Rep. Lou Lang
Filed: 5/29/2018
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1 | AMENDMENT TO SENATE BILL 1707
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2 | AMENDMENT NO. ______. Amend Senate Bill 1707 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356g, | ||||||
13 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
14 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
15 | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25 , and 356z.26 of | ||||||
16 | the
Illinois Insurance Code.
The program of health benefits |
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1 | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, | ||||||
2 | and 370c.1 of the
Illinois Insurance Code. The Department of | ||||||
3 | Insurance shall enforce the requirements of this Section.
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4 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
5 | any, is conditioned on the rules being adopted in accordance | ||||||
6 | with all provisions of the Illinois Administrative Procedure | ||||||
7 | Act and all rules and procedures of the Joint Committee on | ||||||
8 | Administrative Rules; any purported rule not so adopted, for | ||||||
9 | whatever reason, is unauthorized. | ||||||
10 | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | ||||||
11 | 100-138, eff. 8-18-17; revised 10-3-17.) | ||||||
12 | Section 10. The State Finance Act is amended by changing | ||||||
13 | Section 5.872 as follows:
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14 | (30 ILCS 105/5.872)
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15 | Sec. 5.872. The Parity Advancement Education Fund. | ||||||
16 | (Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
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17 | Section 15. The Counties Code is amended by changing | ||||||
18 | Section 5-1069.3 as follows: | ||||||
19 | (55 ILCS 5/5-1069.3)
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20 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
21 | including a home
rule
county, is a self-insurer for purposes of | ||||||
22 | providing health insurance coverage
for its employees, the |
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1 | coverage shall include coverage for the post-mastectomy
care | ||||||
2 | benefits required to be covered by a policy of accident and | ||||||
3 | health
insurance under Section 356t and the coverage required | ||||||
4 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
5 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
6 | 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
the | ||||||
7 | Illinois Insurance Code. The coverage shall comply with | ||||||
8 | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | ||||||
9 | Insurance Code. The Department of Insurance shall enforce the | ||||||
10 | requirements of this Section. The requirement that health | ||||||
11 | benefits be covered
as provided in this Section is an
exclusive | ||||||
12 | power and function of the State and is a denial and limitation | ||||||
13 | under
Article VII, Section 6, subsection (h) of the Illinois | ||||||
14 | Constitution. A home
rule county to which this Section applies | ||||||
15 | must comply with every provision of
this Section.
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16 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
17 | any, is conditioned on the rules being adopted in accordance | ||||||
18 | with all provisions of the Illinois Administrative Procedure | ||||||
19 | Act and all rules and procedures of the Joint Committee on | ||||||
20 | Administrative Rules; any purported rule not so adopted, for | ||||||
21 | whatever reason, is unauthorized. | ||||||
22 | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | ||||||
23 | 100-138, eff. 8-18-17; revised 10-5-17.) | ||||||
24 | Section 20. The Illinois Municipal Code is amended by | ||||||
25 | changing Section 10-4-2.3 as follows: |
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1 | (65 ILCS 5/10-4-2.3)
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2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a
home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health
insurance | ||||||
5 | coverage for its employees, the coverage shall include coverage | ||||||
6 | for
the post-mastectomy care benefits required to be covered by | ||||||
7 | a policy of
accident and health insurance under Section 356t | ||||||
8 | and the coverage required
under Sections 356g, 356g.5, | ||||||
9 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
10 | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and | ||||||
11 | 356z.25 , and 356z.26 of the Illinois
Insurance
Code. The | ||||||
12 | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | ||||||
13 | 370c of
the Illinois Insurance Code. The Department of | ||||||
14 | Insurance shall enforce the requirements of this Section. The | ||||||
15 | requirement that health
benefits be covered as provided in this | ||||||
16 | is an exclusive power and function of
the State and is a denial | ||||||
17 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
18 | the Illinois Constitution. A home rule municipality to which
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19 | this Section applies must comply with every provision of this | ||||||
20 | Section.
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21 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
22 | any, is conditioned on the rules being adopted in accordance | ||||||
23 | with all provisions of the Illinois Administrative Procedure | ||||||
24 | Act and all rules and procedures of the Joint Committee on | ||||||
25 | Administrative Rules; any purported rule not so adopted, for |
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1 | whatever reason, is unauthorized. | ||||||
2 | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | ||||||
3 | 100-138, eff. 8-18-17; revised 10-5-17.) | ||||||
4 | Section 25. The School Code is amended by changing Section | ||||||
5 | 10-22.3f as follows: | ||||||
6 | (105 ILCS 5/10-22.3f)
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7 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
8 | protection and
benefits
for employees shall provide the | ||||||
9 | post-mastectomy care benefits required to be
covered by a | ||||||
10 | policy of accident and health insurance under Section 356t and | ||||||
11 | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
12 | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | ||||||
13 | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
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14 | the
Illinois Insurance Code.
Insurance policies shall comply | ||||||
15 | with Section 356z.19 of the Illinois Insurance Code. The | ||||||
16 | coverage shall comply with Sections 155.22a , and 355b , and 370c | ||||||
17 | of
the Illinois Insurance Code. The Department of Insurance | ||||||
18 | shall enforce the requirements of this Section.
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19 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
20 | any, is conditioned on the rules being adopted in accordance | ||||||
21 | with all provisions of the Illinois Administrative Procedure | ||||||
22 | Act and all rules and procedures of the Joint Committee on | ||||||
23 | Administrative Rules; any purported rule not so adopted, for | ||||||
24 | whatever reason, is unauthorized. |
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1 | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | ||||||
2 | revised 9-25-17.) | ||||||
3 | Section 30. The Illinois Insurance Code is amended by | ||||||
4 | changing Sections 370c and 370c.1 as follows:
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5 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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6 | Sec. 370c. Mental and emotional disorders.
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7 | (a)(1) On and after the effective date of this amendatory | ||||||
8 | Act of the 100th General Assembly the effective date of this | ||||||
9 | amendatory Act of the 97th General Assembly ,
every insurer that | ||||||
10 | which amends, delivers, issues, or renews
group accident and | ||||||
11 | health policies providing coverage for hospital or medical | ||||||
12 | treatment or
services for illness on an expense-incurred basis | ||||||
13 | shall provide offer to the
applicant or group policyholder | ||||||
14 | subject to the insurer's standards of
insurability, coverage | ||||||
15 | for reasonable and necessary treatment and services
for mental, | ||||||
16 | emotional , or nervous , or substance use disorders or | ||||||
17 | conditions , other than serious
mental illnesses as defined in | ||||||
18 | item (2) of subsection (b), consistent with the parity | ||||||
19 | requirements of Section 370c.1 of this Code.
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20 | (2) Each insured that is covered for mental, emotional, | ||||||
21 | nervous, or substance use
disorders or conditions shall be free | ||||||
22 | to select the physician licensed to
practice medicine in all | ||||||
23 | its branches, licensed clinical psychologist,
licensed | ||||||
24 | clinical social worker, licensed clinical professional |
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1 | counselor, licensed marriage and family therapist, licensed | ||||||
2 | speech-language pathologist, or other licensed or certified | ||||||
3 | professional at a program licensed pursuant to the Illinois | ||||||
4 | Alcoholism and Other Drug Abuse and Dependency Act of
his | ||||||
5 | choice to treat such disorders, and
the insurer shall pay the | ||||||
6 | covered charges of such physician licensed to
practice medicine | ||||||
7 | in all its branches, licensed clinical psychologist,
licensed | ||||||
8 | clinical social worker, licensed clinical professional | ||||||
9 | counselor, licensed marriage and family therapist, licensed | ||||||
10 | speech-language pathologist, or other licensed or certified | ||||||
11 | professional at a program licensed pursuant to the Illinois | ||||||
12 | Alcoholism and Other Drug Abuse and Dependency Act up
to the | ||||||
13 | limits of coverage, provided (i)
the disorder or condition | ||||||
14 | treated is covered by the policy, and (ii) the
physician, | ||||||
15 | licensed psychologist, licensed clinical social worker, | ||||||
16 | licensed
clinical professional counselor, licensed marriage | ||||||
17 | and family therapist, licensed speech-language pathologist, or | ||||||
18 | other licensed or certified professional at a program licensed | ||||||
19 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
20 | Dependency Act is
authorized to provide said services under the | ||||||
21 | statutes of this State and in
accordance with accepted | ||||||
22 | principles of his profession.
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23 | (3) Insofar as this Section applies solely to licensed | ||||||
24 | clinical social
workers, licensed clinical professional | ||||||
25 | counselors, licensed marriage and family therapists, licensed | ||||||
26 | speech-language pathologists, and other licensed or certified |
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1 | professionals at programs licensed pursuant to the Illinois | ||||||
2 | Alcoholism and Other Drug Abuse and Dependency Act, those | ||||||
3 | persons who may
provide services to individuals shall do so
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4 | after the licensed clinical social worker, licensed clinical | ||||||
5 | professional
counselor, licensed marriage and family | ||||||
6 | therapist, licensed speech-language pathologist, or other | ||||||
7 | licensed or certified professional at a program licensed | ||||||
8 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
9 | Dependency Act has informed the patient of the
desirability of | ||||||
10 | the patient conferring with the patient's primary care
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11 | physician and the licensed clinical social worker, licensed | ||||||
12 | clinical
professional counselor, licensed marriage and family | ||||||
13 | therapist, licensed speech-language pathologist, or other | ||||||
14 | licensed or certified professional at a program licensed | ||||||
15 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
16 | Dependency Act has
provided written
notification to the | ||||||
17 | patient's primary care physician, if any, that services
are | ||||||
18 | being provided to the patient. That notification may, however, | ||||||
19 | be
waived by the patient on a written form. Those forms shall | ||||||
20 | be retained by
the licensed clinical social worker, licensed | ||||||
21 | clinical professional counselor, licensed marriage and family | ||||||
22 | therapist, licensed speech-language pathologist, or other | ||||||
23 | licensed or certified professional at a program licensed | ||||||
24 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
25 | Dependency Act
for a period of not less than 5 years .
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26 | (4) "Mental, emotional, nervous, or substance use disorder |
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1 | or condition" means a condition or disorder that involves a | ||||||
2 | mental health condition or substance use disorder that falls | ||||||
3 | under any of the diagnostic categories listed in the mental and | ||||||
4 | behavioral disorders chapter of the current edition of the | ||||||
5 | International Classification of Disease or that is listed in | ||||||
6 | the most recent version of the Diagnostic and Statistical | ||||||
7 | Manual of Mental Disorders. | ||||||
8 | (b)(1) (Blank). An insurer that provides coverage for | ||||||
9 | hospital or medical
expenses under a group or individual policy | ||||||
10 | of accident and health insurance or
health care plan amended, | ||||||
11 | delivered, issued, or renewed on or after the effective
date of | ||||||
12 | this amendatory Act of the 100th General Assembly shall provide | ||||||
13 | coverage
under the policy for treatment of serious mental | ||||||
14 | illness and substance use disorders consistent with the parity | ||||||
15 | requirements of Section 370c.1 of this Code. This subsection | ||||||
16 | does not apply to any group policy of accident and health | ||||||
17 | insurance or health care plan for any plan year of a small | ||||||
18 | employer as defined in Section 5 of the Illinois Health | ||||||
19 | Insurance Portability and Accountability Act.
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20 | (2) (Blank). "Serious mental illness" means the following | ||||||
21 | psychiatric illnesses as
defined in the most current edition of | ||||||
22 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
23 | American Psychiatric Association:
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24 | (A) schizophrenia;
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25 | (B) paranoid and other psychotic disorders;
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26 | (C) bipolar disorders (hypomanic, manic, depressive, |
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1 | and mixed);
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2 | (D) major depressive disorders (single episode or | ||||||
3 | recurrent);
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4 | (E) schizoaffective disorders (bipolar or depressive);
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5 | (F) pervasive developmental disorders;
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6 | (G) obsessive-compulsive disorders;
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7 | (H) depression in childhood and adolescence;
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8 | (I) panic disorder; | ||||||
9 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
10 | or with delayed onset); and
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11 | (K) eating disorders, including, but not limited to, | ||||||
12 | anorexia nervosa, bulimia nervosa, pica, rumination | ||||||
13 | disorder, avoidant/restrictive food intake disorder, other | ||||||
14 | specified feeding or eating disorder (OSFED), and any other | ||||||
15 | eating disorder contained in the most recent version of the | ||||||
16 | Diagnostic and Statistical Manual of Mental Disorders | ||||||
17 | published by the American Psychiatric Association. | ||||||
18 | (2.5) (Blank). "Substance use disorder" means the | ||||||
19 | following mental disorders as defined in the most current | ||||||
20 | edition of the Diagnostic and Statistical Manual (DSM) | ||||||
21 | published by the American Psychiatric Association: | ||||||
22 | (A) substance abuse disorders; | ||||||
23 | (B) substance dependence disorders; and | ||||||
24 | (C) substance induced disorders. | ||||||
25 | (3) Unless otherwise prohibited by federal law and | ||||||
26 | consistent with the parity requirements of Section 370c.1 of |
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1 | this Code, the reimbursing insurer that amends, delivers, | ||||||
2 | issues, or renews a group or individual policy of accident and | ||||||
3 | health insurance, a qualified health plan offered through the | ||||||
4 | health insurance marketplace, or , a provider of treatment of | ||||||
5 | mental, emotional, nervous,
serious mental illness or | ||||||
6 | substance use disorders or conditions disorder shall furnish | ||||||
7 | medical records or other necessary data
that substantiate that | ||||||
8 | initial or continued treatment is at all times medically
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9 | necessary. An insurer shall provide a mechanism for the timely | ||||||
10 | review by a
provider holding the same license and practicing in | ||||||
11 | the same specialty as the
patient's provider, who is | ||||||
12 | unaffiliated with the insurer, jointly selected by
the patient | ||||||
13 | (or the patient's next of kin or legal representative if the
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14 | patient is unable to act for himself or herself), the patient's | ||||||
15 | provider, and
the insurer in the event of a dispute between the | ||||||
16 | insurer and patient's
provider regarding the medical necessity | ||||||
17 | of a treatment proposed by a patient's
provider. If the | ||||||
18 | reviewing provider determines the treatment to be medically
| ||||||
19 | necessary, the insurer shall provide reimbursement for the | ||||||
20 | treatment. Future
contractual or employment actions by the | ||||||
21 | insurer regarding the patient's
provider may not be based on | ||||||
22 | the provider's participation in this procedure.
Nothing | ||||||
23 | prevents
the insured from agreeing in writing to continue | ||||||
24 | treatment at his or her
expense. When making a determination of | ||||||
25 | the medical necessity for a treatment
modality for mental, | ||||||
26 | emotional, nervous, serious mental illness or substance use |
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1 | disorders or conditions disorder , an insurer must make the | ||||||
2 | determination in a
manner that is consistent with the manner | ||||||
3 | used to make that determination with
respect to other diseases | ||||||
4 | or illnesses covered under the policy, including an
appeals | ||||||
5 | process. Medical necessity determinations for substance use | ||||||
6 | disorders shall be made in accordance with appropriate patient | ||||||
7 | placement criteria established by the American Society of | ||||||
8 | Addiction Medicine. No additional criteria may be used to make | ||||||
9 | medical necessity determinations for substance use disorders.
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10 | (4) A group health benefit plan amended, delivered, issued, | ||||||
11 | or renewed on or after the effective date of this amendatory | ||||||
12 | Act of the 100th General Assembly or an individual policy of | ||||||
13 | accident and health insurance or a qualified health plan | ||||||
14 | offered through the health insurance marketplace amended, | ||||||
15 | delivered, issued, or renewed on or after the effective date of | ||||||
16 | this amendatory Act of the 100th General Assembly the effective | ||||||
17 | date of this amendatory Act of the 97th General Assembly :
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18 | (A) shall provide coverage based upon medical | ||||||
19 | necessity for the
treatment of a mental, emotional, | ||||||
20 | nervous, or mental illness and substance use disorder or | ||||||
21 | condition disorders consistent with the parity | ||||||
22 | requirements of Section 370c.1 of this Code; provided, | ||||||
23 | however, that in each calendar year coverage shall not be | ||||||
24 | less than the following:
| ||||||
25 | (i) 45 days of inpatient treatment; and
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26 | (ii) beginning on June 26, 2006 (the effective date |
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1 | of Public Act 94-921), 60 visits for outpatient | ||||||
2 | treatment including group and individual
outpatient | ||||||
3 | treatment; and | ||||||
4 | (iii) for plans or policies delivered, issued for | ||||||
5 | delivery, renewed, or modified after January 1, 2007 | ||||||
6 | (the effective date of Public Act 94-906),
20 | ||||||
7 | additional outpatient visits for speech therapy for | ||||||
8 | treatment of pervasive developmental disorders that | ||||||
9 | will be in addition to speech therapy provided pursuant | ||||||
10 | to item (ii) of this subparagraph (A); and
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11 | (B) may not include a lifetime limit on the number of | ||||||
12 | days of inpatient
treatment or the number of outpatient | ||||||
13 | visits covered under the plan.
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14 | (C) (Blank).
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15 | (5) An issuer of a group health benefit plan or an | ||||||
16 | individual policy of accident and health insurance or a | ||||||
17 | qualified health plan offered through the health insurance | ||||||
18 | marketplace may not count toward the number
of outpatient | ||||||
19 | visits required to be covered under this Section an outpatient
| ||||||
20 | visit for the purpose of medication management and shall cover | ||||||
21 | the outpatient
visits under the same terms and conditions as it | ||||||
22 | covers outpatient visits for
the treatment of physical illness.
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23 | (5.5) An individual or group health benefit plan amended, | ||||||
24 | delivered, issued, or renewed on or after the effective date of | ||||||
25 | this amendatory Act of the 99th General Assembly shall offer | ||||||
26 | coverage for medically necessary acute treatment services and |
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1 | medically necessary clinical stabilization services. The | ||||||
2 | treating provider shall base all treatment recommendations and | ||||||
3 | the health benefit plan shall base all medical necessity | ||||||
4 | determinations for substance use disorders in accordance with | ||||||
5 | the most current edition of the Treatment Criteria for | ||||||
6 | Addictive, Substance-Related, and Co-Occurring Conditions | ||||||
7 | established by the American Society of Addiction Medicine | ||||||
8 | Patient Placement Criteria . The treating provider shall base | ||||||
9 | all treatment recommendations and the health benefit plan shall | ||||||
10 | base all medical necessity determinations for | ||||||
11 | medication-assisted treatment in accordance with the most | ||||||
12 | current Treatment Criteria for Addictive, Substance-Related, | ||||||
13 | and Co-Occurring Conditions established by the American | ||||||
14 | Society of Addiction Medicine. | ||||||
15 | As used in this subsection: | ||||||
16 | "Acute treatment services" means 24-hour medically | ||||||
17 | supervised addiction treatment that provides evaluation and | ||||||
18 | withdrawal management and may include biopsychosocial | ||||||
19 | assessment, individual and group counseling, psychoeducational | ||||||
20 | groups, and discharge planning. | ||||||
21 | "Clinical stabilization services" means 24-hour treatment, | ||||||
22 | usually following acute treatment services for substance | ||||||
23 | abuse, which may include intensive education and counseling | ||||||
24 | regarding the nature of addiction and its consequences, relapse | ||||||
25 | prevention, outreach to families and significant others, and | ||||||
26 | aftercare planning for individuals beginning to engage in |
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1 | recovery from addiction. | ||||||
2 | (6) An issuer of a group health benefit
plan may provide or | ||||||
3 | offer coverage required under this Section through a
managed | ||||||
4 | care plan.
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5 | (6.5) An individual or group health benefit plan amended, | ||||||
6 | delivered, issued, or renewed on or after the effective date of | ||||||
7 | this amendatory Act of the 100th General Assembly: | ||||||
8 | (A) shall not impose prior authorization requirements, | ||||||
9 | other than those established under the Treatment Criteria | ||||||
10 | for Addictive, Substance-Related, and Co-Occurring | ||||||
11 | Conditions established by the American Society of | ||||||
12 | Addiction Medicine, on a prescription medication approved | ||||||
13 | by the United States Food and Drug Administration that is | ||||||
14 | prescribed or administered for the treatment of substance | ||||||
15 | use disorders; | ||||||
16 | (B) shall not impose any step therapy requirements, | ||||||
17 | other than those established under the Treatment Criteria | ||||||
18 | for Addictive, Substance-Related, and Co-Occurring | ||||||
19 | Conditions established by the American Society of | ||||||
20 | Addiction Medicine, before authorizing coverage for a | ||||||
21 | prescription medication approved by the United States Food | ||||||
22 | and Drug Administration that is prescribed or administered | ||||||
23 | for the treatment of substance use disorders; | ||||||
24 | (C) shall place all prescription medications approved | ||||||
25 | by the United States Food and Drug Administration | ||||||
26 | prescribed or administered for the treatment of substance |
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1 | use disorders on, for brand medications, the lowest tier of | ||||||
2 | the drug formulary developed and maintained by the | ||||||
3 | individual or group health benefit plan that covers brand | ||||||
4 | medications and, for generic medications, the lowest tier | ||||||
5 | of the drug formulary developed and maintained by the | ||||||
6 | individual or group health benefit plan that covers generic | ||||||
7 | medications; and | ||||||
8 | (D) shall not exclude coverage for a prescription | ||||||
9 | medication approved by the United States Food and Drug | ||||||
10 | Administration for the treatment of substance use | ||||||
11 | disorders and any associated counseling or wraparound | ||||||
12 | services on the grounds that such medications and services | ||||||
13 | were court ordered. | ||||||
14 | (7) (Blank).
| ||||||
15 | (8)
(Blank).
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16 | (9) With respect to all mental, emotional, nervous, or | ||||||
17 | substance use disorders or conditions , coverage for inpatient | ||||||
18 | treatment shall include coverage for treatment in a residential | ||||||
19 | treatment center certified or licensed by the Department of | ||||||
20 | Public Health or the Department of Human Services. | ||||||
21 | (c) This Section shall not be interpreted to require | ||||||
22 | coverage for speech therapy or other habilitative services for | ||||||
23 | those individuals covered under Section 356z.15
of this Code. | ||||||
24 | (d) With respect to a group or individual policy of | ||||||
25 | accident and health insurance or a qualified health plan | ||||||
26 | offered through the health insurance marketplace, the |
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1 | Department and, with respect to medical assistance, the | ||||||
2 | Department of Healthcare and Family Services shall each enforce | ||||||
3 | the requirements of this Section and Sections 356z.23 and | ||||||
4 | 370c.1 of this Code, the Paul Wellstone and Pete Domenici | ||||||
5 | Mental Health Parity and Addiction Equity Act of 2008, 42 | ||||||
6 | U.S.C. 18031(j), and any amendments to, and federal guidance or | ||||||
7 | regulations issued under, those Acts, including, but not | ||||||
8 | limited to, final regulations issued under the Paul Wellstone | ||||||
9 | and Pete Domenici Mental Health Parity and Addiction Equity Act | ||||||
10 | of 2008 and final regulations applying the Paul Wellstone and | ||||||
11 | Pete Domenici Mental Health Parity and Addiction Equity Act of | ||||||
12 | 2008 to Medicaid managed care organizations, the Children's | ||||||
13 | Health Insurance Program, and alternative benefit plans. | ||||||
14 | Specifically, the Department and the Department of Healthcare | ||||||
15 | and Family Services shall take action: | ||||||
16 | (1) proactively ensuring compliance by individual and | ||||||
17 | group policies, including by requiring that insurers | ||||||
18 | submit comparative analyses, as set forth in paragraph (6) | ||||||
19 | of subsection (k) of Section 370c.1, demonstrating how they | ||||||
20 | design and apply nonquantitative treatment limitations, | ||||||
21 | both as written and in operation, for mental, emotional, | ||||||
22 | nervous, or substance use disorder or condition benefits as | ||||||
23 | compared to how they design and apply nonquantitative | ||||||
24 | treatment limitations, as written and in operation, for | ||||||
25 | medical and surgical benefits; | ||||||
26 | (2) evaluating all consumer or provider complaints |
| |||||||
| |||||||
1 | regarding mental, emotional, nervous, or substance use | ||||||
2 | disorder or condition coverage for possible parity | ||||||
3 | violations; | ||||||
4 | (3) performing parity compliance market conduct | ||||||
5 | examinations or, in the case of the Department of | ||||||
6 | Healthcare and Family Services, parity compliance audits | ||||||
7 | of individual and group plans and policies, including, but | ||||||
8 | not limited to, reviews of: | ||||||
9 | (A) nonquantitative treatment limitations, | ||||||
10 | including, but not limited to, prior authorization | ||||||
11 | requirements, concurrent review, retrospective review, | ||||||
12 | step therapy, network admission standards, | ||||||
13 | reimbursement rates, and geographic restrictions; | ||||||
14 | (B) denials of authorization, payment, and | ||||||
15 | coverage; and | ||||||
16 | (C) other specific criteria as may be determined by | ||||||
17 | the Department. | ||||||
18 | The findings and the conclusions of the parity compliance | ||||||
19 | market conduct examinations and audits shall be made public. | ||||||
20 | The Director may adopt rules to effectuate any provisions | ||||||
21 | of the Paul Wellstone and Pete Domenici Mental Health Parity | ||||||
22 | and Addiction Equity Act of 2008 that relate to the business of | ||||||
23 | insurance. | ||||||
24 | (d) The Department shall enforce the requirements of State | ||||||
25 | and federal parity law, which includes ensuring compliance by | ||||||
26 | individual and group policies; detecting violations of the law |
| |||||||
| |||||||
1 | by individual and group policies proactively monitoring | ||||||
2 | discriminatory practices; accepting, evaluating, and | ||||||
3 | responding to complaints regarding such violations; and | ||||||
4 | ensuring violations are appropriately remedied and deterred. | ||||||
5 | (e) Availability of plan information. | ||||||
6 | (1) The criteria for medical necessity determinations | ||||||
7 | made under a group health plan , an individual policy of | ||||||
8 | accident and health insurance, or a qualified health plan | ||||||
9 | offered through the health insurance marketplace with | ||||||
10 | respect to mental health or substance use disorder benefits | ||||||
11 | (or health insurance coverage offered in connection with | ||||||
12 | the plan with respect to such benefits) must be made | ||||||
13 | available by the plan administrator (or the health | ||||||
14 | insurance issuer offering such coverage) to any current or | ||||||
15 | potential participant, beneficiary, or contracting | ||||||
16 | provider upon request. | ||||||
17 | (2) The reason for any denial under a group health | ||||||
18 | benefit plan , an individual policy of accident and health | ||||||
19 | insurance, or a qualified health plan offered through the | ||||||
20 | health insurance marketplace (or health insurance coverage | ||||||
21 | offered in connection with such plan or policy ) of | ||||||
22 | reimbursement or payment for services with respect to | ||||||
23 | mental , emotional, nervous, health or substance use | ||||||
24 | disorders or conditions disorder benefits in the case of | ||||||
25 | any participant or beneficiary must be made available | ||||||
26 | within a reasonable time and in a reasonable manner and in |
| |||||||
| |||||||
1 | readily understandable language by the plan administrator | ||||||
2 | (or the health insurance issuer offering such coverage) to | ||||||
3 | the participant or beneficiary upon request. | ||||||
4 | (f) As used in this Section, "group policy of accident and | ||||||
5 | health insurance" and "group health benefit plan" includes (1) | ||||||
6 | State-regulated employer-sponsored group health insurance | ||||||
7 | plans written in Illinois or which purport to provide coverage | ||||||
8 | for a resident of this State; and (2) State employee health | ||||||
9 | plans. | ||||||
10 | (Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.) | ||||||
11 | (215 ILCS 5/370c.1) | ||||||
12 | Sec. 370c.1. Mental , emotional, nervous, or substance use | ||||||
13 | disorder or condition health and addiction parity. | ||||||
14 | (a) On and after the effective date of this amendatory Act | ||||||
15 | of the 99th General Assembly, every insurer that amends, | ||||||
16 | delivers, issues, or renews a group or individual policy of | ||||||
17 | accident and health insurance or a qualified health plan | ||||||
18 | offered through the Health Insurance Marketplace in this State | ||||||
19 | providing coverage for hospital or medical treatment and for | ||||||
20 | the treatment of mental, emotional, nervous, or substance use | ||||||
21 | disorders or conditions shall ensure that: | ||||||
22 | (1) the financial requirements applicable to such | ||||||
23 | mental, emotional, nervous, or substance use disorder or | ||||||
24 | condition benefits are no more restrictive than the | ||||||
25 | predominant financial requirements applied to |
| |||||||
| |||||||
1 | substantially all hospital and medical benefits covered by | ||||||
2 | the policy and that there are no separate cost-sharing | ||||||
3 | requirements that are applicable only with respect to | ||||||
4 | mental, emotional, nervous, or substance use disorder or | ||||||
5 | condition benefits; and | ||||||
6 | (2) the treatment limitations applicable to such | ||||||
7 | mental, emotional, nervous, or substance use disorder or | ||||||
8 | condition benefits are no more restrictive than the | ||||||
9 | predominant treatment limitations applied to substantially | ||||||
10 | all hospital and medical benefits covered by the policy and | ||||||
11 | that there are no separate treatment limitations that are | ||||||
12 | applicable only with respect to mental, emotional, | ||||||
13 | nervous, or substance use disorder or condition benefits. | ||||||
14 | (b) The following provisions shall apply concerning | ||||||
15 | aggregate lifetime limits: | ||||||
16 | (1) In the case of a group or individual policy of | ||||||
17 | accident and health insurance or a qualified health plan | ||||||
18 | offered through the Health Insurance Marketplace amended, | ||||||
19 | delivered, issued, or renewed in this State on or after the | ||||||
20 | effective date of this amendatory Act of the 99th General | ||||||
21 | Assembly that provides coverage for hospital or medical | ||||||
22 | treatment and for the treatment of mental, emotional, | ||||||
23 | nervous, or substance use disorders or conditions the | ||||||
24 | following provisions shall apply: | ||||||
25 | (A) if the policy does not include an aggregate | ||||||
26 | lifetime limit on substantially all hospital and |
| |||||||
| |||||||
1 | medical benefits, then the policy may not impose any | ||||||
2 | aggregate lifetime limit on mental, emotional, | ||||||
3 | nervous, or substance use disorder or condition | ||||||
4 | benefits; or | ||||||
5 | (B) if the policy includes an aggregate lifetime | ||||||
6 | limit on substantially all hospital and medical | ||||||
7 | benefits (in this subsection referred to as the | ||||||
8 | "applicable lifetime limit"), then the policy shall | ||||||
9 | either: | ||||||
10 | (i) apply the applicable lifetime limit both | ||||||
11 | to the hospital and medical benefits to which it | ||||||
12 | otherwise would apply and to mental, emotional, | ||||||
13 | nervous, or substance use disorder or condition | ||||||
14 | benefits and not distinguish in the application of | ||||||
15 | the limit between the hospital and medical | ||||||
16 | benefits and mental, emotional, nervous, or | ||||||
17 | substance use disorder or condition benefits; or | ||||||
18 | (ii) not include any aggregate lifetime limit | ||||||
19 | on mental, emotional, nervous, or substance use | ||||||
20 | disorder or condition benefits that is less than | ||||||
21 | the applicable lifetime limit. | ||||||
22 | (2) In the case of a policy that is not described in | ||||||
23 | paragraph (1) of subsection (b) of this Section and that | ||||||
24 | includes no or different aggregate lifetime limits on | ||||||
25 | different categories of hospital and medical benefits, the | ||||||
26 | Director shall establish rules under which subparagraph |
| |||||||
| |||||||
1 | (B) of paragraph (1) of subsection (b) of this Section is | ||||||
2 | applied to such policy with respect to mental, emotional, | ||||||
3 | nervous, or substance use disorder or condition benefits by | ||||||
4 | substituting for the applicable lifetime limit an average | ||||||
5 | aggregate lifetime limit that is computed taking into | ||||||
6 | account the weighted average of the aggregate lifetime | ||||||
7 | limits applicable to such categories. | ||||||
8 | (c) The following provisions shall apply concerning annual | ||||||
9 | limits: | ||||||
10 | (1) In the case of a group or individual policy of | ||||||
11 | accident and health insurance or a qualified health plan | ||||||
12 | offered through the Health Insurance Marketplace amended, | ||||||
13 | delivered, issued, or renewed in this State on or after the | ||||||
14 | effective date of this amendatory Act of the 99th General | ||||||
15 | Assembly that provides coverage for hospital or medical | ||||||
16 | treatment and for the treatment of mental, emotional, | ||||||
17 | nervous, or substance use disorders or conditions the | ||||||
18 | following provisions shall apply: | ||||||
19 | (A) if the policy does not include an annual limit | ||||||
20 | on substantially all hospital and medical benefits, | ||||||
21 | then the policy may not impose any annual limits on | ||||||
22 | mental, emotional, nervous, or substance use disorder | ||||||
23 | or condition benefits; or | ||||||
24 | (B) if the policy includes an annual limit on | ||||||
25 | substantially all hospital and medical benefits (in | ||||||
26 | this subsection referred to as the "applicable annual |
| |||||||
| |||||||
1 | limit"), then the policy shall either: | ||||||
2 | (i) apply the applicable annual limit both to | ||||||
3 | the hospital and medical benefits to which it | ||||||
4 | otherwise would apply and to mental, emotional, | ||||||
5 | nervous, or substance use disorder or condition | ||||||
6 | benefits and not distinguish in the application of | ||||||
7 | the limit between the hospital and medical | ||||||
8 | benefits and mental, emotional, nervous, or | ||||||
9 | substance use disorder or condition benefits; or | ||||||
10 | (ii) not include any annual limit on mental, | ||||||
11 | emotional, nervous, or substance use disorder or | ||||||
12 | condition benefits that is less than the | ||||||
13 | applicable annual limit. | ||||||
14 | (2) In the case of a policy that is not described in | ||||||
15 | paragraph (1) of subsection (c) of this Section and that | ||||||
16 | includes no or different annual limits on different | ||||||
17 | categories of hospital and medical benefits, the Director | ||||||
18 | shall establish rules under which subparagraph (B) of | ||||||
19 | paragraph (1) of subsection (c) of this Section is applied | ||||||
20 | to such policy with respect to mental, emotional, nervous, | ||||||
21 | or substance use disorder or condition benefits by | ||||||
22 | substituting for the applicable annual limit an average | ||||||
23 | annual limit that is computed taking into account the | ||||||
24 | weighted average of the annual limits applicable to such | ||||||
25 | categories. | ||||||
26 | (d) With respect to mental, emotional, nervous, or |
| |||||||
| |||||||
1 | substance use disorders or conditions , an insurer shall use | ||||||
2 | policies and procedures for the election and placement of | ||||||
3 | mental, emotional, nervous, or substance use disorder or | ||||||
4 | condition substance abuse treatment drugs on their formulary | ||||||
5 | that are no less favorable to the insured as those policies and | ||||||
6 | procedures the insurer uses for the selection and placement of | ||||||
7 | other drugs for medical or surgical conditions and shall follow | ||||||
8 | the expedited coverage determination requirements for | ||||||
9 | substance abuse treatment drugs set forth in Section 45.2 of | ||||||
10 | the Managed Care Reform and Patient Rights Act. | ||||||
11 | (e) This Section shall be interpreted in a manner | ||||||
12 | consistent with all applicable federal parity regulations | ||||||
13 | including, but not limited to, the Paul Wellstone and Pete | ||||||
14 | Domenici Mental Health Parity and Addiction Equity Act of 2008 , | ||||||
15 | final regulations issued under the Paul Wellstone and Pete | ||||||
16 | Domenici Mental Health Parity and Addiction Equity Act of 2008 | ||||||
17 | and final regulations applying the Paul Wellstone and Pete | ||||||
18 | Domenici Mental Health Parity and Addiction Equity Act of 2008 | ||||||
19 | to Medicaid managed care organizations, the Children's Health | ||||||
20 | Insurance Program, and alternative benefit plans at 78 FR | ||||||
21 | 68240 . | ||||||
22 | (f) The provisions of subsections (b) and (c) of this | ||||||
23 | Section shall not be interpreted to allow the use of lifetime | ||||||
24 | or annual limits otherwise prohibited by State or federal law. | ||||||
25 | (g) As used in this Section: | ||||||
26 | "Financial requirement" includes deductibles, copayments, |
| |||||||
| |||||||
1 | coinsurance, and out-of-pocket maximums, but does not include | ||||||
2 | an aggregate lifetime limit or an annual limit subject to | ||||||
3 | subsections (b) and (c). | ||||||
4 | "Mental, emotional, nervous, or substance use disorder or | ||||||
5 | condition" means a condition or disorder that involves a mental | ||||||
6 | health condition or substance use disorder that falls under any | ||||||
7 | of the diagnostic categories listed in the mental and | ||||||
8 | behavioral disorders chapter of the current edition of the | ||||||
9 | International Classification of Disease or that is listed in | ||||||
10 | the most recent version of the Diagnostic and Statistical | ||||||
11 | Manual of Mental Disorders. | ||||||
12 | "Treatment limitation" includes limits on benefits based | ||||||
13 | on the frequency of treatment, number of visits, days of | ||||||
14 | coverage, days in a waiting period, or other similar limits on | ||||||
15 | the scope or duration of treatment. "Treatment limitation" | ||||||
16 | includes both quantitative treatment limitations, which are | ||||||
17 | expressed numerically (such as 50 outpatient visits per year), | ||||||
18 | and nonquantitative treatment limitations, which otherwise | ||||||
19 | limit the scope or duration of treatment. A permanent exclusion | ||||||
20 | of all benefits for a particular condition or disorder shall | ||||||
21 | not be considered a treatment limitation. "Nonquantitative | ||||||
22 | treatment" means those limitations as described under federal | ||||||
23 | regulations (26 CFR 54.9812-1). "Nonquantitative treatment | ||||||
24 | limitations" include, but are not limited to, those limitations | ||||||
25 | described under federal regulations 26 CFR 54.9812-1, 29 CFR | ||||||
26 | 2590.712, and 45 CFR 146.136.
|
| |||||||
| |||||||
1 | (h) The Department of Insurance shall implement the | ||||||
2 | following education initiatives: | ||||||
3 | (1) By January 1, 2016, the Department shall develop a | ||||||
4 | plan for a Consumer Education Campaign on parity. The | ||||||
5 | Consumer Education Campaign shall focus its efforts | ||||||
6 | throughout the State and include trainings in the northern, | ||||||
7 | southern, and central regions of the State, as defined by | ||||||
8 | the Department, as well as each of the 5 managed care | ||||||
9 | regions of the State as identified by the Department of | ||||||
10 | Healthcare and Family Services. Under this Consumer | ||||||
11 | Education Campaign, the Department shall: (1) by January 1, | ||||||
12 | 2017, provide at least one live training in each region on | ||||||
13 | parity for consumers and providers and one webinar training | ||||||
14 | to be posted on the Department website and (2) establish a | ||||||
15 | consumer hotline to assist consumers in navigating the | ||||||
16 | parity process by March 1, 2017 2016 . By January 1, 2018 | ||||||
17 | the Department shall issue a report to the General Assembly | ||||||
18 | on the success of the Consumer Education Campaign, which | ||||||
19 | shall indicate whether additional training is necessary or | ||||||
20 | would be recommended. | ||||||
21 | (2) The Department, in coordination with the | ||||||
22 | Department of Human Services and the Department of | ||||||
23 | Healthcare and Family Services, shall convene a working | ||||||
24 | group of health care insurance carriers, mental health | ||||||
25 | advocacy groups, substance abuse patient advocacy groups, | ||||||
26 | and mental health physician groups for the purpose of |
| |||||||
| |||||||
1 | discussing issues related to the treatment and coverage of | ||||||
2 | mental, emotional, nervous, or substance use abuse | ||||||
3 | disorders or conditions and compliance with parity | ||||||
4 | obligations under State and federal law. Compliance shall | ||||||
5 | be measured, tracked, and shared during the meetings of the | ||||||
6 | working group and mental illness . The working group shall | ||||||
7 | meet once before January 1, 2016 and shall meet | ||||||
8 | semiannually thereafter. The Department shall issue an | ||||||
9 | annual report to the General Assembly that includes a list | ||||||
10 | of the health care insurance carriers, mental health | ||||||
11 | advocacy groups, substance abuse patient advocacy groups, | ||||||
12 | and mental health physician groups that participated in the | ||||||
13 | working group meetings, details on the issues and topics | ||||||
14 | covered, and any legislative recommendations developed by | ||||||
15 | the working group . | ||||||
16 | (3) Not later than August 1 of each year, the | ||||||
17 | Department, in conjunction with the Department of | ||||||
18 | Healthcare and Family Services, shall issue a joint report | ||||||
19 | to the General Assembly and provide an educational | ||||||
20 | presentation to the General Assembly. The report and | ||||||
21 | presentation shall: | ||||||
22 | (A) Cover the methodology the Departments use to | ||||||
23 | check for compliance with the federal Paul Wellstone | ||||||
24 | and Pete Domenici Mental Health Parity and Addiction | ||||||
25 | Equity Act of 2008, 42 U.S.C. 18031(j), and any federal | ||||||
26 | regulations or guidance relating to the compliance and |
| |||||||
| |||||||
1 | oversight of the federal Paul Wellstone and Pete | ||||||
2 | Domenici Mental Health Parity and Addiction Equity Act | ||||||
3 | of 2008 and 42 U.S.C. 18031(j). | ||||||
4 | (B) Cover the methodology the Departments use to | ||||||
5 | check for compliance with this Section and Sections | ||||||
6 | 356z.23 and 370c of this Code. | ||||||
7 | (C) Identify market conduct examinations or, in | ||||||
8 | the case of the Department of Healthcare and Family | ||||||
9 | Services, audits conducted or completed during the | ||||||
10 | preceding 12-month period regarding compliance with | ||||||
11 | parity in mental, emotional, nervous, and substance | ||||||
12 | use disorder or condition benefits under State and | ||||||
13 | federal laws and summarize the results of such market | ||||||
14 | conduct examinations and audits. This shall include: | ||||||
15 | (i) the number of market conduct examinations | ||||||
16 | and audits initiated and completed; | ||||||
17 | (ii) the benefit classifications examined by | ||||||
18 | each market conduct examination and audit; | ||||||
19 | (iii) the subject matter of each market | ||||||
20 | conduct examination and audit, including | ||||||
21 | quantitative and non-quantitative treatment | ||||||
22 | limitations; and | ||||||
23 | (iv) a summary of the basis for the final | ||||||
24 | decision rendered in each market conduct | ||||||
25 | examination and audit. | ||||||
26 | Individually identifiable information shall be |
| |||||||
| |||||||
1 | excluded from the reports consistent with federal | ||||||
2 | privacy protections. | ||||||
3 | (D) Detail any educational or corrective actions | ||||||
4 | the Departments have taken to ensure compliance with | ||||||
5 | the federal Paul Wellstone and Pete Domenici Mental | ||||||
6 | Health Parity and Addiction Equity Act of 2008, 42 | ||||||
7 | U.S.C. 18031(j), this Section, and Sections 356z.23 | ||||||
8 | and 370c of this Code. | ||||||
9 | (E) The report must be written in non-technical, | ||||||
10 | readily understandable language and shall be made | ||||||
11 | available to the public by, among such other means as | ||||||
12 | the Departments find appropriate, posting the report | ||||||
13 | on the Departments' websites. | ||||||
14 | (i) The Parity Advancement Education Fund is created as a | ||||||
15 | special fund in the State treasury. Moneys from fines and | ||||||
16 | penalties collected from insurers for violations of this | ||||||
17 | Section shall be deposited into the Fund. Moneys deposited into | ||||||
18 | the Fund for appropriation by the General Assembly to the | ||||||
19 | Department of Insurance shall be used for the purpose of | ||||||
20 | providing financial support of the Consumer Education | ||||||
21 | Campaign , parity compliance advocacy, and other initiatives | ||||||
22 | that support parity implementation and enforcement on behalf of | ||||||
23 | consumers . | ||||||
24 | (j) The Department of Insurance and the Department of | ||||||
25 | Healthcare and Family Services shall convene and provide | ||||||
26 | technical support to a workgroup of 11 members that shall be |
| |||||||
| |||||||
1 | comprised of 3 mental health parity experts recommended by an | ||||||
2 | organization advocating on behalf of mental health parity | ||||||
3 | appointed by the President of the Senate; 3 behavioral health | ||||||
4 | providers recommended by an organization that represents | ||||||
5 | behavioral health providers appointed by the Speaker of the | ||||||
6 | House of Representatives; 2 representing Medicaid managed care | ||||||
7 | organizations recommended by an organization that represents | ||||||
8 | Medicaid managed care plans appointed by the Minority Leader of | ||||||
9 | the House of Representatives; 2 representing commercial | ||||||
10 | insurers recommended by an organization that represents | ||||||
11 | insurers appointed by the Minority Leader of the Senate; and a | ||||||
12 | representative of an organization that represents Medicaid | ||||||
13 | managed care plans appointed by the Governor. | ||||||
14 | The workgroup shall provide recommendations to the General | ||||||
15 | Assembly on health plan data reporting requirements that | ||||||
16 | separately break out data on mental, emotional, nervous, or | ||||||
17 | substance use disorder or condition benefits and data on other | ||||||
18 | medical benefits, including physical health and related health | ||||||
19 | services no later than December 31, 2019. The recommendations | ||||||
20 | to the General Assembly shall be filed with the Clerk of the | ||||||
21 | House of Representatives and the Secretary of the Senate in | ||||||
22 | electronic form only, in the manner that the Clerk and the | ||||||
23 | Secretary shall direct. This workgroup shall take into account | ||||||
24 | federal requirements and recommendations on mental health | ||||||
25 | parity reporting for the Medicaid program. This workgroup shall | ||||||
26 | also develop the format and provide any needed definitions for |
| |||||||
| |||||||
1 | reporting requirements in subsection (k). The research and | ||||||
2 | evaluation of the working group shall include, but not be | ||||||
3 | limited to: | ||||||
4 | (1) claims denials due to benefit limits, if | ||||||
5 | applicable; | ||||||
6 | (2) administrative denials for no prior authorization; | ||||||
7 | (3) denials due to not meeting medical necessity; | ||||||
8 | (4) denials that went to external review and whether | ||||||
9 | they were upheld or overturned for medical necessity; | ||||||
10 | (5) out-of-network claims; | ||||||
11 | (6) emergency care claims; | ||||||
12 | (7) network directory providers in the outpatient | ||||||
13 | benefits classification who filed no claims in the last 6 | ||||||
14 | months, if applicable; | ||||||
15 | (8) the impact of existing and pertinent limitations | ||||||
16 | and restrictions related to approved services, licensed | ||||||
17 | providers, reimbursement levels, and reimbursement | ||||||
18 | methodologies within the Division of Mental Health, the | ||||||
19 | Division of Substance Use Prevention and Recovery | ||||||
20 | programs, the Department of Healthcare and Family | ||||||
21 | Services, and, to the extent possible, federal regulations | ||||||
22 | and law; and | ||||||
23 | (9) when reporting and publishing should begin. | ||||||
24 | Representatives from the Department of Healthcare and | ||||||
25 | Family Services, representatives from the Division of Mental | ||||||
26 | Health, and representatives from the Division of Substance Use |
| |||||||
| |||||||
1 | Prevention and Recovery shall provide technical advice to the | ||||||
2 | workgroup. | ||||||
3 | (k) An insurer that amends, delivers, issues, or renews a | ||||||
4 | group or individual policy of accident and health insurance or | ||||||
5 | a qualified health plan offered through the health insurance | ||||||
6 | marketplace in this State providing coverage for hospital or | ||||||
7 | medical treatment and for the treatment of mental, emotional, | ||||||
8 | nervous, or substance use disorders or conditions shall submit | ||||||
9 | an annual report, the format and definitions for which will be | ||||||
10 | developed by the workgroup in subsection (j), to the | ||||||
11 | Department, or, with respect to medical assistance, the | ||||||
12 | Department of Healthcare and Family Services starting on or | ||||||
13 | before July 1, 2020 that contains the following information | ||||||
14 | separately for inpatient in-network benefits, inpatient | ||||||
15 | out-of-network benefits, outpatient in-network benefits, | ||||||
16 | outpatient out-of-network benefits, emergency care benefits, | ||||||
17 | and prescription drug benefits in the case of accident and | ||||||
18 | health insurance or qualified health plans, or inpatient, | ||||||
19 | outpatient, emergency care, and prescription drug benefits in | ||||||
20 | the case of medical assistance: | ||||||
21 | (1) A summary of the plan's pharmacy management | ||||||
22 | processes for mental, emotional, nervous, or substance use | ||||||
23 | disorder or condition benefits compared to those for other | ||||||
24 | medical benefits. | ||||||
25 | (2) A summary of the internal processes of review for | ||||||
26 | experimental benefits and unproven technology for mental, |
| |||||||
| |||||||
1 | emotional, nervous, or substance use disorder or condition | ||||||
2 | benefits and those for
other medical benefits. | ||||||
3 | (3) A summary of how the plan's policies and procedures | ||||||
4 | for utilization management for mental, emotional, nervous, | ||||||
5 | or substance use disorder or condition benefits compare to | ||||||
6 | those for other medical benefits. | ||||||
7 | (4) A description of the process used to develop or | ||||||
8 | select the medical necessity criteria for mental, | ||||||
9 | emotional, nervous, or substance use disorder or condition | ||||||
10 | benefits and the process used to develop or select the | ||||||
11 | medical necessity criteria for medical and surgical | ||||||
12 | benefits. | ||||||
13 | (5) Identification of all nonquantitative treatment | ||||||
14 | limitations that are applied to both mental, emotional, | ||||||
15 | nervous, or substance use disorder or condition benefits | ||||||
16 | and medical and surgical benefits within each | ||||||
17 | classification of benefits. | ||||||
18 | (6) The results of an analysis that demonstrates that | ||||||
19 | for the medical necessity criteria described in | ||||||
20 | subparagraph (A) and for each nonquantitative treatment | ||||||
21 | limitation identified in subparagraph (B), as written and | ||||||
22 | in operation, the processes, strategies, evidentiary | ||||||
23 | standards, or other factors used in applying the medical | ||||||
24 | necessity criteria and each nonquantitative treatment | ||||||
25 | limitation to mental, emotional, nervous, or substance use | ||||||
26 | disorder or condition benefits within each classification |
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1 | of benefits are comparable to, and are applied no more | ||||||
2 | stringently than, the processes, strategies, evidentiary | ||||||
3 | standards, or other factors used in applying the medical | ||||||
4 | necessity criteria and each nonquantitative treatment | ||||||
5 | limitation to medical and surgical benefits within the | ||||||
6 | corresponding classification of benefits; at a minimum, | ||||||
7 | the results of the analysis shall: | ||||||
8 | (A) identify the factors used to determine that a | ||||||
9 | nonquantitative treatment limitation applies to a | ||||||
10 | benefit, including factors that were considered but | ||||||
11 | rejected; | ||||||
12 | (B) identify and define the specific evidentiary | ||||||
13 | standards used to define the factors and any other | ||||||
14 | evidence relied upon in designing each nonquantitative | ||||||
15 | treatment limitation; | ||||||
16 | (C) provide the comparative analyses, including | ||||||
17 | the results of the analyses, performed to determine | ||||||
18 | that the processes and strategies used to design each | ||||||
19 | nonquantitative treatment limitation, as written, for | ||||||
20 | mental, emotional, nervous, or substance use disorder | ||||||
21 | or condition benefits are comparable to, and are | ||||||
22 | applied no more stringently than, the processes and | ||||||
23 | strategies used to design each nonquantitative | ||||||
24 | treatment limitation, as written, for medical and | ||||||
25 | surgical benefits; | ||||||
26 | (D) provide the comparative analyses, including |
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1 | the results of the analyses, performed to determine | ||||||
2 | that the processes and strategies used to apply each | ||||||
3 | nonquantitative treatment limitation, in operation, | ||||||
4 | for mental, emotional, nervous, or substance use | ||||||
5 | disorder or condition benefits are comparable to, and | ||||||
6 | applied no more stringently than, the processes or | ||||||
7 | strategies used to apply each nonquantitative | ||||||
8 | treatment limitation, in operation, for medical and | ||||||
9 | surgical benefits; and | ||||||
10 | (E) disclose the specific findings and conclusions | ||||||
11 | reached by the insurer that the results of the analyses | ||||||
12 | described in subparagraphs (C) and (D) indicate that | ||||||
13 | the insurer is in compliance with this Section and the | ||||||
14 | Mental Health Parity and Addiction Equity Act of 2008 | ||||||
15 | and its implementing regulations, which includes 42 | ||||||
16 | CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any | ||||||
17 | other related federal regulations found in the Code of | ||||||
18 | Federal Regulations. | ||||||
19 | (7) Any other information necessary to clarify data | ||||||
20 | provided in accordance with this Section requested by the | ||||||
21 | Director, including information that may be proprietary or | ||||||
22 | have commercial value, under the requirements of Section 30 | ||||||
23 | of the Viatical Settlements Act of 2009. | ||||||
24 | (l) An insurer that amends, delivers, issues, or renews a | ||||||
25 | group or individual policy of accident and health insurance or | ||||||
26 | a qualified health plan offered through the health insurance |
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1 | marketplace in this State providing coverage for hospital or | ||||||
2 | medical treatment and for the treatment of mental, emotional, | ||||||
3 | nervous, or substance use disorders or conditions on or after | ||||||
4 | the effective date of this amendatory Act of the 100th General | ||||||
5 | Assembly shall, in advance of the plan year, make available to | ||||||
6 | the Department or, with respect to medical assistance, the | ||||||
7 | Department of Healthcare and Family Services and to all plan | ||||||
8 | participants and beneficiaries the information required in | ||||||
9 | subparagraphs (C) through (E) of paragraph (6) of subsection | ||||||
10 | (k). For plan participants and medical assistance | ||||||
11 | beneficiaries, the information required in subparagraphs (C) | ||||||
12 | through (E) of paragraph (6) of subsection (k) shall be made | ||||||
13 | available on a publicly-available website whose web address is | ||||||
14 | prominently displayed in plan and managed care organization | ||||||
15 | informational and marketing materials. | ||||||
16 | (m) In conjunction with its compliance examination program | ||||||
17 | conducted in accordance with the Illinois State Auditing Act, | ||||||
18 | the Auditor General shall undertake a review of
compliance by | ||||||
19 | the Department and the Department of Healthcare and Family | ||||||
20 | Services with Section 370c and this Section. Any
findings | ||||||
21 | resulting from the review conducted under this Section shall be | ||||||
22 | included in the applicable State agency's compliance | ||||||
23 | examination report. Each compliance examination report shall | ||||||
24 | be issued in accordance with Section 3-14 of the Illinois State
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25 | Auditing Act. A copy of each report shall also be delivered to
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26 | the head of the applicable State agency and posted on the |
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1 | Auditor General's website. | ||||||
2 | (Source: P.A. 99-480, eff. 9-9-15.)
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3 | Section 99. Effective date. This Act takes effect January | ||||||
4 | 1, 2019.".
|