Full Text of HB2595 102nd General Assembly
HB2595eng 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. This Act may be referred to as the Generally | 5 | | Accepted Standards of Behavioral Health Care Act of 2021. | 6 | | Section 2. The General Assembly finds and declares the | 7 | | following:
| 8 | | (a) The State of Illinois and the entire country faces a | 9 | | mental health and addiction crisis.
| 10 | | (1) One in 5 adults experience a mental health | 11 | | disorder, and data from 2017 shows that one in 12 had a | 12 | | substance use disorder. The COVID-19 pandemic has | 13 | | exacerbated the nation's mental health and addiction | 14 | | crisis. According the U.S. Center for Disease Control and | 15 | | Prevention, since the start of the COVID-19 pandemic, | 16 | | Americans have experienced higher rates of depression, | 17 | | anxiety, and trauma, and rates of substance use and | 18 | | suicidal ideation have increased.
| 19 | | (2) Nationally, the suicide rate has increased 35% in | 20 | | the past 20 years. According to the Illinois Department of | 21 | | Public Health, more than 1,000 Illinoisans die by suicide | 22 | | every year, including 1,439 deaths in 2019, and it is the | 23 | | third leading cause of death among young adults aged 15 to |
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| 1 | | 34.
| 2 | | (3) Between 2013 and 2019, Illinois saw a 1,861% | 3 | | increase in synthetic opioid overdose deaths and a 68% | 4 | | increase in heroin overdose deaths. In 2019 alone, there | 5 | | were 2.3 and 2 times as many opioid deaths as homicides and | 6 | | car crash deaths, respectively.
| 7 | | (4) Communities of color are disproportionately | 8 | | impacted by lack of access to and inequities in mental | 9 | | health and substance use disorder care.
| 10 | | (A) According to the Substance Abuse and Mental | 11 | | Health Services Administration, two-thirds of Black | 12 | | and Hispanic Americans with a mental illness and | 13 | | nearly 90% with a substance use disorder do not | 14 | | receive medically necessary treatment.
| 15 | | (B) Data from the U.S. Census Bureau demonstrates | 16 | | that Black Americans saw the highest increases in | 17 | | rates of anxiety and depression in 2020.
| 18 | | (C) Data from the Illinois Department of Public | 19 | | Health reveals that Black Illinoisans are hospitalized | 20 | | for opioid overdoses at a rate 6 times higher than | 21 | | white Illinoisans.
| 22 | | (D) In the first half of 2020, the number of | 23 | | suicides among Black Chicagoans had increased 106% | 24 | | from the previous year. Nationally, from 2001 to 2017, | 25 | | suicide rates doubled among Black girls aged 13 to 19 | 26 | | and increased 60% for Black boys of the same age.
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| 1 | | (E) According to the Substance Abuse and Mental | 2 | | Health Services Administration, between 2008 and 2018 | 3 | | there were significant increases in serious mental | 4 | | illness and suicide ideation in Hispanics aged 18 to | 5 | | 25 and there remains a large gap in treatment need | 6 | | among Hispanics.
| 7 | | (5) According to the U.S. Center for Disease Control | 8 | | and Prevention, children with adverse childhood | 9 | | experiences are more likely to experience negative | 10 | | outcomes like post-traumatic stress disorder, increased | 11 | | anxiety and depression, suicide, and substance use. A 2020 | 12 | | report from Mental Health America shows that 62.1% of | 13 | | Illinois youth with severe depression do not receive any | 14 | | mental health treatment. Survey results found that 80% of | 15 | | college students report that COVID-19 has negatively | 16 | | impacted their mental health.
| 17 | | (6) In rural communities, between 2001 and 2015, the | 18 | | suicide rate increased by 27%, and between 1999 and 2015 | 19 | | the overdose rate increased 325%.
| 20 | | (7) According to the U.S. Department of Veterans | 21 | | Affairs, 154 veterans died by suicide in 2018, which | 22 | | accounts for more than 10% of all suicide deaths reported | 23 | | by the Illinois Department of Public Health in the same | 24 | | year, despite only accounting for approximately 5.7% of | 25 | | the State's total population. Nationally, between 2008 and | 26 | | 2017, more than 6,000 veterans died by suicide each year.
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| 1 | | (8) According to the National Alliance on Mental | 2 | | Illness, 2,000,000 people with mental illness are | 3 | | incarcerated every year, where they do not receive the | 4 | | treatment they need.
| 5 | | (b) A recent landmark federal court ruling offers a | 6 | | concrete demonstration of how the mental health and addiction | 7 | | crisis described in subsection (a) is worsened through the | 8 | | denial of medically necessary mental health and substance use | 9 | | disorder treatment.
| 10 | | (1) In March 2019, the United States District Court of | 11 | | the Northern District of California ruled in Wit v. United | 12 | | Behavioral Health, 2019 WL 1033730 (Wit; N.D.CA Mar. 5, | 13 | | 2019), that United Behavioral Health created flawed level | 14 | | of care placement criteria that were inconsistent with | 15 | | generally accepted standards of mental health and | 16 | | substance use disorder care in order to "mitigate" the | 17 | | requirements of the federal Mental Health Parity and | 18 | | Addiction Equity Act of 2008.
| 19 | | (2) As described by the federal court in Wit, the 8 | 20 | | generally accepted standards of mental health and | 21 | | substance use disorder care require all of the following:
| 22 | | (A) Effective treatment of underlying conditions, | 23 | | rather than mere amelioration of current symptoms, | 24 | | such as suicidality or psychosis.
| 25 | | (B) Treatment of co-occurring behavioral health | 26 | | disorders or medical conditions in a coordinated |
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| 1 | | manner.
| 2 | | (C) Treatment at the least intensive and | 3 | | restrictive level of care that is safe and effective | 4 | | and meets the needs of the patient's condition; a | 5 | | lower level or less intensive care is appropriate only | 6 | | if it is safe and just as effective as treatment at a | 7 | | higher level or service intensity.
| 8 | | (D) Erring on the side of caution, by placing | 9 | | patients in higher levels of care when there is | 10 | | ambiguity as to the appropriate level of care, or when | 11 | | the recommended level of care is not available.
| 12 | | (E) Treatment to maintain functioning or prevent | 13 | | deterioration.
| 14 | | (F) Treatment of mental health and substance use | 15 | | disorders for an appropriate duration based on | 16 | | individual patient needs rather than on specific time | 17 | | limits.
| 18 | | (G) Accounting for the unique needs of children | 19 | | and adolescents when making level of care decisions.
| 20 | | (H) Applying multidimensional assessments of | 21 | | patient needs when making determinations regarding the | 22 | | appropriate level of care.
| 23 | | (3) The court in Wit found that all parties' expert | 24 | | witnesses regarded the American Society of Addiction | 25 | | Medicine (ASAM) criteria for substance use disorders and | 26 | | Level of Care Utilization System (LOCUS), Child and |
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| 1 | | Adolescent Level of Care Utilization System (CALOCUS), | 2 | | Child and Adolescent Service Intensity Instrument (CASII), | 3 | | and Early Childhood Service Intensity Instrument (ECSII) | 4 | | criteria for mental health disorders as prime examples of | 5 | | level of care criteria that are fully consistent with | 6 | | generally accepted standards of mental health and | 7 | | substance use care.
| 8 | | (4) In particular, the coverage of intermediate levels | 9 | | of care, such as residential treatment, which are | 10 | | essential components of the level of care continuum called | 11 | | for by nonprofit, and clinical specialty associations such | 12 | | as the American Society of Addiction Medicine, are often | 13 | | denied through overly restrictive medical necessity | 14 | | determinations.
| 15 | | (5) On November 3, 2020, the court issued a remedies | 16 | | order requiring United Behavioral Health to reprocess | 17 | | 67,000 mental health and substance use disorder claims and | 18 | | mandating that, for the next decade, United Behavioral | 19 | | Health must use the relevant nonprofit clinical society | 20 | | guidelines for its medical necessity determinations.
| 21 | | (6) The court's findings also demonstrated how United | 22 | | Behavioral Health was in violation of Section 370c of the | 23 | | Illinois Insurance Code for its failure to use the | 24 | | American Society of Addiction Medicine Criteria for | 25 | | substance use disorders. The results of market conduct | 26 | | examinations released by the Illinois Department of |
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| 1 | | Insurance on July 15, 2020 confirmed these findings citing | 2 | | United Healthcare and CIGNA for their failure to use the | 3 | | American Society of Addiction Medicine Criteria when | 4 | | making medical necessity determinations for substance use | 5 | | disorders as required by Illinois law.
| 6 | | (c) Insurers should not be permitted to deny medically | 7 | | necessary mental health and substance use disorder care | 8 | | through the use of utilization review practices and criteria | 9 | | that are inconsistent with generally accepted standards of | 10 | | mental health and substance use disorder care.
| 11 | | (1) Illinois parity law (Sections 370c and 370c.1 of | 12 | | the Illinois Insurance Code) requires that health plans | 13 | | treat illnesses of the brain, such as addiction and | 14 | | depression, the same way they treat illness of other parts | 15 | | of the body, such as cancer and diabetes. The Illinois | 16 | | General Assembly significantly strengthened Illinois' | 17 | | parity law, which incorporates provisions of the federal | 18 | | Paul Wellstone and Pete Domenici Mental Health Parity and | 19 | | Addiction Equity Act of 2008, in both 2015 and 2018.
| 20 | | (2) While the federal Patient Protection and | 21 | | Affordable Care Act includes mental health and addiction | 22 | | coverage as one of the 10 essential health benefits, it | 23 | | does not contain a definition for medical necessity, and | 24 | | despite the Patient Protection and Affordable Care Act, | 25 | | needed mental health and addiction coverage can be denied | 26 | | through overly restrictive medical necessity |
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| 1 | | determinations.
| 2 | | (3) Despite the strong actions taken by the Illinois | 3 | | General Assembly, the court in Wit v. United Behavioral | 4 | | Health demonstrated how insurers can mitigate compliance | 5 | | with parity laws due by denying medically necessary mental | 6 | | health and treatment by using flawed medical necessity | 7 | | criteria.
| 8 | | (4) When medically necessary mental health and | 9 | | substance use disorder care is denied, the manifestations | 10 | | of the mental health and addiction crisis described in | 11 | | subsection (a) are severely exacerbated. Individuals with | 12 | | mental health and substance use disorders often have their | 13 | | conditions worsen, sometimes ending up in the criminal | 14 | | justice system or on the streets, resulting in increased | 15 | | emergency hospitalizations, harm to individuals and | 16 | | communities, and higher costs to taxpayers.
| 17 | | (5) In order to realize the promise of mental health | 18 | | and addiction parity and remove barriers to mental health | 19 | | and substance use disorder care for all Illinoisans, | 20 | | insurers must be required to cover medically necessary | 21 | | mental health and substance use disorder care and follow | 22 | | generally accepted standards of mental health and | 23 | | substance use disorder care. | 24 | | Section 5. The Illinois Insurance Code is amended by | 25 | | changing Section 370c as follows:
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| 1 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 2 | | Sec. 370c. Mental and emotional disorders.
| 3 | | (a)(1) On and after the effective date of this amendatory | 4 | | Act of the 102nd General Assembly January 1, 2019 (the | 5 | | effective date of this amendatory Act of the 101st General | 6 | | Assembly Public Act 100-1024) ,
every insurer that amends, | 7 | | delivers, issues, or renews
group accident and health policies | 8 | | providing coverage for hospital or medical treatment or
| 9 | | services for illness on an expense-incurred basis shall | 10 | | provide coverage for the medically necessary treatment of | 11 | | reasonable and necessary treatment and services
for mental, | 12 | | emotional, nervous, or substance use disorders or conditions | 13 | | consistent with the parity requirements of Section 370c.1 of | 14 | | this Code.
| 15 | | (2) Each insured that is covered for mental, emotional, | 16 | | nervous, or substance use
disorders or conditions shall be | 17 | | free to select the physician licensed to
practice medicine in | 18 | | all its branches, licensed clinical psychologist,
licensed | 19 | | clinical social worker, licensed clinical professional | 20 | | counselor, licensed marriage and family therapist, licensed | 21 | | speech-language pathologist, or other licensed or certified | 22 | | professional at a program licensed pursuant to the Substance | 23 | | Use Disorder Act of
his or her choice to treat such disorders, | 24 | | and
the insurer shall pay the covered charges of such | 25 | | physician licensed to
practice medicine in all its branches, |
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| 1 | | licensed clinical psychologist,
licensed clinical social | 2 | | worker, licensed clinical professional counselor, licensed | 3 | | marriage and family therapist, licensed speech-language | 4 | | pathologist, or other licensed or certified professional at a | 5 | | program licensed pursuant to the Substance Use Disorder Act up
| 6 | | to the limits of coverage, provided (i)
the disorder or | 7 | | condition treated is covered by the policy, and (ii) the
| 8 | | physician, licensed psychologist, licensed clinical social | 9 | | worker, licensed
clinical professional counselor, licensed | 10 | | marriage and family therapist, licensed speech-language | 11 | | pathologist, or other licensed or certified professional at a | 12 | | program licensed pursuant to the Substance Use Disorder Act is
| 13 | | authorized to provide said services under the statutes of this | 14 | | State and in
accordance with accepted principles of his or her | 15 | | profession.
| 16 | | (3) Insofar as this Section applies solely to licensed | 17 | | clinical social
workers, licensed clinical professional | 18 | | counselors, licensed marriage and family therapists, licensed | 19 | | speech-language pathologists, and other licensed or certified | 20 | | professionals at programs licensed pursuant to the Substance | 21 | | Use Disorder Act, those persons who may
provide services to | 22 | | individuals shall do so
after the licensed clinical social | 23 | | worker, licensed clinical professional
counselor, licensed | 24 | | marriage and family therapist, licensed speech-language | 25 | | pathologist, or other licensed or certified professional at a | 26 | | program licensed pursuant to the Substance Use Disorder Act |
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| 1 | | has informed the patient of the
desirability of the patient | 2 | | conferring with the patient's primary care
physician.
| 3 | | (4) "Mental, emotional, nervous, or substance use disorder | 4 | | or condition" means a condition or disorder that involves a | 5 | | mental health condition or substance use disorder that falls | 6 | | under any of the diagnostic categories listed in the mental | 7 | | and behavioral disorders chapter of the current edition of the | 8 | | World Health Organization's International Classification of | 9 | | Disease or that is listed in the most recent version of the | 10 | | American Psychiatric Association's Diagnostic and Statistical | 11 | | Manual of Mental Disorders. "Mental, emotional, nervous, or | 12 | | substance use disorder or condition" includes any mental | 13 | | health condition that occurs during pregnancy or during the | 14 | | postpartum period and includes, but is not limited to, | 15 | | postpartum depression. | 16 | | (5) Medically necessary treatment and medical necessity | 17 | | determinations shall be interpreted and made in a manner that | 18 | | is consistent with and pursuant to subsections (h) through | 19 | | (t). | 20 | | (b)(1) (Blank).
| 21 | | (2) (Blank).
| 22 | | (2.5) (Blank). | 23 | | (3) Unless otherwise prohibited by federal law and | 24 | | consistent with the parity requirements of Section 370c.1 of | 25 | | this Code, the reimbursing insurer that amends, delivers, | 26 | | issues, or renews a group or individual policy of accident and |
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| 1 | | health insurance, a qualified health plan offered through the | 2 | | health insurance marketplace, or a provider of treatment of | 3 | | mental, emotional, nervous,
or substance use disorders or | 4 | | conditions shall furnish medical records or other necessary | 5 | | data
that substantiate that initial or continued treatment is | 6 | | at all times medically
necessary. An insurer shall provide a | 7 | | mechanism for the timely review by a
provider holding the same | 8 | | license and practicing in the same specialty as the
patient's | 9 | | provider, who is unaffiliated with the insurer, jointly | 10 | | selected by
the patient (or the patient's next of kin or legal | 11 | | representative if the
patient is unable to act for himself or | 12 | | herself), the patient's provider, and
the insurer in the event | 13 | | of a dispute between the insurer and patient's
provider | 14 | | regarding the medical necessity of a treatment proposed by a | 15 | | patient's
provider. If the reviewing provider determines the | 16 | | treatment to be medically
necessary, the insurer shall provide | 17 | | reimbursement for the treatment. Future
contractual or | 18 | | employment actions by the insurer regarding the patient's
| 19 | | provider may not be based on the provider's participation in | 20 | | this procedure.
Nothing prevents
the insured from agreeing in | 21 | | writing to continue treatment at his or her
expense. When | 22 | | making a determination of the medical necessity for a | 23 | | treatment
modality for mental, emotional, nervous, or | 24 | | substance use disorders or conditions, an insurer must make | 25 | | the determination in a
manner that is consistent with the | 26 | | manner used to make that determination with
respect to other |
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| 1 | | diseases or illnesses covered under the policy, including an
| 2 | | appeals process. Medical necessity determinations for | 3 | | substance use disorders shall be made in accordance with | 4 | | appropriate patient placement criteria established by the | 5 | | American Society of Addiction Medicine. No additional criteria | 6 | | may be used to make medical necessity determinations for | 7 | | substance use disorders.
| 8 | | (4) A group health benefit plan amended, delivered, | 9 | | issued, or renewed on or after January 1, 2019 (the effective | 10 | | date of Public Act 100-1024) or an individual policy of | 11 | | accident and health insurance or a qualified health plan | 12 | | offered through the health insurance marketplace amended, | 13 | | delivered, issued, or renewed on or after January 1, 2019 (the | 14 | | effective date of Public Act 100-1024):
| 15 | | (A) shall provide coverage based upon medical | 16 | | necessity for the
treatment of a mental, emotional, | 17 | | nervous, or substance use disorder or condition consistent | 18 | | with the parity requirements of Section 370c.1 of this | 19 | | Code; provided, however, that in each calendar year | 20 | | coverage shall not be less than the following:
| 21 | | (i) 45 days of inpatient treatment; and
| 22 | | (ii) beginning on June 26, 2006 (the effective | 23 | | date of Public Act 94-921), 60 visits for outpatient | 24 | | treatment including group and individual
outpatient | 25 | | treatment; and | 26 | | (iii) for plans or policies delivered, issued for |
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| 1 | | delivery, renewed, or modified after January 1, 2007 | 2 | | (the effective date of Public Act 94-906),
20 | 3 | | additional outpatient visits for speech therapy for | 4 | | treatment of pervasive developmental disorders that | 5 | | will be in addition to speech therapy provided | 6 | | pursuant to item (ii) of this subparagraph (A); and
| 7 | | (B) may not include a lifetime limit on the number of | 8 | | days of inpatient
treatment or the number of outpatient | 9 | | visits covered under the plan.
| 10 | | (C) (Blank).
| 11 | | (5) An issuer of a group health benefit plan or an | 12 | | individual policy of accident and health insurance or a | 13 | | qualified health plan offered through the health insurance | 14 | | marketplace may not count toward the number
of outpatient | 15 | | visits required to be covered under this Section an outpatient
| 16 | | visit for the purpose of medication management and shall cover | 17 | | the outpatient
visits under the same terms and conditions as | 18 | | it covers outpatient visits for
the treatment of physical | 19 | | illness.
| 20 | | (5.5) An individual or group health benefit plan amended, | 21 | | delivered, issued, or renewed on or after September 9, 2015 | 22 | | (the effective date of Public Act 99-480) shall offer coverage | 23 | | for medically necessary acute treatment services and medically | 24 | | necessary clinical stabilization services. The treating | 25 | | provider shall base all treatment recommendations and the | 26 | | health benefit plan shall base all medical necessity |
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| 1 | | determinations for substance use disorders in accordance with | 2 | | the most current edition of the Treatment Criteria for | 3 | | Addictive, Substance-Related, and Co-Occurring Conditions | 4 | | established by the American Society of Addiction Medicine. The | 5 | | treating provider shall base all treatment recommendations and | 6 | | the health benefit plan shall base all medical necessity | 7 | | determinations for medication-assisted treatment in accordance | 8 | | with the most current Treatment Criteria for Addictive, | 9 | | Substance-Related, and Co-Occurring Conditions established by | 10 | | the American Society of Addiction Medicine. | 11 | | As used in this subsection: | 12 | | "Acute treatment services" means 24-hour medically | 13 | | supervised addiction treatment that provides evaluation and | 14 | | withdrawal management and may include biopsychosocial | 15 | | assessment, individual and group counseling, psychoeducational | 16 | | groups, and discharge planning. | 17 | | "Clinical stabilization services" means 24-hour treatment, | 18 | | usually following acute treatment services for substance | 19 | | abuse, which may include intensive education and counseling | 20 | | regarding the nature of addiction and its consequences, | 21 | | relapse prevention, outreach to families and significant | 22 | | others, and aftercare planning for individuals beginning to | 23 | | engage in recovery from addiction. | 24 | | (6) An issuer of a group health benefit
plan may provide or | 25 | | offer coverage required under this Section through a
managed | 26 | | care plan.
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| 1 | | (6.5) An individual or group health benefit plan amended, | 2 | | delivered, issued, or renewed on or after January 1, 2019 (the | 3 | | effective date of Public Act 100-1024): | 4 | | (A) shall not impose prior authorization requirements, | 5 | | other than those established under the Treatment Criteria | 6 | | for Addictive, Substance-Related, and Co-Occurring | 7 | | Conditions established by the American Society of | 8 | | Addiction Medicine, on a prescription medication approved | 9 | | by the United States Food and Drug Administration that is | 10 | | prescribed or administered for the treatment of substance | 11 | | use disorders; | 12 | | (B) shall not impose any step therapy requirements, | 13 | | other than those established under the Treatment Criteria | 14 | | for Addictive, Substance-Related, and Co-Occurring | 15 | | Conditions established by the American Society of | 16 | | Addiction Medicine, before authorizing coverage for a | 17 | | prescription medication approved by the United States Food | 18 | | and Drug Administration that is prescribed or administered | 19 | | for the treatment of substance use disorders; | 20 | | (C) shall place all prescription medications approved | 21 | | by the United States Food and Drug Administration | 22 | | prescribed or administered for the treatment of substance | 23 | | use disorders on, for brand medications, the lowest tier | 24 | | of the drug formulary developed and maintained by the | 25 | | individual or group health benefit plan that covers brand | 26 | | medications and, for generic medications, the lowest tier |
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| 1 | | of the drug formulary developed and maintained by the | 2 | | individual or group health benefit plan that covers | 3 | | generic medications; and | 4 | | (D) shall not exclude coverage for a prescription | 5 | | medication approved by the United States Food and Drug | 6 | | Administration for the treatment of substance use | 7 | | disorders and any associated counseling or wraparound | 8 | | services on the grounds that such medications and services | 9 | | were court ordered. | 10 | | (7) (Blank).
| 11 | | (8)
(Blank).
| 12 | | (9) With respect to all mental, emotional, nervous, or | 13 | | substance use disorders or conditions, coverage for inpatient | 14 | | treatment shall include coverage for treatment in a | 15 | | residential treatment center certified or licensed by the | 16 | | Department of Public Health or the Department of Human | 17 | | Services. | 18 | | (c) This Section shall not be interpreted to require | 19 | | coverage for speech therapy or other habilitative services for | 20 | | those individuals covered under Section 356z.15
of this Code. | 21 | | (d) With respect to a group or individual policy of | 22 | | accident and health insurance or a qualified health plan | 23 | | offered through the health insurance marketplace, the | 24 | | Department and, with respect to medical assistance, the | 25 | | Department of Healthcare and Family Services shall each | 26 | | enforce the requirements of this Section and Sections 356z.23 |
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| 1 | | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 2 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 3 | | U.S.C. 18031(j), and any amendments to, and federal guidance | 4 | | or regulations issued under, those Acts, including, but not | 5 | | limited to, final regulations issued under the Paul Wellstone | 6 | | and Pete Domenici Mental Health Parity and Addiction Equity | 7 | | Act of 2008 and final regulations applying the Paul Wellstone | 8 | | and Pete Domenici Mental Health Parity and Addiction Equity | 9 | | Act of 2008 to Medicaid managed care organizations, the | 10 | | Children's Health Insurance Program, and alternative benefit | 11 | | plans. Specifically, the Department and the Department of | 12 | | Healthcare and Family Services shall take action: | 13 | | (1) proactively ensuring compliance by individual and | 14 | | group policies, including by requiring that insurers | 15 | | submit comparative analyses, as set forth in paragraph (6) | 16 | | of subsection (k) of Section 370c.1, demonstrating how | 17 | | they design and apply nonquantitative treatment | 18 | | limitations, both as written and in operation, for mental, | 19 | | emotional, nervous, or substance use disorder or condition | 20 | | benefits as compared to how they design and apply | 21 | | nonquantitative treatment limitations, as written and in | 22 | | operation, for medical and surgical benefits; | 23 | | (2) evaluating all consumer or provider complaints | 24 | | regarding mental, emotional, nervous, or substance use | 25 | | disorder or condition coverage for possible parity | 26 | | violations; |
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| 1 | | (3) performing parity compliance market conduct | 2 | | examinations or, in the case of the Department of | 3 | | Healthcare and Family Services, parity compliance audits | 4 | | of individual and group plans and policies, including, but | 5 | | not limited to, reviews of: | 6 | | (A) nonquantitative treatment limitations, | 7 | | including, but not limited to, prior authorization | 8 | | requirements, concurrent review, retrospective review, | 9 | | step therapy, network admission standards, | 10 | | reimbursement rates, and geographic restrictions; | 11 | | (B) denials of authorization, payment, and | 12 | | coverage; and | 13 | | (C) other specific criteria as may be determined | 14 | | by the Department. | 15 | | The findings and the conclusions of the parity compliance | 16 | | market conduct examinations and audits shall be made public. | 17 | | The Director may adopt rules to effectuate any provisions | 18 | | of the Paul Wellstone and Pete Domenici Mental Health Parity | 19 | | and Addiction Equity Act of 2008 that relate to the business of | 20 | | insurance. | 21 | | (e) Availability of plan information. | 22 | | (1) The criteria for medical necessity determinations | 23 | | made under a group health plan, an individual policy of | 24 | | accident and health insurance, or a qualified health plan | 25 | | offered through the health insurance marketplace with | 26 | | respect to mental health or substance use disorder |
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| 1 | | benefits (or health insurance coverage offered in | 2 | | connection with the plan with respect to such benefits) | 3 | | must be made available by the plan administrator (or the | 4 | | health insurance issuer offering such coverage) to any | 5 | | current or potential participant, beneficiary, or | 6 | | contracting provider upon request. | 7 | | (2) The reason for any denial under a group health | 8 | | benefit plan, an individual policy of accident and health | 9 | | insurance, or a qualified health plan offered through the | 10 | | health insurance marketplace (or health insurance coverage | 11 | | offered in connection with such plan or policy) of | 12 | | reimbursement or payment for services with respect to | 13 | | mental, emotional, nervous, or substance use disorders or | 14 | | conditions benefits in the case of any participant or | 15 | | beneficiary must be made available within a reasonable | 16 | | time and in a reasonable manner and in readily | 17 | | understandable language by the plan administrator (or the | 18 | | health insurance issuer offering such coverage) to the | 19 | | participant or beneficiary upon request. | 20 | | (f) As used in this Section, "group policy of accident and | 21 | | health insurance" and "group health benefit plan" includes (1) | 22 | | State-regulated employer-sponsored group health insurance | 23 | | plans written in Illinois or which purport to provide coverage | 24 | | for a resident of this State; and (2) State employee health | 25 | | plans. | 26 | | (g) (1) As used in this subsection: |
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| 1 | | "Benefits", with respect to insurers, means
the benefits | 2 | | provided for treatment services for inpatient and outpatient | 3 | | treatment of substance use disorders or conditions at American | 4 | | Society of Addiction Medicine levels of treatment 2.1 | 5 | | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | 6 | | (Clinically Managed Low-Intensity Residential), 3.3 | 7 | | (Clinically Managed Population-Specific High-Intensity | 8 | | Residential), 3.5 (Clinically Managed High-Intensity | 9 | | Residential), and 3.7 (Medically Monitored Intensive | 10 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 11 | | "Benefits", with respect to managed care organizations, | 12 | | means the benefits provided for treatment services for | 13 | | inpatient and outpatient treatment of substance use disorders | 14 | | or conditions at American Society of Addiction Medicine levels | 15 | | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | 16 | | Hospitalization), 3.5 (Clinically Managed High-Intensity | 17 | | Residential), and 3.7 (Medically Monitored Intensive | 18 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 19 | | "Substance use disorder treatment provider or facility" | 20 | | means a licensed physician, licensed psychologist, licensed | 21 | | psychiatrist, licensed advanced practice registered nurse, or | 22 | | licensed, certified, or otherwise State-approved facility or | 23 | | provider of substance use disorder treatment. | 24 | | (2) A group health insurance policy, an individual health | 25 | | benefit plan, or qualified health plan that is offered through | 26 | | the health insurance marketplace, small employer group health |
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| 1 | | plan, and large employer group health plan that is amended, | 2 | | delivered, issued, executed, or renewed in this State, or | 3 | | approved for issuance or renewal in this State, on or after | 4 | | January 1, 2019 (the effective date of Public Act 100-1023) | 5 | | shall comply with the requirements of this Section and Section | 6 | | 370c.1. The services for the treatment and the ongoing | 7 | | assessment of the patient's progress in treatment shall follow | 8 | | the requirements of 77 Ill. Adm. Code 2060. | 9 | | (3) Prior authorization shall not be utilized for the | 10 | | benefits under this subsection. The substance use disorder | 11 | | treatment provider or facility shall notify the insurer of the | 12 | | initiation of treatment. For an insurer that is not a managed | 13 | | care organization, the substance use disorder treatment | 14 | | provider or facility notification shall occur for the | 15 | | initiation of treatment of the covered person within 2 | 16 | | business days. For managed care organizations, the substance | 17 | | use disorder treatment provider or facility notification shall | 18 | | occur in accordance with the protocol set forth in the | 19 | | provider agreement for initiation of treatment within 24 | 20 | | hours. If the managed care organization is not capable of | 21 | | accepting the notification in accordance with the contractual | 22 | | protocol during the 24-hour period following admission, the | 23 | | substance use disorder treatment provider or facility shall | 24 | | have one additional business day to provide the notification | 25 | | to the appropriate managed care organization. Treatment plans | 26 | | shall be developed in accordance with the requirements and |
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| 1 | | timeframes established in 77 Ill. Adm. Code 2060. If the | 2 | | substance use disorder treatment provider or facility fails to | 3 | | notify the insurer of the initiation of treatment in | 4 | | accordance with these provisions, the insurer may follow its | 5 | | normal prior authorization processes. | 6 | | (4) For an insurer that is not a managed care | 7 | | organization, if an insurer determines that benefits are no | 8 | | longer medically necessary, the insurer shall notify the | 9 | | covered person, the covered person's authorized | 10 | | representative, if any, and the covered person's health care | 11 | | provider in writing of the covered person's right to request | 12 | | an external review pursuant to the Health Carrier External | 13 | | Review Act. The notification shall occur within 24 hours | 14 | | following the adverse determination. | 15 | | Pursuant to the requirements of the Health Carrier | 16 | | External Review Act, the covered person or the covered | 17 | | person's authorized representative may request an expedited | 18 | | external review.
An expedited external review may not occur if | 19 | | the substance use disorder treatment provider or facility | 20 | | determines that continued treatment is no longer medically | 21 | | necessary. Under this subsection, a request for expedited | 22 | | external review must be initiated within 24 hours following | 23 | | the adverse determination notification by the insurer. Failure | 24 | | to request an expedited external review within 24 hours shall | 25 | | preclude a covered person or a covered person's authorized | 26 | | representative from requesting an expedited external review. |
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| 1 | | If an expedited external review request meets the criteria | 2 | | of the Health Carrier External Review Act, an independent | 3 | | review organization shall make a final determination of | 4 | | medical necessity within 72 hours. If an independent review | 5 | | organization upholds an adverse determination, an insurer | 6 | | shall remain responsible to provide coverage of benefits | 7 | | through the day following the determination of the independent | 8 | | review organization. A decision to reverse an adverse | 9 | | determination shall comply with the Health Carrier External | 10 | | Review Act. | 11 | | (5) The substance use disorder treatment provider or | 12 | | facility shall provide the insurer with 7 business days' | 13 | | advance notice of the planned discharge of the patient from | 14 | | the substance use disorder treatment provider or facility and | 15 | | notice on the day that the patient is discharged from the | 16 | | substance use disorder treatment provider or facility. | 17 | | (6) The benefits required by this subsection shall be | 18 | | provided to all covered persons with a diagnosis of substance | 19 | | use disorder or conditions. The presence of additional related | 20 | | or unrelated diagnoses shall not be a basis to reduce or deny | 21 | | the benefits required by this subsection. | 22 | | (7) Nothing in this subsection shall be construed to | 23 | | require an insurer to provide coverage for any of the benefits | 24 | | in this subsection. | 25 | | (h) As used in this Section: | 26 | | "Generally accepted standards of mental, emotional, |
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| 1 | | nervous, or substance use disorder or condition care" means | 2 | | standards of care and clinical practice that are generally | 3 | | recognized by health care providers practicing in relevant | 4 | | clinical specialties such as psychiatry, psychology, clinical | 5 | | sociology, social work, addiction medicine and counseling, and | 6 | | behavioral health treatment. Valid, evidence-based sources | 7 | | reflecting generally accepted standards of mental, emotional, | 8 | | nervous, or substance use disorder or condition care include | 9 | | peer-reviewed scientific studies and medical literature, | 10 | | recommendations of nonprofit health care provider professional | 11 | | associations and specialty societies, including, but not | 12 | | limited to, patient placement criteria and clinical practice | 13 | | guidelines, recommendations of federal government agencies, | 14 | | and drug labeling approved by the United States Food and Drug | 15 | | Administration. | 16 | | "Medically necessary treatment of mental, emotional, | 17 | | nervous, or substance use disorders or conditions" means a | 18 | | service or product addressing the specific needs of that | 19 | | patient, for the purpose of screening, preventing, diagnosing, | 20 | | managing, or treating an illness, injury, condition, or its | 21 | | symptoms, including minimizing the progression of an illness, | 22 | | injury, condition, or its symptoms in a manner that is all of | 23 | | the following: | 24 | | (1) in accordance with the generally accepted | 25 | | standards of mental, emotional, nervous, or substance use | 26 | | disorder or condition care; |
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| 1 | | (2) clinically appropriate in terms of type, | 2 | | frequency, extent, site, and duration; and | 3 | | (3) not primarily for the economic benefit of the | 4 | | insurer, purchaser, or for the convenience of the patient, | 5 | | treating physician, or other health care provider. | 6 | | "Utilization review" means either of the following: | 7 | | (1) prospectively, retrospectively, or concurrently | 8 | | reviewing and approving, modifying, delaying, or denying, | 9 | | based in whole or in part on medical necessity, requests | 10 | | by health care providers, insureds, or their authorized | 11 | | representatives for coverage of health care services | 12 | | before, retrospectively, or concurrently with the | 13 | | provision of health care services to insureds. | 14 | | (2) evaluating the medical necessity, appropriateness, | 15 | | level of care, service intensity, efficacy, or efficiency | 16 | | of health care services, benefits, procedures, or | 17 | | settings, under any circumstances, to determine whether a | 18 | | health care service or benefit subject to a medical | 19 | | necessity coverage requirement in an insurance policy is | 20 | | covered as medically necessary for an insured. | 21 | | "Utilization review criteria" means patient placement | 22 | | criteria or any criteria, standards, protocols, or guidelines | 23 | | used by an insurer to conduct utilization review. | 24 | | (i)(1) Every insurer that amends, delivers, issues, or | 25 | | renews a group or individual policy of accident and health | 26 | | insurance or a qualified health plan offered through the |
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| 1 | | health insurance marketplace in this State and Medicaid | 2 | | managed care organizations providing coverage for hospital or | 3 | | medical treatment on or after January 1, 2022 shall, pursuant | 4 | | to subsections (h) through (s), provide coverage for medically | 5 | | necessary treatment of mental, emotional, nervous, or | 6 | | substance use disorders or conditions. | 7 | | (2) An insurer shall not set a specific limit on the | 8 | | duration of benefits or coverage of medically necessary | 9 | | treatment of mental, emotional, nervous, or substance use | 10 | | disorders or conditions or limit coverage only to alleviation | 11 | | of the insured's current symptoms; insurers shall base the | 12 | | duration of treatment on the insured's individual needs, | 13 | | including treating the insured's underlying mental, emotional, | 14 | | nervous, or substance use disorders or conditions and | 15 | | comorbidities. | 16 | | (3) All medical necessity determinations made by the | 17 | | insurer concerning service intensity, level of care placement, | 18 | | continued stay, and transfer or discharge of insureds | 19 | | diagnosed with mental, emotional, nervous, or substance use | 20 | | disorders or conditions shall be conducted in accordance with | 21 | | the requirements of subsections (k) through (u). | 22 | | (4) An insurer that authorizes a specific type of | 23 | | treatment by a provider pursuant to this Section shall not | 24 | | rescind or modify the authorization after that provider | 25 | | renders the health care service in good faith and pursuant to | 26 | | this authorization for any reason, including, but not limited |
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| 1 | | to, the insurer's subsequent cancellation or modification of | 2 | | the insured's or policyholder's contract, or the insured's or | 3 | | policyholder's eligibility. Nothing in this Section shall | 4 | | require the insurer to cover a treatment when the | 5 | | authorization was granted based on a material | 6 | | misrepresentation by the insured, the policyholder, or the | 7 | | provider. As used in this paragraph, "material" means a fact | 8 | | or situation that is not merely technical in nature and | 9 | | results in or could result in a substantial change in the | 10 | | situation. | 11 | | (j) An insurer shall not limit benefits or coverage for | 12 | | medically necessary services on the basis that those services | 13 | | should be or could be covered by a public program, including, | 14 | | but not limited to, special education or an individualized | 15 | | education program, Medicaid, Medicare, Supplemental Security | 16 | | Income, or Social Security Disability Insurance, and shall not | 17 | | include or enforce a contract term that excludes otherwise | 18 | | covered benefits on the basis that those services should be or | 19 | | could be covered by a public program. | 20 | | (k) An insurer shall base any medical necessity | 21 | | determination or the utilization review criteria that the | 22 | | insurer, and any entity acting on the insurer's behalf, | 23 | | applies to determine the medical necessity of health care | 24 | | services and benefits for the diagnosis, prevention, and | 25 | | treatment of mental, emotional, nervous, or substance use | 26 | | disorders or conditions on current generally accepted |
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| 1 | | standards of mental, emotional, nervous, or substance use | 2 | | disorder or condition care. All denials and appeals shall be | 3 | | reviewed by a professional with experience or expertise | 4 | | comparable to the provider requesting the authorization. | 5 | | (l) In conducting utilization review of all covered health | 6 | | care services and benefits for the diagnosis, prevention, and | 7 | | treatment of mental, emotional, and nervous disorders or | 8 | | conditions in children, adolescents, and adults, an insurer | 9 | | shall exclusively apply without modification the criteria and | 10 | | guidelines set forth in the most recent version of the | 11 | | treatment criteria developed by an unaffiliated nonprofit | 12 | | professional association for the relevant clinical specialty. | 13 | | Pursuant to subsection (b), in conducting utilization review | 14 | | of all covered services and benefits for the diagnosis, | 15 | | prevention, and treatment of substance use disorders an | 16 | | insurer shall use the most recent edition of the patient | 17 | | placement criteria established by the American Society of | 18 | | Addiction Medicine. | 19 | | (m) In conducting utilization review involving level of | 20 | | care placement decisions or any other patient care decisions | 21 | | that are within the scope of the sources specified in | 22 | | subsection (l), an insurer shall not apply different, | 23 | | additional, conflicting, or more restrictive utilization | 24 | | review criteria than the criteria and guidelines set forth in | 25 | | those sources. For all level of care placement decisions, the | 26 | | insurer shall authorize placement at the level of care |
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| 1 | | consistent with the assessment of the insured using the | 2 | | relevant criteria and guidelines as specified in subsection | 3 | | (l). If that level of placement is not available, the insurer | 4 | | shall authorize the next higher level of care. In the event of | 5 | | disagreement, the insurer shall provide full detail of its | 6 | | assessment using the relevant criteria and guidelines as | 7 | | specified in subsection (l) to the provider of the service. | 8 | | This subsection does not prohibit an insurer from applying | 9 | | utilization review criteria that were developed in accordance | 10 | | with subsection (k) to health care services and benefits for | 11 | | mental, emotional, and nervous disorders or conditions that: | 12 | | (1) are outside the scope of the criteria and | 13 | | guidelines set forth in the sources specified in | 14 | | subsection (l); or | 15 | | (2) relate to advancements in technology or types of | 16 | | care that are not covered in the most recent versions of | 17 | | the sources specified in subsection (l). | 18 | | (n) An insurer shall only engage applicable qualified | 19 | | providers in the treatment of mental, emotional, nervous, or | 20 | | substance use disorders or conditions or the appropriate | 21 | | subspecialty therein and who possess an active professional | 22 | | license or certificate, to review, approve, or deny services. | 23 | | (o) This Section does not in any way limit the rights of a | 24 | | patient under the Medical Patient Rights Act. | 25 | | (p) This Section does not in any way limit early and | 26 | | periodic screening, diagnostic, and treatment benefits as |
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| 1 | | defined under 42 U.S.C. 1396d(r). | 2 | | (q) To ensure the proper use of the criteria described in | 3 | | subsection (l), every insurer shall do all of the following: | 4 | | (1) Sponsor a formal education program by nonprofit | 5 | | clinical specialty associations to educate the insurer's | 6 | | staff, including any third parties contracted with the | 7 | | insurer to review claims, conduct utilization reviews, or | 8 | | make medical necessity determinations about the clinical | 9 | | review criteria. | 10 | | (2) Make the education program available to other | 11 | | stakeholders, including the insurer's participating or | 12 | | contracted providers and potential participants, | 13 | | beneficiaries, or covered lives. The education program | 14 | | must be provided, at minimum, on a quarterly basis, | 15 | | in-person or digitally, or recordings of the education | 16 | | program must be made available to the aforementioned | 17 | | stakeholders. | 18 | | (3) Provide, at no cost, the clinical review criteria | 19 | | and any training material or resources to providers and | 20 | | insured patients. | 21 | | (4) Track, identify, and analyze how the clinical | 22 | | review criteria are used to certify care, deny care, and | 23 | | support the appeals process. | 24 | | (5) Conduct interrater reliability testing to ensure | 25 | | consistency in utilization review decision making that | 26 | | covers how medical necessity decisions are made; this |
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| 1 | | assessment shall cover all aspects of utilization review | 2 | | as defined in subsection (h). | 3 | | (6) Run interrater reliability reports about how the | 4 | | clinical guidelines are used in conjunction with the | 5 | | utilization review process and parity compliance | 6 | | activities. | 7 | | (7) Achieve interrater reliability pass rates of at | 8 | | least 90% and, if this threshold is not met, immediately | 9 | | provide for the remediation of poor interrater reliability | 10 | | and interrater reliability testing for all new staff | 11 | | before they can conduct utilization review without | 12 | | supervision. | 13 | | (8) Submit to the Department of Insurance or, in the | 14 | | case of Medicaid managed care organizations, the | 15 | | Department of Healthcare and Family Services every year on | 16 | | or before July 1 results of interrater reliability reports | 17 | | and a summary of the remediation actions taken for those | 18 | | with pass rates lower than 90%. | 19 | | (r) This Section applies to all health care services and | 20 | | benefits for the diagnosis, prevention, and treatment of | 21 | | mental, emotional, nervous, or substance use disorders or | 22 | | conditions covered by an insurance policy, including | 23 | | prescription drugs. | 24 | | (s) This Section applies to an insurer that amends, | 25 | | delivers, issues, or renews a group or individual policy of | 26 | | accident and health insurance or a qualified health plan |
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| 1 | | offered through the health insurance marketplace in this State | 2 | | providing coverage for hospital or medical treatment and | 3 | | conducts utilization review as defined in this Section, | 4 | | including Medicaid managed care organizations, and any entity | 5 | | or contracting provider that performs utilization review or | 6 | | utilization management functions on an insurer's behalf. | 7 | | (t) If the Director determines that an insurer has | 8 | | violated this Section, the Director may, after appropriate | 9 | | notice and opportunity for hearing, by order, assess a civil | 10 | | penalty between $1,000 and $5,000 for each violation. Moneys | 11 | | collected from penalties shall be deposited into the Parity | 12 | | Advancement Fund established in subsection (i) of Section | 13 | | 370c.1. | 14 | | (u) An insurer shall not adopt, impose, or enforce terms | 15 | | in its policies or provider agreements, in writing or in | 16 | | operation, that undermine, alter, or conflict with the | 17 | | requirements of this Section. | 18 | | (v) The provisions of this Section are severable. If any | 19 | | provision of this Section or its application is held invalid, | 20 | | that invalidity shall not affect other provisions or | 21 | | applications that can be given effect without the invalid | 22 | | provision or application. | 23 | | (Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19; | 24 | | 100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff. | 25 | | 8-16-19; revised 9-20-19.) |
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| 1 | | Section 10. The Health Carrier External Review Act is | 2 | | amended by changing Sections 35 and 40 as follows: | 3 | | (215 ILCS 180/35)
| 4 | | Sec. 35. Standard external review. | 5 | | (a) Within 4 months after the date of receipt of a notice | 6 | | of an adverse determination or final adverse determination, a | 7 | | covered person or the covered person's authorized | 8 | | representative may file a request for an external review with | 9 | | the Director. Within one business day after the date of | 10 | | receipt of a request for external review, the Director shall | 11 | | send a copy of the request to the health carrier. | 12 | | (b) Within 5 business days following the date of receipt | 13 | | of the external review request, the health carrier shall | 14 | | complete a preliminary review of the request to determine | 15 | | whether:
| 16 | | (1) the individual is or was a covered person in the | 17 | | health benefit plan at the time the health care service | 18 | | was requested or at the time the health care service was | 19 | | provided; | 20 | | (2) the health care service that is the subject of the | 21 | | adverse determination or the final adverse determination | 22 | | is a covered service under the covered person's health | 23 | | benefit plan, but the health carrier has determined that | 24 | | the health care service is not covered; | 25 | | (3) the covered person has exhausted the health |
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| 1 | | carrier's internal appeal process unless the covered | 2 | | person is not required to exhaust the health carrier's | 3 | | internal appeal process pursuant to this Act; | 4 | | (4) (blank); and | 5 | | (5) the covered person has provided all the | 6 | | information and forms required to process an external | 7 | | review, as specified in this Act. | 8 | | (c) Within one business day after completion of the | 9 | | preliminary review, the health carrier shall notify the | 10 | | Director and covered person and, if applicable, the covered | 11 | | person's authorized representative in writing whether the | 12 | | request is complete and eligible for external review. If the | 13 | | request: | 14 | | (1) is not complete, the health carrier shall inform | 15 | | the Director and covered person and, if applicable, the | 16 | | covered person's authorized representative in writing and | 17 | | include in the notice what information or materials are | 18 | | required by this Act to make the request complete; or | 19 | | (2) is not eligible for external review, the health | 20 | | carrier shall inform the Director and covered person and, | 21 | | if applicable, the covered person's authorized | 22 | | representative in writing and include in the notice the | 23 | | reasons for its ineligibility.
| 24 | | The Department may specify the form for the health | 25 | | carrier's notice of initial determination under this | 26 | | subsection (c) and any supporting information to be included |
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| 1 | | in the notice. | 2 | | The notice of initial determination of ineligibility shall | 3 | | include a statement informing the covered person and, if | 4 | | applicable, the covered person's authorized representative | 5 | | that a health carrier's initial determination that the | 6 | | external review request is ineligible for review may be | 7 | | appealed to the Director by filing a complaint with the | 8 | | Director. | 9 | | Notwithstanding a health carrier's initial determination | 10 | | that the request is ineligible for external review, the | 11 | | Director may determine that a request is eligible for external | 12 | | review and require that it be referred for external review. In | 13 | | making such determination, the Director's decision shall be in | 14 | | accordance with the terms of the covered person's health | 15 | | benefit plan, unless such terms are inconsistent with | 16 | | applicable law, and shall be subject to all applicable | 17 | | provisions of this Act. | 18 | | (d) Whenever the Director receives notice that a request | 19 | | is eligible for external review following the preliminary | 20 | | review conducted pursuant to this Section, within one business | 21 | | day after the date of receipt of the notice, the Director | 22 | | shall: | 23 | | (1) assign an independent review organization from the | 24 | | list of approved independent review organizations compiled | 25 | | and maintained by the Director pursuant to this Act and | 26 | | notify the health carrier of the name of the assigned |
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| 1 | | independent review organization; and | 2 | | (2) notify in writing the covered person and, if | 3 | | applicable, the covered person's authorized representative | 4 | | of the request's eligibility and acceptance for external | 5 | | review and the name of the independent review | 6 | | organization. | 7 | | The Director shall include in the notice provided to the | 8 | | covered person and, if applicable, the covered person's | 9 | | authorized representative a statement that the covered person | 10 | | or the covered person's authorized representative may, within | 11 | | 5 business days following the date of receipt of the notice | 12 | | provided pursuant to item (2) of this subsection (d), submit | 13 | | in writing to the assigned independent review organization | 14 | | additional information that the independent review | 15 | | organization shall consider when conducting the external | 16 | | review. The independent review organization is not required | 17 | | to, but may, accept and consider additional information | 18 | | submitted after 5 business days. | 19 | | (e) The assignment by the Director of an approved | 20 | | independent review organization to conduct an external review | 21 | | in accordance with this Section shall be done on a random basis | 22 | | among those independent review organizations approved by the | 23 | | Director pursuant to this Act. | 24 | | (f) Within 5 business days after the date of receipt of the | 25 | | notice provided pursuant to item (1) of subsection (d) of this | 26 | | Section, the health carrier or its designee utilization review |
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| 1 | | organization shall provide to the assigned independent review | 2 | | organization the documents and any information considered in | 3 | | making the adverse determination or final adverse | 4 | | determination; in such cases, the following provisions shall | 5 | | apply: | 6 | | (1) Except as provided in item (2) of this subsection | 7 | | (f), failure by the health carrier or its utilization | 8 | | review organization to provide the documents and | 9 | | information within the specified time frame shall not | 10 | | delay the conduct of the external review. | 11 | | (2) If the health carrier or its utilization review | 12 | | organization fails to provide the documents and | 13 | | information within the specified time frame, the assigned | 14 | | independent review organization may terminate the external | 15 | | review and make a decision to reverse the adverse | 16 | | determination or final adverse determination. | 17 | | (3) Within one business day after making the decision | 18 | | to terminate the external review and make a decision to | 19 | | reverse the adverse determination or final adverse | 20 | | determination under item (2) of this subsection (f), the | 21 | | independent review organization shall notify the Director, | 22 | | the health carrier, the covered person and, if applicable, | 23 | | the covered person's authorized representative, of its | 24 | | decision to reverse the adverse determination. | 25 | | (g) Upon receipt of the information from the health | 26 | | carrier or its utilization review organization, the assigned |
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| 1 | | independent review organization shall review all of the | 2 | | information and documents and any other information submitted | 3 | | in writing to the independent review organization by the | 4 | | covered person and the covered person's authorized | 5 | | representative. | 6 | | (h) Upon receipt of any information submitted by the | 7 | | covered person or the covered person's authorized | 8 | | representative, the independent review organization shall | 9 | | forward the information to the health carrier within 1 | 10 | | business day. | 11 | | (1) Upon receipt of the information, if any, the | 12 | | health carrier may reconsider its adverse determination or | 13 | | final adverse determination that is the subject of the | 14 | | external review.
| 15 | | (2) Reconsideration by the health carrier of its | 16 | | adverse determination or final adverse determination shall | 17 | | not delay or terminate the external review.
| 18 | | (3) The external review may only be terminated if the | 19 | | health carrier decides, upon completion of its | 20 | | reconsideration, to reverse its adverse determination or | 21 | | final adverse determination and provide coverage or | 22 | | payment for the health care service that is the subject of | 23 | | the adverse determination or final adverse determination. | 24 | | In such cases, the following provisions shall apply: | 25 | | (A) Within one business day after making the | 26 | | decision to reverse its adverse determination or final |
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| 1 | | adverse determination, the health carrier shall notify | 2 | | the Director, the covered person and, if applicable, | 3 | | the covered person's authorized representative, and | 4 | | the assigned independent review organization in | 5 | | writing of its decision. | 6 | | (B) Upon notice from the health carrier that the | 7 | | health carrier has made a decision to reverse its | 8 | | adverse determination or final adverse determination, | 9 | | the assigned independent review organization shall | 10 | | terminate the external review. | 11 | | (i) In addition to the documents and information provided | 12 | | by the health carrier or its utilization review organization | 13 | | and the covered person and the covered person's authorized | 14 | | representative, if any, the independent review organization, | 15 | | to the extent the information or documents are available and | 16 | | the independent review organization considers them | 17 | | appropriate, shall consider the following in reaching a | 18 | | decision: | 19 | | (1) the covered person's pertinent medical records; | 20 | | (2) the covered person's health care provider's | 21 | | recommendation; | 22 | | (3) consulting reports from appropriate health care | 23 | | providers and other documents submitted by the health | 24 | | carrier or its designee utilization review organization, | 25 | | the covered person, the covered person's authorized | 26 | | representative, or the covered person's treating provider; |
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| 1 | | (4) the terms of coverage under the covered person's | 2 | | health benefit plan with the health carrier to ensure that | 3 | | the independent review organization's decision is not | 4 | | contrary to the terms of coverage under the covered | 5 | | person's health benefit plan with the health carrier, | 6 | | unless the terms are inconsistent with applicable law; | 7 | | (5) the most appropriate practice guidelines, which | 8 | | shall include applicable evidence-based standards and may | 9 | | include any other practice guidelines developed by the | 10 | | federal government, national or professional medical | 11 | | societies, boards, and associations; | 12 | | (6) any applicable clinical review criteria developed | 13 | | and used by the health carrier or its designee utilization | 14 | | review organization; | 15 | | (7) the opinion of the independent review | 16 | | organization's clinical reviewer or reviewers after | 17 | | considering items (1) through (6) of this subsection (i) | 18 | | to the extent the information or documents are available | 19 | | and the clinical reviewer or reviewers considers the | 20 | | information or documents appropriate; | 21 | | (8) (blank); and | 22 | | (9) in the case of medically necessary determinations | 23 | | for substance use disorders, the patient placement | 24 | | criteria established by the American Society of Addiction | 25 | | Medicine. | 26 | | (i-5) For an adverse determination or final adverse |
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| 1 | | determination involving mental, emotional, nervous, or | 2 | | substance use disorders or conditions, the independent review | 3 | | organization shall: | 4 | | (1) consider the documents and information as set | 5 | | forth in subsection (i), except that all practice | 6 | | guidelines and clinical review criteria must be consistent | 7 | | with the requirements set forth in Section 370c of the | 8 | | Illinois Insurance Code; and | 9 | | (2) make its decision, pursuant to subsection (j), | 10 | | whether to uphold or reverse the adverse determination or | 11 | | final adverse determination based on whether the service | 12 | | constitutes medically necessary treatment of a mental, | 13 | | emotional, nervous, or substance use disorders or | 14 | | condition as defined in Section 370c of the Illinois | 15 | | Insurance Code. | 16 | | (j) Within 5 days after the date of receipt of all | 17 | | necessary information, but in no event more than 45 days after | 18 | | the date of receipt of the request for an external review, the | 19 | | assigned independent review organization shall provide written | 20 | | notice of its decision to uphold or reverse the adverse | 21 | | determination or the final adverse determination to the | 22 | | Director, the health carrier, the covered person, and, if | 23 | | applicable, the covered person's authorized representative. In | 24 | | reaching a decision, the assigned independent review | 25 | | organization is not bound by any claim determinations reached | 26 | | prior to the submission of information to the independent |
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| 1 | | review organization. In such cases, the following provisions | 2 | | shall apply: | 3 | | (1) The independent review organization shall include | 4 | | in the notice: | 5 | | (A) a general description of the reason for the | 6 | | request for external review; | 7 | | (B) the date the independent review organization | 8 | | received the assignment from the Director to conduct | 9 | | the external review; | 10 | | (C) the time period during which the external | 11 | | review was conducted; | 12 | | (D) references to the evidence or documentation, | 13 | | including the evidence-based standards, considered in | 14 | | reaching its decision; | 15 | | (E) the date of its decision; | 16 | | (F) the principal reason or reasons for its | 17 | | decision, including what applicable, if any, | 18 | | evidence-based standards that were a basis for its | 19 | | decision; and
| 20 | | (G) the rationale for its decision. | 21 | | (2) (Blank). | 22 | | (3) (Blank). | 23 | | (4) Upon receipt of a notice of a decision reversing | 24 | | the adverse determination or final adverse determination, | 25 | | the health carrier immediately shall approve the coverage | 26 | | that was the subject of the adverse determination or final |
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| 1 | | adverse determination.
| 2 | | (Source: P.A. 99-480, eff. 9-9-15.) | 3 | | (215 ILCS 180/40)
| 4 | | Sec. 40. Expedited external review. | 5 | | (a) A covered person or a covered person's authorized | 6 | | representative may file a request for an expedited external | 7 | | review with the Director either orally or in writing: | 8 | | (1) immediately after the date of receipt of a notice | 9 | | prior to a final adverse determination as provided by | 10 | | subsection (b) of Section 20 of this Act; | 11 | | (2) immediately after the date of receipt of a notice | 12 | | upon final adverse determination as provided by subsection | 13 | | (c) of Section 20 of this Act; or | 14 | | (3) if a health carrier fails to provide a decision on | 15 | | request for an expedited internal appeal within 48 hours | 16 | | as provided by item (2) of Section 30 of this Act. | 17 | | (b) Upon receipt of a request for an expedited external | 18 | | review, the Director shall immediately send a copy of the | 19 | | request to the health carrier. Immediately upon receipt of the | 20 | | request for an expedited external review, the health carrier | 21 | | shall determine whether the request meets the reviewability | 22 | | requirements set forth in subsection (b) of Section 35. In | 23 | | such cases, the following provisions shall apply: | 24 | | (1) The health carrier shall immediately notify the | 25 | | Director, the covered person, and, if applicable, the |
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| 1 | | covered person's authorized representative of its | 2 | | eligibility determination. | 3 | | (2) The notice of initial determination shall include | 4 | | a statement informing the covered person and, if | 5 | | applicable, the covered person's authorized representative | 6 | | that a health carrier's initial determination that an | 7 | | external review request is ineligible for review may be | 8 | | appealed to the Director. | 9 | | (3) The Director may determine that a request is | 10 | | eligible for expedited external review notwithstanding a | 11 | | health carrier's initial determination that the request is | 12 | | ineligible and require that it be referred for external | 13 | | review. | 14 | | (4) In making a determination under item (3) of this | 15 | | subsection (b), the Director's decision shall be made in | 16 | | accordance with the terms of the covered person's health | 17 | | benefit plan, unless such terms are inconsistent with | 18 | | applicable law, and shall be subject to all applicable | 19 | | provisions of this Act. | 20 | | (5) The Director may specify the form for the health | 21 | | carrier's notice of initial determination under this | 22 | | subsection (b) and any supporting information to be | 23 | | included in the notice. | 24 | | (c) Upon receipt of the notice that the request meets the | 25 | | reviewability requirements, the Director shall immediately | 26 | | assign an independent review organization from the list of |
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| 1 | | approved independent review organizations compiled and | 2 | | maintained by the Director to conduct the expedited review. In | 3 | | such cases, the following provisions shall apply: | 4 | | (1) The assignment of an approved independent review | 5 | | organization to conduct an external review in accordance | 6 | | with this Section shall be made from those approved | 7 | | independent review organizations qualified to conduct | 8 | | external review as required by Sections 50 and 55 of this | 9 | | Act.
| 10 | | (2) The Director shall immediately notify the health | 11 | | carrier of the name of the assigned independent review | 12 | | organization. Immediately upon receipt from the Director | 13 | | of the name of the independent review organization | 14 | | assigned to conduct the external review, but in no case | 15 | | more than 24 hours after receiving such notice, the health | 16 | | carrier or its designee utilization review organization | 17 | | shall provide or transmit all necessary documents and | 18 | | information considered in making the adverse determination | 19 | | or final adverse determination to the assigned independent | 20 | | review organization electronically or by telephone or | 21 | | facsimile or any other available expeditious method. | 22 | | (3) If the health carrier or its utilization review | 23 | | organization fails to provide the documents and | 24 | | information within the specified timeframe, the assigned | 25 | | independent review organization may terminate the external | 26 | | review and make a decision to reverse the adverse |
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| 1 | | determination or final adverse determination. | 2 | | (4) Within one business day after making the decision | 3 | | to terminate the external review and make a decision to | 4 | | reverse the adverse determination or final adverse | 5 | | determination under item (3) of this subsection (c), the | 6 | | independent review organization shall notify the Director, | 7 | | the health carrier, the covered person, and, if | 8 | | applicable, the covered person's authorized representative | 9 | | of its decision to reverse the adverse determination or | 10 | | final adverse determination.
| 11 | | (d) In addition to the documents and information provided | 12 | | by the health carrier or its utilization review organization | 13 | | and any documents and information provided by the covered | 14 | | person and the covered person's authorized representative, the | 15 | | independent review organization, to the extent the information | 16 | | or documents are available and the independent review | 17 | | organization considers them appropriate, shall consider | 18 | | information as required by subsection (i) of Section 35 of | 19 | | this Act in reaching a decision. | 20 | | (d-5) For expedited external reviews involving mental, | 21 | | emotional, nervous, or substance use disorders or conditions, | 22 | | the independent review organization shall consider documents | 23 | | and information and shall make a decision to uphold or reverse | 24 | | the adverse determination or final adverse determination | 25 | | pursuant to subsection (i-5) of Section 35. | 26 | | (e) As expeditiously as the covered person's medical |
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| 1 | | condition or circumstances requires, but in no event more than | 2 | | 72 hours after the date of receipt of the request for an | 3 | | expedited external review, the assigned independent review | 4 | | organization shall: | 5 | | (1) make a decision to uphold or reverse the final | 6 | | adverse determination; and | 7 | | (2) notify the Director, the health carrier, the | 8 | | covered person, the covered person's health care provider, | 9 | | and, if applicable, the covered person's authorized | 10 | | representative, of the decision. | 11 | | (f) In reaching a decision, the assigned independent | 12 | | review organization is not bound by any decisions or | 13 | | conclusions reached during the health carrier's utilization | 14 | | review process or the health carrier's internal appeal | 15 | | process.
| 16 | | (g) Upon receipt of notice of a decision reversing the | 17 | | adverse determination or final adverse determination, the | 18 | | health carrier shall immediately approve the coverage that was | 19 | | the subject of the adverse determination or final adverse | 20 | | determination. | 21 | | (h) If the notice provided pursuant to subsection (e) of | 22 | | this Section was not in writing, then within 48 hours after the | 23 | | date of providing that notice, the assigned independent review | 24 | | organization shall provide written confirmation of the | 25 | | decision to the Director, the health carrier, the covered | 26 | | person, and, if applicable, the covered person's authorized |
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| 1 | | representative including the information set forth in | 2 | | subsection (j) of Section 35 of this Act as applicable. | 3 | | (i) An expedited external review may not be provided for | 4 | | retrospective adverse or final adverse determinations.
| 5 | | (j) The assignment by the Director of an approved | 6 | | independent review organization to conduct an external review | 7 | | in accordance with this Section shall be done on a random basis | 8 | | among those independent review organizations approved by the | 9 | | Director pursuant to this Act. | 10 | | (Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11; | 11 | | 97-574, eff. 8-26-11.)
| 12 | | Section 99. Effective date. This Act takes effect January | 13 | | 1, 2022.
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