Illinois General Assembly - Full Text of HB2595
Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Full Text of HB2595  102nd General Assembly

HB2595sam001 102ND GENERAL ASSEMBLY

Sen. Laura Fine

Filed: 5/14/2021

 

 


 

 


 
10200HB2595sam001LRB102 10633 BMS 26514 a

1
AMENDMENT TO HOUSE BILL 2595

2    AMENDMENT NO. ______. Amend House Bill 2595 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. This Act may be referred to as the Generally
5Accepted Standards of Behavioral Health Care Act of 2021.
 
6    Section 2. The General Assembly finds and declares the
7following:
8    (a) The State of Illinois and the entire country faces a
9mental 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,

 

 

10200HB2595sam001- 2 -LRB102 10633 BMS 26514 a

1    anxiety, and trauma, and rates of substance use and
2    suicidal ideation have increased.
3        (2) Nationally, the suicide rate has increased 35% in
4    the past 20 years. According to the Illinois Department of
5    Public Health, more than 1,000 Illinoisans die by suicide
6    every year, including 1,439 deaths in 2019, and it is the
7    third leading cause of death among young adults aged 15 to
8    34.
9        (3) Between 2013 and 2019, Illinois saw a 1,861%
10    increase in synthetic opioid overdose deaths and a 68%
11    increase in heroin overdose deaths. In 2019 alone, there
12    were 2.3 and 2 times as many opioid deaths as homicides and
13    car crash deaths, respectively.
14        (4) Communities of color are disproportionately
15    impacted by lack of access to and inequities in mental
16    health and substance use disorder care.
17            (A) According to the Substance Abuse and Mental
18        Health Services Administration, two-thirds of Black
19        and Hispanic Americans with a mental illness and
20        nearly 90% with a substance use disorder do not
21        receive medically necessary treatment.
22            (B) Data from the U.S. Census Bureau demonstrates
23        that Black Americans saw the highest increases in
24        rates of anxiety and depression in 2020.
25            (C) Data from the Illinois Department of Public
26        Health reveals that Black Illinoisans are hospitalized

 

 

10200HB2595sam001- 3 -LRB102 10633 BMS 26514 a

1        for opioid overdoses at a rate 6 times higher than
2        white Illinoisans.
3            (D) In the first half of 2020, the number of
4        suicides among Black Chicagoans had increased 106%
5        from the previous year. Nationally, from 2001 to 2017,
6        suicide rates doubled among Black girls aged 13 to 19
7        and increased 60% for Black boys of the same age.
8            (E) According to the Substance Abuse and Mental
9        Health Services Administration, between 2008 and 2018
10        there were significant increases in serious mental
11        illness and suicide ideation in Hispanics aged 18 to
12        25 and there remains a large gap in treatment need
13        among Hispanics.
14        (5) According to the U.S. Center for Disease Control
15    and Prevention, children with adverse childhood
16    experiences are more likely to experience negative
17    outcomes like post-traumatic stress disorder, increased
18    anxiety and depression, suicide, and substance use. A 2020
19    report from Mental Health America shows that 62.1% of
20    Illinois youth with severe depression do not receive any
21    mental health treatment. Survey results found that 80% of
22    college students report that COVID-19 has negatively
23    impacted their mental health.
24        (6) In rural communities, between 2001 and 2015, the
25    suicide rate increased by 27%, and between 1999 and 2015
26    the overdose rate increased 325%.

 

 

10200HB2595sam001- 4 -LRB102 10633 BMS 26514 a

1        (7) According to the U.S. Department of Veterans
2    Affairs, 154 veterans died by suicide in 2018, which
3    accounts for more than 10% of all suicide deaths reported
4    by the Illinois Department of Public Health in the same
5    year, despite only accounting for approximately 5.7% of
6    the State's total population. Nationally, between 2008 and
7    2017, more than 6,000 veterans died by suicide each year.
8        (8) According to the National Alliance on Mental
9    Illness, 2,000,000 people with mental illness are
10    incarcerated every year, where they do not receive the
11    treatment they need.
12    (b) A recent landmark federal court ruling offers a
13concrete demonstration of how the mental health and addiction
14crisis described in subsection (a) is worsened through the
15denial of medically necessary mental health and substance use
16disorder treatment.
17        (1) In March 2019, the United States District Court of
18    the Northern District of California ruled in Wit v. United
19    Behavioral Health, 2019 WL 1033730 (Wit; N.D.CA Mar. 5,
20    2019), that United Behavioral Health created flawed level
21    of care placement criteria that were inconsistent with
22    generally accepted standards of mental health and
23    substance use disorder care in order to "mitigate" the
24    requirements of the federal Mental Health Parity and
25    Addiction Equity Act of 2008.
26        (2) As described by the federal court in Wit, the 8

 

 

10200HB2595sam001- 5 -LRB102 10633 BMS 26514 a

1    generally accepted standards of mental health and
2    substance use disorder care require all of the following:
3            (A) Effective treatment of underlying conditions,
4        rather than mere amelioration of current symptoms,
5        such as suicidality or psychosis.
6            (B) Treatment of co-occurring behavioral health
7        disorders or medical conditions in a coordinated
8        manner.
9            (C) Treatment at the least intensive and
10        restrictive level of care that is safe and effective
11        and meets the needs of the patient's condition; a
12        lower level or less intensive care is appropriate only
13        if it is safe and just as effective as treatment at a
14        higher level or service intensity.
15            (D) Erring on the side of caution, by placing
16        patients in higher levels of care when there is
17        ambiguity as to the appropriate level of care, or when
18        the recommended level of care is not available.
19            (E) Treatment to maintain functioning or prevent
20        deterioration.
21            (F) Treatment of mental health and substance use
22        disorders for an appropriate duration based on
23        individual patient needs rather than on specific time
24        limits.
25            (G) Accounting for the unique needs of children
26        and adolescents when making level of care decisions.

 

 

10200HB2595sam001- 6 -LRB102 10633 BMS 26514 a

1            (H) Applying multidimensional assessments of
2        patient needs when making determinations regarding the
3        appropriate level of care.
4        (3) The court in Wit found that all parties' expert
5    witnesses regarded the American Society of Addiction
6    Medicine (ASAM) criteria for substance use disorders and
7    Level of Care Utilization System (LOCUS), Child and
8    Adolescent Level of Care Utilization System (CALOCUS),
9    Child and Adolescent Service Intensity Instrument (CASII),
10    and Early Childhood Service Intensity Instrument (ECSII)
11    criteria for mental health disorders as prime examples of
12    level of care criteria that are fully consistent with
13    generally accepted standards of mental health and
14    substance use care.
15        (4) In particular, the coverage of intermediate levels
16    of care, such as residential treatment, which are
17    essential components of the level of care continuum called
18    for by nonprofit, and clinical specialty associations such
19    as the American Society of Addiction Medicine, are often
20    denied through overly restrictive medical necessity
21    determinations.
22        (5) On November 3, 2020, the court issued a remedies
23    order requiring United Behavioral Health to reprocess
24    67,000 mental health and substance use disorder claims and
25    mandating that, for the next decade, United Behavioral
26    Health must use the relevant nonprofit clinical society

 

 

10200HB2595sam001- 7 -LRB102 10633 BMS 26514 a

1    guidelines for its medical necessity determinations.
2        (6) The court's findings also demonstrated how United
3    Behavioral Health was in violation of Section 370c of the
4    Illinois Insurance Code for its failure to use the
5    American Society of Addiction Medicine Criteria for
6    substance use disorders. The results of market conduct
7    examinations released by the Illinois Department of
8    Insurance on July 15, 2020 confirmed these findings citing
9    United Healthcare and CIGNA for their failure to use the
10    American Society of Addiction Medicine Criteria when
11    making medical necessity determinations for substance use
12    disorders as required by Illinois law.
13    (c) Insurers should not be permitted to deny medically
14necessary mental health and substance use disorder care
15through the use of utilization review practices and criteria
16that are inconsistent with generally accepted standards of
17mental health and substance use disorder care.
18        (1) Illinois parity law (Sections 370c and 370c.1 of
19    the Illinois Insurance Code) requires that health plans
20    treat illnesses of the brain, such as addiction and
21    depression, the same way they treat illness of other parts
22    of the body, such as cancer and diabetes. The Illinois
23    General Assembly significantly strengthened Illinois'
24    parity law, which incorporates provisions of the federal
25    Paul Wellstone and Pete Domenici Mental Health Parity and
26    Addiction Equity Act of 2008, in both 2015 and 2018.

 

 

10200HB2595sam001- 8 -LRB102 10633 BMS 26514 a

1        (2) While the federal Patient Protection and
2    Affordable Care Act includes mental health and addiction
3    coverage as one of the 10 essential health benefits, it
4    does not contain a definition for medical necessity, and
5    despite the Patient Protection and Affordable Care Act,
6    needed mental health and addiction coverage can be denied
7    through overly restrictive medical necessity
8    determinations.
9        (3) Despite the strong actions taken by the Illinois
10    General Assembly, the court in Wit v. United Behavioral
11    Health demonstrated how insurers can mitigate compliance
12    with parity laws due by denying medically necessary mental
13    health and treatment by using flawed medical necessity
14    criteria.
15        (4) When medically necessary mental health and
16    substance use disorder care is denied, the manifestations
17    of the mental health and addiction crisis described in
18    subsection (a) are severely exacerbated. Individuals with
19    mental health and substance use disorders often have their
20    conditions worsen, sometimes ending up in the criminal
21    justice system or on the streets, resulting in increased
22    emergency hospitalizations, harm to individuals and
23    communities, and higher costs to taxpayers.
24        (5) In order to realize the promise of mental health
25    and addiction parity and remove barriers to mental health
26    and substance use disorder care for all Illinoisans,

 

 

10200HB2595sam001- 9 -LRB102 10633 BMS 26514 a

1    insurers must be required to cover medically necessary
2    mental health and substance use disorder care and follow
3    generally accepted standards of mental health and
4    substance use disorder care.
 
5    Section 5. The Illinois Insurance Code is amended by
6changing Sections 370c and 370c.1 as follows:
 
7    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
8    Sec. 370c. Mental and emotional disorders.
9    (a)(1) On and after the effective date of this amendatory
10Act of the 102nd General Assembly January 1, 2019 (the
11effective date of this amendatory Act of the 101st General
12Assembly Public Act 100-1024), every insurer that amends,
13delivers, issues, or renews group accident and health policies
14providing coverage for hospital or medical treatment or
15services for illness on an expense-incurred basis shall
16provide coverage for the medically necessary treatment of
17reasonable and necessary treatment and services for mental,
18emotional, nervous, or substance use disorders or conditions
19consistent with the parity requirements of Section 370c.1 of
20this Code.
21    (2) Each insured that is covered for mental, emotional,
22nervous, or substance use disorders or conditions shall be
23free to select the physician licensed to practice medicine in
24all its branches, licensed clinical psychologist, licensed

 

 

10200HB2595sam001- 10 -LRB102 10633 BMS 26514 a

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

 

 

10200HB2595sam001- 11 -LRB102 10633 BMS 26514 a

1professionals at programs licensed pursuant to the Substance
2Use Disorder Act, those persons who may provide services to
3individuals shall do so after the licensed clinical social
4worker, licensed clinical professional counselor, licensed
5marriage and family therapist, licensed speech-language
6pathologist, or other licensed or certified professional at a
7program licensed pursuant to the Substance Use Disorder Act
8has informed the patient of the desirability of the patient
9conferring with the patient's primary care physician.
10    (4) "Mental, emotional, nervous, or substance use disorder
11or condition" means a condition or disorder that involves a
12mental health condition or substance use disorder that falls
13under any of the diagnostic categories listed in the mental
14and behavioral disorders chapter of the current edition of the
15World Health Organization's International Classification of
16Disease or that is listed in the most recent version of the
17American Psychiatric Association's Diagnostic and Statistical
18Manual of Mental Disorders. "Mental, emotional, nervous, or
19substance use disorder or condition" includes any mental
20health condition that occurs during pregnancy or during the
21postpartum period and includes, but is not limited to,
22postpartum depression.
23    (5) Medically necessary treatment and medical necessity
24determinations shall be interpreted and made in a manner that
25is consistent with and pursuant to subsections (h) through
26(t).

 

 

10200HB2595sam001- 12 -LRB102 10633 BMS 26514 a

1    (b)(1) (Blank).
2    (2) (Blank).
3    (2.5) (Blank).
4    (3) Unless otherwise prohibited by federal law and
5consistent with the parity requirements of Section 370c.1 of
6this Code, the reimbursing insurer that amends, delivers,
7issues, or renews a group or individual policy of accident and
8health insurance, a qualified health plan offered through the
9health insurance marketplace, or a provider of treatment of
10mental, emotional, nervous, or substance use disorders or
11conditions shall furnish medical records or other necessary
12data that substantiate that initial or continued treatment is
13at all times medically necessary. An insurer shall provide a
14mechanism for the timely review by a provider holding the same
15license and practicing in the same specialty as the patient's
16provider, who is unaffiliated with the insurer, jointly
17selected by the patient (or the patient's next of kin or legal
18representative if the patient is unable to act for himself or
19herself), the patient's provider, and the insurer in the event
20of a dispute between the insurer and patient's provider
21regarding the medical necessity of a treatment proposed by a
22patient's provider. If the reviewing provider determines the
23treatment to be medically necessary, the insurer shall provide
24reimbursement for the treatment. Future contractual or
25employment actions by the insurer regarding the patient's
26provider may not be based on the provider's participation in

 

 

10200HB2595sam001- 13 -LRB102 10633 BMS 26514 a

1this procedure. Nothing prevents the insured from agreeing in
2writing to continue treatment at his or her expense. When
3making a determination of the medical necessity for a
4treatment modality for mental, emotional, nervous, or
5substance use disorders or conditions, an insurer must make
6the determination in a manner that is consistent with the
7manner used to make that determination with respect to other
8diseases or illnesses covered under the policy, including an
9appeals process. Medical necessity determinations for
10substance use disorders shall be made in accordance with
11appropriate patient placement criteria established by the
12American Society of Addiction Medicine. No additional criteria
13may be used to make medical necessity determinations for
14substance use disorders.
15    (4) A group health benefit plan amended, delivered,
16issued, or renewed on or after January 1, 2019 (the effective
17date of Public Act 100-1024) or an individual policy of
18accident and health insurance or a qualified health plan
19offered through the health insurance marketplace amended,
20delivered, issued, or renewed on or after January 1, 2019 (the
21effective date of Public Act 100-1024):
22        (A) shall provide coverage based upon medical
23    necessity for the treatment of a mental, emotional,
24    nervous, or substance use disorder or condition consistent
25    with the parity requirements of Section 370c.1 of this
26    Code; provided, however, that in each calendar year

 

 

10200HB2595sam001- 14 -LRB102 10633 BMS 26514 a

1    coverage shall not be less than the following:
2            (i) 45 days of inpatient treatment; and
3            (ii) beginning on June 26, 2006 (the effective
4        date of Public Act 94-921), 60 visits for outpatient
5        treatment including group and individual outpatient
6        treatment; and
7            (iii) for plans or policies delivered, issued for
8        delivery, renewed, or modified after January 1, 2007
9        (the effective date of Public Act 94-906), 20
10        additional outpatient visits for speech therapy for
11        treatment of pervasive developmental disorders that
12        will be in addition to speech therapy provided
13        pursuant to item (ii) of this subparagraph (A); and
14        (B) may not include a lifetime limit on the number of
15    days of inpatient treatment or the number of outpatient
16    visits covered under the plan.
17        (C) (Blank).
18    (5) An issuer of a group health benefit plan or an
19individual policy of accident and health insurance or a
20qualified health plan offered through the health insurance
21marketplace may not count toward the number of outpatient
22visits required to be covered under this Section an outpatient
23visit for the purpose of medication management and shall cover
24the outpatient visits under the same terms and conditions as
25it covers outpatient visits for the treatment of physical
26illness.

 

 

10200HB2595sam001- 15 -LRB102 10633 BMS 26514 a

1    (5.5) An individual or group health benefit plan amended,
2delivered, issued, or renewed on or after September 9, 2015
3(the effective date of Public Act 99-480) shall offer coverage
4for medically necessary acute treatment services and medically
5necessary clinical stabilization services. The treating
6provider shall base all treatment recommendations and the
7health benefit plan shall base all medical necessity
8determinations for substance use disorders in accordance with
9the most current edition of the Treatment Criteria for
10Addictive, Substance-Related, and Co-Occurring Conditions
11established by the American Society of Addiction Medicine. The
12treating provider shall base all treatment recommendations and
13the health benefit plan shall base all medical necessity
14determinations for medication-assisted treatment in accordance
15with the most current Treatment Criteria for Addictive,
16Substance-Related, and Co-Occurring Conditions established by
17the American Society of Addiction Medicine.
18    As used in this subsection:
19    "Acute treatment services" means 24-hour medically
20supervised addiction treatment that provides evaluation and
21withdrawal management and may include biopsychosocial
22assessment, individual and group counseling, psychoeducational
23groups, and discharge planning.
24    "Clinical stabilization services" means 24-hour treatment,
25usually following acute treatment services for substance
26abuse, which may include intensive education and counseling

 

 

10200HB2595sam001- 16 -LRB102 10633 BMS 26514 a

1regarding the nature of addiction and its consequences,
2relapse prevention, outreach to families and significant
3others, and aftercare planning for individuals beginning to
4engage in recovery from addiction.
5    (6) An issuer of a group health benefit plan may provide or
6offer coverage required under this Section through a managed
7care plan.
8    (6.5) An individual or group health benefit plan amended,
9delivered, issued, or renewed on or after January 1, 2019 (the
10effective date of Public Act 100-1024):
11        (A) shall not impose prior authorization requirements,
12    other than those established under the Treatment Criteria
13    for Addictive, Substance-Related, and Co-Occurring
14    Conditions established by the American Society of
15    Addiction Medicine, on a prescription medication approved
16    by the United States Food and Drug Administration that is
17    prescribed or administered for the treatment of substance
18    use disorders;
19        (B) shall not impose any step therapy requirements,
20    other than those established under the Treatment Criteria
21    for Addictive, Substance-Related, and Co-Occurring
22    Conditions established by the American Society of
23    Addiction Medicine, before authorizing coverage for a
24    prescription medication approved by the United States Food
25    and Drug Administration that is prescribed or administered
26    for the treatment of substance use disorders;

 

 

10200HB2595sam001- 17 -LRB102 10633 BMS 26514 a

1        (C) shall place all prescription medications approved
2    by the United States Food and Drug Administration
3    prescribed or administered for the treatment of substance
4    use disorders on, for brand medications, the lowest tier
5    of the drug formulary developed and maintained by the
6    individual or group health benefit plan that covers brand
7    medications and, for generic medications, the lowest tier
8    of the drug formulary developed and maintained by the
9    individual or group health benefit plan that covers
10    generic medications; and
11        (D) shall not exclude coverage for a prescription
12    medication approved by the United States Food and Drug
13    Administration for the treatment of substance use
14    disorders and any associated counseling or wraparound
15    services on the grounds that such medications and services
16    were court ordered.
17    (7) (Blank).
18    (8) (Blank).
19    (9) With respect to all mental, emotional, nervous, or
20substance use disorders or conditions, coverage for inpatient
21treatment shall include coverage for treatment in a
22residential treatment center certified or licensed by the
23Department of Public Health or the Department of Human
24Services.
25    (c) This Section shall not be interpreted to require
26coverage for speech therapy or other habilitative services for

 

 

10200HB2595sam001- 18 -LRB102 10633 BMS 26514 a

1those individuals covered under Section 356z.15 of this Code.
2    (d) With respect to a group or individual policy of
3accident and health insurance or a qualified health plan
4offered through the health insurance marketplace, the
5Department and, with respect to medical assistance, the
6Department of Healthcare and Family Services shall each
7enforce the requirements of this Section and Sections 356z.23
8and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
9Mental Health Parity and Addiction Equity Act of 2008, 42
10U.S.C. 18031(j), and any amendments to, and federal guidance
11or regulations issued under, those Acts, including, but not
12limited to, final regulations issued under the Paul Wellstone
13and Pete Domenici Mental Health Parity and Addiction Equity
14Act of 2008 and final regulations applying the Paul Wellstone
15and Pete Domenici Mental Health Parity and Addiction Equity
16Act of 2008 to Medicaid managed care organizations, the
17Children's Health Insurance Program, and alternative benefit
18plans. Specifically, the Department and the Department of
19Healthcare and Family Services shall take action:
20        (1) proactively ensuring compliance by individual and
21    group policies, including by requiring that insurers
22    submit comparative analyses, as set forth in paragraph (6)
23    of subsection (k) of Section 370c.1, demonstrating how
24    they design and apply nonquantitative treatment
25    limitations, both as written and in operation, for mental,
26    emotional, nervous, or substance use disorder or condition

 

 

10200HB2595sam001- 19 -LRB102 10633 BMS 26514 a

1    benefits as compared to how they design and apply
2    nonquantitative treatment limitations, as written and in
3    operation, for medical and surgical benefits;
4        (2) evaluating all consumer or provider complaints
5    regarding mental, emotional, nervous, or substance use
6    disorder or condition coverage for possible parity
7    violations;
8        (3) performing parity compliance market conduct
9    examinations or, in the case of the Department of
10    Healthcare and Family Services, parity compliance audits
11    of individual and group plans and policies, including, but
12    not limited to, reviews of:
13            (A) nonquantitative treatment limitations,
14        including, but not limited to, prior authorization
15        requirements, concurrent review, retrospective review,
16        step therapy, network admission standards,
17        reimbursement rates, and geographic restrictions;
18            (B) denials of authorization, payment, and
19        coverage; and
20            (C) other specific criteria as may be determined
21        by the Department.
22    The findings and the conclusions of the parity compliance
23market conduct examinations and audits shall be made public.
24    The Director may adopt rules to effectuate any provisions
25of the Paul Wellstone and Pete Domenici Mental Health Parity
26and Addiction Equity Act of 2008 that relate to the business of

 

 

10200HB2595sam001- 20 -LRB102 10633 BMS 26514 a

1insurance.
2    (e) Availability of plan information.
3        (1) The criteria for medical necessity determinations
4    made under a group health plan, an individual policy of
5    accident and health insurance, or a qualified health plan
6    offered through the health insurance marketplace with
7    respect to mental health or substance use disorder
8    benefits (or health insurance coverage offered in
9    connection with the plan with respect to such benefits)
10    must be made available by the plan administrator (or the
11    health insurance issuer offering such coverage) to any
12    current or potential participant, beneficiary, or
13    contracting provider upon request.
14        (2) The reason for any denial under a group health
15    benefit plan, an individual policy of accident and health
16    insurance, or a qualified health plan offered through the
17    health insurance marketplace (or health insurance coverage
18    offered in connection with such plan or policy) of
19    reimbursement or payment for services with respect to
20    mental, emotional, nervous, or substance use disorders or
21    conditions benefits in the case of any participant or
22    beneficiary must be made available within a reasonable
23    time and in a reasonable manner and in readily
24    understandable language by the plan administrator (or the
25    health insurance issuer offering such coverage) to the
26    participant or beneficiary upon request.

 

 

10200HB2595sam001- 21 -LRB102 10633 BMS 26514 a

1    (f) As used in this Section, "group policy of accident and
2health insurance" and "group health benefit plan" includes (1)
3State-regulated employer-sponsored group health insurance
4plans written in Illinois or which purport to provide coverage
5for a resident of this State; and (2) State employee health
6plans.
7    (g) (1) As used in this subsection:
8    "Benefits", with respect to insurers, means the benefits
9provided for treatment services for inpatient and outpatient
10treatment of substance use disorders or conditions at American
11Society of Addiction Medicine levels of treatment 2.1
12(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
13(Clinically Managed Low-Intensity Residential), 3.3
14(Clinically Managed Population-Specific High-Intensity
15Residential), 3.5 (Clinically Managed High-Intensity
16Residential), and 3.7 (Medically Monitored Intensive
17Inpatient) and OMT (Opioid Maintenance Therapy) services.
18    "Benefits", with respect to managed care organizations,
19means the benefits provided for treatment services for
20inpatient and outpatient treatment of substance use disorders
21or conditions at American Society of Addiction Medicine levels
22of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
23Hospitalization), 3.5 (Clinically Managed High-Intensity
24Residential), and 3.7 (Medically Monitored Intensive
25Inpatient) and OMT (Opioid Maintenance Therapy) services.
26    "Substance use disorder treatment provider or facility"

 

 

10200HB2595sam001- 22 -LRB102 10633 BMS 26514 a

1means a licensed physician, licensed psychologist, licensed
2psychiatrist, licensed advanced practice registered nurse, or
3licensed, certified, or otherwise State-approved facility or
4provider of substance use disorder treatment.
5    (2) A group health insurance policy, an individual health
6benefit plan, or qualified health plan that is offered through
7the health insurance marketplace, small employer group health
8plan, and large employer group health plan that is amended,
9delivered, issued, executed, or renewed in this State, or
10approved for issuance or renewal in this State, on or after
11January 1, 2019 (the effective date of Public Act 100-1023)
12shall comply with the requirements of this Section and Section
13370c.1. The services for the treatment and the ongoing
14assessment of the patient's progress in treatment shall follow
15the requirements of 77 Ill. Adm. Code 2060.
16    (3) Prior authorization shall not be utilized for the
17benefits under this subsection. The substance use disorder
18treatment provider or facility shall notify the insurer of the
19initiation of treatment. For an insurer that is not a managed
20care organization, the substance use disorder treatment
21provider or facility notification shall occur for the
22initiation of treatment of the covered person within 2
23business days. For managed care organizations, the substance
24use disorder treatment provider or facility notification shall
25occur in accordance with the protocol set forth in the
26provider agreement for initiation of treatment within 24

 

 

10200HB2595sam001- 23 -LRB102 10633 BMS 26514 a

1hours. If the managed care organization is not capable of
2accepting the notification in accordance with the contractual
3protocol during the 24-hour period following admission, the
4substance use disorder treatment provider or facility shall
5have one additional business day to provide the notification
6to the appropriate managed care organization. Treatment plans
7shall be developed in accordance with the requirements and
8timeframes established in 77 Ill. Adm. Code 2060. If the
9substance use disorder treatment provider or facility fails to
10notify the insurer of the initiation of treatment in
11accordance with these provisions, the insurer may follow its
12normal prior authorization processes.
13    (4) For an insurer that is not a managed care
14organization, if an insurer determines that benefits are no
15longer medically necessary, the insurer shall notify the
16covered person, the covered person's authorized
17representative, if any, and the covered person's health care
18provider in writing of the covered person's right to request
19an external review pursuant to the Health Carrier External
20Review Act. The notification shall occur within 24 hours
21following the adverse determination.
22    Pursuant to the requirements of the Health Carrier
23External Review Act, the covered person or the covered
24person's authorized representative may request an expedited
25external review. An expedited external review may not occur if
26the substance use disorder treatment provider or facility

 

 

10200HB2595sam001- 24 -LRB102 10633 BMS 26514 a

1determines that continued treatment is no longer medically
2necessary. Under this subsection, a request for expedited
3external review must be initiated within 24 hours following
4the adverse determination notification by the insurer. Failure
5to request an expedited external review within 24 hours shall
6preclude a covered person or a covered person's authorized
7representative from requesting an expedited external review.
8    If an expedited external review request meets the criteria
9of the Health Carrier External Review Act, an independent
10review organization shall make a final determination of
11medical necessity within 72 hours. If an independent review
12organization upholds an adverse determination, an insurer
13shall remain responsible to provide coverage of benefits
14through the day following the determination of the independent
15review organization. A decision to reverse an adverse
16determination shall comply with the Health Carrier External
17Review Act.
18    (5) The substance use disorder treatment provider or
19facility shall provide the insurer with 7 business days'
20advance notice of the planned discharge of the patient from
21the substance use disorder treatment provider or facility and
22notice on the day that the patient is discharged from the
23substance use disorder treatment provider or facility.
24    (6) The benefits required by this subsection shall be
25provided to all covered persons with a diagnosis of substance
26use disorder or conditions. The presence of additional related

 

 

10200HB2595sam001- 25 -LRB102 10633 BMS 26514 a

1or unrelated diagnoses shall not be a basis to reduce or deny
2the benefits required by this subsection.
3    (7) Nothing in this subsection shall be construed to
4require an insurer to provide coverage for any of the benefits
5in this subsection.
6    (h) As used in this Section:
7    "Generally accepted standards of mental, emotional,
8nervous, or substance use disorder or condition care" means
9standards of care and clinical practice that are generally
10recognized by health care providers practicing in relevant
11clinical specialties such as psychiatry, psychology, clinical
12sociology, social work, addiction medicine and counseling, and
13behavioral health treatment. Valid, evidence-based sources
14reflecting generally accepted standards of mental, emotional,
15nervous, or substance use disorder or condition care include
16peer-reviewed scientific studies and medical literature,
17recommendations of nonprofit health care provider professional
18associations and specialty societies, including, but not
19limited to, patient placement criteria and clinical practice
20guidelines, recommendations of federal government agencies,
21and drug labeling approved by the United States Food and Drug
22Administration.
23    "Medically necessary treatment of mental, emotional,
24nervous, or substance use disorders or conditions" means a
25service or product addressing the specific needs of that
26patient, for the purpose of screening, preventing, diagnosing,

 

 

10200HB2595sam001- 26 -LRB102 10633 BMS 26514 a

1managing, or treating an illness, injury, or condition or its
2symptoms and comorbidities, including minimizing the
3progression of an illness, injury, or condition or its
4symptoms and comorbidities in a manner that is all of the
5following:
6        (1) in accordance with the generally accepted
7    standards of mental, emotional, nervous, or substance use
8    disorder or condition care;
9        (2) clinically appropriate in terms of type,
10    frequency, extent, site, and duration; and
11        (3) not primarily for the economic benefit of the
12    insurer, purchaser, or for the convenience of the patient,
13    treating physician, or other health care provider.
14    "Utilization review" means either of the following:
15        (1) prospectively, retrospectively, or concurrently
16    reviewing and approving, modifying, delaying, or denying,
17    based in whole or in part on medical necessity, requests
18    by health care providers, insureds, or their authorized
19    representatives for coverage of health care services
20    before, retrospectively, or concurrently with the
21    provision of health care services to insureds.
22        (2) evaluating the medical necessity, appropriateness,
23    level of care, service intensity, efficacy, or efficiency
24    of health care services, benefits, procedures, or
25    settings, under any circumstances, to determine whether a
26    health care service or benefit subject to a medical

 

 

10200HB2595sam001- 27 -LRB102 10633 BMS 26514 a

1    necessity coverage requirement in an insurance policy is
2    covered as medically necessary for an insured.
3    "Utilization review criteria" means patient placement
4criteria or any criteria, standards, protocols, or guidelines
5used by an insurer to conduct utilization review.
6    (i)(1) Every insurer that amends, delivers, issues, or
7renews a group or individual policy of accident and health
8insurance or a qualified health plan offered through the
9health insurance marketplace in this State and Medicaid
10managed care organizations providing coverage for hospital or
11medical treatment on or after January 1, 2023 shall, pursuant
12to subsections (h) through (s), provide coverage for medically
13necessary treatment of mental, emotional, nervous, or
14substance use disorders or conditions.
15    (2) An insurer shall not set a specific limit on the
16duration of benefits or coverage of medically necessary
17treatment of mental, emotional, nervous, or substance use
18disorders or conditions or limit coverage only to alleviation
19of the insured's current symptoms.
20    (3) All medical necessity determinations made by the
21insurer concerning service intensity, level of care placement,
22continued stay, and transfer or discharge of insureds
23diagnosed with mental, emotional, nervous, or substance use
24disorders or conditions shall be conducted in accordance with
25the requirements of subsections (k) through (u).
26    (4) An insurer that authorizes a specific type of

 

 

10200HB2595sam001- 28 -LRB102 10633 BMS 26514 a

1treatment by a provider pursuant to this Section shall not
2rescind or modify the authorization after that provider
3renders the health care service in good faith and pursuant to
4this authorization for any reason, including, but not limited
5to, the insurer's subsequent cancellation or modification of
6the insured's or policyholder's contract, or the insured's or
7policyholder's eligibility. Nothing in this Section shall
8require the insurer to cover a treatment when the
9authorization was granted based on a material
10misrepresentation by the insured, the policyholder, or the
11provider. Nothing in this Section shall require Medicaid
12managed care organizations to pay for services if the
13individual was not eligible for Medicaid at the time the
14service was rendered. Nothing in this Section shall require an
15insurer to pay for services if the individual was not the
16insurer's enrollee at the time services were rendered. As used
17in this paragraph, "material" means a fact or situation that
18is not merely technical in nature and results in or could
19result in a substantial change in the situation.
20    (j) An insurer shall not limit benefits or coverage for
21medically necessary services on the basis that those services
22should be or could be covered by a public entitlement program,
23including, but not limited to, special education or an
24individualized education program, Medicaid, Medicare,
25Supplemental Security Income, or Social Security Disability
26Insurance, and shall not include or enforce a contract term

 

 

10200HB2595sam001- 29 -LRB102 10633 BMS 26514 a

1that excludes otherwise covered benefits on the basis that
2those services should be or could be covered by a public
3entitlement program. Nothing in this subsection shall be
4construed to require an insurer to cover benefits that have
5been authorized and provided for a covered person by a public
6entitlement program. Medicaid managed care organizations are
7not subject to this subsection.
8    (k) An insurer shall base any medical necessity
9determination or the utilization review criteria that the
10insurer, and any entity acting on the insurer's behalf,
11applies to determine the medical necessity of health care
12services and benefits for the diagnosis, prevention, and
13treatment of mental, emotional, nervous, or substance use
14disorders or conditions on current generally accepted
15standards of mental, emotional, nervous, or substance use
16disorder or condition care. All denials and appeals shall be
17reviewed by a professional with experience or expertise
18comparable to the provider requesting the authorization.
19    (l) For medical necessity determinations relating to level
20of care placement, continued stay, and transfer or discharge
21of insureds diagnosed with mental, emotional, and nervous
22disorders or conditions, an insurer shall apply the patient
23placement criteria set forth in the most recent version of the
24treatment criteria developed by an unaffiliated nonprofit
25professional association for the relevant clinical specialty
26or, for Medicaid managed care organizations, patient placement

 

 

10200HB2595sam001- 30 -LRB102 10633 BMS 26514 a

1criteria determined by the Department of Healthcare and Family
2Services that are consistent with generally accepted standards
3of mental, emotional, nervous or substance use disorder or
4condition care. Pursuant to subsection (b), in conducting
5utilization review of all covered services and benefits for
6the diagnosis, prevention, and treatment of substance use
7disorders an insurer shall use the most recent edition of the
8patient placement criteria established by the American Society
9of Addiction Medicine.
10    (m) For medical necessity determinations relating to level
11of care placement, continued stay, and transfer or discharge
12that are within the scope of the sources specified in
13subsection (l), an insurer shall not apply different,
14additional, conflicting, or more restrictive utilization
15review criteria than the criteria set forth in those sources.
16For all level of care placement decisions, the insurer shall
17authorize placement at the level of care consistent with the
18assessment of the insured using the relevant patient placement
19criteria as specified in subsection (l). If that level of
20placement is not available, the insurer shall authorize the
21next higher level of care. In the event of disagreement, the
22insurer shall provide full detail of its assessment using the
23relevant criteria as specified in subsection (l) to the
24provider of the service and the patient.
25    Nothing in this subsection or subsection (l) prohibits an
26insurer from applying utilization review criteria that were

 

 

10200HB2595sam001- 31 -LRB102 10633 BMS 26514 a

1developed in accordance with subsection (k) to health care
2services and benefits for mental, emotional, and nervous
3disorders or conditions that are not related to medical
4necessity determinations for level of care placement,
5continued stay, and transfer or discharge. If an insurer
6purchases or licenses utilization review criteria pursuant to
7this subsection, the insurer shall verify and document before
8use that the criteria were developed in accordance with
9subsection (k).
10    (n) In conducting utilization review that is outside the
11scope of the criteria as specified in subsection (l) or
12relates to the advancements in technology or in the types or
13levels of care that are not addressed in the most recent
14versions of the sources specified in subsection (l), an
15insurer shall conduct utilization review in accordance with
16subsection (k).
17    (o) This Section does not in any way limit the rights of a
18patient under the Medical Patient Rights Act.
19    (p) This Section does not in any way limit early and
20periodic screening, diagnostic, and treatment benefits as
21defined under 42 U.S.C. 1396d(r).
22    (q) To ensure the proper use of the criteria described in
23subsection (l), every insurer shall do all of the following:
24        (1) Educate the insurer's staff, including any third
25    parties contracted with the insurer to review claims,
26    conduct utilization reviews, or make medical necessity

 

 

10200HB2595sam001- 32 -LRB102 10633 BMS 26514 a

1    determinations about the utilization review criteria.
2        (2) Make the educational program available to other
3    stakeholders, including the insurer's participating or
4    contracted providers and potential participants,
5    beneficiaries, or covered lives. The education program
6    must be provided at least once a year, in-person or
7    digitally, or recordings of the education program must be
8    made available to the aforementioned stakeholders.
9        (3) Provide, at no cost, the utilization review
10    criteria and any training material or resources to
11    providers and insured patients upon request. For
12    utilization review criteria not concerning level of care
13    placement, continued stay, and transfer or discharge used
14    by the insurer pursuant to subsection (m), the insurer may
15    place the criteria on a secure, password-protected website
16    so long as the access requirements of the website do not
17    unreasonably restrict access to insureds or their
18    providers. No restrictions shall be placed upon the
19    insured's or treating provider's access right to
20    utilization review criteria obtained under this paragraph
21    at any point in time, including before an initial request
22    for authorization.
23        (4) Track, identify, and analyze how the utilization
24    review criteria are used to certify care, deny care, and
25    support the appeals process.
26        (5) Conduct interrater reliability testing to ensure

 

 

10200HB2595sam001- 33 -LRB102 10633 BMS 26514 a

1    consistency in utilization review decision making that
2    covers how medical necessity decisions are made; this
3    assessment shall cover all aspects of utilization review
4    as defined in subsection (h).
5        (6) Run interrater reliability reports about how the
6    clinical guidelines are used in conjunction with the
7    utilization review process and parity compliance
8    activities.
9        (7) Achieve interrater reliability pass rates of at
10    least 90% and, if this threshold is not met, immediately
11    provide for the remediation of poor interrater reliability
12    and interrater reliability testing for all new staff
13    before they can conduct utilization review without
14    supervision.
15        (8) Maintain documentation of interrater reliability
16    testing and the remediation actions taken for those with
17    pass rates lower than 90% and submit to the Department of
18    Insurance or, in the case of Medicaid managed care
19    organizations, the Department of Healthcare and Family
20    Services the testing results and a summary of remedial
21    actions as part of parity compliance reporting set forth
22    in subsection (k) of Section 370c.1.
23    (r) This Section applies to all health care services and
24benefits for the diagnosis, prevention, and treatment of
25mental, emotional, nervous, or substance use disorders or
26conditions covered by an insurance policy, including

 

 

10200HB2595sam001- 34 -LRB102 10633 BMS 26514 a

1prescription drugs.
2    (s) This Section applies to an insurer that amends,
3delivers, issues, or renews a group or individual policy of
4accident and health insurance or a qualified health plan
5offered through the health insurance marketplace in this State
6providing coverage for hospital or medical treatment and
7conducts utilization review as defined in this Section,
8including Medicaid managed care organizations, and any entity
9or contracting provider that performs utilization review or
10utilization management functions on an insurer's behalf.
11    (t) If the Director determines that an insurer has
12violated this Section, the Director may, after appropriate
13notice and opportunity for hearing, by order, assess a civil
14penalty between $1,000 and $5,000 for each violation. Moneys
15collected from penalties shall be deposited into the Parity
16Advancement Fund established in subsection (i) of Section
17370c.1.
18    (u) An insurer shall not adopt, impose, or enforce terms
19in its policies or provider agreements, in writing or in
20operation, that undermine, alter, or conflict with the
21requirements of this Section.
22    (v) The provisions of this Section are severable. If any
23provision of this Section or its application is held invalid,
24that invalidity shall not affect other provisions or
25applications that can be given effect without the invalid
26provision or application.

 

 

10200HB2595sam001- 35 -LRB102 10633 BMS 26514 a

1(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
2100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
38-16-19; revised 9-20-19.)
 
4    (215 ILCS 5/370c.1)
5    Sec. 370c.1. Mental, emotional, nervous, or substance use
6disorder or condition parity.
7    (a) On and after the effective date of this amendatory Act
8of the 99th General Assembly, every insurer that amends,
9delivers, issues, or renews a group or individual policy of
10accident and health insurance or a qualified health plan
11offered through the Health Insurance Marketplace in this State
12providing coverage for hospital or medical treatment and for
13the treatment of mental, emotional, nervous, or substance use
14disorders or conditions shall ensure that:
15        (1) the financial requirements applicable to such
16    mental, emotional, nervous, or substance use disorder or
17    condition benefits are no more restrictive than the
18    predominant financial requirements applied to
19    substantially all hospital and medical benefits covered by
20    the policy and that there are no separate cost-sharing
21    requirements that are applicable only with respect to
22    mental, emotional, nervous, or substance use disorder or
23    condition benefits; and
24        (2) the treatment limitations applicable to such
25    mental, emotional, nervous, or substance use disorder or

 

 

10200HB2595sam001- 36 -LRB102 10633 BMS 26514 a

1    condition benefits are no more restrictive than the
2    predominant treatment limitations applied to substantially
3    all hospital and medical benefits covered by the policy
4    and that there are no separate treatment limitations that
5    are applicable only with respect to mental, emotional,
6    nervous, or substance use disorder or condition benefits.
7    (b) The following provisions shall apply concerning
8aggregate lifetime limits:
9        (1) In the case of a group or individual policy of
10    accident and health insurance or a qualified health plan
11    offered through the Health Insurance Marketplace amended,
12    delivered, issued, or renewed in this State on or after
13    the effective date of this amendatory Act of the 99th
14    General Assembly that provides coverage for hospital or
15    medical treatment and for the treatment of mental,
16    emotional, nervous, or substance use disorders or
17    conditions the following provisions shall apply:
18            (A) if the policy does not include an aggregate
19        lifetime limit on substantially all hospital and
20        medical benefits, then the policy may not impose any
21        aggregate lifetime limit on mental, emotional,
22        nervous, or substance use disorder or condition
23        benefits; or
24            (B) if the policy includes an aggregate lifetime
25        limit on substantially all hospital and medical
26        benefits (in this subsection referred to as the

 

 

10200HB2595sam001- 37 -LRB102 10633 BMS 26514 a

1        "applicable lifetime limit"), then the policy shall
2        either:
3                (i) apply the applicable lifetime limit both
4            to the hospital and medical benefits to which it
5            otherwise would apply and to mental, emotional,
6            nervous, or substance use disorder or condition
7            benefits and not distinguish in the application of
8            the limit between the hospital and medical
9            benefits and mental, emotional, nervous, or
10            substance use disorder or condition benefits; or
11                (ii) not include any aggregate lifetime limit
12            on mental, emotional, nervous, or substance use
13            disorder or condition benefits that is less than
14            the applicable lifetime limit.
15        (2) In the case of a policy that is not described in
16    paragraph (1) of subsection (b) of this Section and that
17    includes no or different aggregate lifetime limits on
18    different categories of hospital and medical benefits, the
19    Director shall establish rules under which subparagraph
20    (B) of paragraph (1) of subsection (b) of this Section is
21    applied to such policy with respect to mental, emotional,
22    nervous, or substance use disorder or condition benefits
23    by substituting for the applicable lifetime limit an
24    average aggregate lifetime limit that is computed taking
25    into account the weighted average of the aggregate
26    lifetime limits applicable to such categories.

 

 

10200HB2595sam001- 38 -LRB102 10633 BMS 26514 a

1    (c) The following provisions shall apply concerning annual
2limits:
3        (1) In the case of a group or individual policy of
4    accident and health insurance or a qualified health plan
5    offered through the Health Insurance Marketplace amended,
6    delivered, issued, or renewed in this State on or after
7    the effective date of this amendatory Act of the 99th
8    General Assembly that provides coverage for hospital or
9    medical treatment and for the treatment of mental,
10    emotional, nervous, or substance use disorders or
11    conditions the following provisions shall apply:
12            (A) if the policy does not include an annual limit
13        on substantially all hospital and medical benefits,
14        then the policy may not impose any annual limits on
15        mental, emotional, nervous, or substance use disorder
16        or condition benefits; or
17            (B) if the policy includes an annual limit on
18        substantially all hospital and medical benefits (in
19        this subsection referred to as the "applicable annual
20        limit"), then the policy shall either:
21                (i) apply the applicable annual limit both to
22            the hospital and medical benefits to which it
23            otherwise would apply and to mental, emotional,
24            nervous, or substance use disorder or condition
25            benefits and not distinguish in the application of
26            the limit between the hospital and medical

 

 

10200HB2595sam001- 39 -LRB102 10633 BMS 26514 a

1            benefits and mental, emotional, nervous, or
2            substance use disorder or condition benefits; or
3                (ii) not include any annual limit on mental,
4            emotional, nervous, or substance use disorder or
5            condition benefits that is less than the
6            applicable annual limit.
7        (2) In the case of a policy that is not described in
8    paragraph (1) of subsection (c) of this Section and that
9    includes no or different annual limits on different
10    categories of hospital and medical benefits, the Director
11    shall establish rules under which subparagraph (B) of
12    paragraph (1) of subsection (c) of this Section is applied
13    to such policy with respect to mental, emotional, nervous,
14    or substance use disorder or condition benefits by
15    substituting for the applicable annual limit an average
16    annual limit that is computed taking into account the
17    weighted average of the annual limits applicable to such
18    categories.
19    (d) With respect to mental, emotional, nervous, or
20substance use disorders or conditions, an insurer shall use
21policies and procedures for the election and placement of
22mental, emotional, nervous, or substance use disorder or
23condition treatment drugs on their formulary that are no less
24favorable to the insured as those policies and procedures the
25insurer uses for the selection and placement of drugs for
26medical or surgical conditions and shall follow the expedited

 

 

10200HB2595sam001- 40 -LRB102 10633 BMS 26514 a

1coverage determination requirements for substance abuse
2treatment drugs set forth in Section 45.2 of the Managed Care
3Reform and Patient Rights Act.
4    (e) This Section shall be interpreted in a manner
5consistent with all applicable federal parity regulations
6including, but not limited to, the Paul Wellstone and Pete
7Domenici Mental Health Parity and Addiction Equity Act of
82008, final regulations issued under the Paul Wellstone and
9Pete Domenici Mental Health Parity and Addiction Equity Act of
102008 and final regulations applying the Paul Wellstone and
11Pete Domenici Mental Health Parity and Addiction Equity Act of
122008 to Medicaid managed care organizations, the Children's
13Health Insurance Program, and alternative benefit plans.
14    (f) The provisions of subsections (b) and (c) of this
15Section shall not be interpreted to allow the use of lifetime
16or annual limits otherwise prohibited by State or federal law.
17    (g) As used in this Section:
18    "Financial requirement" includes deductibles, copayments,
19coinsurance, and out-of-pocket maximums, but does not include
20an aggregate lifetime limit or an annual limit subject to
21subsections (b) and (c).
22    "Mental, emotional, nervous, or substance use disorder or
23condition" means a condition or disorder that involves a
24mental health condition or substance use disorder that falls
25under any of the diagnostic categories listed in the mental
26and behavioral disorders chapter of the current edition of the

 

 

10200HB2595sam001- 41 -LRB102 10633 BMS 26514 a

1International Classification of Disease or that is listed in
2the most recent version of the Diagnostic and Statistical
3Manual of Mental Disorders.
4    "Treatment limitation" includes limits on benefits based
5on the frequency of treatment, number of visits, days of
6coverage, days in a waiting period, or other similar limits on
7the scope or duration of treatment. "Treatment limitation"
8includes both quantitative treatment limitations, which are
9expressed numerically (such as 50 outpatient visits per year),
10and nonquantitative treatment limitations, which otherwise
11limit the scope or duration of treatment. A permanent
12exclusion of all benefits for a particular condition or
13disorder shall not be considered a treatment limitation.
14"Nonquantitative treatment" means those limitations as
15described under federal regulations (26 CFR 54.9812-1).
16"Nonquantitative treatment limitations" include, but are not
17limited to, those limitations described under federal
18regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
19146.136.
20    (h) The Department of Insurance shall implement the
21following education initiatives:
22        (1) By January 1, 2016, the Department shall develop a
23    plan for a Consumer Education Campaign on parity. The
24    Consumer Education Campaign shall focus its efforts
25    throughout the State and include trainings in the
26    northern, southern, and central regions of the State, as

 

 

10200HB2595sam001- 42 -LRB102 10633 BMS 26514 a

1    defined by the Department, as well as each of the 5 managed
2    care regions of the State as identified by the Department
3    of Healthcare and Family Services. Under this Consumer
4    Education Campaign, the Department shall: (1) by January
5    1, 2017, provide at least one live training in each region
6    on parity for consumers and providers and one webinar
7    training to be posted on the Department website and (2)
8    establish a consumer hotline to assist consumers in
9    navigating the parity process by March 1, 2017. By January
10    1, 2018 the Department shall issue a report to the General
11    Assembly on the success of the Consumer Education
12    Campaign, which shall indicate whether additional training
13    is necessary or would be recommended.
14        (2) The Department, in coordination with the
15    Department of Human Services and the Department of
16    Healthcare and Family Services, shall convene a working
17    group of health care insurance carriers, mental health
18    advocacy groups, substance abuse patient advocacy groups,
19    and mental health physician groups for the purpose of
20    discussing issues related to the treatment and coverage of
21    mental, emotional, nervous, or substance use disorders or
22    conditions and compliance with parity obligations under
23    State and federal law. Compliance shall be measured,
24    tracked, and shared during the meetings of the working
25    group. The working group shall meet once before January 1,
26    2016 and shall meet semiannually thereafter. The

 

 

10200HB2595sam001- 43 -LRB102 10633 BMS 26514 a

1    Department shall issue an annual report to the General
2    Assembly that includes a list of the health care insurance
3    carriers, mental health advocacy groups, substance abuse
4    patient advocacy groups, and mental health physician
5    groups that participated in the working group meetings,
6    details on the issues and topics covered, and any
7    legislative recommendations developed by the working
8    group.
9        (3) Not later than January August 1 of each year, the
10    Department, in conjunction with the Department of
11    Healthcare and Family Services, shall issue a joint report
12    to the General Assembly and provide an educational
13    presentation to the General Assembly. The report and
14    presentation shall:
15            (A) Cover the methodology the Departments use to
16        check for compliance with the federal Paul Wellstone
17        and Pete Domenici Mental Health Parity and Addiction
18        Equity Act of 2008, 42 U.S.C. 18031(j), and any
19        federal regulations or guidance relating to the
20        compliance and oversight of the federal Paul Wellstone
21        and Pete Domenici Mental Health Parity and Addiction
22        Equity Act of 2008 and 42 U.S.C. 18031(j).
23            (B) Cover the methodology the Departments use to
24        check for compliance with this Section and Sections
25        356z.23 and 370c of this Code.
26            (C) Identify market conduct examinations or, in

 

 

10200HB2595sam001- 44 -LRB102 10633 BMS 26514 a

1        the case of the Department of Healthcare and Family
2        Services, audits conducted or completed during the
3        preceding 12-month period regarding compliance with
4        parity in mental, emotional, nervous, and substance
5        use disorder or condition benefits under State and
6        federal laws and summarize the results of such market
7        conduct examinations and audits. This shall include:
8                (i) the number of market conduct examinations
9            and audits initiated and completed;
10                (ii) the benefit classifications examined by
11            each market conduct examination and audit;
12                (iii) the subject matter of each market
13            conduct examination and audit, including
14            quantitative and nonquantitative treatment
15            limitations; and
16                (iv) a summary of the basis for the final
17            decision rendered in each market conduct
18            examination and audit.
19            Individually identifiable information shall be
20        excluded from the reports consistent with federal
21        privacy protections.
22            (D) Detail any educational or corrective actions
23        the Departments have taken to ensure compliance with
24        the federal Paul Wellstone and Pete Domenici Mental
25        Health Parity and Addiction Equity Act of 2008, 42
26        U.S.C. 18031(j), this Section, and Sections 356z.23

 

 

10200HB2595sam001- 45 -LRB102 10633 BMS 26514 a

1        and 370c of this Code.
2            (E) The report must be written in non-technical,
3        readily understandable language and shall be made
4        available to the public by, among such other means as
5        the Departments find appropriate, posting the report
6        on the Departments' websites.
7    (i) The Parity Advancement Fund is created as a special
8fund in the State treasury. Moneys from fines and penalties
9collected from insurers for violations of this Section shall
10be deposited into the Fund. Moneys deposited into the Fund for
11appropriation by the General Assembly to the Department shall
12be used for the purpose of providing financial support of the
13Consumer Education Campaign, parity compliance advocacy, and
14other initiatives that support parity implementation and
15enforcement on behalf of consumers.
16    (j) The Department of Insurance and the Department of
17Healthcare and Family Services shall convene and provide
18technical support to a workgroup of 11 members that shall be
19comprised of 3 mental health parity experts recommended by an
20organization advocating on behalf of mental health parity
21appointed by the President of the Senate; 3 behavioral health
22providers recommended by an organization that represents
23behavioral health providers appointed by the Speaker of the
24House of Representatives; 2 representing Medicaid managed care
25organizations recommended by an organization that represents
26Medicaid managed care plans appointed by the Minority Leader

 

 

10200HB2595sam001- 46 -LRB102 10633 BMS 26514 a

1of the House of Representatives; 2 representing commercial
2insurers recommended by an organization that represents
3insurers appointed by the Minority Leader of the Senate; and a
4representative of an organization that represents Medicaid
5managed care plans appointed by the Governor.
6    The workgroup shall provide recommendations to the General
7Assembly on health plan data reporting requirements that
8separately break out data on mental, emotional, nervous, or
9substance use disorder or condition benefits and data on other
10medical benefits, including physical health and related health
11services no later than December 31, 2019. The recommendations
12to the General Assembly shall be filed with the Clerk of the
13House of Representatives and the Secretary of the Senate in
14electronic form only, in the manner that the Clerk and the
15Secretary shall direct. This workgroup shall take into account
16federal requirements and recommendations on mental health
17parity reporting for the Medicaid program. This workgroup
18shall also develop the format and provide any needed
19definitions for reporting requirements in subsection (k). The
20research and evaluation of the working group shall include,
21but not be limited to:
22        (1) claims denials due to benefit limits, if
23    applicable;
24        (2) administrative denials for no prior authorization;
25        (3) denials due to not meeting medical necessity;
26        (4) denials that went to external review and whether

 

 

10200HB2595sam001- 47 -LRB102 10633 BMS 26514 a

1    they were upheld or overturned for medical necessity;
2        (5) out-of-network claims;
3        (6) emergency care claims;
4        (7) network directory providers in the outpatient
5    benefits classification who filed no claims in the last 6
6    months, if applicable;
7        (8) the impact of existing and pertinent limitations
8    and restrictions related to approved services, licensed
9    providers, reimbursement levels, and reimbursement
10    methodologies within the Division of Mental Health, the
11    Division of Substance Use Prevention and Recovery
12    programs, the Department of Healthcare and Family
13    Services, and, to the extent possible, federal regulations
14    and law; and
15        (9) when reporting and publishing should begin.
16    Representatives from the Department of Healthcare and
17Family Services, representatives from the Division of Mental
18Health, and representatives from the Division of Substance Use
19Prevention and Recovery shall provide technical advice to the
20workgroup.
21    (k) An insurer that amends, delivers, issues, or renews a
22group or individual policy of accident and health insurance or
23a qualified health plan offered through the health insurance
24marketplace in this State providing coverage for hospital or
25medical treatment and for the treatment of mental, emotional,
26nervous, or substance use disorders or conditions shall submit

 

 

10200HB2595sam001- 48 -LRB102 10633 BMS 26514 a

1an annual report, the format and definitions for which will be
2developed by the workgroup in subsection (j), to the
3Department, or, with respect to medical assistance, the
4Department of Healthcare and Family Services starting on or
5before July 1, 2020 that contains the following information
6separately for inpatient in-network benefits, inpatient
7out-of-network benefits, outpatient in-network benefits,
8outpatient out-of-network benefits, emergency care benefits,
9and prescription drug benefits in the case of accident and
10health insurance or qualified health plans, or inpatient,
11outpatient, emergency care, and prescription drug benefits in
12the case of medical assistance:
13        (1) A summary of the plan's pharmacy management
14    processes for mental, emotional, nervous, or substance use
15    disorder or condition benefits compared to those for other
16    medical benefits.
17        (2) A summary of the internal processes of review for
18    experimental benefits and unproven technology for mental,
19    emotional, nervous, or substance use disorder or condition
20    benefits and those for other medical benefits.
21        (3) A summary of how the plan's policies and
22    procedures for utilization management for mental,
23    emotional, nervous, or substance use disorder or condition
24    benefits compare to those for other medical benefits.
25        (4) A description of the process used to develop or
26    select the medical necessity criteria for mental,

 

 

10200HB2595sam001- 49 -LRB102 10633 BMS 26514 a

1    emotional, nervous, or substance use disorder or condition
2    benefits and the process used to develop or select the
3    medical necessity criteria for medical and surgical
4    benefits.
5        (5) Identification of all nonquantitative treatment
6    limitations that are applied to both mental, emotional,
7    nervous, or substance use disorder or condition benefits
8    and medical and surgical benefits within each
9    classification of benefits.
10        (6) The results of an analysis that demonstrates that
11    for the medical necessity criteria described in
12    subparagraph (A) and for each nonquantitative treatment
13    limitation identified in subparagraph (B), as written and
14    in operation, the processes, strategies, evidentiary
15    standards, or other factors used in applying the medical
16    necessity criteria and each nonquantitative treatment
17    limitation to mental, emotional, nervous, or substance use
18    disorder or condition benefits within each classification
19    of benefits are comparable to, and are applied no more
20    stringently than, the processes, strategies, evidentiary
21    standards, or other factors used in applying the medical
22    necessity criteria and each nonquantitative treatment
23    limitation to medical and surgical benefits within the
24    corresponding classification of benefits; at a minimum,
25    the results of the analysis shall:
26            (A) identify the factors used to determine that a

 

 

10200HB2595sam001- 50 -LRB102 10633 BMS 26514 a

1        nonquantitative treatment limitation applies to a
2        benefit, including factors that were considered but
3        rejected;
4            (B) identify and define the specific evidentiary
5        standards used to define the factors and any other
6        evidence relied upon in designing each nonquantitative
7        treatment limitation;
8            (C) provide the comparative analyses, including
9        the results of the analyses, performed to determine
10        that the processes and strategies used to design each
11        nonquantitative treatment limitation, as written, for
12        mental, emotional, nervous, or substance use disorder
13        or condition benefits are comparable to, and are
14        applied no more stringently than, the processes and
15        strategies used to design each nonquantitative
16        treatment limitation, as written, for medical and
17        surgical benefits;
18            (D) provide the comparative analyses, including
19        the results of the analyses, performed to determine
20        that the processes and strategies used to apply each
21        nonquantitative treatment limitation, in operation,
22        for mental, emotional, nervous, or substance use
23        disorder or condition benefits are comparable to, and
24        applied no more stringently than, the processes or
25        strategies used to apply each nonquantitative
26        treatment limitation, in operation, for medical and

 

 

10200HB2595sam001- 51 -LRB102 10633 BMS 26514 a

1        surgical benefits; and
2            (E) disclose the specific findings and conclusions
3        reached by the insurer that the results of the
4        analyses described in subparagraphs (C) and (D)
5        indicate that the insurer is in compliance with this
6        Section and the Mental Health Parity and Addiction
7        Equity Act of 2008 and its implementing regulations,
8        which includes 42 CFR Parts 438, 440, and 457 and 45
9        CFR 146.136 and any other related federal regulations
10        found in the Code of Federal Regulations.
11        (7) Any other information necessary to clarify data
12    provided in accordance with this Section requested by the
13    Director, including information that may be proprietary or
14    have commercial value, under the requirements of Section
15    30 of the Viatical Settlements Act of 2009.
16    (l) An insurer that amends, delivers, issues, or renews a
17group or individual policy of accident and health insurance or
18a qualified health plan offered through the health insurance
19marketplace in this State providing coverage for hospital or
20medical treatment and for the treatment of mental, emotional,
21nervous, or substance use disorders or conditions on or after
22the effective date of this amendatory Act of the 100th General
23Assembly shall, in advance of the plan year, make available to
24the Department or, with respect to medical assistance, the
25Department of Healthcare and Family Services and to all plan
26participants and beneficiaries the information required in

 

 

10200HB2595sam001- 52 -LRB102 10633 BMS 26514 a

1subparagraphs (C) through (E) of paragraph (6) of subsection
2(k). For plan participants and medical assistance
3beneficiaries, the information required in subparagraphs (C)
4through (E) of paragraph (6) of subsection (k) shall be made
5available on a publicly-available website whose web address is
6prominently displayed in plan and managed care organization
7informational and marketing materials.
8    (m) In conjunction with its compliance examination program
9conducted in accordance with the Illinois State Auditing Act,
10the Auditor General shall undertake a review of compliance by
11the Department and the Department of Healthcare and Family
12Services with Section 370c and this Section. Any findings
13resulting from the review conducted under this Section shall
14be included in the applicable State agency's compliance
15examination report. Each compliance examination report shall
16be issued in accordance with Section 3-14 of the Illinois
17State Auditing Act. A copy of each report shall also be
18delivered to the head of the applicable State agency and
19posted on the Auditor General's website.
20(Source: P.A. 99-480, eff. 9-9-15; 100-1024, eff. 1-1-19.)
 
21    Section 10. The Health Carrier External Review Act is
22amended by changing Sections 35 and 40 as follows:
 
23    (215 ILCS 180/35)
24    Sec. 35. Standard external review.

 

 

10200HB2595sam001- 53 -LRB102 10633 BMS 26514 a

1    (a) Within 4 months after the date of receipt of a notice
2of an adverse determination or final adverse determination, a
3covered person or the covered person's authorized
4representative may file a request for an external review with
5the Director. Within one business day after the date of
6receipt of a request for external review, the Director shall
7send a copy of the request to the health carrier.
8    (b) Within 5 business days following the date of receipt
9of the external review request, the health carrier shall
10complete a preliminary review of the request to determine
11whether:
12        (1) the individual is or was a covered person in the
13    health benefit plan at the time the health care service
14    was requested or at the time the health care service was
15    provided;
16        (2) the health care service that is the subject of the
17    adverse determination or the final adverse determination
18    is a covered service under the covered person's health
19    benefit plan, but the health carrier has determined that
20    the health care service is not covered;
21        (3) the covered person has exhausted the health
22    carrier's internal appeal process unless the covered
23    person is not required to exhaust the health carrier's
24    internal appeal process pursuant to this Act;
25        (4) (blank); and
26        (5) the covered person has provided all the

 

 

10200HB2595sam001- 54 -LRB102 10633 BMS 26514 a

1    information and forms required to process an external
2    review, as specified in this Act.
3    (c) Within one business day after completion of the
4preliminary review, the health carrier shall notify the
5Director and covered person and, if applicable, the covered
6person's authorized representative in writing whether the
7request is complete and eligible for external review. If the
8request:
9        (1) is not complete, the health carrier shall inform
10    the Director and covered person and, if applicable, the
11    covered person's authorized representative in writing and
12    include in the notice what information or materials are
13    required by this Act to make the request complete; or
14        (2) is not eligible for external review, the health
15    carrier shall inform the Director and covered person and,
16    if applicable, the covered person's authorized
17    representative in writing and include in the notice the
18    reasons for its ineligibility.
19    The Department may specify the form for the health
20carrier's notice of initial determination under this
21subsection (c) and any supporting information to be included
22in the notice.
23    The notice of initial determination of ineligibility shall
24include a statement informing the covered person and, if
25applicable, the covered person's authorized representative
26that a health carrier's initial determination that the

 

 

10200HB2595sam001- 55 -LRB102 10633 BMS 26514 a

1external review request is ineligible for review may be
2appealed to the Director by filing a complaint with the
3Director.
4    Notwithstanding a health carrier's initial determination
5that the request is ineligible for external review, the
6Director may determine that a request is eligible for external
7review and require that it be referred for external review. In
8making such determination, the Director's decision shall be in
9accordance with the terms of the covered person's health
10benefit plan, unless such terms are inconsistent with
11applicable law, and shall be subject to all applicable
12provisions of this Act.
13    (d) Whenever the Director receives notice that a request
14is eligible for external review following the preliminary
15review conducted pursuant to this Section, within one business
16day after the date of receipt of the notice, the Director
17shall:
18        (1) assign an independent review organization from the
19    list of approved independent review organizations compiled
20    and maintained by the Director pursuant to this Act and
21    notify the health carrier of the name of the assigned
22    independent review organization; and
23        (2) notify in writing the covered person and, if
24    applicable, the covered person's authorized representative
25    of the request's eligibility and acceptance for external
26    review and the name of the independent review

 

 

10200HB2595sam001- 56 -LRB102 10633 BMS 26514 a

1    organization.
2    The Director shall include in the notice provided to the
3covered person and, if applicable, the covered person's
4authorized representative a statement that the covered person
5or the covered person's authorized representative may, within
65 business days following the date of receipt of the notice
7provided pursuant to item (2) of this subsection (d), submit
8in writing to the assigned independent review organization
9additional information that the independent review
10organization shall consider when conducting the external
11review. The independent review organization is not required
12to, but may, accept and consider additional information
13submitted after 5 business days.
14    (e) The assignment by the Director of an approved
15independent review organization to conduct an external review
16in accordance with this Section shall be done on a random basis
17among those independent review organizations approved by the
18Director pursuant to this Act.
19    (f) Within 5 business days after the date of receipt of the
20notice provided pursuant to item (1) of subsection (d) of this
21Section, the health carrier or its designee utilization review
22organization shall provide to the assigned independent review
23organization the documents and any information considered in
24making the adverse determination or final adverse
25determination; in such cases, the following provisions shall
26apply:

 

 

10200HB2595sam001- 57 -LRB102 10633 BMS 26514 a

1        (1) Except as provided in item (2) of this subsection
2    (f), failure by the health carrier or its utilization
3    review organization to provide the documents and
4    information within the specified time frame shall not
5    delay the conduct of the external review.
6        (2) If the health carrier or its utilization review
7    organization fails to provide the documents and
8    information within the specified time frame, the assigned
9    independent review organization may terminate the external
10    review and make a decision to reverse the adverse
11    determination or final adverse determination.
12        (3) Within one business day after making the decision
13    to terminate the external review and make a decision to
14    reverse the adverse determination or final adverse
15    determination under item (2) of this subsection (f), the
16    independent review organization shall notify the Director,
17    the health carrier, the covered person and, if applicable,
18    the covered person's authorized representative, of its
19    decision to reverse the adverse determination.
20    (g) Upon receipt of the information from the health
21carrier or its utilization review organization, the assigned
22independent review organization shall review all of the
23information and documents and any other information submitted
24in writing to the independent review organization by the
25covered person and the covered person's authorized
26representative.

 

 

10200HB2595sam001- 58 -LRB102 10633 BMS 26514 a

1    (h) Upon receipt of any information submitted by the
2covered person or the covered person's authorized
3representative, the independent review organization shall
4forward the information to the health carrier within 1
5business day.
6        (1) Upon receipt of the information, if any, the
7    health carrier may reconsider its adverse determination or
8    final adverse determination that is the subject of the
9    external review.
10        (2) Reconsideration by the health carrier of its
11    adverse determination or final adverse determination shall
12    not delay or terminate the external review.
13        (3) The external review may only be terminated if the
14    health carrier decides, upon completion of its
15    reconsideration, to reverse its adverse determination or
16    final adverse determination and provide coverage or
17    payment for the health care service that is the subject of
18    the adverse determination or final adverse determination.
19    In such cases, the following provisions shall apply:
20            (A) Within one business day after making the
21        decision to reverse its adverse determination or final
22        adverse determination, the health carrier shall notify
23        the Director, the covered person and, if applicable,
24        the covered person's authorized representative, and
25        the assigned independent review organization in
26        writing of its decision.

 

 

10200HB2595sam001- 59 -LRB102 10633 BMS 26514 a

1            (B) Upon notice from the health carrier that the
2        health carrier has made a decision to reverse its
3        adverse determination or final adverse determination,
4        the assigned independent review organization shall
5        terminate the external review.
6    (i) In addition to the documents and information provided
7by the health carrier or its utilization review organization
8and the covered person and the covered person's authorized
9representative, if any, the independent review organization,
10to the extent the information or documents are available and
11the independent review organization considers them
12appropriate, shall consider the following in reaching a
13decision:
14        (1) the covered person's pertinent medical records;
15        (2) the covered person's health care provider's
16    recommendation;
17        (3) consulting reports from appropriate health care
18    providers and other documents submitted by the health
19    carrier or its designee utilization review organization,
20    the covered person, the covered person's authorized
21    representative, or the covered person's treating provider;
22        (4) the terms of coverage under the covered person's
23    health benefit plan with the health carrier to ensure that
24    the independent review organization's decision is not
25    contrary to the terms of coverage under the covered
26    person's health benefit plan with the health carrier,

 

 

10200HB2595sam001- 60 -LRB102 10633 BMS 26514 a

1    unless the terms are inconsistent with applicable law;
2        (5) the most appropriate practice guidelines, which
3    shall include applicable evidence-based standards and may
4    include any other practice guidelines developed by the
5    federal government, national or professional medical
6    societies, boards, and associations;
7        (6) any applicable clinical review criteria developed
8    and used by the health carrier or its designee utilization
9    review organization;
10        (7) the opinion of the independent review
11    organization's clinical reviewer or reviewers after
12    considering items (1) through (6) of this subsection (i)
13    to the extent the information or documents are available
14    and the clinical reviewer or reviewers considers the
15    information or documents appropriate;
16        (8) (blank); and
17        (9) in the case of medically necessary determinations
18    for substance use disorders, the patient placement
19    criteria established by the American Society of Addiction
20    Medicine.
21    (i-5) For an adverse determination or final adverse
22determination involving mental, emotional, nervous, or
23substance use disorders or conditions, the independent review
24organization shall:
25        (1) consider the documents and information as set
26    forth in subsection (i), except that all practice

 

 

10200HB2595sam001- 61 -LRB102 10633 BMS 26514 a

1    guidelines and clinical review criteria must be consistent
2    with the requirements set forth in Section 370c of the
3    Illinois Insurance Code; and
4        (2) make its decision, pursuant to subsection (j),
5    whether to uphold or reverse the adverse determination or
6    final adverse determination based on whether the service
7    constitutes medically necessary treatment of a mental,
8    emotional, nervous, or substance use disorders or
9    condition as defined in Section 370c of the Illinois
10    Insurance Code.
11    (j) Within 5 days after the date of receipt of all
12necessary information, but in no event more than 45 days after
13the date of receipt of the request for an external review, the
14assigned independent review organization shall provide written
15notice of its decision to uphold or reverse the adverse
16determination or the final adverse determination to the
17Director, the health carrier, the covered person, and, if
18applicable, the covered person's authorized representative. In
19reaching a decision, the assigned independent review
20organization is not bound by any claim determinations reached
21prior to the submission of information to the independent
22review organization. In such cases, the following provisions
23shall apply:
24        (1) The independent review organization shall include
25    in the notice:
26            (A) a general description of the reason for the

 

 

10200HB2595sam001- 62 -LRB102 10633 BMS 26514 a

1        request for external review;
2            (B) the date the independent review organization
3        received the assignment from the Director to conduct
4        the external review;
5            (C) the time period during which the external
6        review was conducted;
7            (D) references to the evidence or documentation,
8        including the evidence-based standards, considered in
9        reaching its decision;
10            (E) the date of its decision;
11            (F) the principal reason or reasons for its
12        decision, including what applicable, if any,
13        evidence-based standards that were a basis for its
14        decision; and
15            (G) the rationale for its decision.
16        (2) (Blank).
17        (3) (Blank).
18        (4) Upon receipt of a notice of a decision reversing
19    the adverse determination or final adverse determination,
20    the health carrier immediately shall approve the coverage
21    that was the subject of the adverse determination or final
22    adverse determination.
23(Source: P.A. 99-480, eff. 9-9-15.)
 
24    (215 ILCS 180/40)
25    Sec. 40. Expedited external review.

 

 

10200HB2595sam001- 63 -LRB102 10633 BMS 26514 a

1    (a) A covered person or a covered person's authorized
2representative may file a request for an expedited external
3review with the Director either orally or in writing:
4        (1) immediately after the date of receipt of a notice
5    prior to a final adverse determination as provided by
6    subsection (b) of Section 20 of this Act;
7        (2) immediately after the date of receipt of a notice
8    upon final adverse determination as provided by subsection
9    (c) of Section 20 of this Act; or
10        (3) if a health carrier fails to provide a decision on
11    request for an expedited internal appeal within 48 hours
12    as provided by item (2) of Section 30 of this Act.
13    (b) Upon receipt of a request for an expedited external
14review, the Director shall immediately send a copy of the
15request to the health carrier. Immediately upon receipt of the
16request for an expedited external review, the health carrier
17shall determine whether the request meets the reviewability
18requirements set forth in subsection (b) of Section 35. In
19such cases, the following provisions shall apply:
20        (1) The health carrier shall immediately notify the
21    Director, the covered person, and, if applicable, the
22    covered person's authorized representative of its
23    eligibility determination.
24        (2) The notice of initial determination shall include
25    a statement informing the covered person and, if
26    applicable, the covered person's authorized representative

 

 

10200HB2595sam001- 64 -LRB102 10633 BMS 26514 a

1    that a health carrier's initial determination that an
2    external review request is ineligible for review may be
3    appealed to the Director.
4        (3) The Director may determine that a request is
5    eligible for expedited external review notwithstanding a
6    health carrier's initial determination that the request is
7    ineligible and require that it be referred for external
8    review.
9        (4) In making a determination under item (3) of this
10    subsection (b), the Director's decision shall be made in
11    accordance with the terms of the covered person's health
12    benefit plan, unless such terms are inconsistent with
13    applicable law, and shall be subject to all applicable
14    provisions of this Act.
15        (5) The Director may specify the form for the health
16    carrier's notice of initial determination under this
17    subsection (b) and any supporting information to be
18    included in the notice.
19    (c) Upon receipt of the notice that the request meets the
20reviewability requirements, the Director shall immediately
21assign an independent review organization from the list of
22approved independent review organizations compiled and
23maintained by the Director to conduct the expedited review. In
24such cases, the following provisions shall apply:
25        (1) The assignment of an approved independent review
26    organization to conduct an external review in accordance

 

 

10200HB2595sam001- 65 -LRB102 10633 BMS 26514 a

1    with this Section shall be made from those approved
2    independent review organizations qualified to conduct
3    external review as required by Sections 50 and 55 of this
4    Act.
5        (2) The Director shall immediately notify the health
6    carrier of the name of the assigned independent review
7    organization. Immediately upon receipt from the Director
8    of the name of the independent review organization
9    assigned to conduct the external review, but in no case
10    more than 24 hours after receiving such notice, the health
11    carrier or its designee utilization review organization
12    shall provide or transmit all necessary documents and
13    information considered in making the adverse determination
14    or final adverse determination to the assigned independent
15    review organization electronically or by telephone or
16    facsimile or any other available expeditious method.
17        (3) If the health carrier or its utilization review
18    organization fails to provide the documents and
19    information within the specified timeframe, the assigned
20    independent review organization may terminate the external
21    review and make a decision to reverse the adverse
22    determination or final adverse determination.
23        (4) Within one business day after making the decision
24    to terminate the external review and make a decision to
25    reverse the adverse determination or final adverse
26    determination under item (3) of this subsection (c), the

 

 

10200HB2595sam001- 66 -LRB102 10633 BMS 26514 a

1    independent review organization shall notify the Director,
2    the health carrier, the covered person, and, if
3    applicable, the covered person's authorized representative
4    of its decision to reverse the adverse determination or
5    final adverse determination.
6    (d) In addition to the documents and information provided
7by the health carrier or its utilization review organization
8and any documents and information provided by the covered
9person and the covered person's authorized representative, the
10independent review organization, to the extent the information
11or documents are available and the independent review
12organization considers them appropriate, shall consider
13information as required by subsection (i) of Section 35 of
14this Act in reaching a decision.
15    (d-5) For expedited external reviews involving mental,
16emotional, nervous, or substance use disorders or conditions,
17the independent review organization shall consider documents
18and information and shall make a decision to uphold or reverse
19the adverse determination or final adverse determination
20pursuant to subsection (i-5) of Section 35.
21    (e) As expeditiously as the covered person's medical
22condition or circumstances requires, but in no event more than
2372 hours after the date of receipt of the request for an
24expedited external review, the assigned independent review
25organization shall:
26        (1) make a decision to uphold or reverse the final

 

 

10200HB2595sam001- 67 -LRB102 10633 BMS 26514 a

1    adverse determination; and
2        (2) notify the Director, the health carrier, the
3    covered person, the covered person's health care provider,
4    and, if applicable, the covered person's authorized
5    representative, of the decision.
6    (f) In reaching a decision, the assigned independent
7review organization is not bound by any decisions or
8conclusions reached during the health carrier's utilization
9review process or the health carrier's internal appeal
10process.
11    (g) Upon receipt of notice of a decision reversing the
12adverse determination or final adverse determination, the
13health carrier shall immediately approve the coverage that was
14the subject of the adverse determination or final adverse
15determination.
16    (h) If the notice provided pursuant to subsection (e) of
17this Section was not in writing, then within 48 hours after the
18date of providing that notice, the assigned independent review
19organization shall provide written confirmation of the
20decision to the Director, the health carrier, the covered
21person, and, if applicable, the covered person's authorized
22representative including the information set forth in
23subsection (j) of Section 35 of this Act as applicable.
24    (i) An expedited external review may not be provided for
25retrospective adverse or final adverse determinations.
26    (j) The assignment by the Director of an approved

 

 

10200HB2595sam001- 68 -LRB102 10633 BMS 26514 a

1independent review organization to conduct an external review
2in accordance with this Section shall be done on a random basis
3among those independent review organizations approved by the
4Director pursuant to this Act.
5(Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11;
697-574, eff. 8-26-11.)
 
7    Section 99. Effective date. This Act takes effect January
81, 2022, except that this Section and the changes to Section
9370c.1 of the Illinois Insurance Code take effect upon
10becoming law.".