HB5464 100TH GENERAL ASSEMBLY

LRB100 18700 SMS 33932 b

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.

A BILL FOR

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 97th General Assembly, every insurer which 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 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.

(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.

(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 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 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.

(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.

(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:

(A) schizophrenia;

(B) paranoid and other psychotic disorders;

(C) bipolar disorders (hypomanic, manic, depressive, and mixed);

(D) major depressive disorders (single episode or recurrent);

(E) schizoaffective disorders (bipolar or depressive);

(F) pervasive developmental disorders;

(G) obsessive-compulsive disorders;

(H) depression in childhood and adolescence;

(I) panic disorder;

(J) post-traumatic stress disorders (acute, chronic, or with delayed onset); and

(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 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 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 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 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 the effective date of this amendatory Act of the 97th General Assembly:

(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:

(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 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 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.

(7) (Blank).

(8) (Blank).

(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) 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 this amendatory Act of the 100th General Assembly, shall provide unlimited benefits for inpatient and outpatient treatment of mental, emotional, nervous, or substance use disorder or conditions at in-network facilities. The services for the treatment of mental, emotional, nervous, or substance use disorder or condition shall be prescribed by a licensed physician, licensed psychologist, licensed psychiatrist, or licensed advanced practice registered nurse and provided by licensed health care professionals or licensed or certified mental, emotional, nervous, or substance use disorder or conditions providers in licensed, certified, or otherwise State-approved facilities.

Benefits under this subsection shall be as follows:

(1) The benefits provided for treatment services for the first 180 days per plan year of inpatient and outpatient treatment of mental, emotional, nervous, or substance use disorder or conditions shall be provided when determined medically necessary by the covered person's licensed physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider without the imposition of any prior authorization or other prospective utilization review requirements. The facility or provider shall notify the insurer of both the admission and the initial treatment plan within 48 hours after admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, the insurer shall provide necessary exceptions to its network to ensure admission and treatment with a provider or at a treatment facility within 24 hours.

(2) The benefits for the first 28 days of an inpatient stay, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, and outpatient treatment during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined solely by the covered person's physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider.

(3) The benefits for days 29 and thereafter of inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, and outpatient treatment shall be subject to concurrent review as defined in the Health Carrier External Review Act. A request for approval of inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, and outpatient treatment beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, and outpatient treatment beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No insurer shall initiate concurrent review more frequently than at two-week intervals. If an insurer determines that continued inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment in a facility is no longer medically necessary, the insurer shall, within 24 hours, provide written notice to the covered person and the covered person's physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider of its decision and the right to file an expedited internal appeal of the determination. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider. If the determination is to uphold the denial, the covered person and the covered person's physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider have the right to file an expedited external appeal. An independent utilization review organization shall make a determination within 24 hours. If the insurer's determination is upheld and it is determined continued inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment is not medically necessary, the insurer shall remain responsible to provide benefits for the inpatient care, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible, and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility, detoxification/withdrawal management, partial hospitalization, intensive outpatient treatment, or outpatient treatment until all internal appeals and independent utilization review organization appeals are exhausted.

(4) The benefits for outpatient prescription drugs to treat mental, emotional, nervous, or substance use disorder or conditions shall be provided when determined medically necessary by the covered person's physician, licensed psychologist, licensed psychiatrist, licensed advanced practice registered nurse, or licensed or certified mental, emotional, nervous, or substance use disorder or conditions provider with prescriptive authority, without the imposition of any prior authorization or other prospective utilization management requirements.

(5) The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for 2 outpatient visits. All extended outpatient services, such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection.

(6) Except as otherwise stated in this subsection, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy.

(7) The benefits required by this subsection are to be provided to all covered persons with a diagnosis of mental, emotional, nervous, or 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.

(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)