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Public Act 100-1023 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 1. This Act may be referred to as the Emergency | ||||
Opioid and Addiction Treatment Access Act. | ||||
Section 3. Findings. The General Assembly finds and | ||||
declares the following: | ||||
(1) The opioid epidemic is the most significant public | ||||
health and public safety crisis in Illinois. | ||||
(2) Opioid overdoses have killed nearly 11,000 people | ||||
since 2008 and have now become the leading cause of death | ||||
nationwide for people under the age of 50. | ||||
(3) The opioid epidemic has devastated both rural and | ||||
urban Illinois residents. Families have lost their loved | ||||
ones to drug overdoses. Incidence of suicide are on the | ||||
rise. Illinois' criminal justice system is flooded with | ||||
individuals with critical substance use disorder treatment | ||||
needs. | ||||
(4) Speeding access to treatments will ensure that | ||||
Illinois residents suffering from a substance abuse crisis | ||||
will obtain the services they need. | ||||
Section 5. The Illinois Insurance Code is amended by |
changing Section 370c as follows:
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(215 ILCS 5/370c) (from Ch. 73, par. 982c)
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Sec. 370c. Mental and emotional disorders.
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(a)(1) On and after the effective date of this amendatory | ||
Act of the 97th General Assembly,
every insurer which amends, | ||
delivers, issues, or renews
group accident and health policies | ||
providing coverage for hospital or medical treatment or
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services for illness on an expense-incurred basis shall offer | ||
to the
applicant or group policyholder subject to the insurer's | ||
standards of
insurability, coverage for reasonable and | ||
necessary treatment and services
for mental, emotional or | ||
nervous disorders or conditions, other than serious
mental | ||
illnesses as defined in item (2) of subsection (b), consistent | ||
with the parity requirements of Section 370c.1 of this Code.
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(2) Each insured that is covered for mental, emotional, | ||
nervous, or substance use
disorders or conditions shall be free | ||
to select the physician licensed to
practice medicine in all | ||
its branches, licensed clinical psychologist,
licensed | ||
clinical social worker, licensed clinical professional | ||
counselor, licensed marriage and family therapist, licensed | ||
speech-language pathologist, or other licensed or certified | ||
professional at a program licensed pursuant to the Illinois | ||
Alcoholism and Other Drug Abuse and Dependency Act of
his | ||
choice to treat such disorders, and
the insurer shall pay the | ||
covered charges of such physician licensed to
practice medicine |
in all its branches, licensed clinical psychologist,
licensed | ||
clinical social worker, licensed clinical professional | ||
counselor, licensed marriage and family therapist, licensed | ||
speech-language pathologist, or other licensed or certified | ||
professional at a program licensed pursuant to the Illinois | ||
Alcoholism and Other Drug Abuse and Dependency Act up
to the | ||
limits of coverage, provided (i)
the disorder or condition | ||
treated is covered by the policy, and (ii) the
physician, | ||
licensed psychologist, licensed clinical social worker, | ||
licensed
clinical professional counselor, licensed marriage | ||
and family therapist, licensed speech-language pathologist, or | ||
other licensed or certified professional at a program licensed | ||
pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||
Dependency Act is
authorized to provide said services under the | ||
statutes of this State and in
accordance with accepted | ||
principles of his profession.
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(3) Insofar as this Section applies solely to licensed | ||
clinical social
workers, licensed clinical professional | ||
counselors, licensed marriage and family therapists, licensed | ||
speech-language pathologists, and other licensed or certified | ||
professionals at programs licensed pursuant to the Illinois | ||
Alcoholism and Other Drug Abuse and Dependency Act, those | ||
persons who may
provide services to individuals shall do so
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after the licensed clinical social worker, licensed clinical | ||
professional
counselor, licensed marriage and family | ||
therapist, licensed speech-language pathologist, or other |
licensed or certified professional at a program licensed | ||
pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||
Dependency Act has informed the patient of the
desirability of | ||
the patient conferring with the patient's primary care
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physician and the licensed clinical social worker, licensed | ||
clinical
professional counselor, licensed marriage and family | ||
therapist, licensed speech-language pathologist, or other | ||
licensed or certified professional at a program licensed | ||
pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||
Dependency Act has
provided written
notification to the | ||
patient's primary care physician, if any, that services
are | ||
being provided to the patient. That notification may, however, | ||
be
waived by the patient on a written form. Those forms shall | ||
be retained by
the licensed clinical social worker, licensed | ||
clinical professional counselor, licensed marriage and family | ||
therapist, licensed speech-language pathologist, or other | ||
licensed or certified professional at a program licensed | ||
pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||
Dependency Act
for a period of not less than 5 years.
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(b)(1) An insurer that provides coverage for hospital or | ||
medical
expenses under a group or individual policy of accident | ||
and health insurance or
health care plan amended, delivered, | ||
issued, or renewed on or after the effective
date of this | ||
amendatory Act of the 100th General Assembly shall provide | ||
coverage
under the policy for treatment of serious mental | ||
illness and substance use disorders consistent with the parity |
requirements of Section 370c.1 of this Code. This subsection | ||
does not apply to any group policy of accident and health | ||
insurance or health care plan for any plan year of a small | ||
employer as defined in Section 5 of the Illinois Health | ||
Insurance Portability and Accountability Act.
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(2) "Serious mental illness" means the following | ||
psychiatric illnesses as
defined in the most current edition of | ||
the Diagnostic and Statistical Manual
(DSM) published by the | ||
American Psychiatric Association:
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(A) schizophrenia;
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(B) paranoid and other psychotic disorders;
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(C) bipolar disorders (hypomanic, manic, depressive, | ||
and mixed);
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(D) major depressive disorders (single episode or | ||
recurrent);
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(E) schizoaffective disorders (bipolar or depressive);
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(F) pervasive developmental disorders;
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(G) obsessive-compulsive disorders;
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(H) depression in childhood and adolescence;
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(I) panic disorder; | ||
(J) post-traumatic stress disorders (acute, chronic, | ||
or with delayed onset); and
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(K) eating disorders, including, but not limited to, | ||
anorexia nervosa, bulimia nervosa, pica, rumination | ||
disorder, avoidant/restrictive food intake disorder, other | ||
specified feeding or eating disorder (OSFED), and any other |
eating disorder contained in the most recent version of the | ||
Diagnostic and Statistical Manual of Mental Disorders | ||
published by the American Psychiatric Association. | ||
(2.5) "Substance use disorder" means the following mental | ||
disorders as defined in the most current edition of the | ||
Diagnostic and Statistical Manual (DSM) published by the | ||
American Psychiatric Association: | ||
(A) substance abuse disorders; | ||
(B) substance dependence disorders; and | ||
(C) substance induced disorders. | ||
(3) Unless otherwise prohibited by federal law and | ||
consistent with the parity requirements of Section 370c.1 of | ||
this Code, the reimbursing insurer, a provider of treatment of
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serious mental illness or substance use disorder shall furnish | ||
medical records or other necessary data
that substantiate that | ||
initial or continued treatment is at all times medically
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necessary. An insurer shall provide a mechanism for the timely | ||
review by a
provider holding the same license and practicing in | ||
the same specialty as the
patient's provider, who is | ||
unaffiliated with the insurer, jointly selected by
the patient | ||
(or the patient's next of kin or legal representative if the
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patient is unable to act for himself or herself), the patient's | ||
provider, and
the insurer in the event of a dispute between the | ||
insurer and patient's
provider regarding the medical necessity | ||
of a treatment proposed by a patient's
provider. If the | ||
reviewing provider determines the treatment to be medically
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necessary, the insurer shall provide reimbursement for the | ||
treatment. Future
contractual or employment actions by the | ||
insurer regarding the patient's
provider may not be based on | ||
the provider's participation in this procedure.
Nothing | ||
prevents
the insured from agreeing in writing to continue | ||
treatment at his or her
expense. When making a determination of | ||
the medical necessity for a treatment
modality for serious | ||
mental illness or substance use disorder, an insurer must make | ||
the determination in a
manner that is consistent with the | ||
manner used to make that determination with
respect to other | ||
diseases or illnesses covered under the policy, including an
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appeals process. Medical necessity determinations for | ||
substance use disorders shall be made in accordance with | ||
appropriate patient placement criteria established by the | ||
American Society of Addiction Medicine. No additional criteria | ||
may be used to make medical necessity determinations for | ||
substance use disorders.
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(4) A group health benefit plan amended, delivered, issued, | ||
or renewed on or after the effective date of this amendatory | ||
Act of the 97th General Assembly:
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(A) shall provide coverage based upon medical | ||
necessity for the
treatment of mental illness and substance | ||
use disorders consistent with the parity requirements of | ||
Section 370c.1 of this Code; provided, however, that in | ||
each calendar year coverage shall not be less than the | ||
following:
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(i) 45 days of inpatient treatment; and
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(ii) beginning on June 26, 2006 (the effective date | ||
of Public Act 94-921), 60 visits for outpatient | ||
treatment including group and individual
outpatient | ||
treatment; and | ||
(iii) for plans or policies delivered, issued for | ||
delivery, renewed, or modified after January 1, 2007 | ||
(the effective date of Public Act 94-906),
20 | ||
additional outpatient visits for speech therapy for | ||
treatment of pervasive developmental disorders that | ||
will be in addition to speech therapy provided pursuant | ||
to item (ii) of this subparagraph (A); and
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(B) may not include a lifetime limit on the number of | ||
days of inpatient
treatment or the number of outpatient | ||
visits covered under the plan.
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(C) (Blank).
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(5) An issuer of a group health benefit plan may not count | ||
toward the number
of outpatient visits required to be covered | ||
under this Section an outpatient
visit for the purpose of | ||
medication management and shall cover the outpatient
visits | ||
under the same terms and conditions as it covers outpatient | ||
visits for
the treatment of physical illness.
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(5.5) An individual or group health benefit plan amended, | ||
delivered, issued, or renewed on or after the effective date of | ||
this amendatory Act of the 99th General Assembly shall offer | ||
coverage for medically necessary acute treatment services and |
medically necessary clinical stabilization services. The | ||
treating provider shall base all treatment recommendations and | ||
the health benefit plan shall base all medical necessity | ||
determinations for substance use disorders in accordance with | ||
the most current edition of the American Society of Addiction | ||
Medicine Patient Placement Criteria. | ||
As used in this subsection: | ||
"Acute treatment services" means 24-hour medically | ||
supervised addiction treatment that provides evaluation and | ||
withdrawal management and may include biopsychosocial | ||
assessment, individual and group counseling, psychoeducational | ||
groups, and discharge planning. | ||
"Clinical stabilization services" means 24-hour treatment, | ||
usually following acute treatment services for substance | ||
abuse, which may include intensive education and counseling | ||
regarding the nature of addiction and its consequences, relapse | ||
prevention, outreach to families and significant others, and | ||
aftercare planning for individuals beginning to engage in | ||
recovery from addiction. | ||
(6) An issuer of a group health benefit
plan may provide or | ||
offer coverage required under this Section through a
managed | ||
care plan.
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(7) (Blank).
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(8)
(Blank).
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(9) With respect to substance use disorders, coverage for | ||
inpatient treatment shall include coverage for treatment in a |
residential treatment center licensed by the Department of | ||
Public Health or the Department of Human Services. | ||
(c) This Section shall not be interpreted to require | ||
coverage for speech therapy or other habilitative services for | ||
those individuals covered under Section 356z.15
of this Code. | ||
(d) The Department shall enforce the requirements of State | ||
and federal parity law, which includes ensuring compliance by | ||
individual and group policies; detecting violations of the law | ||
by individual and group policies proactively monitoring | ||
discriminatory practices; accepting, evaluating, and | ||
responding to complaints regarding such violations; and | ||
ensuring violations are appropriately remedied and deterred. | ||
(e) Availability of plan information. | ||
(1) The criteria for medical necessity determinations | ||
made under a group health plan with respect to mental | ||
health or substance use disorder benefits (or health | ||
insurance coverage offered in connection with the plan with | ||
respect to such benefits) must be made available by the | ||
plan administrator (or the health insurance issuer | ||
offering such coverage) to any current or potential | ||
participant, beneficiary, or contracting provider upon | ||
request. | ||
(2) The reason for any denial under a group health plan | ||
(or health insurance coverage offered in connection with | ||
such plan) of reimbursement or payment for services with | ||
respect to mental health or substance use disorder benefits |
in the case of any participant or beneficiary must be made | ||
available within a reasonable time and in a reasonable | ||
manner by the plan administrator (or the health insurance | ||
issuer offering such coverage) to the participant or | ||
beneficiary upon request. | ||
(f) As used in this Section, "group policy of accident and | ||
health insurance" and "group health benefit plan" includes (1) | ||
State-regulated employer-sponsored group health insurance | ||
plans written in Illinois and (2) State employee health plans. | ||
(g) (1) As used in this subsection: | ||
"Benefits", with respect to insurers, means
the benefits | ||
provided for treatment services for inpatient and outpatient | ||
treatment of substance use disorders or conditions at American | ||
Society of Addiction Medicine levels of treatment 2.1 | ||
(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | ||
(Clinically Managed Low-Intensity Residential), 3.3 | ||
(Clinically Managed Population-Specific High-Intensity | ||
Residential), 3.5 (Clinically Managed High-Intensity | ||
Residential), and 3.7 (Medically Monitored Intensive | ||
Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||
"Benefits", with respect to managed care organizations, | ||
means the benefits provided for treatment services for | ||
inpatient and outpatient treatment of substance use disorders | ||
or conditions at American Society of Addiction Medicine levels | ||
of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | ||
Hospitalization), 3.5 (Clinically Managed High-Intensity |
Residential), and 3.7 (Medically Monitored Intensive | ||
Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||
"Substance use disorder treatment provider or facility" | ||
means a licensed physician, licensed psychologist, licensed | ||
psychiatrist, licensed advanced practice registered nurse, or | ||
licensed, certified, or otherwise State-approved facility or | ||
provider of substance use disorder treatment. | ||
(2) A group health insurance policy, an individual health | ||
benefit plan, or qualified health plan that is offered through | ||
the health insurance marketplace, small employer group health | ||
plan, and large employer group health plan that is amended, | ||
delivered, issued, executed, or renewed in this State, or | ||
approved for issuance or renewal in this State, on or after the | ||
effective date of this amendatory Act of the 100th General | ||
Assembly shall comply with the requirements of this Section and | ||
Section 370c.1. The services for the treatment and the ongoing | ||
assessment of the patient's progress in treatment shall follow | ||
the requirements of 77 Ill. Adm. Code 2060. | ||
(3) Prior authorization shall not be utilized for the | ||
benefits under this subsection. The substance use disorder | ||
treatment provider or facility shall notify the insurer of the | ||
initiation of treatment. For an insurer that is not a managed | ||
care organization, the substance use disorder treatment | ||
provider or facility notification shall occur for the | ||
initiation of treatment of the covered person within 2 business | ||
days. For managed care organizations, the substance use |
disorder treatment provider or facility notification shall | ||
occur in accordance with the protocol set forth in the provider | ||
agreement for initiation of treatment within 24 hours. If the | ||
managed care organization is not capable of accepting the | ||
notification in accordance with the contractual protocol | ||
during the 24-hour period following admission, the substance | ||
use disorder treatment provider or facility shall have one | ||
additional business day to provide the notification to the | ||
appropriate managed care organization. Treatment plans shall | ||
be developed in accordance with the requirements and timeframes | ||
established in 77 Ill. Adm. Code 2060. If the substance use | ||
disorder treatment provider or facility fails to notify the | ||
insurer of the initiation of treatment in accordance with these | ||
provisions, the insurer may follow its normal prior | ||
authorization processes. | ||
(4) For an insurer that is not a managed care organization, | ||
if an insurer determines that benefits are no longer medically | ||
necessary, the insurer shall notify the covered person, the | ||
covered person's authorized representative, if any, and the | ||
covered person's health care provider in writing of the covered | ||
person's right to request an external review pursuant to the | ||
Health Carrier External Review Act. The notification shall | ||
occur within 24 hours following the adverse determination. | ||
Pursuant to the requirements of the Health Carrier External | ||
Review Act, the covered person or the covered person's | ||
authorized representative may request an expedited external |
review.
An expedited external review may not occur if the | ||
substance use disorder treatment provider or facility | ||
determines that continued treatment is no longer medically | ||
necessary. Under this subsection, a request for expedited | ||
external review must be initiated within 24 hours following the | ||
adverse determination notification by the insurer. Failure to | ||
request an expedited external review within 24 hours shall | ||
preclude a covered person or a covered person's authorized | ||
representative from requesting an expedited external review. | ||
If an expedited external review request meets the criteria | ||
of the Health Carrier External Review Act, an independent | ||
review organization shall make a final determination of medical | ||
necessity within 72 hours. If an independent review | ||
organization upholds an adverse determination, an insurer | ||
shall remain responsible to provide coverage of benefits | ||
through the day following the determination of the independent | ||
review organization. A decision to reverse an adverse | ||
determination shall comply with the Health Carrier External | ||
Review Act. | ||
(5) The substance use disorder treatment provider or | ||
facility shall provide the insurer with 7 business days' | ||
advance notice of the planned discharge of the patient from the | ||
substance use disorder treatment provider or facility and | ||
notice on the day that the patient is discharged from the | ||
substance use disorder treatment provider or facility. | ||
(6) The benefits required by this subsection shall be |
provided to all covered persons with a diagnosis of substance | ||
use disorder or conditions. The presence of additional related | ||
or unrelated diagnoses shall not be a basis to reduce or deny | ||
the benefits required by this subsection. | ||
(7) Nothing in this subsection shall be construed to | ||
require an insurer to provide coverage for any of the benefits | ||
in this subsection. | ||
(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2019.
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