100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB5464

 

Introduced , by Rep. Sara Feigenholtz

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c  from Ch. 73, par. 982c

    Amends the Illinois Insurance Code. Provides that a group health insurance policy, an individual health policy, a group policy of accident and health insurance, group health benefit plan, 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 the amendatory Act, shall provide unlimited benefits for inpatient and outpatient treatment of mental, emotional, nervous, or substance use disorder or conditions at in-network facilities. Provides specified benefits for treatment of mental, emotional, nervous, or substance use disorders or conditions.


LRB100 18700 SMS 33932 b

 

 

A BILL FOR

 

HB5464LRB100 18700 SMS 33932 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 370c as follows:
 
6    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
7    Sec. 370c. Mental and emotional disorders.
8    (a)(1) On and after the effective date of this amendatory
9Act of the 97th General Assembly, every insurer which amends,
10delivers, issues, or renews group accident and health policies
11providing coverage for hospital or medical treatment or
12services for illness on an expense-incurred basis shall offer
13to the applicant or group policyholder subject to the insurer's
14standards of insurability, coverage for reasonable and
15necessary treatment and services for mental, emotional or
16nervous disorders or conditions, other than serious mental
17illnesses as defined in item (2) of subsection (b), consistent
18with the parity requirements of Section 370c.1 of this Code.
19    (2) Each insured that is covered for mental, emotional,
20nervous, or substance use disorders or conditions shall be free
21to select the physician licensed to practice medicine in all
22its branches, licensed clinical psychologist, licensed
23clinical social worker, licensed clinical professional

 

 

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1counselor, licensed marriage and family therapist, licensed
2speech-language pathologist, or other licensed or certified
3professional at a program licensed pursuant to the Illinois
4Alcoholism and Other Drug Abuse and Dependency Act of his
5choice to treat such disorders, and the insurer shall pay the
6covered charges of such physician licensed to practice medicine
7in all its branches, licensed clinical psychologist, licensed
8clinical social worker, licensed clinical professional
9counselor, licensed marriage and family therapist, licensed
10speech-language pathologist, or other licensed or certified
11professional at a program licensed pursuant to the Illinois
12Alcoholism and Other Drug Abuse and Dependency Act up to the
13limits of coverage, provided (i) the disorder or condition
14treated is covered by the policy, and (ii) the physician,
15licensed psychologist, licensed clinical social worker,
16licensed clinical professional counselor, licensed marriage
17and family therapist, licensed speech-language pathologist, or
18other licensed or certified professional at a program licensed
19pursuant to the Illinois Alcoholism and Other Drug Abuse and
20Dependency Act is authorized to provide said services under the
21statutes of this State and in accordance with accepted
22principles of his profession.
23    (3) Insofar as this Section applies solely to licensed
24clinical social workers, licensed clinical professional
25counselors, licensed marriage and family therapists, licensed
26speech-language pathologists, and other licensed or certified

 

 

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1professionals at programs licensed pursuant to the Illinois
2Alcoholism and Other Drug Abuse and Dependency Act, those
3persons who may provide services to individuals shall do so
4after the licensed clinical social worker, licensed clinical
5professional counselor, licensed marriage and family
6therapist, licensed speech-language pathologist, or other
7licensed or certified professional at a program licensed
8pursuant to the Illinois Alcoholism and Other Drug Abuse and
9Dependency Act has informed the patient of the desirability of
10the patient conferring with the patient's primary care
11physician and the licensed clinical social worker, licensed
12clinical professional counselor, licensed marriage and family
13therapist, licensed speech-language pathologist, or other
14licensed or certified professional at a program licensed
15pursuant to the Illinois Alcoholism and Other Drug Abuse and
16Dependency Act has provided written notification to the
17patient's primary care physician, if any, that services are
18being provided to the patient. That notification may, however,
19be waived by the patient on a written form. Those forms shall
20be retained by the licensed clinical social worker, licensed
21clinical professional counselor, licensed marriage and family
22therapist, licensed speech-language pathologist, or other
23licensed or certified professional at a program licensed
24pursuant to the Illinois Alcoholism and Other Drug Abuse and
25Dependency Act for a period of not less than 5 years.
26    (b)(1) An insurer that provides coverage for hospital or

 

 

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1medical expenses under a group or individual policy of accident
2and health insurance or health care plan amended, delivered,
3issued, or renewed on or after the effective date of this
4amendatory Act of the 100th General Assembly shall provide
5coverage under the policy for treatment of serious mental
6illness and substance use disorders consistent with the parity
7requirements of Section 370c.1 of this Code. This subsection
8does not apply to any group policy of accident and health
9insurance or health care plan for any plan year of a small
10employer as defined in Section 5 of the Illinois Health
11Insurance Portability and Accountability Act.
12    (2) "Serious mental illness" means the following
13psychiatric illnesses as defined in the most current edition of
14the Diagnostic and Statistical Manual (DSM) published by the
15American Psychiatric Association:
16        (A) schizophrenia;
17        (B) paranoid and other psychotic disorders;
18        (C) bipolar disorders (hypomanic, manic, depressive,
19    and mixed);
20        (D) major depressive disorders (single episode or
21    recurrent);
22        (E) schizoaffective disorders (bipolar or depressive);
23        (F) pervasive developmental disorders;
24        (G) obsessive-compulsive disorders;
25        (H) depression in childhood and adolescence;
26        (I) panic disorder;

 

 

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1        (J) post-traumatic stress disorders (acute, chronic,
2    or with delayed onset); and
3        (K) eating disorders, including, but not limited to,
4    anorexia nervosa, bulimia nervosa, pica, rumination
5    disorder, avoidant/restrictive food intake disorder, other
6    specified feeding or eating disorder (OSFED), and any other
7    eating disorder contained in the most recent version of the
8    Diagnostic and Statistical Manual of Mental Disorders
9    published by the American Psychiatric Association.
10    (2.5) "Substance use disorder" means the following mental
11disorders as defined in the most current edition of the
12Diagnostic and Statistical Manual (DSM) published by the
13American Psychiatric Association:
14        (A) substance abuse disorders;
15        (B) substance dependence disorders; and
16        (C) substance induced disorders.
17    (3) Unless otherwise prohibited by federal law and
18consistent with the parity requirements of Section 370c.1 of
19this Code, the reimbursing insurer, a provider of treatment of
20serious mental illness or substance use disorder shall furnish
21medical records or other necessary data that substantiate that
22initial or continued treatment is at all times medically
23necessary. An insurer shall provide a mechanism for the timely
24review by a provider holding the same license and practicing in
25the same specialty as the patient's provider, who is
26unaffiliated with the insurer, jointly selected by the patient

 

 

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1(or the patient's next of kin or legal representative if the
2patient is unable to act for himself or herself), the patient's
3provider, and the insurer in the event of a dispute between the
4insurer and patient's provider regarding the medical necessity
5of a treatment proposed by a patient's provider. If the
6reviewing provider determines the treatment to be medically
7necessary, the insurer shall provide reimbursement for the
8treatment. Future contractual or employment actions by the
9insurer regarding the patient's provider may not be based on
10the provider's participation in this procedure. Nothing
11prevents the insured from agreeing in writing to continue
12treatment at his or her expense. When making a determination of
13the medical necessity for a treatment modality for serious
14mental illness or substance use disorder, an insurer must make
15the determination in a manner that is consistent with the
16manner used to make that determination with respect to other
17diseases or illnesses covered under the policy, including an
18appeals process. Medical necessity determinations for
19substance use disorders shall be made in accordance with
20appropriate patient placement criteria established by the
21American Society of Addiction Medicine. No additional criteria
22may be used to make medical necessity determinations for
23substance use disorders.
24    (4) A group health benefit plan amended, delivered, issued,
25or renewed on or after the effective date of this amendatory
26Act of the 97th General Assembly:

 

 

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1        (A) shall provide coverage based upon medical
2    necessity for the treatment of mental illness and substance
3    use disorders consistent with the parity requirements of
4    Section 370c.1 of this Code; provided, however, that in
5    each calendar year coverage shall not be less than the
6    following:
7            (i) 45 days of inpatient treatment; and
8            (ii) beginning on June 26, 2006 (the effective date
9        of Public Act 94-921), 60 visits for outpatient
10        treatment including group and individual outpatient
11        treatment; and
12            (iii) for plans or policies delivered, issued for
13        delivery, renewed, or modified after January 1, 2007
14        (the effective date of Public Act 94-906), 20
15        additional outpatient visits for speech therapy for
16        treatment of pervasive developmental disorders that
17        will be in addition to speech therapy provided pursuant
18        to item (ii) of this subparagraph (A); and
19        (B) may not include a lifetime limit on the number of
20    days of inpatient treatment or the number of outpatient
21    visits covered under the plan.
22        (C) (Blank).
23    (5) An issuer of a group health benefit plan may not count
24toward the number of outpatient visits required to be covered
25under this Section an outpatient visit for the purpose of
26medication management and shall cover the outpatient visits

 

 

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1under the same terms and conditions as it covers outpatient
2visits for the treatment of physical illness.
3    (5.5) An individual or group health benefit plan amended,
4delivered, issued, or renewed on or after the effective date of
5this amendatory Act of the 99th General Assembly shall offer
6coverage for medically necessary acute treatment services and
7medically necessary clinical stabilization services. The
8treating provider shall base all treatment recommendations and
9the health benefit plan shall base all medical necessity
10determinations for substance use disorders in accordance with
11the most current edition of the American Society of Addiction
12Medicine Patient Placement Criteria.
13    As used in this subsection:
14    "Acute treatment services" means 24-hour medically
15supervised addiction treatment that provides evaluation and
16withdrawal management and may include biopsychosocial
17assessment, individual and group counseling, psychoeducational
18groups, and discharge planning.
19    "Clinical stabilization services" means 24-hour treatment,
20usually following acute treatment services for substance
21abuse, which may include intensive education and counseling
22regarding the nature of addiction and its consequences, relapse
23prevention, outreach to families and significant others, and
24aftercare planning for individuals beginning to engage in
25recovery from addiction.
26    (6) An issuer of a group health benefit plan may provide or

 

 

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1offer coverage required under this Section through a managed
2care plan.
3    (7) (Blank).
4    (8) (Blank).
5    (9) With respect to substance use disorders, coverage for
6inpatient treatment shall include coverage for treatment in a
7residential treatment center licensed by the Department of
8Public Health or the Department of Human Services.
9    (c) This Section shall not be interpreted to require
10coverage for speech therapy or other habilitative services for
11those individuals covered under Section 356z.15 of this Code.
12    (d) The Department shall enforce the requirements of State
13and federal parity law, which includes ensuring compliance by
14individual and group policies; detecting violations of the law
15by individual and group policies proactively monitoring
16discriminatory practices; accepting, evaluating, and
17responding to complaints regarding such violations; and
18ensuring violations are appropriately remedied and deterred.
19    (e) Availability of plan information.
20        (1) The criteria for medical necessity determinations
21    made under a group health plan with respect to mental
22    health or substance use disorder benefits (or health
23    insurance coverage offered in connection with the plan with
24    respect to such benefits) must be made available by the
25    plan administrator (or the health insurance issuer
26    offering such coverage) to any current or potential

 

 

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1    participant, beneficiary, or contracting provider upon
2    request.
3        (2) The reason for any denial under a group health plan
4    (or health insurance coverage offered in connection with
5    such plan) of reimbursement or payment for services with
6    respect to mental health or substance use disorder benefits
7    in the case of any participant or beneficiary must be made
8    available within a reasonable time and in a reasonable
9    manner by the plan administrator (or the health insurance
10    issuer offering such coverage) to the participant or
11    beneficiary upon request.
12    (f) As used in this Section, "group policy of accident and
13health insurance" and "group health benefit plan" includes (1)
14State-regulated employer-sponsored group health insurance
15plans written in Illinois and (2) State employee health plans.
16    (g) A group health insurance policy, an individual health
17policy, a group policy of accident and health insurance, group
18health benefit plan, qualified health plan that is offered
19through the health insurance marketplace, small employer group
20health plan, and large employer group health plan that is
21amended, delivered, issued, executed, or renewed in this State,
22or approved for issuance or renewal in this State, on or after
23the effective date of this amendatory Act of the 100th General
24Assembly, shall provide unlimited benefits for inpatient and
25outpatient treatment of mental, emotional, nervous, or
26substance use disorder or conditions at in-network facilities.

 

 

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1The services for the treatment of mental, emotional, nervous,
2or substance use disorder or condition shall be prescribed by a
3licensed physician, licensed psychologist, licensed
4psychiatrist, or licensed advanced practice registered nurse
5and provided by licensed health care professionals or licensed
6or certified mental, emotional, nervous, or substance use
7disorder or conditions providers in licensed, certified, or
8otherwise State-approved facilities.
9    Benefits under this subsection shall be as follows:
10        (1) The benefits provided for treatment services for
11    the first 180 days per plan year of inpatient and
12    outpatient treatment of mental, emotional, nervous, or
13    substance use disorder or conditions shall be provided when
14    determined medically necessary by the covered person's
15    licensed physician, licensed psychologist, licensed
16    psychiatrist, licensed advanced practice registered nurse,
17    or licensed or certified mental, emotional, nervous, or
18    substance use disorder or conditions provider without the
19    imposition of any prior authorization or other prospective
20    utilization review requirements. The facility or provider
21    shall notify the insurer of both the admission and the
22    initial treatment plan within 48 hours after admission or
23    initiation of treatment. If there is no in-network facility
24    immediately available for a covered person, the insurer
25    shall provide necessary exceptions to its network to ensure
26    admission and treatment with a provider or at a treatment

 

 

HB5464- 12 -LRB100 18700 SMS 33932 b

1    facility within 24 hours.
2        (2) The benefits for the first 28 days of an inpatient
3    stay, detoxification/withdrawal management, partial
4    hospitalization, intensive outpatient treatment, and
5    outpatient treatment during each plan year shall be
6    provided without any retrospective review or concurrent
7    review of medical necessity and medical necessity shall be
8    as determined solely by the covered person's physician,
9    licensed psychologist, licensed psychiatrist, licensed
10    advanced practice registered nurse, or licensed or
11    certified mental, emotional, nervous, or substance use
12    disorder or conditions provider.
13        (3) The benefits for days 29 and thereafter of
14    inpatient care, detoxification/withdrawal management,
15    partial hospitalization, intensive outpatient treatment,
16    and outpatient treatment shall be subject to concurrent
17    review as defined in the Health Carrier External Review
18    Act. A request for approval of inpatient care,
19    detoxification/withdrawal management, partial
20    hospitalization, intensive outpatient treatment, and
21    outpatient treatment beyond the first 28 days shall be
22    submitted for concurrent review before the expiration of
23    the initial 28-day period. A request for approval of
24    inpatient care, detoxification/withdrawal management,
25    partial hospitalization, intensive outpatient treatment,
26    and outpatient treatment beyond any period that is approved

 

 

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1    under concurrent review shall be submitted within the
2    period that was previously approved. No insurer shall
3    initiate concurrent review more frequently than at
4    two-week intervals. If an insurer determines that
5    continued inpatient care, detoxification/withdrawal
6    management, partial hospitalization, intensive outpatient
7    treatment, or outpatient treatment in a facility is no
8    longer medically necessary, the insurer shall, within 24
9    hours, provide written notice to the covered person and the
10    covered person's physician, licensed psychologist,
11    licensed psychiatrist, licensed advanced practice
12    registered nurse, or licensed or certified mental,
13    emotional, nervous, or substance use disorder or
14    conditions provider of its decision and the right to file
15    an expedited internal appeal of the determination. The
16    insurer shall review and make a determination with respect
17    to the internal appeal within 24 hours and communicate such
18    determination to the covered person and the covered
19    person's physician, licensed psychologist, licensed
20    psychiatrist, licensed advanced practice registered nurse,
21    or licensed or certified mental, emotional, nervous, or
22    substance use disorder or conditions provider. If the
23    determination is to uphold the denial, the covered person
24    and the covered person's physician, licensed psychologist,
25    licensed psychiatrist, licensed advanced practice
26    registered nurse, or licensed or certified mental,

 

 

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1    emotional, nervous, or substance use disorder or
2    conditions provider have the right to file an expedited
3    external appeal. An independent utilization review
4    organization shall make a determination within 24 hours. If
5    the insurer's determination is upheld and it is determined
6    continued inpatient care, detoxification/withdrawal
7    management, partial hospitalization, intensive outpatient
8    treatment, or outpatient treatment is not medically
9    necessary, the insurer shall remain responsible to provide
10    benefits for the inpatient care, detoxification/withdrawal
11    management, partial hospitalization, intensive outpatient
12    treatment, or outpatient treatment through the day
13    following the date the determination is made and the
14    covered person shall only be responsible for any applicable
15    co-payment, deductible, and co-insurance for the stay
16    through that date as applicable under the policy. The
17    covered person shall not be discharged or released from the
18    inpatient facility, detoxification/withdrawal management,
19    partial hospitalization, intensive outpatient treatment,
20    or outpatient treatment until all internal appeals and
21    independent utilization review organization appeals are
22    exhausted.
23        (4) The benefits for outpatient prescription drugs to
24    treat mental, emotional, nervous, or substance use
25    disorder or conditions shall be provided when determined
26    medically necessary by the covered person's physician,

 

 

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1    licensed psychologist, licensed psychiatrist, licensed
2    advanced practice registered nurse, or licensed or
3    certified mental, emotional, nervous, or substance use
4    disorder or conditions provider with prescriptive
5    authority, without the imposition of any prior
6    authorization or other prospective utilization management
7    requirements.
8        (5) The first 180 days per plan year of benefits shall
9    be computed based on inpatient days. One or more unused
10    inpatient days may be exchanged for 2 outpatient visits.
11    All extended outpatient services, such as partial
12    hospitalization and intensive outpatient, shall be deemed
13    inpatient days for the purpose of the visit to day exchange
14    provided in this subsection.
15        (6) Except as otherwise stated in this subsection, the
16    benefits and cost-sharing shall be provided to the same
17    extent as for any other medical condition covered under the
18    policy.
19        (7) The benefits required by this subsection are to be
20    provided to all covered persons with a diagnosis of mental,
21    emotional, nervous, or substance use disorder or
22    conditions. The presence of additional related or
23    unrelated diagnoses shall not be a basis to reduce or deny
24    the benefits required by this subsection.
25(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)