Bill Amendment: IL HB0068 | 2017-2018 | 100th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

---

Bill Title: REGULATION-TECH

Status: 2019-01-08 - Session Sine Die [HB0068 Detail]

Download: Illinois-2017-HB0068-House_Amendment_001.html

---

Rep. Lou Lang

Filed: 3/16/2017

10000HB0068ham001 LRB100 03757 SMS 23221 a
AMENDMENT TO HOUSE BILL 68
AMENDMENT NO. ______. Amend House Bill 68 by replacing
everything after the enacting clause with the following:
"Section 5. The State Finance Act is amended by changing
Section 5.872 as follows:
(30 ILCS 105/5.872)
Sec. 5.872. The Parity Advancement Education Fund.
(Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
Section 10. The Illinois Insurance Code is amended by
changing Sections 370c and 370c.1 as follows:
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a) (1) On and after the effective date of this amendatory
Act of the 100th General Assembly the effective date of this

10000HB0068ham001 - 2 - LRB100 03757 SMS 23221 a
amendatory Act of the 97th General Assembly, every insurer that
which amends, delivers, issues, or renews group accident and
health policies providing coverage for hospital or medical
treatment or services for illness on an expense-incurred basis
shall provide offer to the applicant or group policyholder
subject to the insurer's standards of insurability, coverage
for reasonable and necessary treatment and services for mental,
emotional, or nervous, or substance use disorders or
conditions, other than serious mental illnesses as defined in
item (2) of subsection (b), consistent with the parity
requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be free
to select the physician licensed to practice medicine in all
its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act of his
choice to treat such disorders, and the insurer shall pay the
covered charges of such physician licensed to practice medicine
in all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified

10000HB0068ham001 - 3 - LRB100 03757 SMS 23221 a
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act up to the
limits of coverage, provided (i) the disorder or condition
treated is covered by the policy, and (ii) the physician,
licensed psychologist, licensed clinical social worker,
licensed clinical professional counselor, licensed marriage
and family therapist, licensed speech-language pathologist, or
other licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act is authorized to provide said services under the
statutes of this State and in accordance with accepted
principles of his profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act, those
persons who may provide services to individuals shall do so
after the licensed clinical social worker, licensed clinical
professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act has informed the patient of the desirability of
the patient conferring with the patient's primary care

10000HB0068ham001 - 4 - LRB100 03757 SMS 23221 a
physician and the licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act has provided written notification to the
patient's primary care physician, if any, that services are
being provided to the patient. That notification may, however,
be waived by the patient on a written form. Those forms shall
be retained by the licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act for a period of not less than 5 years.
(4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental and
behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders.
(b) (1) (Blank). An insurer that provides coverage for
hospital or medical expenses under a group policy of accident
and health insurance or health care plan amended, delivered,

10000HB0068ham001 - 5 - LRB100 03757 SMS 23221 a
issued, or renewed on or after the effective date of this
amendatory Act of the 97th General Assembly shall provide
coverage under the policy for treatment of serious mental
illness and substance use disorders consistent with the parity
requirements of Section 370c.1 of this Code. This subsection
does not apply to any group policy of accident and health
insurance or health care plan for any plan year of a small
employer as defined in Section 5 of the Illinois Health
Insurance Portability and Accountability Act.
(2) (Blank). "Serious mental illness" means the following
psychiatric illnesses as defined in the most current edition of
the Diagnostic and Statistical Manual (DSM) published by the
American Psychiatric Association:
(A) schizophrenia;
(B) paranoid and other psychotic disorders;
(C) bipolar disorders (hypomanic, manic, depressive,
and mixed);
(D) major depressive disorders (single episode or
recurrent);
(E) schizoaffective disorders (bipolar or depressive);
(F) pervasive developmental disorders;
(G) obsessive-compulsive disorders;
(H) depression in childhood and adolescence;
(I) panic disorder;
(J) post-traumatic stress disorders (acute, chronic,
or with delayed onset); and

10000HB0068ham001 - 6 - LRB100 03757 SMS 23221 a
(K) anorexia nervosa and bulimia nervosa.
(2.5) (Blank). "Substance use disorder" means the
following mental disorders as defined in the most current
edition of the Diagnostic and Statistical Manual (DSM)
published by the American Psychiatric Association:
(A) substance abuse disorders;
(B) substance dependence disorders; and
(C) substance induced disorders.
(3) Unless otherwise prohibited by federal law and
consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer that amends, delivers,
issues, or renews a group or individual policy of accident and
health insurance, a qualified health plan offered through the
health insurance marketplace, or , a provider of treatment of
mental, emotional, nervous, or serious mental illness or
substance use disorders or conditions disorder shall furnish
medical records or other necessary data that substantiate that
initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the timely
review by a provider holding the same license and practicing in
the same specialty as the patient's provider, who is
unaffiliated with the insurer, jointly selected by the patient
(or the patient's next of kin or legal representative if the
patient is unable to act for himself or herself), the patient's
provider, and the insurer in the event of a dispute between the
insurer and patient's provider regarding the medical necessity

10000HB0068ham001 - 7 - LRB100 03757 SMS 23221 a
of a treatment proposed by a patient's provider. If the
reviewing provider determines the treatment to be medically
necessary, the insurer shall provide reimbursement for the
treatment. Future contractual or employment actions by the
insurer regarding the patient's provider may not be based on
the provider's participation in this procedure. Nothing
prevents the insured from agreeing in writing to continue
treatment at his or her expense. When making a determination of
the medical necessity for a treatment modality for mental,
emotional, nervous, or serious mental illness or substance use
disorders or conditions disorder, an insurer must make the
determination in a manner that is consistent with the manner
used to make that determination with respect to other diseases
or illnesses covered under the policy, including an appeals
process. Medical necessity determinations for substance use
disorders shall be made in accordance with appropriate patient
placement criteria established by the American Society of
Addiction Medicine. No additional criteria may be used to make
medical necessity determinations for substance use disorders.
(4) A group health benefit plan amended, delivered, issued,
or renewed on or after the effective date of this amendatory
Act of the 100th General Assembly or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after the effective date of
this amendatory Act of the 100th General Assembly the effective

10000HB0068ham001 - 8 - LRB100 03757 SMS 23221 a
date of this amendatory Act of the 97th General Assembly :
(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or mental illness and substance use disorder or
condition disorders consistent with the parity
requirements of Section 370c.1 of this Code; provided,
however, that in each calendar year coverage shall not be
less than the following:
(i) 45 days of inpatient treatment; and
(ii) beginning on June 26, 2006 (the effective date
of Public Act 94-921), 60 visits for outpatient
treatment including group and individual outpatient
treatment; and
(iii) for plans or policies delivered, issued for
delivery, renewed, or modified after January 1, 2007
(the effective date of Public Act 94-906), 20
additional outpatient visits for speech therapy for
treatment of pervasive developmental disorders that
will be in addition to speech therapy provided pursuant
to item (ii) of this subparagraph (A); and
(B) may not include a lifetime limit on the number of
days of inpatient treatment or the number of outpatient
visits covered under the plan.
(C) (Blank).
(5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a

10000HB0068ham001 - 9 - LRB100 03757 SMS 23221 a
qualified health plan offered through the health insurance
marketplace may not count toward the number of outpatient
visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover
the outpatient visits under the same terms and conditions as it
covers outpatient visits for the treatment of physical illness.
(5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after the effective date of
this amendatory Act of the 99th General Assembly shall offer
coverage for medically necessary acute treatment services and
medically necessary clinical stabilization services. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine
Patient Placement Criteria. The treating provider shall base
all treatment recommendations and the health benefit plan shall
base all medical necessity determinations for
medication-assisted treatment in accordance with the most
current Treatment Criteria for Addictive, Substance-Related,
and Co-Occurring Conditions established by the American
Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically

10000HB0068ham001 - 10 - LRB100 03757 SMS 23221 a
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial
assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
"Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences, relapse
prevention, outreach to families and significant others, and
aftercare planning for individuals beginning to engage in
recovery from addiction.
(6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
(7) (Blank).
(8) (Blank).
(9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
treatment shall include coverage for treatment in a residential
treatment center certified or licensed by the Department of
Public Health or the Department of Human Services.
(c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
(d) With respect to a group or individual policy of
accident and health insurance or a qualified health plan

10000HB0068ham001 - 11 - LRB100 03757 SMS 23221 a
offered through the health insurance marketplace, the The
Department, and with respect to medical assistance, the
Department of Healthcare and Family Services, shall each
enforce the requirements of this Section and Sections 356z.23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance or
regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity Act
of 2008 and final regulations applying the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 to Medicaid managed care organizations, the Children's
Health Insurance Program, and alternative benefit plans.
Specifically, the Department and the Department of Healthcare
and Family Services shall take action: State and federal parity
law, which includes
(1) ensuring compliance by individual and group
policies;
(2) detecting violations of the law by individual and
group policies proactively monitoring discriminatory
practices;
(3) accepting, evaluating, and responding to
complaints regarding such violations;
(4) maintaining and regularly reviewing for possible
parity violations a publicly available consumer complaint

10000HB0068ham001 - 12 - LRB100 03757 SMS 23221 a
log regarding mental, emotional, nervous, or substance use
disorders or conditions coverage;
(5) performing parity compliance pre-market and
post-market conduct examinations of individual and group
plans and policies, including, but not limited to, reviews
of:
(A) network adequacy using established criteria as
set forth in federal and State requirements for medical
assistance and individual or group health policies;
(B) reimbursement rates;
(C) denials of authorization, payment, and
coverage;
(D) prior authorization requirements; and
(E) other specific criteria as shall be set forth
in rules adopted by the Department.
The findings and conclusions of the parity compliance
market conduct examinations shall be made public and shall be
reported to the General Assembly.
The Director shall adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance. and ensuring violations are appropriately remedied
and deterred.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of

10000HB0068ham001 - 13 - LRB100 03757 SMS 23221 a
accident and health insurance, or a qualified health plan
offered through the health insurance marketplace with
respect to mental health or substance use disorder benefits
(or health insurance coverage offered in connection with
the plan with respect to such benefits) must be made
available by the plan administrator (or the health
insurance issuer offering such coverage) to any current or
potential participant, beneficiary, or contracting
provider upon request.
(2) The reason for any denial under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage
offered in connection with such plan or policy) of
reimbursement or payment for services with respect to
mental, emotional, nervous, health or substance use
disorders or conditions disorder benefits in the case of
any participant or beneficiary must be made available
within a reasonable time and in a reasonable manner and in
readily understandable language by the plan administrator
(or the health insurance issuer offering such coverage) to
the participant or beneficiary upon request.
(3) The following information under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage

10000HB0068ham001 - 14 - LRB100 03757 SMS 23221 a
offered in connection with such plan or policy) must be
made available upon request:
(A) a Summary Plan Description, or similar summary
information;
(B) the specific plan or policy language regarding
the imposition of a nonquantitative treatment
limitation (such as a preauthorization requirement);
(C) the specific underlying processes, strategies,
evidentiary standards, and other factors (including,
but not limited to, all evidence) considered by the
plan or policy (including factors that were relied upon
and were rejected) in determining that a
nonquantitative treatment limitation applies to any
particular mental health or substance use disorder
benefit;
(D) information regarding the application of a
nonquantitative treatment limitation to any medical or
surgical benefits within any benefit classification at
issue;
(E) the specific underlying processes, strategies,
evidentiary standards, and other factors (including,
but not limited to, all evidence) considered by the
plan or policy (including factors that were relied upon
and were rejected) in determining the extent to which a
nonquantitative treatment limitation applies to a
particular medical or surgical benefit within a

10000HB0068ham001 - 15 - LRB100 03757 SMS 23221 a
benefit classification at issue; and
(F) any analyses performed by the plan or under the
policy as to how any nonquantitative treatment
limitation complies with this Section and Sections
356z.23 and 370c.1 of this Code, the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008, 42 U.S.C. 18031(j), and any
amendments to, and federal guidance or regulations
issued under, those Acts, including, but not limited
to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008 and final regulations applying the
Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 to Medicaid managed
care organizations, the Children's Health Insurance
Program, and alternative benefit plans.
(f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois or which purport to provide coverage
for a resident of this State; and (2) State employee health
plans.
(g) The General Assembly decrees that it is the public
policy of the State of Illinois to allow for private
enforcement of mental, emotional, nervous, or substance use
disorder or condition parity protections in a court of

10000HB0068ham001 - 16 - LRB100 03757 SMS 23221 a
competent jurisdiction, without administrative exhaustion or
arbitration, even if otherwise required by an insurance policy.
Members, patients, subscribers, enrollees, and providers
(in-network and out-of-network) on behalf of members,
patients, subscribers, and enrollees have the right to commence
a civil action against any group health plan, an issuer of an
individual policy of accident and health insurance, or a
qualified health plan offered through the health insurance
marketplace (or health insurance coverage offered in
connection with such plan or policy) that violates the
provisions of this Section, such that any member of a group
health plan or an individual covered under a policy of accident
and health insurance or a qualified health plan offered through
the health insurance marketplace (or health insurance coverage
offered in connection with such plan or policy) authorized
representative of such plan or related entity, advocacy
organization representing the interests of members of a health
plan carrier or related entity, health care providers, or
organization representing the interests of providers
reimbursed by a health plan carrier or related entity, against
which the violation is alleged, shall have standing to commence
a civil action in a court of competent jurisdiction.
The remedy under this Section is limited to a $5,000
penalty for each act or offense; injunctive relief; general and
special damages, which may be trebled; restitution of premium;
and attorney's fees and costs.

10000HB0068ham001 - 17 - LRB100 03757 SMS 23221 a
A violation consists of any violation of this Section or
Section 370c.1 of this Code, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008,
42 U.S.C. 18031(j), and any amendments to, and federal guidance
or regulations issued under, those acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity Act
of 2008 and final regulations applying the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 to Medicaid Managed Care Organizations, Children's Health
Insurance Programs (CHIP), and Alternative Benefit Plans.
A violation of this Section shall not be contingent upon
the plaintiff proving the medical necessity of any prescribed
procedure, service, or medication.
(Source: P.A. 99-480, eff. 9-9-15.)
(215 ILCS 5/370c.1)
Sec. 370c.1. Mental, emotional, nervous, or substance use
disorder or condition health and addiction parity.
(a) On and after the effective date of this amendatory Act
of the 99th General Assembly, every insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace in this State
providing coverage for hospital or medical treatment and for
the treatment of mental, emotional, nervous, or substance use

10000HB0068ham001 - 18 - LRB100 03757 SMS 23221 a
disorders or conditions shall ensure that:
(1) the financial requirements applicable to such
mental, emotional, nervous, or substance use disorder or
condition benefits are no more restrictive than the
predominant financial requirements applied to
substantially all hospital and medical benefits covered by
the policy and that there are no separate cost-sharing
requirements that are applicable only with respect to
mental, emotional, nervous, or substance use disorder or
condition benefits; and
(2) the treatment limitations applicable to such
mental, emotional, nervous, or substance use disorder or
condition benefits are no more restrictive than the
predominant treatment limitations applied to substantially
all hospital and medical benefits covered by the policy and
that there are no separate treatment limitations that are
applicable only with respect to mental, emotional,
nervous, or substance use disorder or condition benefits.
(b) The following provisions shall apply concerning
aggregate lifetime limits:
(1) In the case of a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace amended,
delivered, issued, or renewed in this State on or after the
effective date of this amendatory Act of the 99th General
Assembly that provides coverage for hospital or medical

10000HB0068ham001 - 19 - LRB100 03757 SMS 23221 a
treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions the
following provisions shall apply:
(A) if the policy does not include an aggregate
lifetime limit on substantially all hospital and
medical benefits, then the policy may not impose any
aggregate lifetime limit on mental, emotional,
nervous, or substance use disorder or condition
benefits; or
(B) if the policy includes an aggregate lifetime
limit on substantially all hospital and medical
benefits (in this subsection referred to as the
"applicable lifetime limit"), then the policy shall
either:
(i) apply the applicable lifetime limit both
to the hospital and medical benefits to which it
otherwise would apply and to mental, emotional,
nervous, or substance use disorder or condition
benefits and not distinguish in the application of
the limit between the hospital and medical
benefits and mental, emotional, nervous, or
substance use disorder or condition benefits; or
(ii) not include any aggregate lifetime limit
on mental, emotional, nervous, or substance use
disorder or condition benefits that is less than
the applicable lifetime limit.

10000HB0068ham001 - 20 - LRB100 03757 SMS 23221 a
(2) In the case of a policy that is not described in
paragraph (1) of subsection (b) of this Section and that
includes no or different aggregate lifetime limits on
different categories of hospital and medical benefits, the
Director shall establish rules under which subparagraph
(B) of paragraph (1) of subsection (b) of this Section is
applied to such policy with respect to mental, emotional,
nervous, or substance use disorder or condition benefits by
substituting for the applicable lifetime limit an average
aggregate lifetime limit that is computed taking into
account the weighted average of the aggregate lifetime
limits applicable to such categories.
(c) The following provisions shall apply concerning annual
limits:
(1) In the case of a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace amended,
delivered, issued, or renewed in this State on or after the
effective date of this amendatory Act of the 99th General
Assembly that provides coverage for hospital or medical
treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions the
following provisions shall apply:
(A) if the policy does not include an annual limit
on substantially all hospital and medical benefits,
then the policy may not impose any annual limits on

10000HB0068ham001 - 21 - LRB100 03757 SMS 23221 a
mental, emotional, nervous, or substance use disorder
or condition benefits; or
(B) if the policy includes an annual limit on
substantially all hospital and medical benefits (in
this subsection referred to as the "applicable annual
limit"), then the policy shall either:
(i) apply the applicable annual limit both to
the hospital and medical benefits to which it
otherwise would apply and to mental, emotional,
nervous, or substance use disorder or condition
benefits and not distinguish in the application of
the limit between the hospital and medical
benefits and mental, emotional, nervous, or
substance use disorder or condition benefits; or
(ii) not include any annual limit on mental,
emotional, nervous, or substance use disorder or
condition benefits that is less than the
applicable annual limit.
(2) In the case of a policy that is not described in
paragraph (1) of subsection (c) of this Section and that
includes no or different annual limits on different
categories of hospital and medical benefits, the Director
shall establish rules under which subparagraph (B) of
paragraph (1) of subsection (c) of this Section is applied
to such policy with respect to mental, emotional, nervous,
or substance use disorder or condition benefits by

10000HB0068ham001 - 22 - LRB100 03757 SMS 23221 a
substituting for the applicable annual limit an average
annual limit that is computed taking into account the
weighted average of the annual limits applicable to such
categories.
(d) With respect to mental, emotional, nervous, or
substance use disorders or conditions, an insurer shall use
policies and procedures for the election and placement of
mental, emotional, nervous, or substance use disorder or
condition substance abuse treatment drugs on their formulary
that are no less favorable to the insured as those policies and
procedures the insurer uses for the selection and placement of
other drugs for medical or surgical conditions and shall follow
the expedited coverage determination requirements for
substance abuse treatment drugs set forth in Section 45.2 of
the Managed Care Reform and Patient Rights Act.
(e) This Section shall be interpreted in a manner
consistent with all applicable federal parity regulations
including, but not limited to, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008,
final regulations issued under the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
and final regulations applying the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
to Medicaid managed care organizations, the Children's Health
Insurance Program, and alternative benefit plans at 78 FR
68240.

10000HB0068ham001 - 23 - LRB100 03757 SMS 23221 a
(f) The provisions of subsections (b) and (c) of this
Section shall not be interpreted to allow the use of lifetime
or annual limits otherwise prohibited by State or federal law.
(g) As used in this Section:
"Financial requirement" includes deductibles, copayments,
coinsurance, and out-of-pocket maximums, but does not include
an aggregate lifetime limit or an annual limit subject to
subsections (b) and (c).
"Mental, emotional, nervous, or substance use disorder or
condition" means a condition or disorder that involves a mental
health condition or substance use disorder that falls under any
of the diagnostic categories listed in the mental and
behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders.
"Treatment limitation" includes limits on benefits based
on the frequency of treatment, number of visits, days of
coverage, days in a waiting period, or other similar limits on
the scope or duration of treatment. "Treatment limitation"
includes both quantitative treatment limitations, which are
expressed numerically (such as 50 outpatient visits per year),
and nonquantitative treatment limitations, which otherwise
limit the scope or duration of treatment. A permanent exclusion
of all benefits for a particular condition or disorder shall
not be considered a treatment limitation. "Nonquantitative

10000HB0068ham001 - 24 - LRB100 03757 SMS 23221 a
treatment" means those limitations as described under federal
regulations (26 CFR 54.9812-1). Nonquantitative treatment
limitations include, but are not limited to:
(1) medical management standards limiting or excluding
benefits based on medical necessity or medical
appropriateness, or based on whether the treatment is
experimental or investigative;
(2) formulary design for prescription drugs;
(3) for plans with multiple network tiers (such as
preferred providers and participating providers), network
tier design;
(4) standards for provider admission to participate in
a network, including reimbursement rates;
(5) plan methods for determining usual, customary, and
reasonable charges;
(6) refusal to pay for higher-cost therapies until it
can be shown that a lower-cost therapy is not effective
(also known as fail-first policies or step therapy
protocols);
(7) exclusions based on failure to complete a course of
treatment;
(8) restrictions based on geographic location,
facility type, provider specialty, and other criteria that
limit the scope or duration of benefits for services
provided under the plan or coverage;
(9) in-network and out-of-network geographic

10000HB0068ham001 - 25 - LRB100 03757 SMS 23221 a
limitations;
(10) standards for providing access to out-of-network
providers;
(11) limitations on inpatient services for situations
where the participant is a threat to self or others;
(12) exclusions for court-ordered and involuntary
holds;
(13) experimental treatment limitations;
(14) service coding;
(15) exclusions for services provided by clinical
social workers, physicians, licensed psychologists,
licensed clinical professional counselors, licensed
marriage and family therapists, licensed speech-language
pathologists, or other licensed or certified professionals
at a program licensed pursuant to the Illinois Alcoholism
and Other Drug Abuse and Dependency Act;
(16) network adequacy as set forth in federal and State
requirements for medical assistance and individual or
group health policies; and
(17) provider reimbursement rates, including
reimbursement rates for mental, emotional, nervous, or
substance use disorder or condition screenings or
diagnostic tests performed in primary care and integrated
settings.
(h) The Department of Insurance shall implement the
following education initiatives:

10000HB0068ham001 - 26 - LRB100 03757 SMS 23221 a
(1) By January 1, 2016, the Department shall develop a
plan for a Consumer Education Campaign on parity. The
Consumer Education Campaign shall focus its efforts
throughout the State and include trainings in the northern,
southern, and central regions of the State, as defined by
the Department, as well as each of the 5 managed care
regions of the State as identified by the Department of
Healthcare and Family Services. Under this Consumer
Education Campaign, the Department shall: (1) by January 1,
2017, provide at least one live training in each region on
parity for consumers and providers and one webinar training
to be posted on the Department website and (2) establish a
consumer hotline to assist consumers in navigating the
parity process by March 1, 2017 2016. By January 1, 2018
the Department shall issue a report to the General Assembly
on the success of the Consumer Education Campaign, which
shall indicate whether additional training is necessary or
would be recommended.
(2) The Department, in coordination with the
Department of Human Services and the Department of
Healthcare and Family Services, shall convene a working
group of health care insurance carriers, mental health
advocacy groups, substance abuse patient advocacy groups,
and mental health physician groups for the purpose of
discussing issues related to the treatment and coverage of
mental, emotional, nervous, or substance use abuse

10000HB0068ham001 - 27 - LRB100 03757 SMS 23221 a
disorders or conditions and compliance with parity
obligations under State and federal law. Compliance shall
be measured, tracked, and shared during the meetings of the
working group and mental illness. The working group shall
meet once before January 1, 2016 and shall meet
semiannually thereafter. The Department shall issue an
annual report to the General Assembly that includes a list
of the health care insurance carriers, mental health
advocacy groups, substance abuse patient advocacy groups,
and mental health physician groups that participated in the
working group meetings, details on the issues and topics
covered, and any legislative recommendations developed by
the working group.
(3) Not later than August 1 of each year, the
Department, in conjunction with the Department of
Healthcare and Family Services, shall issue a joint report
to the General Assembly and provide an educational
presentation to the General Assembly. The report and
presentation shall:
(A) Cover the methodology the Departments use to
check for compliance with the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008, 42 U.S.C. 18031(j), and any federal
regulations or guidance relating to the compliance and
oversight of the federal Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act

10000HB0068ham001 - 28 - LRB100 03757 SMS 23221 a
of 2008 and 42 U.S.C. 18031(j).
(B) Cover the methodology the Departments use to
check for compliance with this Section and Sections
356z.23 and 370c of this Code.
(C) Identify pre-market and post-market conduct
examinations conducted or completed during the
preceding 12-month period regarding compliance with
parity in mental, emotional, nervous, and substance
use disorder or condition benefits under State and
federal laws and summarize the results of such market
conduct examinations. This shall include:
(i) the number of market conduct examinations
initiated and completed;
(ii) the benefit classifications examined by
each market conduct examination;
(iii) the subject matter of each market
conduct examination, including quantitative and
non-quantitative treatment limitations; and
(iv) a summary of the basis for the final
decision rendered in each market conduct
examination.
Individually identifiable information shall be
excluded from the reports consistent with federal
privacy protections.
(D) Detail any educational or corrective actions
the Departments have taken to ensure compliance with

10000HB0068ham001 - 29 - LRB100 03757 SMS 23221 a
the federal Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), this Section, and Sections 356z.23
and 370c of this Code.
(E) The report must be written in non-technical,
readily understandable language and shall be made
available to the public by, among such other means as
the Departments find appropriate, posting the report
on the Departments' websites.
(4) In the event of uncertainty or disagreement with
respect to the application, interpretation,
implementation, or enforcement of the federal Paul
Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008, 42 U.S.C. 18031(j), and any
amendments to, and federal guidance or regulations issued
under, those Acts, including, but not limited to, final
regulations issued under the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of
2008, final regulations applying the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act
of 2008 to Medicaid managed care organizations, the
Children's Health Insurance Program, and alternative
benefit plans, Section 370c of this Code, and this Section,
the Department and the Department of Healthcare and Family
Services may request a formal written opinion from the
Attorney General. The requests and opinions shall be issued

10000HB0068ham001 - 30 - LRB100 03757 SMS 23221 a
in accordance with State law and policies of the Attorney
General. The Departments shall inform the public on their
websites and in writing that any aggrieved beneficiary may
ask the Departments to request a formal written opinion
from the Attorney General.
(i) The Parity Advancement Education Fund is created as a
special fund in the State treasury. Moneys from fines and
penalties collected from insurers for violations of this
Section shall be deposited into the Fund. Moneys deposited into
the Fund for appropriation by the General Assembly to the
Department of Insurance shall be used for the purpose of
providing financial support of the Consumer Education
Campaign, parity compliance advocacy, and other initiatives
that support parity implementation and enforcement on behalf of
consumers and to the Department of Human Services for treatment
grants.
(j) An insurer that amends, delivers, issues, or renews a
group or individual policy of accident and health insurance or
a qualified health plan offered through the health insurance
marketplace in this State providing coverage for hospital or
medical treatment and for the treatment of mental, emotional,
nervous, or substance use disorders or conditions shall submit
an annual report to the Department, or with respect to medical
assistance the Department of Healthcare and Family Services, on
or before March 1 that contains the following information
separately for inpatient in-network benefits, inpatient

10000HB0068ham001 - 31 - LRB100 03757 SMS 23221 a
out-of-network benefits, outpatient in-network benefits,
outpatient out-of-network benefits, emergency care benefits,
and prescription drug benefits in the case of accident and
health insurance or qualified health plans, or inpatient,
outpatient, emergency care, and prescription drug benefits in
the case of medical assistance:
(1) The number and percentage of times a benefit limit
is exceeded for a mental, emotional, nervous, or substance
use disorder or condition benefit and the number and
percentage of times a benefit limit is exceeded for other
medical benefits.
(2) The number and percentage of times a co-pay or
co-insurance limit for a mental, emotional, nervous, or
substance use disorder or condition benefit is different
from other medical benefits.
(3) The number and percentage of claim denials for
mental, emotional, nervous, or substance use disorder or
condition benefits due to benefit limits and the number and
percentage of claim denials for other medical benefits due
to benefit limits.
(4) The number and percentage of denials for
experimental benefits or the use of unproven technology for
a mental, emotional, nervous, or substance use disorder or
condition benefit and the number and percentage of denials
for experimental benefits or the use of unproven technology
for other medical benefits.

10000HB0068ham001 - 32 - LRB100 03757 SMS 23221 a
(5) The number and percentage of administrative
denials for no prior authorization for a mental, emotional,
nervous, or substance use disorder or condition benefit and
the number and percentage of administrative denials for no
prior authorization for other medical benefits.
(6) The number and percentage of denials due to a
mental, emotional, nervous, or substance use disorder or
condition benefit not being a covered benefit and the
number and percentage of denials for other medical benefits
not being a covered benefit.
(7) The number and percentage of denials due to a
mental, emotional, nervous, or substance use disorder or
condition benefit not meeting medical necessity and the
number and percentage of denials for other medical benefits
not meeting medical necessity.
(8) The number and percentage of denials upheld on
appeal for a mental, emotional, nervous, or substance use
disorder or condition benefit for not meeting medical
necessity and the number and percentage of those for other
medical benefits.
(9) The number and percentage of denials due to a
mental, emotional, nervous, or substance use disorder or
condition benefit being denied administratively or any
reason other than medical necessity.
(10) The number and percentage of denials of mental,
emotional, nervous, or substance use disorder or condition

10000HB0068ham001 - 33 - LRB100 03757 SMS 23221 a
benefits that went to the plan's external quality review
organization, or similar reviewing body and were upheld and
those that were overturned for medical necessity.
(11) The number and percentage of continued stay review
denials for mental, emotional, nervous, or substance use
disorder or condition benefits.
(12) The number and percentage of out-of-network
claims for mental, emotional, nervous, or substance use
disorder or condition benefits in each classification of
benefits and the number and percentage of out-of-network
claims for other medical benefits in each classification of
benefits.
(13) The number and percentage of emergency care claims
for mental, emotional, nervous, or substance use disorder
or condition benefits in each classification of benefits
and the number and percentage of emergency care claims for
other medical benefits in each classification of benefits.
(14) The number and percentage of network directory
providers in the outpatient benefits classification who
filed no claims in the last 6 months of the plan's claims
reporting period and all pertinent summary information and
results respecting the tests and metrics the insurer used
to assess the availability of each of the following types
of mental, emotional, nervous, or substance use disorder or
condition providers: MD/DO; doctoral level non-MD/DO and
non-doctoral level non-MD/DO practitioners; and inpatient,

10000HB0068ham001 - 34 - LRB100 03757 SMS 23221 a
residential, and ambulatory provider organizations.
(15) A summary of the plan's pharmacy management
processes for mental, emotional, nervous, or substance use
disorder or condition benefits compared to those for other
medical benefits.
(16) A summary of the internal processes of review for
experimental benefits and unproven technology for mental,
emotional, nervous, or substance use disorder or condition
benefits and those for other medical benefits.
(17) A summary of how the plan's policies and
procedures for utilization management for mental,
emotional, nervous, or substance use disorder or condition
benefits compare to those for other medical benefits.
(18) The results of an analysis that demonstrates that
for each nonquantitative treatment limitation, as written
and in operation, the processes, strategies, evidentiary
standards, or other factors used to apply each
nonquantitative treatment limitation to mental, emotional,
nervous, or substance use disorder or condition benefits
are comparable to, and are applied no more stringently than
the processes, strategies, evidentiary standards, or other
factors used to apply each nonquantitative treatment
limitation, as written and in operation, to medical and
surgical benefits; at a minimum, the results of the
analysis shall:
(A) identify the factors used to determine that a

10000HB0068ham001 - 35 - LRB100 03757 SMS 23221 a
nonquantitative treatment limitation will apply to a
benefit, including factors that were considered but
rejected;
(B) identify and define the specific evidentiary
standards used to define the factors and any other
evidentiary standards relied upon in designing each
nonquantitative treatment limitation;
(C) identify and describe the methods and analyses
used, including the results of the analyses, to
determine that the processes and strategies used to
design each nonquantitative treatment limitation as
written for mental, emotional, nervous, or substance
use disorders or conditions benefits are comparable to
and no more stringent than the processes and strategies
used to design each nonquantitative treatment
limitation as written for medical and surgical
benefits;
(D) identify and describe the methods and analyses
used, including the results of the analyses, to
determine that the processes and strategies used to
apply each nonquantitative treatment limitation in
operation for mental, emotional, nervous, or substance
use disorders or conditions benefits are comparable to
and no more stringent than the processes or strategies
used to apply each nonquantitative treatment
limitation in operation for medical and surgical

10000HB0068ham001 - 36 - LRB100 03757 SMS 23221 a
benefits; and
(E) disclose the specific findings and conclusions
reached by the insurer that the results of the analyses
above indicate that the insurer is in compliance with
this Section and the Mental Health Parity and Addiction
Equity Act of 2008 and its implementing regulations,
which includes 45 CFR 146.136 and any other relevant
current or future regulations.
(19) A certification signed by the insurer's chief
executive officer and chief medical officer that states
that the insurer has completed a comprehensive review of
the administrative practices of the insurer for the prior
calendar year for compliance with the necessary provisions
of this Section and Sections 356z.23 and 370c of this Code,
the federal Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008, 42 U.S.C.
18031(j), and any amendments to, and federal guidance or
regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul
Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 and final regulations applying
the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 to Medicaid managed care
organizations, the Children's Health Insurance Program,
and alternative benefit plans.
(20) Any other information necessary to clarify data

10000HB0068ham001 - 37 - LRB100 03757 SMS 23221 a
provided in accordance with this Section requested by the
Director, including information that may be proprietary or
have commercial value.
The Director shall not certify any policy of an insurer
that fails to submit all data as required by this Section.
(k) There is created within the Office of the Attorney
General an Office of Consumer Advocate, which shall assist
consumers, insureds, health care providers, and recipients in:
(1) ensuring compliance with the requirements of this
Section;
(2) addressing issues related to insurance
availability;
(3) identifying and rectifying claims processing
issues;
(4) clarifying and resolving coverage questions; and
(5) addressing other matters related to insurance
consumer education and assistance.
(Source: P.A. 99-480, eff. 9-9-15.)".