p) This Section does not in any way limit early and
26periodic screening, diagnostic, and treatment benefits as

 

 

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1defined under 42 U.S.C. 1396d(r).
2    (q) To ensure the proper use of the criteria described in
3subsection (l), every insurer shall do all of the following:
4        (1) Sponsor a formal education program by nonprofit
5    clinical specialty associations to educate the insurer's
6    staff, including any third parties contracted with the
7    insurer to review claims, conduct utilization reviews, or
8    make medical necessity determinations about the clinical
9    review criteria.
10        (2) Make the education program available to other
11    stakeholders, including the insurer's participating or
12    contracted providers and potential participants,
13    beneficiaries, or covered lives. The education program
14    must be provided, at minimum, on a quarterly basis,
15    in-person or digitally, or recordings of the education
16    program must be made available to the aforementioned
17    stakeholders.
18        (3) Provide, at no cost, the clinical review criteria
19    and any training material or resources to providers and
20    insured patients.
21        (4) Track, identify, and analyze how the clinical
22    review criteria are used to certify care, deny care, and
23    support the appeals process.
24        (5) Conduct interrater reliability testing to ensure
25    consistency in utilization review decision making that
26    covers how medical necessity decisions are made; this

 

 

HB2595 Engrossed- 32 -LRB102 10633 BMS 15962 b

1    assessment shall cover all aspects of utilization review
2    as defined in subsection (h).
3        (6) Run interrater reliability reports about how the
4    clinical guidelines are used in conjunction with the
5    utilization review process and parity compliance
6    activities.
7        (7) Achieve interrater reliability pass rates of at
8    least 90% and, if this threshold is not met, immediately
9    provide for the remediation of poor interrater reliability
10    and interrater reliability testing for all new staff
11    before they can conduct utilization review without
12    supervision.
13        (8) Submit to the Department of Insurance or, in the
14    case of Medicaid managed care organizations, the
15    Department of Healthcare and Family Services every year on
16    or before July 1 results of interrater reliability reports
17    and a summary of the remediation actions taken for those
18    with pass rates lower than 90%.
19    (r) This Section applies to all health care services and
20benefits for the diagnosis, prevention, and treatment of
21mental, emotional, nervous, or substance use disorders or
22conditions covered by an insurance policy, including
23prescription drugs.
24    (s) This Section applies to an insurer that amends,
25delivers, issues, or renews a group or individual policy of
26accident and health insurance or a qualified health plan

 

 

HB2595 Engrossed- 33 -LRB102 10633 BMS 15962 b

1offered through the health insurance marketplace in this State
2providing coverage for hospital or medical treatment and
3conducts utilization review as defined in this Section,
4including Medicaid managed care organizations, and any entity
5or contracting provider that performs utilization review or
6utilization management functions on an insurer's behalf.
7    (t) If the Director determines that an insurer has
8violated this Section, the Director may, after appropriate
9notice and opportunity for hearing, by order, assess a civil
10penalty between $1,000 and $5,000 for each violation. Moneys
11collected from penalties shall be deposited into the Parity
12Advancement Fund established in subsection (i) of Section
13370c.1.
14    (u) An insurer shall not adopt, impose, or enforce terms
15in its policies or provider agreements, in writing or in
16operation, that undermine, alter, or conflict with the
17requirements of this Section.
18    (v) The provisions of this Section are severable. If any
19provision of this Section or its application is held invalid,
20that invalidity shall not affect other provisions or
21applications that can be given effect without the invalid
22provision or application.
23(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
24100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
258-16-19; revised 9-20-19.)
 

 

 

HB2595 Engrossed- 34 -LRB102 10633 BMS 15962 b

1    Section 10. The Health Carrier External Review Act is
2amended by changing Sections 35 and 40 as follows:
 
3    (215 ILCS 180/35)
4    Sec. 35. Standard external review.
5    (a) Within 4 months after the date of receipt of a notice
6of an adverse determination or final adverse determination, a
7covered person or the covered person's authorized
8representative may file a request for an external review with
9the Director. Within one business day after the date of
10receipt of a request for external review, the Director shall
11send a copy of the request to the health carrier.
12    (b) Within 5 business days following the date of receipt
13of the external review request, the health carrier shall
14complete a preliminary review of the request to determine
15whether:
16        (1) the individual is or was a covered person in the
17    health benefit plan at the time the health care service
18    was requested or at the time the health care service was
19    provided;
20        (2) the health care service that is the subject of the
21    adverse determination or the final adverse determination
22    is a covered service under the covered person's health
23    benefit plan, but the health carrier has determined that
24    the health care service is not covered;
25        (3) the covered person has exhausted the health

 

 

HB2595 Engrossed- 35 -LRB102 10633 BMS 15962 b

1    carrier's internal appeal process unless the covered
2    person is not required to exhaust the health carrier's
3    internal appeal process pursuant to this Act;
4        (4) (blank); and
5        (5) the covered person has provided all the
6    information and forms required to process an external
7    review, as specified in this Act.
8    (c) Within one business day after completion of the
9preliminary review, the health carrier shall notify the
10Director and covered person and, if applicable, the covered
11person's authorized representative in writing whether the
12request is complete and eligible for external review. If the
13request:
14        (1) is not complete, the health carrier shall inform
15    the Director and covered person and, if applicable, the
16    covered person's authorized representative in writing and
17    include in the notice what information or materials are
18    required by this Act to make the request complete; or
19        (2) is not eligible for external review, the health
20    carrier shall inform the Director and covered person and,
21    if applicable, the covered person's authorized
22    representative in writing and include in the notice the
23    reasons for its ineligibility.
24    The Department may specify the form for the health
25carrier's notice of initial determination under this
26subsection (c) and any supporting information to be included

 

 

HB2595 Engrossed- 36 -LRB102 10633 BMS 15962 b

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

 

 

HB2595 Engrossed- 37 -LRB102 10633 BMS 15962 b

1    independent review organization; and
2        (2) notify in writing the covered person and, if
3    applicable, the covered person's authorized representative
4    of the request's eligibility and acceptance for external
5    review and the name of the independent review
6    organization.
7    The Director shall include in the notice provided to the
8covered person and, if applicable, the covered person's
9authorized representative a statement that the covered person
10or the covered person's authorized representative may, within
115 business days following the date of receipt of the notice
12provided pursuant to item (2) of this subsection (d), submit
13in writing to the assigned independent review organization
14additional information that the independent review
15organization shall consider when conducting the external
16review. The independent review organization is not required
17to, but may, accept and consider additional information
18submitted after 5 business days.
19    (e) 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    (f) Within 5 business days after the date of receipt of the
25notice provided pursuant to item (1) of subsection (d) of this
26Section, the health carrier or its designee utilization review

 

 

HB2595 Engrossed- 38 -LRB102 10633 BMS 15962 b

1organization shall provide to the assigned independent review
2organization the documents and any information considered in
3making the adverse determination or final adverse
4determination; in such cases, the following provisions shall
5apply:
6        (1) Except as provided in item (2) of this subsection
7    (f), failure by the health carrier or its utilization
8    review organization to provide the documents and
9    information within the specified time frame shall not
10    delay the conduct of the external review.
11        (2) If the health carrier or its utilization review
12    organization fails to provide the documents and
13    information within the specified time frame, the assigned
14    independent review organization may terminate the external
15    review and make a decision to reverse the adverse
16    determination or final adverse determination.
17        (3) Within one business day after making the decision
18    to terminate the external review and make a decision to
19    reverse the adverse determination or final adverse
20    determination under item (2) of this subsection (f), the
21    independent review organization shall notify the Director,
22    the health carrier, the covered person and, if applicable,
23    the covered person's authorized representative, of its
24    decision to reverse the adverse determination.
25    (g) Upon receipt of the information from the health
26carrier or its utilization review organization, the assigned

 

 

HB2595 Engrossed- 39 -LRB102 10633 BMS 15962 b

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

 

 

HB2595 Engrossed- 40 -LRB102 10633 BMS 15962 b

1        adverse determination, the health carrier shall notify
2        the Director, the covered person and, if applicable,
3        the covered person's authorized representative, and
4        the assigned independent review organization in
5        writing of its decision.
6            (B) Upon notice from the health carrier that the
7        health carrier has made a decision to reverse its
8        adverse determination or final adverse determination,
9        the assigned independent review organization shall
10        terminate the external review.
11    (i) In addition to the documents and information provided
12by the health carrier or its utilization review organization
13and the covered person and the covered person's authorized
14representative, if any, the independent review organization,
15to the extent the information or documents are available and
16the independent review organization considers them
17appropriate, shall consider the following in reaching a
18decision:
19        (1) the covered person's pertinent medical records;
20        (2) the covered person's health care provider's
21    recommendation;
22        (3) consulting reports from appropriate health care
23    providers and other documents submitted by the health
24    carrier or its designee utilization review organization,
25    the covered person, the covered person's authorized
26    representative, or the covered person's treating provider;

 

 

HB2595 Engrossed- 41 -LRB102 10633 BMS 15962 b

1        (4) the terms of coverage under the covered person's
2    health benefit plan with the health carrier to ensure that
3    the independent review organization's decision is not
4    contrary to the terms of coverage under the covered
5    person's health benefit plan with the health carrier,
6    unless the terms are inconsistent with applicable law;
7        (5) the most appropriate practice guidelines, which
8    shall include applicable evidence-based standards and may
9    include any other practice guidelines developed by the
10    federal government, national or professional medical
11    societies, boards, and associations;
12        (6) any applicable clinical review criteria developed
13    and used by the health carrier or its designee utilization
14    review organization;
15        (7) the opinion of the independent review
16    organization's clinical reviewer or reviewers after
17    considering items (1) through (6) of this subsection (i)
18    to the extent the information or documents are available
19    and the clinical reviewer or reviewers considers the
20    information or documents appropriate;
21        (8) (blank); and
22        (9) in the case of medically necessary determinations
23    for substance use disorders, the patient placement
24    criteria established by the American Society of Addiction
25    Medicine.
26    (i-5) For an adverse determination or final adverse

 

 

HB2595 Engrossed- 42 -LRB102 10633 BMS 15962 b

1determination involving mental, emotional, nervous, or
2substance use disorders or conditions, the independent review
3organization shall:
4        (1) consider the documents and information as set
5    forth in subsection (i), except that all practice
6    guidelines and clinical review criteria must be consistent
7    with the requirements set forth in Section 370c of the
8    Illinois Insurance Code; and
9        (2) make its decision, pursuant to subsection (j),
10    whether to uphold or reverse the adverse determination or
11    final adverse determination based on whether the service
12    constitutes medically necessary treatment of a mental,
13    emotional, nervous, or substance use disorders or
14    condition as defined in Section 370c of the Illinois
15    Insurance Code.
16    (j) Within 5 days after the date of receipt of all
17necessary information, but in no event more than 45 days after
18the date of receipt of the request for an external review, the
19assigned independent review organization shall provide written
20notice of its decision to uphold or reverse the adverse
21determination or the final adverse determination to the
22Director, the health carrier, the covered person, and, if
23applicable, the covered person's authorized representative. In
24reaching a decision, the assigned independent review
25organization is not bound by any claim determinations reached
26prior to the submission of information to the independent

 

 

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1review organization. In such cases, the following provisions
2shall apply:
3        (1) The independent review organization shall include
4    in the notice:
5            (A) a general description of the reason for the
6        request for external review;
7            (B) the date the independent review organization
8        received the assignment from the Director to conduct
9        the external review;
10            (C) the time period during which the external
11        review was conducted;
12            (D) references to the evidence or documentation,
13        including the evidence-based standards, considered in
14        reaching its decision;
15            (E) the date of its decision;
16            (F) the principal reason or reasons for its
17        decision, including what applicable, if any,
18        evidence-based standards that were a basis for its
19        decision; and
20            (G) the rationale for its decision.
21        (2) (Blank).
22        (3) (Blank).
23        (4) Upon receipt of a notice of a decision reversing
24    the adverse determination or final adverse determination,
25    the health carrier immediately shall approve the coverage
26    that was the subject of the adverse determination or final

 

 

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1    adverse determination.
2(Source: P.A. 99-480, eff. 9-9-15.)
 
3    (215 ILCS 180/40)
4    Sec. 40. Expedited external review.
5    (a) A covered person or a covered person's authorized
6representative may file a request for an expedited external
7review with the Director either orally or in writing:
8        (1) immediately after the date of receipt of a notice
9    prior to a final adverse determination as provided by
10    subsection (b) of Section 20 of this Act;
11        (2) immediately after the date of receipt of a notice
12    upon final adverse determination as provided by subsection
13    (c) of Section 20 of this Act; or
14        (3) if a health carrier fails to provide a decision on
15    request for an expedited internal appeal within 48 hours
16    as provided by item (2) of Section 30 of this Act.
17    (b) Upon receipt of a request for an expedited external
18review, the Director shall immediately send a copy of the
19request to the health carrier. Immediately upon receipt of the
20request for an expedited external review, the health carrier
21shall determine whether the request meets the reviewability
22requirements set forth in subsection (b) of Section 35. In
23such cases, the following provisions shall apply:
24        (1) The health carrier shall immediately notify the
25    Director, the covered person, and, if applicable, the

 

 

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1    covered person's authorized representative of its
2    eligibility determination.
3        (2) The notice of initial determination shall include
4    a statement informing the covered person and, if
5    applicable, the covered person's authorized representative
6    that a health carrier's initial determination that an
7    external review request is ineligible for review may be
8    appealed to the Director.
9        (3) The Director may determine that a request is
10    eligible for expedited external review notwithstanding a
11    health carrier's initial determination that the request is
12    ineligible and require that it be referred for external
13    review.
14        (4) In making a determination under item (3) of this
15    subsection (b), the Director's decision shall be made in
16    accordance with the terms of the covered person's health
17    benefit plan, unless such terms are inconsistent with
18    applicable law, and shall be subject to all applicable
19    provisions of this Act.
20        (5) The Director may specify the form for the health
21    carrier's notice of initial determination under this
22    subsection (b) and any supporting information to be
23    included in the notice.
24    (c) Upon receipt of the notice that the request meets the
25reviewability requirements, the Director shall immediately
26assign an independent review organization from the list of

 

 

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1approved independent review organizations compiled and
2maintained by the Director to conduct the expedited review. In
3such cases, the following provisions shall apply:
4        (1) The assignment of an approved independent review
5    organization to conduct an external review in accordance
6    with this Section shall be made from those approved
7    independent review organizations qualified to conduct
8    external review as required by Sections 50 and 55 of this
9    Act.
10        (2) The Director shall immediately notify the health
11    carrier of the name of the assigned independent review
12    organization. Immediately upon receipt from the Director
13    of the name of the independent review organization
14    assigned to conduct the external review, but in no case
15    more than 24 hours after receiving such notice, the health
16    carrier or its designee utilization review organization
17    shall provide or transmit all necessary documents and
18    information considered in making the adverse determination
19    or final adverse determination to the assigned independent
20    review organization electronically or by telephone or
21    facsimile or any other available expeditious method.
22        (3) If the health carrier or its utilization review
23    organization fails to provide the documents and
24    information within the specified timeframe, the assigned
25    independent review organization may terminate the external
26    review and make a decision to reverse the adverse

 

 

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1    determination or final adverse determination.
2        (4) Within one business day after making the decision
3    to terminate the external review and make a decision to
4    reverse the adverse determination or final adverse
5    determination under item (3) of this subsection (c), the
6    independent review organization shall notify the Director,
7    the health carrier, the covered person, and, if
8    applicable, the covered person's authorized representative
9    of its decision to reverse the adverse determination or
10    final adverse determination.
11    (d) In addition to the documents and information provided
12by the health carrier or its utilization review organization
13and any documents and information provided by the covered
14person and the covered person's authorized representative, the
15independent review organization, to the extent the information
16or documents are available and the independent review
17organization considers them appropriate, shall consider
18information as required by subsection (i) of Section 35 of
19this Act in reaching a decision.
20    (d-5) For expedited external reviews involving mental,
21emotional, nervous, or substance use disorders or conditions,
22the independent review organization shall consider documents
23and information and shall make a decision to uphold or reverse
24the adverse determination or final adverse determination
25pursuant to subsection (i-5) of Section 35.
26    (e) As expeditiously as the covered person's medical

 

 

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1condition or circumstances requires, but in no event more than
272 hours after the date of receipt of the request for an
3expedited external review, the assigned independent review
4organization shall:
5        (1) make a decision to uphold or reverse the final
6    adverse determination; and
7        (2) notify the Director, the health carrier, the
8    covered person, the covered person's health care provider,
9    and, if applicable, the covered person's authorized
10    representative, of the decision.
11    (f) In reaching a decision, the assigned independent
12review organization is not bound by any decisions or
13conclusions reached during the health carrier's utilization
14review process or the health carrier's internal appeal
15process.
16    (g) Upon receipt of notice of a decision reversing the
17adverse determination or final adverse determination, the
18health carrier shall immediately approve the coverage that was
19the subject of the adverse determination or final adverse
20determination.
21    (h) If the notice provided pursuant to subsection (e) of
22this Section was not in writing, then within 48 hours after the
23date of providing that notice, the assigned independent review
24organization shall provide written confirmation of the
25decision to the Director, the health carrier, the covered
26person, and, if applicable, the covered person's authorized

 

 

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1representative including the information set forth in
2subsection (j) of Section 35 of this Act as applicable.
3    (i) An expedited external review may not be provided for
4retrospective adverse or final adverse determinations.
5    (j) The assignment by the Director of an approved
6independent review organization to conduct an external review
7in accordance with this Section shall be done on a random basis
8among those independent review organizations approved by the
9Director pursuant to this Act.
10(Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11;
1197-574, eff. 8-26-11.)
 
12    Section 99. Effective date. This Act takes effect January
131, 2022.