Full Text of SB0682 100th General Assembly
SB0682enr 100TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. This Act may be referred to as the Emergency | 5 | | Opioid and Addiction Treatment Access Act. | 6 | | Section 3. Findings. The General Assembly finds and | 7 | | declares the following: | 8 | | (1) The opioid epidemic is the most significant public | 9 | | health and public safety crisis in Illinois. | 10 | | (2) Opioid overdoses have killed nearly 11,000 people | 11 | | since 2008 and have now become the leading cause of death | 12 | | nationwide for people under the age of 50. | 13 | | (3) The opioid epidemic has devastated both rural and | 14 | | urban Illinois residents. Families have lost their loved | 15 | | ones to drug overdoses. Incidence of suicide are on the | 16 | | rise. Illinois' criminal justice system is flooded with | 17 | | individuals with critical substance use disorder treatment | 18 | | needs. | 19 | | (4) Speeding access to treatments will ensure that | 20 | | Illinois residents suffering from a substance abuse crisis | 21 | | will obtain the services they need. | 22 | | Section 5. The Illinois Insurance Code is amended by |
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| 1 | | changing Section 370c as follows:
| 2 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 3 | | Sec. 370c. Mental and emotional disorders.
| 4 | | (a)(1) On and after the effective date of this amendatory | 5 | | Act of the 97th General Assembly,
every insurer which amends, | 6 | | delivers, issues, or renews
group accident and health policies | 7 | | providing coverage for hospital or medical treatment or
| 8 | | services for illness on an expense-incurred basis shall offer | 9 | | to the
applicant or group policyholder subject to the insurer's | 10 | | standards of
insurability, coverage for reasonable and | 11 | | necessary treatment and services
for mental, emotional or | 12 | | nervous disorders or conditions, other than serious
mental | 13 | | illnesses as defined in item (2) of subsection (b), consistent | 14 | | with the parity requirements of Section 370c.1 of this Code.
| 15 | | (2) Each insured that is covered for mental, emotional, | 16 | | nervous, or substance use
disorders or conditions shall be free | 17 | | to select the physician licensed to
practice medicine in all | 18 | | its branches, licensed clinical psychologist,
licensed | 19 | | clinical social worker, licensed clinical professional | 20 | | counselor, licensed marriage and family therapist, licensed | 21 | | speech-language pathologist, or other licensed or certified | 22 | | professional at a program licensed pursuant to the Illinois | 23 | | Alcoholism and Other Drug Abuse and Dependency Act of
his | 24 | | choice to treat such disorders, and
the insurer shall pay the | 25 | | covered charges of such physician licensed to
practice medicine |
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| 1 | | in all its branches, licensed clinical psychologist,
licensed | 2 | | clinical social worker, licensed clinical professional | 3 | | counselor, licensed marriage and family therapist, licensed | 4 | | speech-language pathologist, or other licensed or certified | 5 | | professional at a program licensed pursuant to the Illinois | 6 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the | 7 | | limits of coverage, provided (i)
the disorder or condition | 8 | | treated is covered by the policy, and (ii) the
physician, | 9 | | licensed psychologist, licensed clinical social worker, | 10 | | licensed
clinical professional counselor, licensed marriage | 11 | | and family therapist, licensed speech-language pathologist, or | 12 | | other licensed or certified professional at a program licensed | 13 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 14 | | Dependency Act is
authorized to provide said services under the | 15 | | statutes of this State and in
accordance with accepted | 16 | | principles of his profession.
| 17 | | (3) Insofar as this Section applies solely to licensed | 18 | | clinical social
workers, licensed clinical professional | 19 | | counselors, licensed marriage and family therapists, licensed | 20 | | speech-language pathologists, and other licensed or certified | 21 | | professionals at programs licensed pursuant to the Illinois | 22 | | Alcoholism and Other Drug Abuse and Dependency Act, those | 23 | | persons who may
provide services to individuals shall do so
| 24 | | after the licensed clinical social worker, licensed clinical | 25 | | professional
counselor, licensed marriage and family | 26 | | therapist, licensed speech-language pathologist, or other |
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| 1 | | licensed or certified professional at a program licensed | 2 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 3 | | Dependency Act has informed the patient of the
desirability of | 4 | | the patient conferring with the patient's primary care
| 5 | | physician and the licensed clinical social worker, licensed | 6 | | clinical
professional counselor, licensed marriage and family | 7 | | therapist, licensed speech-language pathologist, or other | 8 | | licensed or certified professional at a program licensed | 9 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 10 | | Dependency Act has
provided written
notification to the | 11 | | patient's primary care physician, if any, that services
are | 12 | | being provided to the patient. That notification may, however, | 13 | | be
waived by the patient on a written form. Those forms shall | 14 | | be retained by
the licensed clinical social worker, licensed | 15 | | clinical professional counselor, licensed marriage and family | 16 | | therapist, licensed speech-language pathologist, or other | 17 | | licensed or certified professional at a program licensed | 18 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 19 | | Dependency Act
for a period of not less than 5 years.
| 20 | | (b)(1) An insurer that provides coverage for hospital or | 21 | | medical
expenses under a group or individual policy of accident | 22 | | and health insurance or
health care plan amended, delivered, | 23 | | issued, or renewed on or after the effective
date of this | 24 | | amendatory Act of the 100th General Assembly shall provide | 25 | | coverage
under the policy for treatment of serious mental | 26 | | illness and substance use disorders consistent with the parity |
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| 1 | | requirements of Section 370c.1 of this Code. This subsection | 2 | | does not apply to any group policy of accident and health | 3 | | insurance or health care plan for any plan year of a small | 4 | | employer as defined in Section 5 of the Illinois Health | 5 | | Insurance Portability and Accountability Act.
| 6 | | (2) "Serious mental illness" means the following | 7 | | psychiatric illnesses as
defined in the most current edition of | 8 | | the Diagnostic and Statistical Manual
(DSM) published by the | 9 | | American Psychiatric Association:
| 10 | | (A) schizophrenia;
| 11 | | (B) paranoid and other psychotic disorders;
| 12 | | (C) bipolar disorders (hypomanic, manic, depressive, | 13 | | and mixed);
| 14 | | (D) major depressive disorders (single episode or | 15 | | recurrent);
| 16 | | (E) schizoaffective disorders (bipolar or depressive);
| 17 | | (F) pervasive developmental disorders;
| 18 | | (G) obsessive-compulsive disorders;
| 19 | | (H) depression in childhood and adolescence;
| 20 | | (I) panic disorder; | 21 | | (J) post-traumatic stress disorders (acute, chronic, | 22 | | or with delayed onset); and
| 23 | | (K) eating disorders, including, but not limited to, | 24 | | anorexia nervosa, bulimia nervosa, pica, rumination | 25 | | disorder, avoidant/restrictive food intake disorder, other | 26 | | specified feeding or eating disorder (OSFED), and any other |
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| 1 | | eating disorder contained in the most recent version of the | 2 | | Diagnostic and Statistical Manual of Mental Disorders | 3 | | published by the American Psychiatric Association. | 4 | | (2.5) "Substance use disorder" means the following mental | 5 | | disorders as defined in the most current edition of the | 6 | | Diagnostic and Statistical Manual (DSM) published by the | 7 | | American Psychiatric Association: | 8 | | (A) substance abuse disorders; | 9 | | (B) substance dependence disorders; and | 10 | | (C) substance induced disorders. | 11 | | (3) Unless otherwise prohibited by federal law and | 12 | | consistent with the parity requirements of Section 370c.1 of | 13 | | this Code, the reimbursing insurer, a provider of treatment of
| 14 | | serious mental illness or substance use disorder shall furnish | 15 | | medical records or other necessary data
that substantiate that | 16 | | initial or continued treatment is at all times medically
| 17 | | necessary. An insurer shall provide a mechanism for the timely | 18 | | review by a
provider holding the same license and practicing in | 19 | | the same specialty as the
patient's provider, who is | 20 | | unaffiliated with the insurer, jointly selected by
the patient | 21 | | (or the patient's next of kin or legal representative if the
| 22 | | patient is unable to act for himself or herself), the patient's | 23 | | provider, and
the insurer in the event of a dispute between the | 24 | | insurer and patient's
provider regarding the medical necessity | 25 | | of a treatment proposed by a patient's
provider. If the | 26 | | reviewing provider determines the treatment to be medically
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| 1 | | necessary, the insurer shall provide reimbursement for the | 2 | | treatment. Future
contractual or employment actions by the | 3 | | insurer regarding the patient's
provider may not be based on | 4 | | the provider's participation in this procedure.
Nothing | 5 | | prevents
the insured from agreeing in writing to continue | 6 | | treatment at his or her
expense. When making a determination of | 7 | | the medical necessity for a treatment
modality for serious | 8 | | mental illness or substance use disorder, an insurer must make | 9 | | the determination in a
manner that is consistent with the | 10 | | manner used to make that determination with
respect to other | 11 | | diseases or illnesses covered under the policy, including an
| 12 | | appeals process. Medical necessity determinations for | 13 | | substance use disorders shall be made in accordance with | 14 | | appropriate patient placement criteria established by the | 15 | | American Society of Addiction Medicine. No additional criteria | 16 | | may be used to make medical necessity determinations for | 17 | | substance use disorders.
| 18 | | (4) A group health benefit plan amended, delivered, issued, | 19 | | or renewed on or after the effective date of this amendatory | 20 | | Act of the 97th General Assembly:
| 21 | | (A) shall provide coverage based upon medical | 22 | | necessity for the
treatment of mental illness and substance | 23 | | use disorders consistent with the parity requirements of | 24 | | Section 370c.1 of this Code; provided, however, that in | 25 | | each calendar year coverage shall not be less than the | 26 | | following:
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| 1 | | (i) 45 days of inpatient treatment; and
| 2 | | (ii) beginning on June 26, 2006 (the effective date | 3 | | of Public Act 94-921), 60 visits for outpatient | 4 | | treatment including group and individual
outpatient | 5 | | treatment; and | 6 | | (iii) for plans or policies delivered, issued for | 7 | | delivery, renewed, or modified after January 1, 2007 | 8 | | (the effective date of Public Act 94-906),
20 | 9 | | additional outpatient visits for speech therapy for | 10 | | treatment of pervasive developmental disorders that | 11 | | will be in addition to speech therapy provided pursuant | 12 | | to item (ii) of this subparagraph (A); and
| 13 | | (B) may not include a lifetime limit on the number of | 14 | | days of inpatient
treatment or the number of outpatient | 15 | | visits covered under the plan.
| 16 | | (C) (Blank).
| 17 | | (5) An issuer of a group health benefit plan may not count | 18 | | toward the number
of outpatient visits required to be covered | 19 | | under this Section an outpatient
visit for the purpose of | 20 | | medication management and shall cover the outpatient
visits | 21 | | under the same terms and conditions as it covers outpatient | 22 | | visits for
the treatment of physical illness.
| 23 | | (5.5) An individual or group health benefit plan amended, | 24 | | delivered, issued, or renewed on or after the effective date of | 25 | | this amendatory Act of the 99th General Assembly shall offer | 26 | | coverage for medically necessary acute treatment services and |
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| 1 | | medically necessary clinical stabilization services. The | 2 | | treating provider shall base all treatment recommendations and | 3 | | the health benefit plan shall base all medical necessity | 4 | | determinations for substance use disorders in accordance with | 5 | | the most current edition of the American Society of Addiction | 6 | | Medicine Patient Placement Criteria. | 7 | | As used in this subsection: | 8 | | "Acute treatment services" means 24-hour medically | 9 | | supervised addiction treatment that provides evaluation and | 10 | | withdrawal management and may include biopsychosocial | 11 | | assessment, individual and group counseling, psychoeducational | 12 | | groups, and discharge planning. | 13 | | "Clinical stabilization services" means 24-hour treatment, | 14 | | usually following acute treatment services for substance | 15 | | abuse, which may include intensive education and counseling | 16 | | regarding the nature of addiction and its consequences, relapse | 17 | | prevention, outreach to families and significant others, and | 18 | | aftercare planning for individuals beginning to engage in | 19 | | recovery from addiction. | 20 | | (6) An issuer of a group health benefit
plan may provide or | 21 | | offer coverage required under this Section through a
managed | 22 | | care plan.
| 23 | | (7) (Blank).
| 24 | | (8)
(Blank).
| 25 | | (9) With respect to substance use disorders, coverage for | 26 | | inpatient treatment shall include coverage for treatment in a |
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| 1 | | residential treatment center licensed by the Department of | 2 | | Public Health or the Department of Human Services. | 3 | | (c) This Section shall not be interpreted to require | 4 | | coverage for speech therapy or other habilitative services for | 5 | | those individuals covered under Section 356z.15
of this Code. | 6 | | (d) The Department shall enforce the requirements of State | 7 | | and federal parity law, which includes ensuring compliance by | 8 | | individual and group policies; detecting violations of the law | 9 | | by individual and group policies proactively monitoring | 10 | | discriminatory practices; accepting, evaluating, and | 11 | | responding to complaints regarding such violations; and | 12 | | ensuring violations are appropriately remedied and deterred. | 13 | | (e) Availability of plan information. | 14 | | (1) The criteria for medical necessity determinations | 15 | | made under a group health plan with respect to mental | 16 | | health or substance use disorder benefits (or health | 17 | | insurance coverage offered in connection with the plan with | 18 | | respect to such benefits) must be made available by the | 19 | | plan administrator (or the health insurance issuer | 20 | | offering such coverage) to any current or potential | 21 | | participant, beneficiary, or contracting provider upon | 22 | | request. | 23 | | (2) The reason for any denial under a group health plan | 24 | | (or health insurance coverage offered in connection with | 25 | | such plan) of reimbursement or payment for services with | 26 | | respect to mental health or substance use disorder benefits |
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| 1 | | in the case of any participant or beneficiary must be made | 2 | | available within a reasonable time and in a reasonable | 3 | | manner by the plan administrator (or the health insurance | 4 | | issuer offering such coverage) to the participant or | 5 | | beneficiary upon request. | 6 | | (f) As used in this Section, "group policy of accident and | 7 | | health insurance" and "group health benefit plan" includes (1) | 8 | | State-regulated employer-sponsored group health insurance | 9 | | plans written in Illinois and (2) State employee health plans. | 10 | | (g) (1) As used in this subsection: | 11 | | "Benefits", with respect to insurers, means
the benefits | 12 | | provided for treatment services for inpatient and outpatient | 13 | | treatment of substance use disorders or conditions at American | 14 | | Society of Addiction Medicine levels of treatment 2.1 | 15 | | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | 16 | | (Clinically Managed Low-Intensity Residential), 3.3 | 17 | | (Clinically Managed Population-Specific High-Intensity | 18 | | Residential), 3.5 (Clinically Managed High-Intensity | 19 | | Residential), and 3.7 (Medically Monitored Intensive | 20 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 21 | | "Benefits", with respect to managed care organizations, | 22 | | means the benefits provided for treatment services for | 23 | | inpatient and outpatient treatment of substance use disorders | 24 | | or conditions at American Society of Addiction Medicine levels | 25 | | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | 26 | | Hospitalization), 3.5 (Clinically Managed High-Intensity |
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| 1 | | Residential), and 3.7 (Medically Monitored Intensive | 2 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 3 | | "Substance use disorder treatment provider or facility" | 4 | | means a licensed physician, licensed psychologist, licensed | 5 | | psychiatrist, licensed advanced practice registered nurse, or | 6 | | licensed, certified, or otherwise State-approved facility or | 7 | | provider of substance use disorder treatment. | 8 | | (2) A group health insurance policy, an individual health | 9 | | benefit plan, or qualified health plan that is offered through | 10 | | the health insurance marketplace, small employer group health | 11 | | plan, and large employer group health plan that is amended, | 12 | | delivered, issued, executed, or renewed in this State, or | 13 | | approved for issuance or renewal in this State, on or after the | 14 | | effective date of this amendatory Act of the 100th General | 15 | | Assembly shall comply with the requirements of this Section and | 16 | | Section 370c.1. The services for the treatment and the ongoing | 17 | | assessment of the patient's progress in treatment shall follow | 18 | | the requirements of 77 Ill. Adm. Code 2060. | 19 | | (3) Prior authorization shall not be utilized for the | 20 | | benefits under this subsection. The substance use disorder | 21 | | treatment provider or facility shall notify the insurer of the | 22 | | initiation of treatment. For an insurer that is not a managed | 23 | | care organization, the substance use disorder treatment | 24 | | provider or facility notification shall occur for the | 25 | | initiation of treatment of the covered person within 2 business | 26 | | days. For managed care organizations, the substance use |
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| 1 | | disorder treatment provider or facility notification shall | 2 | | occur in accordance with the protocol set forth in the provider | 3 | | agreement for initiation of treatment within 24 hours. If the | 4 | | managed care organization is not capable of accepting the | 5 | | notification in accordance with the contractual protocol | 6 | | during the 24-hour period following admission, the substance | 7 | | use disorder treatment provider or facility shall have one | 8 | | additional business day to provide the notification to the | 9 | | appropriate managed care organization. Treatment plans shall | 10 | | be developed in accordance with the requirements and timeframes | 11 | | established in 77 Ill. Adm. Code 2060. If the substance use | 12 | | disorder treatment provider or facility fails to notify the | 13 | | insurer of the initiation of treatment in accordance with these | 14 | | provisions, the insurer may follow its normal prior | 15 | | authorization processes. | 16 | | (4) For an insurer that is not a managed care organization, | 17 | | if an insurer determines that benefits are no longer medically | 18 | | necessary, the insurer shall notify the covered person, the | 19 | | covered person's authorized representative, if any, and the | 20 | | covered person's health care provider in writing of the covered | 21 | | person's right to request an external review pursuant to the | 22 | | Health Carrier External Review Act. The notification shall | 23 | | occur within 24 hours following the adverse determination. | 24 | | Pursuant to the requirements of the Health Carrier External | 25 | | Review Act, the covered person or the covered person's | 26 | | authorized representative may request an expedited external |
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| 1 | | review.
An expedited external review may not occur if the | 2 | | substance use disorder treatment provider or facility | 3 | | determines that continued treatment is no longer medically | 4 | | necessary. Under this subsection, a request for expedited | 5 | | external review must be initiated within 24 hours following the | 6 | | adverse determination notification by the insurer. Failure to | 7 | | request an expedited external review within 24 hours shall | 8 | | preclude a covered person or a covered person's authorized | 9 | | representative from requesting an expedited external review. | 10 | | If an expedited external review request meets the criteria | 11 | | of the Health Carrier External Review Act, an independent | 12 | | review organization shall make a final determination of medical | 13 | | necessity within 72 hours. If an independent review | 14 | | organization upholds an adverse determination, an insurer | 15 | | shall remain responsible to provide coverage of benefits | 16 | | through the day following the determination of the independent | 17 | | review organization. A decision to reverse an adverse | 18 | | determination shall comply with the Health Carrier External | 19 | | Review Act. | 20 | | (5) The substance use disorder treatment provider or | 21 | | facility shall provide the insurer with 7 business days' | 22 | | advance notice of the planned discharge of the patient from the | 23 | | substance use disorder treatment provider or facility and | 24 | | notice on the day that the patient is discharged from the | 25 | | substance use disorder treatment provider or facility. | 26 | | (6) The benefits required by this subsection shall be |
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| 1 | | provided to all covered persons with a diagnosis of substance | 2 | | use disorder or conditions. The presence of additional related | 3 | | or unrelated diagnoses shall not be a basis to reduce or deny | 4 | | the benefits required by this subsection. | 5 | | (7) Nothing in this subsection shall be construed to | 6 | | require an insurer to provide coverage for any of the benefits | 7 | | in this subsection. | 8 | | (Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
| 9 | | Section 99. Effective date. This Act takes effect January | 10 | | 1, 2019.
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