Full Text of SB1707 100th General Assembly
SB1707enr 100TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning health.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The State Employees Group Insurance Act of 1971 | 5 | | is amended by changing Section 6.11 as follows:
| 6 | | (5 ILCS 375/6.11)
| 7 | | Sec. 6.11. Required health benefits; Illinois Insurance | 8 | | Code
requirements. The program of health
benefits shall provide | 9 | | the post-mastectomy care benefits required to be covered
by a | 10 | | policy of accident and health insurance under Section 356t of | 11 | | the Illinois
Insurance Code. The program of health benefits | 12 | | shall provide the coverage
required under Sections 356g, | 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25 , and 356z.26 of | 16 | | the
Illinois Insurance Code.
The program of health benefits | 17 | | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, | 18 | | and 370c.1 of the
Illinois Insurance Code. The Department of | 19 | | Insurance shall enforce the requirements of this Section.
| 20 | | Rulemaking authority to implement Public Act 95-1045, if | 21 | | any, is conditioned on the rules being adopted in accordance | 22 | | with all provisions of the Illinois Administrative Procedure | 23 | | Act and all rules and procedures of the Joint Committee on |
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| 1 | | Administrative Rules; any purported rule not so adopted, for | 2 | | whatever reason, is unauthorized. | 3 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 4 | | 100-138, eff. 8-18-17; revised 10-3-17.) | 5 | | Section 10. The State Finance Act is amended by changing | 6 | | Section 5.872 as follows:
| 7 | | (30 ILCS 105/5.872)
| 8 | | Sec. 5.872. The Parity Advancement Education Fund. | 9 | | (Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
| 10 | | Section 15. The Counties Code is amended by changing | 11 | | Section 5-1069.3 as follows: | 12 | | (55 ILCS 5/5-1069.3)
| 13 | | Sec. 5-1069.3. Required health benefits. If a county, | 14 | | including a home
rule
county, is a self-insurer for purposes of | 15 | | providing health insurance coverage
for its employees, the | 16 | | coverage shall include coverage for the post-mastectomy
care | 17 | | benefits required to be covered by a policy of accident and | 18 | | health
insurance under Section 356t and the coverage required | 19 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 20 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 21 | | 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
the | 22 | | Illinois Insurance Code. The coverage shall comply with |
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| 1 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 2 | | Insurance Code. The Department of Insurance shall enforce the | 3 | | requirements of this Section. The requirement that health | 4 | | benefits be covered
as provided in this Section is an
exclusive | 5 | | power and function of the State and is a denial and limitation | 6 | | under
Article VII, Section 6, subsection (h) of the Illinois | 7 | | Constitution. A home
rule county to which this Section applies | 8 | | must comply with every provision of
this Section.
| 9 | | Rulemaking authority to implement Public Act 95-1045, if | 10 | | any, is conditioned on the rules being adopted in accordance | 11 | | with all provisions of the Illinois Administrative Procedure | 12 | | Act and all rules and procedures of the Joint Committee on | 13 | | Administrative Rules; any purported rule not so adopted, for | 14 | | whatever reason, is unauthorized. | 15 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 16 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 17 | | Section 20. The Illinois Municipal Code is amended by | 18 | | changing Section 10-4-2.3 as follows: | 19 | | (65 ILCS 5/10-4-2.3)
| 20 | | Sec. 10-4-2.3. Required health benefits. If a | 21 | | municipality, including a
home rule municipality, is a | 22 | | self-insurer for purposes of providing health
insurance | 23 | | coverage for its employees, the coverage shall include coverage | 24 | | for
the post-mastectomy care benefits required to be covered by |
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| 1 | | a policy of
accident and health insurance under Section 356t | 2 | | and the coverage required
under Sections 356g, 356g.5, | 3 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 4 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and | 5 | | 356z.25 , and 356z.26 of the Illinois
Insurance
Code. The | 6 | | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | 7 | | 370c of
the Illinois Insurance Code. The Department of | 8 | | Insurance shall enforce the requirements of this Section. The | 9 | | requirement that health
benefits be covered as provided in this | 10 | | is an exclusive power and function of
the State and is a denial | 11 | | and limitation under Article VII, Section 6,
subsection (h) of | 12 | | the Illinois Constitution. A home rule municipality to which
| 13 | | this Section applies must comply with every provision of this | 14 | | Section.
| 15 | | Rulemaking authority to implement Public Act 95-1045, if | 16 | | any, is conditioned on the rules being adopted in accordance | 17 | | with all provisions of the Illinois Administrative Procedure | 18 | | Act and all rules and procedures of the Joint Committee on | 19 | | Administrative Rules; any purported rule not so adopted, for | 20 | | whatever reason, is unauthorized. | 21 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 22 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 23 | | Section 25. The School Code is amended by changing Section | 24 | | 10-22.3f as follows: |
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| 1 | | (105 ILCS 5/10-22.3f)
| 2 | | Sec. 10-22.3f. Required health benefits. Insurance | 3 | | protection and
benefits
for employees shall provide the | 4 | | post-mastectomy care benefits required to be
covered by a | 5 | | policy of accident and health insurance under Section 356t and | 6 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 7 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 8 | | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
| 9 | | the
Illinois Insurance Code.
Insurance policies shall comply | 10 | | with Section 356z.19 of the Illinois Insurance Code. The | 11 | | coverage shall comply with Sections 155.22a , and 355b , and 370c | 12 | | of
the Illinois Insurance Code. The Department of Insurance | 13 | | shall enforce the requirements of this Section.
| 14 | | Rulemaking authority to implement Public Act 95-1045, if | 15 | | any, is conditioned on the rules being adopted in accordance | 16 | | with all provisions of the Illinois Administrative Procedure | 17 | | Act and all rules and procedures of the Joint Committee on | 18 | | Administrative Rules; any purported rule not so adopted, for | 19 | | whatever reason, is unauthorized. | 20 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 21 | | revised 9-25-17.) | 22 | | Section 30. The Illinois Insurance Code is amended by | 23 | | changing Sections 370c and 370c.1 as follows:
| 24 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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| 1 | | Sec. 370c. Mental and emotional disorders.
| 2 | | (a)(1) On and after the effective date of this amendatory | 3 | | Act of the 100th General Assembly the effective date of this | 4 | | amendatory Act of the 97th General Assembly ,
every insurer that | 5 | | which amends, delivers, issues, or renews
group accident and | 6 | | health policies providing coverage for hospital or medical | 7 | | treatment or
services for illness on an expense-incurred basis | 8 | | shall provide offer to the
applicant or group policyholder | 9 | | subject to the insurer's standards of
insurability, coverage | 10 | | for reasonable and necessary treatment and services
for mental, | 11 | | emotional , or nervous , or substance use disorders or | 12 | | conditions , other than serious
mental illnesses as defined in | 13 | | item (2) of subsection (b), consistent with the parity | 14 | | 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 | 26 | | in all its branches, licensed clinical psychologist,
licensed |
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| 1 | | clinical social worker, licensed clinical professional | 2 | | counselor, licensed marriage and family therapist, licensed | 3 | | speech-language pathologist, or other licensed or certified | 4 | | professional at a program licensed pursuant to the Illinois | 5 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the | 6 | | limits of coverage, provided (i)
the disorder or condition | 7 | | treated is covered by the policy, and (ii) the
physician, | 8 | | licensed psychologist, licensed clinical social worker, | 9 | | licensed
clinical professional counselor, licensed marriage | 10 | | and family therapist, licensed speech-language pathologist, or | 11 | | other licensed or certified professional at a program licensed | 12 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 13 | | Dependency Act is
authorized to provide said services under the | 14 | | statutes of this State and in
accordance with accepted | 15 | | principles of his profession.
| 16 | | (3) Insofar as this Section applies solely to licensed | 17 | | clinical social
workers, licensed clinical professional | 18 | | counselors, licensed marriage and family therapists, licensed | 19 | | speech-language pathologists, and other licensed or certified | 20 | | professionals at programs licensed pursuant to the Illinois | 21 | | Alcoholism and Other Drug Abuse and Dependency Act, those | 22 | | persons who may
provide services to individuals shall do so
| 23 | | after the licensed clinical social worker, licensed clinical | 24 | | professional
counselor, licensed marriage and family | 25 | | therapist, licensed speech-language pathologist, or other | 26 | | licensed or certified professional at a program licensed |
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| 1 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 2 | | Dependency Act has informed the patient of the
desirability of | 3 | | the patient conferring with the patient's primary care
| 4 | | physician and the licensed clinical social worker, licensed | 5 | | clinical
professional counselor, licensed marriage and family | 6 | | therapist, licensed speech-language pathologist, or other | 7 | | licensed or certified professional at a program licensed | 8 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 9 | | Dependency Act has
provided written
notification to the | 10 | | patient's primary care physician, if any, that services
are | 11 | | being provided to the patient. That notification may, however, | 12 | | be
waived by the patient on a written form. Those forms shall | 13 | | be retained by
the licensed clinical social worker, licensed | 14 | | clinical professional counselor, licensed marriage and family | 15 | | therapist, licensed speech-language pathologist, or other | 16 | | licensed or certified professional at a program licensed | 17 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 18 | | Dependency Act
for a period of not less than 5 years .
| 19 | | (4) "Mental, emotional, nervous, or substance use disorder | 20 | | or condition" means a condition or disorder that involves a | 21 | | mental health condition or substance use disorder that falls | 22 | | under any of the diagnostic categories listed in the mental and | 23 | | behavioral disorders chapter of the current edition of the | 24 | | International Classification of Disease or that is listed in | 25 | | the most recent version of the Diagnostic and Statistical | 26 | | Manual of Mental Disorders. |
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| 1 | | (b)(1) (Blank). An insurer that provides coverage for | 2 | | hospital or medical
expenses under a group or individual policy | 3 | | of accident and health insurance or
health care plan amended, | 4 | | delivered, issued, or renewed on or after the effective
date of | 5 | | this amendatory Act of the 100th General Assembly shall provide | 6 | | coverage
under the policy for treatment of serious mental | 7 | | illness and substance use disorders consistent with the parity | 8 | | requirements of Section 370c.1 of this Code. This subsection | 9 | | does not apply to any group policy of accident and health | 10 | | insurance or health care plan for any plan year of a small | 11 | | employer as defined in Section 5 of the Illinois Health | 12 | | Insurance Portability and Accountability Act.
| 13 | | (2) (Blank). "Serious mental illness" means the following | 14 | | psychiatric illnesses as
defined in the most current edition of | 15 | | the Diagnostic and Statistical Manual
(DSM) published by the | 16 | | American Psychiatric Association:
| 17 | | (A) schizophrenia;
| 18 | | (B) paranoid and other psychotic disorders;
| 19 | | (C) bipolar disorders (hypomanic, manic, depressive, | 20 | | and mixed);
| 21 | | (D) major depressive disorders (single episode or | 22 | | recurrent);
| 23 | | (E) schizoaffective disorders (bipolar or depressive);
| 24 | | (F) pervasive developmental disorders;
| 25 | | (G) obsessive-compulsive disorders;
| 26 | | (H) depression in childhood and adolescence;
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| 1 | | (I) panic disorder; | 2 | | (J) post-traumatic stress disorders (acute, chronic, | 3 | | or with delayed onset); and
| 4 | | (K) eating disorders, including, but not limited to, | 5 | | anorexia nervosa, bulimia nervosa, pica, rumination | 6 | | disorder, avoidant/restrictive food intake disorder, other | 7 | | specified feeding or eating disorder (OSFED), and any other | 8 | | eating disorder contained in the most recent version of the | 9 | | Diagnostic and Statistical Manual of Mental Disorders | 10 | | published by the American Psychiatric Association. | 11 | | (2.5) (Blank). "Substance use disorder" means the | 12 | | following mental disorders as defined in the most current | 13 | | edition of the Diagnostic and Statistical Manual (DSM) | 14 | | published by the American Psychiatric Association: | 15 | | (A) substance abuse disorders; | 16 | | (B) substance dependence disorders; and | 17 | | (C) substance induced disorders. | 18 | | (3) Unless otherwise prohibited by federal law and | 19 | | consistent with the parity requirements of Section 370c.1 of | 20 | | this Code, the reimbursing insurer that amends, delivers, | 21 | | issues, or renews a group or individual policy of accident and | 22 | | health insurance, a qualified health plan offered through the | 23 | | health insurance marketplace, or , a provider of treatment of | 24 | | mental, emotional, nervous,
serious mental illness or | 25 | | substance use disorders or conditions disorder shall furnish | 26 | | medical records or other necessary data
that substantiate that |
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| 1 | | initial or continued treatment is at all times medically
| 2 | | necessary. An insurer shall provide a mechanism for the timely | 3 | | review by a
provider holding the same license and practicing in | 4 | | the same specialty as the
patient's provider, who is | 5 | | unaffiliated with the insurer, jointly selected by
the patient | 6 | | (or the patient's next of kin or legal representative if the
| 7 | | patient is unable to act for himself or herself), the patient's | 8 | | provider, and
the insurer in the event of a dispute between the | 9 | | insurer and patient's
provider regarding the medical necessity | 10 | | of a treatment proposed by a patient's
provider. If the | 11 | | reviewing provider determines the treatment to be medically
| 12 | | necessary, the insurer shall provide reimbursement for the | 13 | | treatment. Future
contractual or employment actions by the | 14 | | insurer regarding the patient's
provider may not be based on | 15 | | the provider's participation in this procedure.
Nothing | 16 | | prevents
the insured from agreeing in writing to continue | 17 | | treatment at his or her
expense. When making a determination of | 18 | | the medical necessity for a treatment
modality for mental, | 19 | | emotional, nervous, serious mental illness or substance use | 20 | | disorders or conditions disorder , an insurer must make the | 21 | | determination in a
manner that is consistent with the manner | 22 | | used to make that determination with
respect to other diseases | 23 | | or illnesses covered under the policy, including an
appeals | 24 | | process. Medical necessity determinations for substance use | 25 | | disorders shall be made in accordance with appropriate patient | 26 | | placement criteria established by the American Society of |
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| 1 | | Addiction Medicine. No additional criteria may be used to make | 2 | | medical necessity determinations for substance use disorders.
| 3 | | (4) A group health benefit plan amended, delivered, issued, | 4 | | or renewed on or after the effective date of this amendatory | 5 | | Act of the 100th General Assembly or an individual policy of | 6 | | accident and health insurance or a qualified health plan | 7 | | offered through the health insurance marketplace amended, | 8 | | delivered, issued, or renewed on or after the effective date of | 9 | | this amendatory Act of the 100th General Assembly the effective | 10 | | date of this amendatory Act of the 97th General Assembly :
| 11 | | (A) shall provide coverage based upon medical | 12 | | necessity for the
treatment of a mental, emotional, | 13 | | nervous, or mental illness and substance use disorder or | 14 | | condition disorders consistent with the parity | 15 | | requirements of Section 370c.1 of this Code; provided, | 16 | | however, that in each calendar year coverage shall not be | 17 | | less than the following:
| 18 | | (i) 45 days of inpatient treatment; and
| 19 | | (ii) beginning on June 26, 2006 (the effective date | 20 | | of Public Act 94-921), 60 visits for outpatient | 21 | | treatment including group and individual
outpatient | 22 | | treatment; and | 23 | | (iii) for plans or policies delivered, issued for | 24 | | delivery, renewed, or modified after January 1, 2007 | 25 | | (the effective date of Public Act 94-906),
20 | 26 | | additional outpatient visits for speech therapy for |
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| 1 | | treatment of pervasive developmental disorders that | 2 | | will be in addition to speech therapy provided pursuant | 3 | | to item (ii) of this subparagraph (A); and
| 4 | | (B) may not include a lifetime limit on the number of | 5 | | days of inpatient
treatment or the number of outpatient | 6 | | visits covered under the plan.
| 7 | | (C) (Blank).
| 8 | | (5) An issuer of a group health benefit plan or an | 9 | | individual policy of accident and health insurance or a | 10 | | qualified health plan offered through the health insurance | 11 | | marketplace may not count toward the number
of outpatient | 12 | | visits required to be covered under this Section an outpatient
| 13 | | visit for the purpose of medication management and shall cover | 14 | | the outpatient
visits under the same terms and conditions as it | 15 | | covers outpatient visits for
the treatment of physical illness.
| 16 | | (5.5) An individual or group health benefit plan amended, | 17 | | delivered, issued, or renewed on or after the effective date of | 18 | | this amendatory Act of the 99th General Assembly shall offer | 19 | | coverage for medically necessary acute treatment services and | 20 | | medically necessary clinical stabilization services. The | 21 | | treating provider shall base all treatment recommendations and | 22 | | the health benefit plan shall base all medical necessity | 23 | | determinations for substance use disorders in accordance with | 24 | | the most current edition of the Treatment Criteria for | 25 | | Addictive, Substance-Related, and Co-Occurring Conditions | 26 | | established by the American Society of Addiction Medicine |
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| 1 | | Patient Placement Criteria . The treating provider shall base | 2 | | all treatment recommendations and the health benefit plan shall | 3 | | base all medical necessity determinations for | 4 | | medication-assisted treatment in accordance with the most | 5 | | current Treatment Criteria for Addictive, Substance-Related, | 6 | | and Co-Occurring Conditions established by the American | 7 | | Society of Addiction Medicine. | 8 | | As used in this subsection: | 9 | | "Acute treatment services" means 24-hour medically | 10 | | supervised addiction treatment that provides evaluation and | 11 | | withdrawal management and may include biopsychosocial | 12 | | assessment, individual and group counseling, psychoeducational | 13 | | groups, and discharge planning. | 14 | | "Clinical stabilization services" means 24-hour treatment, | 15 | | usually following acute treatment services for substance | 16 | | abuse, which may include intensive education and counseling | 17 | | regarding the nature of addiction and its consequences, relapse | 18 | | prevention, outreach to families and significant others, and | 19 | | aftercare planning for individuals beginning to engage in | 20 | | recovery from addiction. | 21 | | (6) An issuer of a group health benefit
plan may provide or | 22 | | offer coverage required under this Section through a
managed | 23 | | care plan.
| 24 | | (6.5) An individual or group health benefit plan amended, | 25 | | delivered, issued, or renewed on or after the effective date of | 26 | | this amendatory Act of the 100th General Assembly: |
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| 1 | | (A) shall not impose prior authorization requirements, | 2 | | other than those established under the Treatment Criteria | 3 | | for Addictive, Substance-Related, and Co-Occurring | 4 | | Conditions established by the American Society of | 5 | | Addiction Medicine, on a prescription medication approved | 6 | | by the United States Food and Drug Administration that is | 7 | | prescribed or administered for the treatment of substance | 8 | | use disorders; | 9 | | (B) shall not impose any step therapy requirements, | 10 | | other than those established under the Treatment Criteria | 11 | | for Addictive, Substance-Related, and Co-Occurring | 12 | | Conditions established by the American Society of | 13 | | Addiction Medicine, before authorizing coverage for a | 14 | | prescription medication approved by the United States Food | 15 | | and Drug Administration that is prescribed or administered | 16 | | for the treatment of substance use disorders; | 17 | | (C) shall place all prescription medications approved | 18 | | by the United States Food and Drug Administration | 19 | | prescribed or administered for the treatment of substance | 20 | | use disorders on, for brand medications, the lowest tier of | 21 | | the drug formulary developed and maintained by the | 22 | | individual or group health benefit plan that covers brand | 23 | | medications and, for generic medications, the lowest tier | 24 | | of the drug formulary developed and maintained by the | 25 | | individual or group health benefit plan that covers generic | 26 | | medications; and |
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| 1 | | (D) shall not exclude coverage for a prescription | 2 | | medication approved by the United States Food and Drug | 3 | | Administration for the treatment of substance use | 4 | | disorders and any associated counseling or wraparound | 5 | | services on the grounds that such medications and services | 6 | | were court ordered. | 7 | | (7) (Blank).
| 8 | | (8)
(Blank).
| 9 | | (9) With respect to all mental, emotional, nervous, or | 10 | | substance use disorders or conditions , coverage for inpatient | 11 | | treatment shall include coverage for treatment in a residential | 12 | | treatment center certified or licensed by the Department of | 13 | | Public Health or the Department of Human Services. | 14 | | (c) This Section shall not be interpreted to require | 15 | | coverage for speech therapy or other habilitative services for | 16 | | those individuals covered under Section 356z.15
of this Code. | 17 | | (d) With respect to a group or individual policy of | 18 | | accident and health insurance or a qualified health plan | 19 | | offered through the health insurance marketplace, the | 20 | | Department and, with respect to medical assistance, the | 21 | | Department of Healthcare and Family Services shall each enforce | 22 | | the requirements of this Section and Sections 356z.23 and | 23 | | 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 24 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 25 | | U.S.C. 18031(j), and any amendments to, and federal guidance or | 26 | | regulations issued under, those Acts, including, but not |
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| 1 | | limited to, final regulations issued under the Paul Wellstone | 2 | | and Pete Domenici Mental Health Parity and Addiction Equity Act | 3 | | of 2008 and final regulations applying the Paul Wellstone and | 4 | | Pete Domenici Mental Health Parity and Addiction Equity Act of | 5 | | 2008 to Medicaid managed care organizations, the Children's | 6 | | Health Insurance Program, and alternative benefit plans. | 7 | | Specifically, the Department and the Department of Healthcare | 8 | | and Family Services shall take action: | 9 | | (1) proactively ensuring compliance by individual and | 10 | | group policies, including by requiring that insurers | 11 | | submit comparative analyses, as set forth in paragraph (6) | 12 | | of subsection (k) of Section 370c.1, demonstrating how they | 13 | | design and apply nonquantitative treatment limitations, | 14 | | both as written and in operation, for mental, emotional, | 15 | | nervous, or substance use disorder or condition benefits as | 16 | | compared to how they design and apply nonquantitative | 17 | | treatment limitations, as written and in operation, for | 18 | | medical and surgical benefits; | 19 | | (2) evaluating all consumer or provider complaints | 20 | | regarding mental, emotional, nervous, or substance use | 21 | | disorder or condition coverage for possible parity | 22 | | violations; | 23 | | (3) performing parity compliance market conduct | 24 | | examinations or, in the case of the Department of | 25 | | Healthcare and Family Services, parity compliance audits | 26 | | of individual and group plans and policies, including, but |
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| 1 | | not limited to, reviews of: | 2 | | (A) nonquantitative treatment limitations, | 3 | | including, but not limited to, prior authorization | 4 | | requirements, concurrent review, retrospective review, | 5 | | step therapy, network admission standards, | 6 | | reimbursement rates, and geographic restrictions; | 7 | | (B) denials of authorization, payment, and | 8 | | coverage; and | 9 | | (C) other specific criteria as may be determined by | 10 | | the Department. | 11 | | The findings and the conclusions of the parity compliance | 12 | | market conduct examinations and audits shall be made public. | 13 | | The Director may adopt rules to effectuate any provisions | 14 | | of the Paul Wellstone and Pete Domenici Mental Health Parity | 15 | | and Addiction Equity Act of 2008 that relate to the business of | 16 | | insurance. | 17 | | (d) The Department shall enforce the requirements of State | 18 | | and federal parity law, which includes ensuring compliance by | 19 | | individual and group policies; detecting violations of the law | 20 | | by individual and group policies proactively monitoring | 21 | | discriminatory practices; accepting, evaluating, and | 22 | | responding to complaints regarding such violations; and | 23 | | ensuring violations are appropriately remedied and deterred. | 24 | | (e) Availability of plan information. | 25 | | (1) The criteria for medical necessity determinations | 26 | | made under a group health plan , an individual policy of |
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| 1 | | accident and health insurance, or a qualified health plan | 2 | | offered through the health insurance marketplace with | 3 | | respect to mental health or substance use disorder benefits | 4 | | (or health insurance coverage offered in connection with | 5 | | the plan with respect to such benefits) must be made | 6 | | available by the plan administrator (or the health | 7 | | insurance issuer offering such coverage) to any current or | 8 | | potential participant, beneficiary, or contracting | 9 | | provider upon request. | 10 | | (2) The reason for any denial under a group health | 11 | | benefit plan , an individual policy of accident and health | 12 | | insurance, or a qualified health plan offered through the | 13 | | health insurance marketplace (or health insurance coverage | 14 | | offered in connection with such plan or policy ) of | 15 | | reimbursement or payment for services with respect to | 16 | | mental , emotional, nervous, health or substance use | 17 | | disorders or conditions disorder benefits in the case of | 18 | | any participant or beneficiary must be made available | 19 | | within a reasonable time and in a reasonable manner and in | 20 | | readily understandable language by the plan administrator | 21 | | (or the health insurance issuer offering such coverage) to | 22 | | the participant or beneficiary upon request. | 23 | | (f) As used in this Section, "group policy of accident and | 24 | | health insurance" and "group health benefit plan" includes (1) | 25 | | State-regulated employer-sponsored group health insurance | 26 | | plans written in Illinois or which purport to provide coverage |
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| 1 | | for a resident of this State; and (2) State employee health | 2 | | plans. | 3 | | (Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.) | 4 | | (215 ILCS 5/370c.1) | 5 | | Sec. 370c.1. Mental , emotional, nervous, or substance use | 6 | | disorder or condition health and addiction parity. | 7 | | (a) On and after the effective date of this amendatory Act | 8 | | of the 99th General Assembly, every insurer that amends, | 9 | | delivers, issues, or renews a group or individual policy of | 10 | | accident and health insurance or a qualified health plan | 11 | | offered through the Health Insurance Marketplace in this State | 12 | | providing coverage for hospital or medical treatment and for | 13 | | the treatment of mental, emotional, nervous, or substance use | 14 | | disorders or conditions shall ensure that: | 15 | | (1) the financial requirements applicable to such | 16 | | mental, emotional, nervous, or substance use disorder or | 17 | | condition benefits are no more restrictive than the | 18 | | predominant financial requirements applied to | 19 | | substantially all hospital and medical benefits covered by | 20 | | the policy and that there are no separate cost-sharing | 21 | | requirements that are applicable only with respect to | 22 | | mental, emotional, nervous, or substance use disorder or | 23 | | condition benefits; and | 24 | | (2) the treatment limitations applicable to such | 25 | | mental, emotional, nervous, or substance use disorder or |
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| 1 | | condition benefits are no more restrictive than the | 2 | | predominant treatment limitations applied to substantially | 3 | | all hospital and medical benefits covered by the policy and | 4 | | that there are no separate treatment limitations that are | 5 | | applicable only with respect to mental, emotional, | 6 | | nervous, or substance use disorder or condition benefits. | 7 | | (b) The following provisions shall apply concerning | 8 | | aggregate lifetime limits: | 9 | | (1) In the case of a group or individual policy of | 10 | | accident and health insurance or a qualified health plan | 11 | | offered through the Health Insurance Marketplace amended, | 12 | | delivered, issued, or renewed in this State on or after the | 13 | | effective date of this amendatory Act of the 99th General | 14 | | Assembly that provides coverage for hospital or medical | 15 | | treatment and for the treatment of mental, emotional, | 16 | | nervous, or substance use disorders or conditions the | 17 | | following provisions shall apply: | 18 | | (A) if the policy does not include an aggregate | 19 | | lifetime limit on substantially all hospital and | 20 | | medical benefits, then the policy may not impose any | 21 | | aggregate lifetime limit on mental, emotional, | 22 | | nervous, or substance use disorder or condition | 23 | | benefits; or | 24 | | (B) if the policy includes an aggregate lifetime | 25 | | limit on substantially all hospital and medical | 26 | | benefits (in this subsection referred to as the |
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| 1 | | "applicable lifetime limit"), then the policy shall | 2 | | either: | 3 | | (i) apply the applicable lifetime limit both | 4 | | to the hospital and medical benefits to which it | 5 | | otherwise would apply and to mental, emotional, | 6 | | nervous, or substance use disorder or condition | 7 | | benefits and not distinguish in the application of | 8 | | the limit between the hospital and medical | 9 | | benefits and mental, emotional, nervous, or | 10 | | substance use disorder or condition benefits; or | 11 | | (ii) not include any aggregate lifetime limit | 12 | | on mental, emotional, nervous, or substance use | 13 | | disorder or condition benefits that is less than | 14 | | the applicable lifetime limit. | 15 | | (2) In the case of a policy that is not described in | 16 | | paragraph (1) of subsection (b) of this Section and that | 17 | | includes no or different aggregate lifetime limits on | 18 | | different categories of hospital and medical benefits, the | 19 | | Director shall establish rules under which subparagraph | 20 | | (B) of paragraph (1) of subsection (b) of this Section is | 21 | | applied to such policy with respect to mental, emotional, | 22 | | nervous, or substance use disorder or condition benefits by | 23 | | substituting for the applicable lifetime limit an average | 24 | | aggregate lifetime limit that is computed taking into | 25 | | account the weighted average of the aggregate lifetime | 26 | | limits applicable to such categories. |
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| 1 | | (c) The following provisions shall apply concerning annual | 2 | | limits: | 3 | | (1) In the case of a group or individual policy of | 4 | | accident and health insurance or a qualified health plan | 5 | | offered through the Health Insurance Marketplace amended, | 6 | | delivered, issued, or renewed in this State on or after the | 7 | | effective date of this amendatory Act of the 99th General | 8 | | Assembly that provides coverage for hospital or medical | 9 | | treatment and for the treatment of mental, emotional, | 10 | | nervous, or substance use disorders or conditions the | 11 | | following provisions shall apply: | 12 | | (A) if the policy does not include an annual limit | 13 | | on substantially all hospital and medical benefits, | 14 | | then the policy may not impose any annual limits on | 15 | | mental, emotional, nervous, or substance use disorder | 16 | | or condition benefits; or | 17 | | (B) if the policy includes an annual limit on | 18 | | substantially all hospital and medical benefits (in | 19 | | this subsection referred to as the "applicable annual | 20 | | limit"), then the policy shall either: | 21 | | (i) apply the applicable annual limit both to | 22 | | the hospital and medical benefits to which it | 23 | | otherwise would apply and to mental, emotional, | 24 | | nervous, or substance use disorder or condition | 25 | | benefits and not distinguish in the application of | 26 | | the limit between the hospital and medical |
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| 1 | | benefits and mental, emotional, nervous, or | 2 | | substance use disorder or condition benefits; or | 3 | | (ii) not include any annual limit on mental, | 4 | | emotional, nervous, or substance use disorder or | 5 | | condition benefits that is less than the | 6 | | applicable annual limit. | 7 | | (2) In the case of a policy that is not described in | 8 | | paragraph (1) of subsection (c) of this Section and that | 9 | | includes no or different annual limits on different | 10 | | categories of hospital and medical benefits, the Director | 11 | | shall establish rules under which subparagraph (B) of | 12 | | paragraph (1) of subsection (c) of this Section is applied | 13 | | to such policy with respect to mental, emotional, nervous, | 14 | | or substance use disorder or condition benefits by | 15 | | substituting for the applicable annual limit an average | 16 | | annual limit that is computed taking into account the | 17 | | weighted average of the annual limits applicable to such | 18 | | categories. | 19 | | (d) With respect to mental, emotional, nervous, or | 20 | | substance use disorders or conditions , an insurer shall use | 21 | | policies and procedures for the election and placement of | 22 | | mental, emotional, nervous, or substance use disorder or | 23 | | condition substance abuse treatment drugs on their formulary | 24 | | that are no less favorable to the insured as those policies and | 25 | | procedures the insurer uses for the selection and placement of | 26 | | other drugs for medical or surgical conditions and shall follow |
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| 1 | | the expedited coverage determination requirements for | 2 | | substance abuse treatment drugs set forth in Section 45.2 of | 3 | | the Managed Care Reform and Patient Rights Act. | 4 | | (e) This Section shall be interpreted in a manner | 5 | | consistent with all applicable federal parity regulations | 6 | | including, but not limited to, the Paul Wellstone and Pete | 7 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 , | 8 | | final regulations issued under the Paul Wellstone and Pete | 9 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 | 10 | | and final regulations applying the Paul Wellstone and Pete | 11 | | Domenici Mental Health Parity and Addiction Equity Act of 2008 | 12 | | to Medicaid managed care organizations, the Children's Health | 13 | | Insurance Program, and alternative benefit plans at 78 FR | 14 | | 68240 . | 15 | | (f) The provisions of subsections (b) and (c) of this | 16 | | Section shall not be interpreted to allow the use of lifetime | 17 | | or annual limits otherwise prohibited by State or federal law. | 18 | | (g) As used in this Section: | 19 | | "Financial requirement" includes deductibles, copayments, | 20 | | coinsurance, and out-of-pocket maximums, but does not include | 21 | | an aggregate lifetime limit or an annual limit subject to | 22 | | subsections (b) and (c). | 23 | | "Mental, emotional, nervous, or substance use disorder or | 24 | | condition" means a condition or disorder that involves a mental | 25 | | health condition or substance use disorder that falls under any | 26 | | of the diagnostic categories listed in the mental and |
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| 1 | | behavioral disorders chapter of the current edition of the | 2 | | International Classification of Disease or that is listed in | 3 | | the most recent version of the Diagnostic and Statistical | 4 | | Manual of Mental Disorders. | 5 | | "Treatment limitation" includes limits on benefits based | 6 | | on the frequency of treatment, number of visits, days of | 7 | | coverage, days in a waiting period, or other similar limits on | 8 | | the scope or duration of treatment. "Treatment limitation" | 9 | | includes both quantitative treatment limitations, which are | 10 | | expressed numerically (such as 50 outpatient visits per year), | 11 | | and nonquantitative treatment limitations, which otherwise | 12 | | limit the scope or duration of treatment. A permanent exclusion | 13 | | of all benefits for a particular condition or disorder shall | 14 | | not be considered a treatment limitation. "Nonquantitative | 15 | | treatment" means those limitations as described under federal | 16 | | regulations (26 CFR 54.9812-1). "Nonquantitative treatment | 17 | | limitations" include, but are not limited to, those limitations | 18 | | described under federal regulations 26 CFR 54.9812-1, 29 CFR | 19 | | 2590.712, and 45 CFR 146.136.
| 20 | | (h) The Department of Insurance shall implement the | 21 | | following education initiatives: | 22 | | (1) By January 1, 2016, the Department shall develop a | 23 | | plan for a Consumer Education Campaign on parity. The | 24 | | Consumer Education Campaign shall focus its efforts | 25 | | throughout the State and include trainings in the northern, | 26 | | southern, and central regions of the State, as defined by |
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| 1 | | the Department, as well as each of the 5 managed care | 2 | | regions of the State as identified by the Department of | 3 | | Healthcare and Family Services. Under this Consumer | 4 | | Education Campaign, the Department shall: (1) by January 1, | 5 | | 2017, provide at least one live training in each region on | 6 | | parity for consumers and providers and one webinar training | 7 | | to be posted on the Department website and (2) establish a | 8 | | consumer hotline to assist consumers in navigating the | 9 | | parity process by March 1, 2017 2016 . By January 1, 2018 | 10 | | the Department shall issue a report to the General Assembly | 11 | | on the success of the Consumer Education Campaign, which | 12 | | shall indicate whether additional training is necessary or | 13 | | would be recommended. | 14 | | (2) The Department, in coordination with the | 15 | | Department of Human Services and the Department of | 16 | | Healthcare and Family Services, shall convene a working | 17 | | group of health care insurance carriers, mental health | 18 | | advocacy groups, substance abuse patient advocacy groups, | 19 | | and mental health physician groups for the purpose of | 20 | | discussing issues related to the treatment and coverage of | 21 | | mental, emotional, nervous, or substance use abuse | 22 | | disorders or conditions and compliance with parity | 23 | | obligations under State and federal law. Compliance shall | 24 | | be measured, tracked, and shared during the meetings of the | 25 | | working group and mental illness . The working group shall | 26 | | meet once before January 1, 2016 and shall meet |
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| 1 | | semiannually thereafter. The Department shall issue an | 2 | | annual report to the General Assembly that includes a list | 3 | | of the health care insurance carriers, mental health | 4 | | advocacy groups, substance abuse patient advocacy groups, | 5 | | and mental health physician groups that participated in the | 6 | | working group meetings, details on the issues and topics | 7 | | covered, and any legislative recommendations developed by | 8 | | the working group . | 9 | | (3) Not later than August 1 of each year, the | 10 | | Department, in conjunction with the Department of | 11 | | Healthcare and Family Services, shall issue a joint report | 12 | | to the General Assembly and provide an educational | 13 | | presentation to the General Assembly. The report and | 14 | | presentation shall: | 15 | | (A) Cover the methodology the Departments use to | 16 | | check for compliance with the federal Paul Wellstone | 17 | | and Pete Domenici Mental Health Parity and Addiction | 18 | | Equity Act of 2008, 42 U.S.C. 18031(j), and any federal | 19 | | regulations or guidance relating to the compliance and | 20 | | oversight of the federal Paul Wellstone and Pete | 21 | | Domenici Mental Health Parity and Addiction Equity Act | 22 | | of 2008 and 42 U.S.C. 18031(j). | 23 | | (B) Cover the methodology the Departments use to | 24 | | check for compliance with this Section and Sections | 25 | | 356z.23 and 370c of this Code. | 26 | | (C) Identify market conduct examinations or, in |
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| 1 | | the case of the Department of Healthcare and Family | 2 | | Services, audits conducted or completed during the | 3 | | preceding 12-month period regarding compliance with | 4 | | parity in mental, emotional, nervous, and substance | 5 | | use disorder or condition benefits under State and | 6 | | federal laws and summarize the results of such market | 7 | | conduct examinations and audits. This shall include: | 8 | | (i) the number of market conduct examinations | 9 | | and audits initiated and completed; | 10 | | (ii) the benefit classifications examined by | 11 | | each market conduct examination and audit; | 12 | | (iii) the subject matter of each market | 13 | | conduct examination and audit, including | 14 | | quantitative and nonquantitative treatment | 15 | | limitations; and | 16 | | (iv) a summary of the basis for the final | 17 | | decision rendered in each market conduct | 18 | | examination and audit. | 19 | | Individually identifiable information shall be | 20 | | excluded from the reports consistent with federal | 21 | | privacy protections. | 22 | | (D) Detail any educational or corrective actions | 23 | | the Departments have taken to ensure compliance with | 24 | | the federal Paul Wellstone and Pete Domenici Mental | 25 | | Health Parity and Addiction Equity Act of 2008, 42 | 26 | | U.S.C. 18031(j), this Section, and Sections 356z.23 |
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| 1 | | and 370c of this Code. | 2 | | (E) The report must be written in non-technical, | 3 | | readily understandable language and shall be made | 4 | | available to the public by, among such other means as | 5 | | the Departments find appropriate, posting the report | 6 | | on the Departments' websites. | 7 | | (i) The Parity Advancement Education Fund is created as a | 8 | | special fund in the State treasury. Moneys from fines and | 9 | | penalties collected from insurers for violations of this | 10 | | Section shall be deposited into the Fund. Moneys deposited into | 11 | | the Fund for appropriation by the General Assembly to the | 12 | | Department of Insurance shall be used for the purpose of | 13 | | providing financial support of the Consumer Education | 14 | | Campaign , parity compliance advocacy, and other initiatives | 15 | | that support parity implementation and enforcement on behalf of | 16 | | consumers . | 17 | | (j) The Department of Insurance and the Department of | 18 | | Healthcare and Family Services shall convene and provide | 19 | | technical support to a workgroup of 11 members that shall be | 20 | | comprised of 3 mental health parity experts recommended by an | 21 | | organization advocating on behalf of mental health parity | 22 | | appointed by the President of the Senate; 3 behavioral health | 23 | | providers recommended by an organization that represents | 24 | | behavioral health providers appointed by the Speaker of the | 25 | | House of Representatives; 2 representing Medicaid managed care | 26 | | organizations recommended by an organization that represents |
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| 1 | | Medicaid managed care plans appointed by the Minority Leader of | 2 | | the House of Representatives; 2 representing commercial | 3 | | insurers recommended by an organization that represents | 4 | | insurers appointed by the Minority Leader of the Senate; and a | 5 | | representative of an organization that represents Medicaid | 6 | | managed care plans appointed by the Governor. | 7 | | The workgroup shall provide recommendations to the General | 8 | | Assembly on health plan data reporting requirements that | 9 | | separately break out data on mental, emotional, nervous, or | 10 | | substance use disorder or condition benefits and data on other | 11 | | medical benefits, including physical health and related health | 12 | | services no later than December 31, 2019. The recommendations | 13 | | to the General Assembly shall be filed with the Clerk of the | 14 | | House of Representatives and the Secretary of the Senate in | 15 | | electronic form only, in the manner that the Clerk and the | 16 | | Secretary shall direct. This workgroup shall take into account | 17 | | federal requirements and recommendations on mental health | 18 | | parity reporting for the Medicaid program. This workgroup shall | 19 | | also develop the format and provide any needed definitions for | 20 | | reporting requirements in subsection (k). The research and | 21 | | evaluation of the working group shall include, but not be | 22 | | limited to: | 23 | | (1) claims denials due to benefit limits, if | 24 | | applicable; | 25 | | (2) administrative denials for no prior authorization; | 26 | | (3) denials due to not meeting medical necessity; |
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| 1 | | (4) denials that went to external review and whether | 2 | | they were upheld or overturned for medical necessity; | 3 | | (5) out-of-network claims; | 4 | | (6) emergency care claims; | 5 | | (7) network directory providers in the outpatient | 6 | | benefits classification who filed no claims in the last 6 | 7 | | months, if applicable; | 8 | | (8) the impact of existing and pertinent limitations | 9 | | and restrictions related to approved services, licensed | 10 | | providers, reimbursement levels, and reimbursement | 11 | | methodologies within the Division of Mental Health, the | 12 | | Division of Substance Use Prevention and Recovery | 13 | | programs, the Department of Healthcare and Family | 14 | | Services, and, to the extent possible, federal regulations | 15 | | and law; and | 16 | | (9) when reporting and publishing should begin. | 17 | | Representatives from the Department of Healthcare and | 18 | | Family Services, representatives from the Division of Mental | 19 | | Health, and representatives from the Division of Substance Use | 20 | | Prevention and Recovery shall provide technical advice to the | 21 | | workgroup. | 22 | | (k) An insurer that amends, delivers, issues, or renews a | 23 | | group or individual policy of accident and health insurance or | 24 | | a qualified health plan offered through the health insurance | 25 | | marketplace in this State providing coverage for hospital or | 26 | | medical treatment and for the treatment of mental, emotional, |
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| 1 | | nervous, or substance use disorders or conditions shall submit | 2 | | an annual report, the format and definitions for which will be | 3 | | developed by the workgroup in subsection (j), to the | 4 | | Department, or, with respect to medical assistance, the | 5 | | Department of Healthcare and Family Services starting on or | 6 | | before July 1, 2020 that contains the following information | 7 | | separately for inpatient in-network benefits, inpatient | 8 | | out-of-network benefits, outpatient in-network benefits, | 9 | | outpatient out-of-network benefits, emergency care benefits, | 10 | | and prescription drug benefits in the case of accident and | 11 | | health insurance or qualified health plans, or inpatient, | 12 | | outpatient, emergency care, and prescription drug benefits in | 13 | | the case of medical assistance: | 14 | | (1) A summary of the plan's pharmacy management | 15 | | processes for mental, emotional, nervous, or substance use | 16 | | disorder or condition benefits compared to those for other | 17 | | medical benefits. | 18 | | (2) A summary of the internal processes of review for | 19 | | experimental benefits and unproven technology for mental, | 20 | | emotional, nervous, or substance use disorder or condition | 21 | | benefits and those for
other medical benefits. | 22 | | (3) A summary of how the plan's policies and procedures | 23 | | for utilization management for mental, emotional, nervous, | 24 | | or substance use disorder or condition benefits compare to | 25 | | those for other medical benefits. | 26 | | (4) A description of the process used to develop or |
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| 1 | | select the medical necessity criteria for mental, | 2 | | emotional, nervous, or substance use disorder or condition | 3 | | benefits and the process used to develop or select the | 4 | | medical necessity criteria for medical and surgical | 5 | | benefits. | 6 | | (5) Identification of all nonquantitative treatment | 7 | | limitations that are applied to both mental, emotional, | 8 | | nervous, or substance use disorder or condition benefits | 9 | | and medical and surgical benefits within each | 10 | | classification of benefits. | 11 | | (6) The results of an analysis that demonstrates that | 12 | | for the medical necessity criteria described in | 13 | | subparagraph (A) and for each nonquantitative treatment | 14 | | limitation identified in subparagraph (B), as written and | 15 | | in operation, the processes, strategies, evidentiary | 16 | | standards, or other factors used in applying the medical | 17 | | necessity criteria and each nonquantitative treatment | 18 | | limitation to mental, emotional, nervous, or substance use | 19 | | disorder or condition benefits within each classification | 20 | | of benefits are comparable to, and are applied no more | 21 | | stringently than, the processes, strategies, evidentiary | 22 | | standards, or other factors used in applying the medical | 23 | | necessity criteria and each nonquantitative treatment | 24 | | limitation to medical and surgical benefits within the | 25 | | corresponding classification of benefits; at a minimum, | 26 | | the results of the analysis shall: |
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| 1 | | (A) identify the factors used to determine that a | 2 | | nonquantitative treatment limitation applies to a | 3 | | benefit, including factors that were considered but | 4 | | rejected; | 5 | | (B) identify and define the specific evidentiary | 6 | | standards used to define the factors and any other | 7 | | evidence relied upon in designing each nonquantitative | 8 | | treatment limitation; | 9 | | (C) provide the comparative analyses, including | 10 | | the results of the analyses, performed to determine | 11 | | that the processes and strategies used to design each | 12 | | nonquantitative treatment limitation, as written, for | 13 | | mental, emotional, nervous, or substance use disorder | 14 | | or condition benefits are comparable to, and are | 15 | | applied no more stringently than, the processes and | 16 | | strategies used to design each nonquantitative | 17 | | treatment limitation, as written, for medical and | 18 | | surgical benefits; | 19 | | (D) provide the comparative analyses, including | 20 | | the results of the analyses, performed to determine | 21 | | that the processes and strategies used to apply each | 22 | | nonquantitative treatment limitation, in operation, | 23 | | for mental, emotional, nervous, or substance use | 24 | | disorder or condition benefits are comparable to, and | 25 | | applied no more stringently than, the processes or | 26 | | strategies used to apply each nonquantitative |
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| 1 | | treatment limitation, in operation, for medical and | 2 | | surgical benefits; and | 3 | | (E) disclose the specific findings and conclusions | 4 | | reached by the insurer that the results of the analyses | 5 | | described in subparagraphs (C) and (D) indicate that | 6 | | the insurer is in compliance with this Section and the | 7 | | Mental Health Parity and Addiction Equity Act of 2008 | 8 | | and its implementing regulations, which includes 42 | 9 | | CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any | 10 | | other related federal regulations found in the Code of | 11 | | Federal Regulations. | 12 | | (7) Any other information necessary to clarify data | 13 | | provided in accordance with this Section requested by the | 14 | | Director, including information that may be proprietary or | 15 | | have commercial value, under the requirements of Section 30 | 16 | | of the Viatical Settlements Act of 2009. | 17 | | (l) An insurer that amends, delivers, issues, or renews a | 18 | | group or individual policy of accident and health insurance or | 19 | | a qualified health plan offered through the health insurance | 20 | | marketplace in this State providing coverage for hospital or | 21 | | medical treatment and for the treatment of mental, emotional, | 22 | | nervous, or substance use disorders or conditions on or after | 23 | | the effective date of this amendatory Act of the 100th General | 24 | | Assembly shall, in advance of the plan year, make available to | 25 | | the Department or, with respect to medical assistance, the | 26 | | Department of Healthcare and Family Services and to all plan |
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| 1 | | participants and beneficiaries the information required in | 2 | | subparagraphs (C) through (E) of paragraph (6) of subsection | 3 | | (k). For plan participants and medical assistance | 4 | | beneficiaries, the information required in subparagraphs (C) | 5 | | through (E) of paragraph (6) of subsection (k) shall be made | 6 | | available on a publicly-available website whose web address is | 7 | | prominently displayed in plan and managed care organization | 8 | | informational and marketing materials. | 9 | | (m) In conjunction with its compliance examination program | 10 | | conducted in accordance with the Illinois State Auditing Act, | 11 | | the Auditor General shall undertake a review of
compliance by | 12 | | the Department and the Department of Healthcare and Family | 13 | | Services with Section 370c and this Section. Any
findings | 14 | | resulting from the review conducted under this Section shall be | 15 | | included in the applicable State agency's compliance | 16 | | examination report. Each compliance examination report shall | 17 | | be issued in accordance with Section 3-14 of the Illinois State
| 18 | | Auditing Act. A copy of each report shall also be delivered to
| 19 | | the head of the applicable State agency and posted on the | 20 | | Auditor General's website. | 21 | | (Source: P.A. 99-480, eff. 9-9-15.)
| 22 | | Section 99. Effective date. This Act takes effect January | 23 | | 1, 2019. |
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