Public Act 101-0386
 
HB2438 EnrolledLRB101 08404 RAB 53474 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
 
    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
    Sec. 370c. Mental and emotional disorders.
    (a)(1) On and after the effective date of this amendatory
Act of the 101st General Assembly this amendatory Act of the
100th General Assembly, every insurer that amends, delivers,
issues, or renews group accident and health policies providing
coverage for hospital or medical treatment or services for
illness on an expense-incurred basis shall provide coverage for
reasonable and necessary treatment and services for mental,
emotional, nervous, or substance use disorders or conditions
consistent with the parity requirements of Section 370c.1 of
this Code.
    (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 Substance
Use Disorder 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 Substance Use Disorder 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 Substance Use Disorder 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.
    (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 Substance
Use Disorder Illinois Alcoholism and Other Drug Abuse and
Dependency Act, those persons who may provide services to
individuals shall do so 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 Substance Use Disorder
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 physician.
    (4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental and
behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental health
condition that occurs during pregnancy or during the postpartum
period and includes, but is not limited to, postpartum
depression.
    (b)(1) (Blank).
    (2) (Blank).
    (2.5) (Blank).
    (3) Unless otherwise prohibited by federal law and
consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance, a qualified health plan offered through the
health insurance marketplace, or a provider of treatment of
mental, emotional, nervous, or substance use disorders or
conditions shall furnish medical records or other necessary
data that substantiate that initial or continued treatment is
at all times medically 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 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 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 mental, emotional, nervous, or substance use
disorders or conditions, 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 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.
    (4) A group health benefit plan amended, delivered, issued,
or renewed on or after January 1, 2019 (the effective date of
Public Act 100-1024) this amendatory Act of the 100th General
Assembly or an individual policy of accident and health
insurance or a qualified health plan offered through the health
insurance marketplace amended, delivered, issued, or renewed
on or after January 1, 2019 (the effective date of Public Act
100-1024) this amendatory Act of the 100th General Assembly:
        (A) shall provide coverage based upon medical
    necessity for the treatment of a mental, emotional,
    nervous, or substance use disorder or condition 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:
            (i) 45 days of inpatient treatment; and
            (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
        (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.
        (C) (Blank).
    (5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a
qualified health plan offered through the health insurance
marketplace 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.
    (5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after September 9, 2015
(the effective date of Public Act 99-480) 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 Treatment Criteria for Addictive, Substance-Related, and
Co-Occurring Conditions established by the American Society of
Addiction Medicine. The treating provider shall base all
treatment recommendations and the health benefit plan shall
base all medical necessity determinations for
medication-assisted treatment in accordance with the most
current Treatment Criteria for Addictive, Substance-Related,
and Co-Occurring Conditions established by the American
Society of Addiction Medicine.
    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.
    (6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024) this amendatory Act of
the 100th General Assembly:
        (A) shall not impose prior authorization requirements,
    other than those established under the Treatment Criteria
    for Addictive, Substance-Related, and Co-Occurring
    Conditions established by the American Society of
    Addiction Medicine, on a prescription medication approved
    by the United States Food and Drug Administration that is
    prescribed or administered for the treatment of substance
    use disorders;
        (B) shall not impose any step therapy requirements,
    other than those established under the Treatment Criteria
    for Addictive, Substance-Related, and Co-Occurring
    Conditions established by the American Society of
    Addiction Medicine, before authorizing coverage for a
    prescription medication approved by the United States Food
    and Drug Administration that is prescribed or administered
    for the treatment of substance use disorders;
        (C) shall place all prescription medications approved
    by the United States Food and Drug Administration
    prescribed or administered for the treatment of substance
    use disorders on, for brand medications, the lowest tier of
    the drug formulary developed and maintained by the
    individual or group health benefit plan that covers brand
    medications and, for generic medications, the lowest tier
    of the drug formulary developed and maintained by the
    individual or group health benefit plan that covers generic
    medications; and
        (D) shall not exclude coverage for a prescription
    medication approved by the United States Food and Drug
    Administration for the treatment of substance use
    disorders and any associated counseling or wraparound
    services on the grounds that such medications and services
    were court ordered.
    (7) (Blank).
    (8) (Blank).
    (9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
treatment shall include coverage for treatment in a residential
treatment center certified or 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) With respect to a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace, the
Department and, with respect to medical assistance, the
Department of Healthcare and Family Services shall each enforce
the requirements of this Section and Sections 356z.23 and
370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance or
regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity Act
of 2008 and final regulations applying the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 to Medicaid managed care organizations, the Children's
Health Insurance Program, and alternative benefit plans.
Specifically, the Department and the Department of Healthcare
and Family Services shall take action:
        (1) proactively ensuring compliance by individual and
    group policies, including by requiring that insurers
    submit comparative analyses, as set forth in paragraph (6)
    of subsection (k) of Section 370c.1, demonstrating how they
    design and apply nonquantitative treatment limitations,
    both as written and in operation, for mental, emotional,
    nervous, or substance use disorder or condition benefits as
    compared to how they design and apply nonquantitative
    treatment limitations, as written and in operation, for
    medical and surgical benefits;
        (2) evaluating all consumer or provider complaints
    regarding mental, emotional, nervous, or substance use
    disorder or condition coverage for possible parity
    violations;
        (3) performing parity compliance market conduct
    examinations or, in the case of the Department of
    Healthcare and Family Services, parity compliance audits
    of individual and group plans and policies, including, but
    not limited to, reviews of:
            (A) nonquantitative treatment limitations,
        including, but not limited to, prior authorization
        requirements, concurrent review, retrospective review,
        step therapy, network admission standards,
        reimbursement rates, and geographic restrictions;
            (B) denials of authorization, payment, and
        coverage; and
            (C) other specific criteria as may be determined by
        the Department.
    The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
    The Director may adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance.
    (e) Availability of plan information.
        (1) The criteria for medical necessity determinations
    made under a group health plan, an individual policy of
    accident and health insurance, or a qualified health plan
    offered through the health insurance marketplace 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
    benefit plan, an individual policy of accident and health
    insurance, or a qualified health plan offered through the
    health insurance marketplace (or health insurance coverage
    offered in connection with such plan or policy) of
    reimbursement or payment for services with respect to
    mental, emotional, nervous, or substance use disorders or
    conditions benefits in the case of any participant or
    beneficiary must be made available within a reasonable time
    and in a reasonable manner and in readily understandable
    language 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 or which purport to provide coverage
for a resident of this State; 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
January 1, 2019 (the effective date of Public Act 100-1023)
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;
100-1023, eff. 1-1-19; 100-1024, eff. 1-1-19; revised
10-18-18.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.