Bill Text: IL HB2595 | 2021-2022 | 102nd General Assembly | Chaptered

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Bill Title: Amends the Illinois Insurance Code. Provides that 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 the State and Medicaid managed care organizations providing coverage for hospital or medical treatment shall provide coverage for medically necessary treatment of mental, emotional, nervous, or substance use disorders or conditions. Provides that an insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public program. Provides that an insurer shall base any medical necessity determination or the utilization review criteria on current generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care. Provides that in conducting utilization review of covered health care services and benefits for the diagnosis, prevention, and treatment of mental, emotional, and nervous disorders or conditions in children, adolescents, and adults, an insurer shall exclusively apply the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty. Provides that an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in the treatment criteria. Provides that the Director may, after appropriate notice and opportunity for hearing, assess a civil penalty between $5,000 and $20,000 for each violation. Amends the Health Carrier External Review Act. Provides that the independent review organization shall comply with specified requirements for an adverse determination or final adverse determination involving mental, emotional, nervous, or substance use disorders or conditions. Makes other changes. Effective immediately.

Spectrum: Partisan Bill (Democrat 67-2)

Status: (Passed) 2021-08-25 - Public Act . . . . . . . . . 102-0579 [HB2595 Detail]

Download: Illinois-2021-HB2595-Chaptered.html

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Public Act 102-0579
HB2595 Enrolled LRB102 10633 BMS 15962 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. This Act may be referred to as the Generally
Accepted Standards of Behavioral Health Care Act of 2021.
Section 2. The General Assembly finds and declares the
following:
(a) The State of Illinois and the entire country faces a
mental health and addiction crisis.
(1) One in 5 adults experience a mental health
disorder, and data from 2017 shows that one in 12 had a
substance use disorder. The COVID-19 pandemic has
exacerbated the nation's mental health and addiction
crisis. According the U.S. Center for Disease Control and
Prevention, since the start of the COVID-19 pandemic,
Americans have experienced higher rates of depression,
anxiety, and trauma, and rates of substance use and
suicidal ideation have increased.
(2) Nationally, the suicide rate has increased 35% in
the past 20 years. According to the Illinois Department of
Public Health, more than 1,000 Illinoisans die by suicide
every year, including 1,439 deaths in 2019, and it is the
third leading cause of death among young adults aged 15 to

34.
(3) Between 2013 and 2019, Illinois saw a 1,861%
increase in synthetic opioid overdose deaths and a 68%
increase in heroin overdose deaths. In 2019 alone, there
were 2.3 and 2 times as many opioid deaths as homicides and
car crash deaths, respectively.
(4) Communities of color are disproportionately
impacted by lack of access to and inequities in mental
health and substance use disorder care.
(A) According to the Substance Abuse and Mental
Health Services Administration, two-thirds of Black
and Hispanic Americans with a mental illness and
nearly 90% with a substance use disorder do not
receive medically necessary treatment.
(B) Data from the U.S. Census Bureau demonstrates
that Black Americans saw the highest increases in
rates of anxiety and depression in 2020.
(C) Data from the Illinois Department of Public
Health reveals that Black Illinoisans are hospitalized
for opioid overdoses at a rate 6 times higher than
white Illinoisans.
(D) In the first half of 2020, the number of
suicides among Black Chicagoans had increased 106%
from the previous year. Nationally, from 2001 to 2017,
suicide rates doubled among Black girls aged 13 to 19
and increased 60% for Black boys of the same age.

(E) According to the Substance Abuse and Mental
Health Services Administration, between 2008 and 2018
there were significant increases in serious mental
illness and suicide ideation in Hispanics aged 18 to
25 and there remains a large gap in treatment need
among Hispanics.
(5) According to the U.S. Center for Disease Control
and Prevention, children with adverse childhood
experiences are more likely to experience negative
outcomes like post-traumatic stress disorder, increased
anxiety and depression, suicide, and substance use. A 2020
report from Mental Health America shows that 62.1% of
Illinois youth with severe depression do not receive any
mental health treatment. Survey results found that 80% of
college students report that COVID-19 has negatively
impacted their mental health.
(6) In rural communities, between 2001 and 2015, the
suicide rate increased by 27%, and between 1999 and 2015
the overdose rate increased 325%.
(7) According to the U.S. Department of Veterans
Affairs, 154 veterans died by suicide in 2018, which
accounts for more than 10% of all suicide deaths reported
by the Illinois Department of Public Health in the same
year, despite only accounting for approximately 5.7% of
the State's total population. Nationally, between 2008 and
2017, more than 6,000 veterans died by suicide each year.

(8) According to the National Alliance on Mental
Illness, 2,000,000 people with mental illness are
incarcerated every year, where they do not receive the
treatment they need.
(b) A recent landmark federal court ruling offers a
concrete demonstration of how the mental health and addiction
crisis described in subsection (a) is worsened through the
denial of medically necessary mental health and substance use
disorder treatment.
(1) In March 2019, the United States District Court of
the Northern District of California ruled in Wit v. United
Behavioral Health, 2019 WL 1033730 (Wit; N.D.CA Mar. 5,
2019), that United Behavioral Health created flawed level
of care placement criteria that were inconsistent with
generally accepted standards of mental health and
substance use disorder care in order to "mitigate" the
requirements of the federal Mental Health Parity and
Addiction Equity Act of 2008.
(2) As described by the federal court in Wit, the 8
generally accepted standards of mental health and
substance use disorder care require all of the following:
(A) Effective treatment of underlying conditions,
rather than mere amelioration of current symptoms,
such as suicidality or psychosis.
(B) Treatment of co-occurring behavioral health
disorders or medical conditions in a coordinated

manner.
(C) Treatment at the least intensive and
restrictive level of care that is safe and effective
and meets the needs of the patient's condition; a
lower level or less intensive care is appropriate only
if it is safe and just as effective as treatment at a
higher level or service intensity.
(D) Erring on the side of caution, by placing
patients in higher levels of care when there is
ambiguity as to the appropriate level of care, or when
the recommended level of care is not available.
(E) Treatment to maintain functioning or prevent
deterioration.
(F) Treatment of mental health and substance use
disorders for an appropriate duration based on
individual patient needs rather than on specific time
limits.
(G) Accounting for the unique needs of children
and adolescents when making level of care decisions.
(H) Applying multidimensional assessments of
patient needs when making determinations regarding the
appropriate level of care.
(3) The court in Wit found that all parties' expert
witnesses regarded the American Society of Addiction
Medicine (ASAM) criteria for substance use disorders and
Level of Care Utilization System (LOCUS), Child and

Adolescent Level of Care Utilization System (CALOCUS),
Child and Adolescent Service Intensity Instrument (CASII),
and Early Childhood Service Intensity Instrument (ECSII)
criteria for mental health disorders as prime examples of
level of care criteria that are fully consistent with
generally accepted standards of mental health and
substance use care.
(4) In particular, the coverage of intermediate levels
of care, such as residential treatment, which are
essential components of the level of care continuum called
for by nonprofit, and clinical specialty associations such
as the American Society of Addiction Medicine, are often
denied through overly restrictive medical necessity
determinations.
(5) On November 3, 2020, the court issued a remedies
order requiring United Behavioral Health to reprocess
67,000 mental health and substance use disorder claims and
mandating that, for the next decade, United Behavioral
Health must use the relevant nonprofit clinical society
guidelines for its medical necessity determinations.
(6) The court's findings also demonstrated how United
Behavioral Health was in violation of Section 370c of the
Illinois Insurance Code for its failure to use the
American Society of Addiction Medicine Criteria for
substance use disorders. The results of market conduct
examinations released by the Illinois Department of

Insurance on July 15, 2020 confirmed these findings citing
United Healthcare and CIGNA for their failure to use the
American Society of Addiction Medicine Criteria when
making medical necessity determinations for substance use
disorders as required by Illinois law.
(c) Insurers should not be permitted to deny medically
necessary mental health and substance use disorder care
through the use of utilization review practices and criteria
that are inconsistent with generally accepted standards of
mental health and substance use disorder care.
(1) Illinois parity law (Sections 370c and 370c.1 of
the Illinois Insurance Code) requires that health plans
treat illnesses of the brain, such as addiction and
depression, the same way they treat illness of other parts
of the body, such as cancer and diabetes. The Illinois
General Assembly significantly strengthened Illinois'
parity law, which incorporates provisions of the federal
Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008, in both 2015 and 2018.
(2) While the federal Patient Protection and
Affordable Care Act includes mental health and addiction
coverage as one of the 10 essential health benefits, it
does not contain a definition for medical necessity, and
despite the Patient Protection and Affordable Care Act,
needed mental health and addiction coverage can be denied
through overly restrictive medical necessity

determinations.
(3) Despite the strong actions taken by the Illinois
General Assembly, the court in Wit v. United Behavioral
Health demonstrated how insurers can mitigate compliance
with parity laws due by denying medically necessary mental
health and treatment by using flawed medical necessity
criteria.
(4) When medically necessary mental health and
substance use disorder care is denied, the manifestations
of the mental health and addiction crisis described in
subsection (a) are severely exacerbated. Individuals with
mental health and substance use disorders often have their
conditions worsen, sometimes ending up in the criminal
justice system or on the streets, resulting in increased
emergency hospitalizations, harm to individuals and
communities, and higher costs to taxpayers.
(5) In order to realize the promise of mental health
and addiction parity and remove barriers to mental health
and substance use disorder care for all Illinoisans,
insurers must be required to cover medically necessary
mental health and substance use disorder care and follow
generally accepted standards of mental health and
substance use disorder care.
Section 5. 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 102nd General Assembly January 1, 2019 (the
effective date of this amendatory Act of the 101st General
Assembly Public Act 100-1024), every insurer that 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 coverage for the medically necessary treatment of
reasonable and necessary treatment and services for mental,
emotional, nervous, or substance use disorders or conditions
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 Substance
Use Disorder Act of his or her choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,

licensed clinical psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder 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 Substance Use Disorder Act is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his or her
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 Substance
Use Disorder 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 Substance Use Disorder Act

has informed the patient of the desirability of the patient
conferring with the patient's primary care physician.
(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
World Health Organization's International Classification of
Disease or that is listed in the most recent version of the
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental
health condition that occurs during pregnancy or during the
postpartum period and includes, but is not limited to,
postpartum depression.
(5) Medically necessary treatment and medical necessity
determinations shall be interpreted and made in a manner that
is consistent with and pursuant to subsections (h) through
(t).
(b)(1) (Blank).
(2) (Blank).
(2.5) (Blank).
(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 substance use disorders or
conditions shall furnish medical records or other necessary
data that substantiate that initial or continued treatment is
at all times medically necessary. An insurer shall provide a
mechanism for the timely review by a provider holding the same
license and practicing in the same specialty as the patient's
provider, who is unaffiliated with the insurer, jointly
selected by the patient (or the patient's next of kin or legal
representative if the patient is unable to act for himself or
herself), the patient's provider, and the insurer in the event
of a dispute between the insurer and patient's provider
regarding the medical necessity of a treatment proposed by a
patient's provider. If the reviewing provider determines the
treatment to be medically necessary, the insurer shall provide
reimbursement for the treatment. Future contractual or
employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in
this procedure. Nothing prevents the insured from agreeing in
writing to continue treatment at his or her expense. When
making a determination of the medical necessity for a
treatment modality for mental, emotional, nervous, or
substance use disorders or conditions, 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 January 1, 2019 (the effective
date of Public Act 100-1024) 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 January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or substance use disorder or condition 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
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 September 9, 2015
(the effective date of Public Act 99-480) 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. 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
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.

(6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
(A) shall not impose prior authorization requirements,
other than those established under the Treatment Criteria
for Addictive, Substance-Related, and Co-Occurring
Conditions established by the American Society of
Addiction Medicine, on a prescription medication approved
by the United States Food and Drug Administration that is
prescribed or administered for the treatment of substance
use disorders;
(B) shall not impose any step therapy requirements,
other than those established under the Treatment Criteria
for Addictive, Substance-Related, and Co-Occurring
Conditions established by the American Society of
Addiction Medicine, before authorizing coverage for a
prescription medication approved by the United States Food
and Drug Administration that is prescribed or administered
for the treatment of substance use disorders;
(C) shall place all prescription medications approved
by the United States Food and Drug Administration
prescribed or administered for the treatment of substance
use disorders on, for brand medications, the lowest tier
of the drug formulary developed and maintained by the
individual or group health benefit plan that covers brand
medications and, for generic medications, the lowest tier

of the drug formulary developed and maintained by the
individual or group health benefit plan that covers
generic medications; and
(D) shall not exclude coverage for a prescription
medication approved by the United States Food and Drug
Administration for the treatment of substance use
disorders and any associated counseling or wraparound
services on the grounds that such medications and services
were court ordered.
(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
offered through the health insurance marketplace, 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:
(1) proactively ensuring compliance by individual and
group policies, including by requiring that insurers
submit comparative analyses, as set forth in paragraph (6)
of subsection (k) of Section 370c.1, demonstrating how
they design and apply nonquantitative treatment
limitations, both as written and in operation, for mental,
emotional, nervous, or substance use disorder or condition
benefits as compared to how they design and apply
nonquantitative treatment limitations, as written and in
operation, for medical and surgical benefits;
(2) evaluating all consumer or provider complaints
regarding mental, emotional, nervous, or substance use
disorder or condition coverage for possible parity
violations;

(3) performing parity compliance market conduct
examinations or, in the case of the Department of
Healthcare and Family Services, parity compliance audits
of individual and group plans and policies, including, but
not limited to, reviews of:
(A) nonquantitative treatment limitations,
including, but not limited to, prior authorization
requirements, concurrent review, retrospective review,
step therapy, network admission standards,
reimbursement rates, and geographic restrictions;
(B) denials of authorization, payment, and
coverage; and
(C) other specific criteria as may be determined
by the Department.
The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
The Director may 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.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of
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, or substance use disorders or
conditions 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.
(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) (1) As used in this subsection:

"Benefits", with respect to insurers, means the benefits
provided for treatment services for inpatient and outpatient
treatment of substance use disorders or conditions at American
Society of Addiction Medicine levels of treatment 2.1
(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
(Clinically Managed Low-Intensity Residential), 3.3
(Clinically Managed Population-Specific High-Intensity
Residential), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Benefits", with respect to managed care organizations,
means the benefits provided for treatment services for
inpatient and outpatient treatment of substance use disorders
or conditions at American Society of Addiction Medicine levels
of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
Hospitalization), 3.5 (Clinically Managed High-Intensity
Residential), and 3.7 (Medically Monitored Intensive
Inpatient) and OMT (Opioid Maintenance Therapy) services.
"Substance use disorder treatment provider or facility"
means a licensed physician, licensed psychologist, licensed
psychiatrist, licensed advanced practice registered nurse, or
licensed, certified, or otherwise State-approved facility or
provider of substance use disorder treatment.
(2) A group health insurance policy, an individual health
benefit plan, or qualified health plan that is offered through
the health insurance marketplace, small employer group health

plan, and large employer group health plan that is amended,
delivered, issued, executed, or renewed in this State, or
approved for issuance or renewal in this State, on or after
January 1, 2019 (the effective date of Public Act 100-1023)
shall comply with the requirements of this Section and Section
370c.1. The services for the treatment and the ongoing
assessment of the patient's progress in treatment shall follow
the requirements of 77 Ill. Adm. Code 2060.
(3) Prior authorization shall not be utilized for the
benefits under this subsection. The substance use disorder
treatment provider or facility shall notify the insurer of the
initiation of treatment. For an insurer that is not a managed
care organization, the substance use disorder treatment
provider or facility notification shall occur for the
initiation of treatment of the covered person within 2
business days. For managed care organizations, the substance
use disorder treatment provider or facility notification shall
occur in accordance with the protocol set forth in the
provider agreement for initiation of treatment within 24
hours. If the managed care organization is not capable of
accepting the notification in accordance with the contractual
protocol during the 24-hour period following admission, the
substance use disorder treatment provider or facility shall
have one additional business day to provide the notification
to the appropriate managed care organization. Treatment plans
shall be developed in accordance with the requirements and

timeframes established in 77 Ill. Adm. Code 2060. If the
substance use disorder treatment provider or facility fails to
notify the insurer of the initiation of treatment in
accordance with these provisions, the insurer may follow its
normal prior authorization processes.
(4) For an insurer that is not a managed care
organization, if an insurer determines that benefits are no
longer medically necessary, the insurer shall notify the
covered person, the covered person's authorized
representative, if any, and the covered person's health care
provider in writing of the covered person's right to request
an external review pursuant to the Health Carrier External
Review Act. The notification shall occur within 24 hours
following the adverse determination.
Pursuant to the requirements of the Health Carrier
External Review Act, the covered person or the covered
person's authorized representative may request an expedited
external review. An expedited external review may not occur if
the substance use disorder treatment provider or facility
determines that continued treatment is no longer medically
necessary. Under this subsection, a request for expedited
external review must be initiated within 24 hours following
the adverse determination notification by the insurer. Failure
to request an expedited external review within 24 hours shall
preclude a covered person or a covered person's authorized
representative from requesting an expedited external review.

If an expedited external review request meets the criteria
of the Health Carrier External Review Act, an independent
review organization shall make a final determination of
medical necessity within 72 hours. If an independent review
organization upholds an adverse determination, an insurer
shall remain responsible to provide coverage of benefits
through the day following the determination of the independent
review organization. A decision to reverse an adverse
determination shall comply with the Health Carrier External
Review Act.
(5) The substance use disorder treatment provider or
facility shall provide the insurer with 7 business days'
advance notice of the planned discharge of the patient from
the substance use disorder treatment provider or facility and
notice on the day that the patient is discharged from the
substance use disorder treatment provider or facility.
(6) The benefits required by this subsection shall be
provided to all covered persons with a diagnosis of substance
use disorder or conditions. The presence of additional related
or unrelated diagnoses shall not be a basis to reduce or deny
the benefits required by this subsection.
(7) Nothing in this subsection shall be construed to
require an insurer to provide coverage for any of the benefits
in this subsection.
(h) As used in this Section:
"Generally accepted standards of mental, emotional,

nervous, or substance use disorder or condition care" means
standards of care and clinical practice that are generally
recognized by health care providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, social work, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
reflecting generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
"Medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions" means a
service or product addressing the specific needs of that
patient, for the purpose of screening, preventing, diagnosing,
managing, or treating an illness, injury, or condition or its
symptoms and comorbidities, including minimizing the
progression of an illness, injury, or condition or its
symptoms and comorbidities in a manner that is all of the
following:
(1) in accordance with the generally accepted
standards of mental, emotional, nervous, or substance use

disorder or condition care;
(2) clinically appropriate in terms of type,
frequency, extent, site, and duration; and
(3) not primarily for the economic benefit of the
insurer, purchaser, or for the convenience of the patient,
treating physician, or other health care provider.
"Utilization review" means either of the following:
(1) prospectively, retrospectively, or concurrently
reviewing and approving, modifying, delaying, or denying,
based in whole or in part on medical necessity, requests
by health care providers, insureds, or their authorized
representatives for coverage of health care services
before, retrospectively, or concurrently with the
provision of health care services to insureds.
(2) evaluating the medical necessity, appropriateness,
level of care, service intensity, efficacy, or efficiency
of health care services, benefits, procedures, or
settings, under any circumstances, to determine whether a
health care service or benefit subject to a medical
necessity coverage requirement in an insurance policy is
covered as medically necessary for an insured.
"Utilization review criteria" means patient placement
criteria or any criteria, standards, protocols, or guidelines
used by an insurer to conduct utilization review.
(i)(1) 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 and Medicaid
managed care organizations providing coverage for hospital or
medical treatment on or after January 1, 2023 shall, pursuant
to subsections (h) through (s), provide coverage for medically
necessary treatment of mental, emotional, nervous, or
substance use disorders or conditions.
(2) An insurer shall not set a specific limit on the
duration of benefits or coverage of medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions or limit coverage only to alleviation
of the insured's current symptoms.
(3) All medical necessity determinations made by the
insurer concerning service intensity, level of care placement,
continued stay, and transfer or discharge of insureds
diagnosed with mental, emotional, nervous, or substance use
disorders or conditions shall be conducted in accordance with
the requirements of subsections (k) through (u).
(4) An insurer that authorizes a specific type of
treatment by a provider pursuant to this Section shall not
rescind or modify the authorization after that provider
renders the health care service in good faith and pursuant to
this authorization for any reason, including, but not limited
to, the insurer's subsequent cancellation or modification of
the insured's or policyholder's contract, or the insured's or
policyholder's eligibility. Nothing in this Section shall

require the insurer to cover a treatment when the
authorization was granted based on a material
misrepresentation by the insured, the policyholder, or the
provider. Nothing in this Section shall require Medicaid
managed care organizations to pay for services if the
individual was not eligible for Medicaid at the time the
service was rendered. Nothing in this Section shall require an
insurer to pay for services if the individual was not the
insurer's enrollee at the time services were rendered. As used
in this paragraph, "material" means a fact or situation that
is not merely technical in nature and results in or could
result in a substantial change in the situation.
(j) An insurer shall not limit benefits or coverage for
medically necessary services on the basis that those services
should be or could be covered by a public entitlement program,
including, but not limited to, special education or an
individualized education program, Medicaid, Medicare,
Supplemental Security Income, or Social Security Disability
Insurance, and shall not include or enforce a contract term
that excludes otherwise covered benefits on the basis that
those services should be or could be covered by a public
entitlement program. Nothing in this subsection shall be
construed to require an insurer to cover benefits that have
been authorized and provided for a covered person by a public
entitlement program. Medicaid managed care organizations are
not subject to this subsection.

(k) An insurer shall base any medical necessity
determination or the utilization review criteria that the
insurer, and any entity acting on the insurer's behalf,
applies to determine the medical necessity of health care
services and benefits for the diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions on current generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care. All denials and appeals shall be
reviewed by a professional with experience or expertise
comparable to the provider requesting the authorization.
(l) For medical necessity determinations relating to level
of care placement, continued stay, and transfer or discharge
of insureds diagnosed with mental, emotional, and nervous
disorders or conditions, an insurer shall apply the patient
placement criteria set forth in the most recent version of the
treatment criteria developed by an unaffiliated nonprofit
professional association for the relevant clinical specialty
or, for Medicaid managed care organizations, patient placement
criteria determined by the Department of Healthcare and Family
Services that are consistent with generally accepted standards
of mental, emotional, nervous or substance use disorder or
condition care. Pursuant to subsection (b), in conducting
utilization review of all covered services and benefits for
the diagnosis, prevention, and treatment of substance use
disorders an insurer shall use the most recent edition of the

patient placement criteria established by the American Society
of Addiction Medicine.
(m) For medical necessity determinations relating to level
of care placement, continued stay, and transfer or discharge
that are within the scope of the sources specified in
subsection (l), an insurer shall not apply different,
additional, conflicting, or more restrictive utilization
review criteria than the criteria set forth in those sources.
For all level of care placement decisions, the insurer shall
authorize placement at the level of care consistent with the
assessment of the insured using the relevant patient placement
criteria as specified in subsection (l). If that level of
placement is not available, the insurer shall authorize the
next higher level of care. In the event of disagreement, the
insurer shall provide full detail of its assessment using the
relevant criteria as specified in subsection (l) to the
provider of the service and the patient.
Nothing in this subsection or subsection (l) prohibits an
insurer from applying utilization review criteria that were
developed in accordance with subsection (k) to health care
services and benefits for mental, emotional, and nervous
disorders or conditions that are not related to medical
necessity determinations for level of care placement,
continued stay, and transfer or discharge. If an insurer
purchases or licenses utilization review criteria pursuant to
this subsection, the insurer shall verify and document before

use that the criteria were developed in accordance with
subsection (k).
(n) In conducting utilization review that is outside the
scope of the criteria as specified in subsection (l) or
relates to the advancements in technology or in the types or
levels of care that are not addressed in the most recent
versions of the sources specified in subsection (l), an
insurer shall conduct utilization review in accordance with
subsection (k).
(o) This Section does not in any way limit the rights of a
patient under the Medical Patient Rights Act.
(p) This Section does not in any way limit early and
periodic screening, diagnostic, and treatment benefits as
defined under 42 U.S.C. 1396d(r).
(q) To ensure the proper use of the criteria described in
subsection (l), every insurer shall do all of the following:
(1) Educate the insurer's staff, including any third
parties contracted with the insurer to review claims,
conduct utilization reviews, or make medical necessity
determinations about the utilization review criteria.
(2) Make the educational program available to other
stakeholders, including the insurer's participating or
contracted providers and potential participants,
beneficiaries, or covered lives. The education program
must be provided at least once a year, in-person or
digitally, or recordings of the education program must be

made available to the aforementioned stakeholders.
(3) Provide, at no cost, the utilization review
criteria and any training material or resources to
providers and insured patients upon request. For
utilization review criteria not concerning level of care
placement, continued stay, and transfer or discharge used
by the insurer pursuant to subsection (m), the insurer may
place the criteria on a secure, password-protected website
so long as the access requirements of the website do not
unreasonably restrict access to insureds or their
providers. No restrictions shall be placed upon the
insured's or treating provider's access right to
utilization review criteria obtained under this paragraph
at any point in time, including before an initial request
for authorization.
(4) Track, identify, and analyze how the utilization
review criteria are used to certify care, deny care, and
support the appeals process.
(5) Conduct interrater reliability testing to ensure
consistency in utilization review decision making that
covers how medical necessity decisions are made; this
assessment shall cover all aspects of utilization review
as defined in subsection (h).
(6) Run interrater reliability reports about how the
clinical guidelines are used in conjunction with the
utilization review process and parity compliance

activities.
(7) Achieve interrater reliability pass rates of at
least 90% and, if this threshold is not met, immediately
provide for the remediation of poor interrater reliability
and interrater reliability testing for all new staff
before they can conduct utilization review without
supervision.
(8) Maintain documentation of interrater reliability
testing and the remediation actions taken for those with
pass rates lower than 90% and submit to the Department of
Insurance or, in the case of Medicaid managed care
organizations, the Department of Healthcare and Family
Services the testing results and a summary of remedial
actions as part of parity compliance reporting set forth
in subsection (k) of Section 370c.1.
(r) This Section applies to all health care services and
benefits for the diagnosis, prevention, and treatment of
mental, emotional, nervous, or substance use disorders or
conditions covered by an insurance policy, including
prescription drugs.
(s) This Section applies to 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
conducts utilization review as defined in this Section,

including Medicaid managed care organizations, and any entity
or contracting provider that performs utilization review or
utilization management functions on an insurer's behalf.
(t) If the Director determines that an insurer has
violated this Section, the Director may, after appropriate
notice and opportunity for hearing, by order, assess a civil
penalty between $1,000 and $5,000 for each violation. Moneys
collected from penalties shall be deposited into the Parity
Advancement Fund established in subsection (i) of Section
370c.1.
(u) An insurer shall not adopt, impose, or enforce terms
in its policies or provider agreements, in writing or in
operation, that undermine, alter, or conflict with the
requirements of this Section.
(v) The provisions of this Section are severable. If any
provision of this Section or its application is held invalid,
that invalidity shall not affect other provisions or
applications that can be given effect without the invalid
provision or application.
(Source: P.A. 100-305, eff. 8-24-17; 100-1023, eff. 1-1-19;
100-1024, eff. 1-1-19; 101-81, eff. 7-12-19; 101-386, eff.
8-16-19; revised 9-20-19.)
(215 ILCS 5/370c.1)
Sec. 370c.1. Mental, emotional, nervous, or substance use
disorder or condition 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
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 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.
(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
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
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 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 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.
(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 treatment" means those limitations as
described under federal regulations (26 CFR 54.9812-1).
"Nonquantitative treatment limitations" include, but are not
limited to, those limitations described under federal
regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45 CFR
146.136.
(h) The Department of Insurance shall implement the
following education initiatives:
(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. 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 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. 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 January 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 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 market conduct examinations or, in
the case of the Department of Healthcare and Family
Services, audits 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 and audits. This shall include:

(i) the number of market conduct examinations
and audits initiated and completed;
(ii) the benefit classifications examined by
each market conduct examination and audit;
(iii) the subject matter of each market
conduct examination and audit, including
quantitative and nonquantitative treatment
limitations; and
(iv) a summary of the basis for the final
decision rendered in each market conduct
examination and audit.
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
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.
(i) The Parity Advancement 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 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.
(j) The Department of Insurance and the Department of
Healthcare and Family Services shall convene and provide
technical support to a workgroup of 11 members that shall be
comprised of 3 mental health parity experts recommended by an
organization advocating on behalf of mental health parity
appointed by the President of the Senate; 3 behavioral health
providers recommended by an organization that represents
behavioral health providers appointed by the Speaker of the
House of Representatives; 2 representing Medicaid managed care
organizations recommended by an organization that represents
Medicaid managed care plans appointed by the Minority Leader
of the House of Representatives; 2 representing commercial
insurers recommended by an organization that represents
insurers appointed by the Minority Leader of the Senate; and a
representative of an organization that represents Medicaid
managed care plans appointed by the Governor.
The workgroup shall provide recommendations to the General
Assembly on health plan data reporting requirements that

separately break out data on mental, emotional, nervous, or
substance use disorder or condition benefits and data on other
medical benefits, including physical health and related health
services no later than December 31, 2019. The recommendations
to the General Assembly shall be filed with the Clerk of the
House of Representatives and the Secretary of the Senate in
electronic form only, in the manner that the Clerk and the
Secretary shall direct. This workgroup shall take into account
federal requirements and recommendations on mental health
parity reporting for the Medicaid program. This workgroup
shall also develop the format and provide any needed
definitions for reporting requirements in subsection (k). The
research and evaluation of the working group shall include,
but not be limited to:
(1) claims denials due to benefit limits, if
applicable;
(2) administrative denials for no prior authorization;
(3) denials due to not meeting medical necessity;
(4) denials that went to external review and whether
they were upheld or overturned for medical necessity;
(5) out-of-network claims;
(6) emergency care claims;
(7) network directory providers in the outpatient
benefits classification who filed no claims in the last 6
months, if applicable;
(8) the impact of existing and pertinent limitations

and restrictions related to approved services, licensed
providers, reimbursement levels, and reimbursement
methodologies within the Division of Mental Health, the
Division of Substance Use Prevention and Recovery
programs, the Department of Healthcare and Family
Services, and, to the extent possible, federal regulations
and law; and
(9) when reporting and publishing should begin.
Representatives from the Department of Healthcare and
Family Services, representatives from the Division of Mental
Health, and representatives from the Division of Substance Use
Prevention and Recovery shall provide technical advice to the
workgroup.
(k) 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, the format and definitions for which will be
developed by the workgroup in subsection (j), to the
Department, or, with respect to medical assistance, the
Department of Healthcare and Family Services starting on or
before July 1, 2020 that contains the following information
separately for inpatient in-network benefits, inpatient
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) 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.
(2) 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.
(3) 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.
(4) A description of the process used to develop or
select the medical necessity criteria for mental,
emotional, nervous, or substance use disorder or condition
benefits and the process used to develop or select the
medical necessity criteria for medical and surgical
benefits.
(5) Identification of all nonquantitative treatment
limitations that are applied to both mental, emotional,
nervous, or substance use disorder or condition benefits

and medical and surgical benefits within each
classification of benefits.
(6) The results of an analysis that demonstrates that
for the medical necessity criteria described in
subparagraph (A) and for each nonquantitative treatment
limitation identified in subparagraph (B), as written and
in operation, the processes, strategies, evidentiary
standards, or other factors used in applying the medical
necessity criteria and each nonquantitative treatment
limitation to mental, emotional, nervous, or substance use
disorder or condition benefits within each classification
of benefits are comparable to, and are applied no more
stringently than, the processes, strategies, evidentiary
standards, or other factors used in applying the medical
necessity criteria and each nonquantitative treatment
limitation to medical and surgical benefits within the
corresponding classification of benefits; at a minimum,
the results of the analysis shall:
(A) identify the factors used to determine that a
nonquantitative treatment limitation applies 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
evidence relied upon in designing each nonquantitative
treatment limitation;

(C) provide the comparative analyses, including
the results of the analyses, performed to determine
that the processes and strategies used to design each
nonquantitative treatment limitation, as written, for
mental, emotional, nervous, or substance use disorder
or condition benefits are comparable to, and are
applied no more stringently than, the processes and
strategies used to design each nonquantitative
treatment limitation, as written, for medical and
surgical benefits;
(D) provide the comparative analyses, including
the results of the analyses, performed to determine
that the processes and strategies used to apply each
nonquantitative treatment limitation, in operation,
for mental, emotional, nervous, or substance use
disorder or condition benefits are comparable to, and
applied no more stringently than, the processes or
strategies used to apply each nonquantitative
treatment limitation, in operation, for medical and
surgical benefits; and
(E) disclose the specific findings and conclusions
reached by the insurer that the results of the
analyses described in subparagraphs (C) and (D)
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 42 CFR Parts 438, 440, and 457 and 45
CFR 146.136 and any other related federal regulations
found in the Code of Federal Regulations.
(7) Any other information necessary to clarify data
provided in accordance with this Section requested by the
Director, including information that may be proprietary or
have commercial value, under the requirements of Section
30 of the Viatical Settlements Act of 2009.
(l) 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 on or after
the effective date of this amendatory Act of the 100th General
Assembly shall, in advance of the plan year, make available to
the Department or, with respect to medical assistance, the
Department of Healthcare and Family Services and to all plan
participants and beneficiaries the information required in
subparagraphs (C) through (E) of paragraph (6) of subsection
(k). For plan participants and medical assistance
beneficiaries, the information required in subparagraphs (C)
through (E) of paragraph (6) of subsection (k) shall be made
available on a publicly-available website whose web address is
prominently displayed in plan and managed care organization
informational and marketing materials.

(m) In conjunction with its compliance examination program
conducted in accordance with the Illinois State Auditing Act,
the Auditor General shall undertake a review of compliance by
the Department and the Department of Healthcare and Family
Services with Section 370c and this Section. Any findings
resulting from the review conducted under this Section shall
be included in the applicable State agency's compliance
examination report. Each compliance examination report shall
be issued in accordance with Section 3-14 of the Illinois
State Auditing Act. A copy of each report shall also be
delivered to the head of the applicable State agency and
posted on the Auditor General's website.
(Source: P.A. 99-480, eff. 9-9-15; 100-1024, eff. 1-1-19.)
Section 10. The Health Carrier External Review Act is
amended by changing Sections 35 and 40 as follows:
(215 ILCS 180/35)
Sec. 35. Standard external review.
(a) Within 4 months after the date of receipt of a notice
of an adverse determination or final adverse determination, a
covered person or the covered person's authorized
representative may file a request for an external review with
the Director. Within one business day after the date of
receipt of a request for external review, the Director shall
send a copy of the request to the health carrier.

(b) Within 5 business days following the date of receipt
of the external review request, the health carrier shall
complete a preliminary review of the request to determine
whether:
(1) the individual is or was a covered person in the
health benefit plan at the time the health care service
was requested or at the time the health care service was
provided;
(2) the health care service that is the subject of the
adverse determination or the final adverse determination
is a covered service under the covered person's health
benefit plan, but the health carrier has determined that
the health care service is not covered;
(3) the covered person has exhausted the health
carrier's internal appeal process unless the covered
person is not required to exhaust the health carrier's
internal appeal process pursuant to this Act;
(4) (blank); and
(5) the covered person has provided all the
information and forms required to process an external
review, as specified in this Act.
(c) Within one business day after completion of the
preliminary review, the health carrier shall notify the
Director and covered person and, if applicable, the covered
person's authorized representative in writing whether the
request is complete and eligible for external review. If the

request:
(1) is not complete, the health carrier shall inform
the Director and covered person and, if applicable, the
covered person's authorized representative in writing and
include in the notice what information or materials are
required by this Act to make the request complete; or
(2) is not eligible for external review, the health
carrier shall inform the Director and covered person and,
if applicable, the covered person's authorized
representative in writing and include in the notice the
reasons for its ineligibility.
The Department may specify the form for the health
carrier's notice of initial determination under this
subsection (c) and any supporting information to be included
in the notice.
The notice of initial determination of ineligibility shall
include a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that the
external review request is ineligible for review may be
appealed to the Director by filing a complaint with the
Director.
Notwithstanding a health carrier's initial determination
that the request is ineligible for external review, the
Director may determine that a request is eligible for external
review and require that it be referred for external review. In

making such determination, the Director's decision shall be in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(d) Whenever the Director receives notice that a request
is eligible for external review following the preliminary
review conducted pursuant to this Section, within one business
day after the date of receipt of the notice, the Director
shall:
(1) assign an independent review organization from the
list of approved independent review organizations compiled
and maintained by the Director pursuant to this Act and
notify the health carrier of the name of the assigned
independent review organization; and
(2) notify in writing the covered person and, if
applicable, the covered person's authorized representative
of the request's eligibility and acceptance for external
review and the name of the independent review
organization.
The Director shall include in the notice provided to the
covered person and, if applicable, the covered person's
authorized representative a statement that the covered person
or the covered person's authorized representative may, within
5 business days following the date of receipt of the notice
provided pursuant to item (2) of this subsection (d), submit

in writing to the assigned independent review organization
additional information that the independent review
organization shall consider when conducting the external
review. The independent review organization is not required
to, but may, accept and consider additional information
submitted after 5 business days.
(e) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act.
(f) Within 5 business days after the date of receipt of the
notice provided pursuant to item (1) of subsection (d) of this
Section, the health carrier or its designee utilization review
organization shall provide to the assigned independent review
organization the documents and any information considered in
making the adverse determination or final adverse
determination; in such cases, the following provisions shall
apply:
(1) Except as provided in item (2) of this subsection
(f), failure by the health carrier or its utilization
review organization to provide the documents and
information within the specified time frame shall not
delay the conduct of the external review.
(2) If the health carrier or its utilization review
organization fails to provide the documents and

information within the specified time frame, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(3) Within one business day after making the decision
to terminate the external review and make a decision to
reverse the adverse determination or final adverse
determination under item (2) of this subsection (f), the
independent review organization shall notify the Director,
the health carrier, the covered person and, if applicable,
the covered person's authorized representative, of its
decision to reverse the adverse determination.
(g) Upon receipt of the information from the health
carrier or its utilization review organization, the assigned
independent review organization shall review all of the
information and documents and any other information submitted
in writing to the independent review organization by the
covered person and the covered person's authorized
representative.
(h) Upon receipt of any information submitted by the
covered person or the covered person's authorized
representative, the independent review organization shall
forward the information to the health carrier within 1
business day.
(1) Upon receipt of the information, if any, the
health carrier may reconsider its adverse determination or

final adverse determination that is the subject of the
external review.
(2) Reconsideration by the health carrier of its
adverse determination or final adverse determination shall
not delay or terminate the external review.
(3) The external review may only be terminated if the
health carrier decides, upon completion of its
reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or
payment for the health care service that is the subject of
the adverse determination or final adverse determination.
In such cases, the following provisions shall apply:
(A) Within one business day after making the
decision to reverse its adverse determination or final
adverse determination, the health carrier shall notify
the Director, the covered person and, if applicable,
the covered person's authorized representative, and
the assigned independent review organization in
writing of its decision.
(B) Upon notice from the health carrier that the
health carrier has made a decision to reverse its
adverse determination or final adverse determination,
the assigned independent review organization shall
terminate the external review.
(i) In addition to the documents and information provided
by the health carrier or its utilization review organization

and the covered person and the covered person's authorized
representative, if any, the independent review organization,
to the extent the information or documents are available and
the independent review organization considers them
appropriate, shall consider the following in reaching a
decision:
(1) the covered person's pertinent medical records;
(2) the covered person's health care provider's
recommendation;
(3) consulting reports from appropriate health care
providers and other documents submitted by the health
carrier or its designee utilization review organization,
the covered person, the covered person's authorized
representative, or the covered person's treating provider;
(4) the terms of coverage under the covered person's
health benefit plan with the health carrier to ensure that
the independent review organization's decision is not
contrary to the terms of coverage under the covered
person's health benefit plan with the health carrier,
unless the terms are inconsistent with applicable law;
(5) the most appropriate practice guidelines, which
shall include applicable evidence-based standards and may
include any other practice guidelines developed by the
federal government, national or professional medical
societies, boards, and associations;
(6) any applicable clinical review criteria developed

and used by the health carrier or its designee utilization
review organization;
(7) the opinion of the independent review
organization's clinical reviewer or reviewers after
considering items (1) through (6) of this subsection (i)
to the extent the information or documents are available
and the clinical reviewer or reviewers considers the
information or documents appropriate;
(8) (blank); and
(9) in the case of medically necessary determinations
for substance use disorders, the patient placement
criteria established by the American Society of Addiction
Medicine.
(i-5) For an adverse determination or final adverse
determination involving mental, emotional, nervous, or
substance use disorders or conditions, the independent review
organization shall:
(1) consider the documents and information as set
forth in subsection (i), except that all practice
guidelines and clinical review criteria must be consistent
with the requirements set forth in Section 370c of the
Illinois Insurance Code; and
(2) make its decision, pursuant to subsection (j),
whether to uphold or reverse the adverse determination or
final adverse determination based on whether the service
constitutes medically necessary treatment of a mental,

emotional, nervous, or substance use disorders or
condition as defined in Section 370c of the Illinois
Insurance Code.
(j) Within 5 days after the date of receipt of all
necessary information, but in no event more than 45 days after
the date of receipt of the request for an external review, the
assigned independent review organization shall provide written
notice of its decision to uphold or reverse the adverse
determination or the final adverse determination to the
Director, the health carrier, the covered person, and, if
applicable, the covered person's authorized representative. In
reaching a decision, the assigned independent review
organization is not bound by any claim determinations reached
prior to the submission of information to the independent
review organization. In such cases, the following provisions
shall apply:
(1) The independent review organization shall include
in the notice:
(A) a general description of the reason for the
request for external review;
(B) the date the independent review organization
received the assignment from the Director to conduct
the external review;
(C) the time period during which the external
review was conducted;
(D) references to the evidence or documentation,

including the evidence-based standards, considered in
reaching its decision;
(E) the date of its decision;
(F) the principal reason or reasons for its
decision, including what applicable, if any,
evidence-based standards that were a basis for its
decision; and
(G) the rationale for its decision.
(2) (Blank).
(3) (Blank).
(4) Upon receipt of a notice of a decision reversing
the adverse determination or final adverse determination,
the health carrier immediately shall approve the coverage
that was the subject of the adverse determination or final
adverse determination.
(Source: P.A. 99-480, eff. 9-9-15.)
(215 ILCS 180/40)
Sec. 40. Expedited external review.
(a) A covered person or a covered person's authorized
representative may file a request for an expedited external
review with the Director either orally or in writing:
(1) immediately after the date of receipt of a notice
prior to a final adverse determination as provided by
subsection (b) of Section 20 of this Act;
(2) immediately after the date of receipt of a notice

upon final adverse determination as provided by subsection
(c) of Section 20 of this Act; or
(3) if a health carrier fails to provide a decision on
request for an expedited internal appeal within 48 hours
as provided by item (2) of Section 30 of this Act.
(b) Upon receipt of a request for an expedited external
review, the Director shall immediately send a copy of the
request to the health carrier. Immediately upon receipt of the
request for an expedited external review, the health carrier
shall determine whether the request meets the reviewability
requirements set forth in subsection (b) of Section 35. In
such cases, the following provisions shall apply:
(1) The health carrier shall immediately notify the
Director, the covered person, and, if applicable, the
covered person's authorized representative of its
eligibility determination.
(2) The notice of initial determination shall include
a statement informing the covered person and, if
applicable, the covered person's authorized representative
that a health carrier's initial determination that an
external review request is ineligible for review may be
appealed to the Director.
(3) The Director may determine that a request is
eligible for expedited external review notwithstanding a
health carrier's initial determination that the request is
ineligible and require that it be referred for external

review.
(4) In making a determination under item (3) of this
subsection (b), the Director's decision shall be made in
accordance with the terms of the covered person's health
benefit plan, unless such terms are inconsistent with
applicable law, and shall be subject to all applicable
provisions of this Act.
(5) The Director may specify the form for the health
carrier's notice of initial determination under this
subsection (b) and any supporting information to be
included in the notice.
(c) Upon receipt of the notice that the request meets the
reviewability requirements, the Director shall immediately
assign an independent review organization from the list of
approved independent review organizations compiled and
maintained by the Director to conduct the expedited review. In
such cases, the following provisions shall apply:
(1) The assignment of an approved independent review
organization to conduct an external review in accordance
with this Section shall be made from those approved
independent review organizations qualified to conduct
external review as required by Sections 50 and 55 of this
Act.
(2) The Director shall immediately notify the health
carrier of the name of the assigned independent review
organization. Immediately upon receipt from the Director

of the name of the independent review organization
assigned to conduct the external review, but in no case
more than 24 hours after receiving such notice, the health
carrier or its designee utilization review organization
shall provide or transmit all necessary documents and
information considered in making the adverse determination
or final adverse determination to the assigned independent
review organization electronically or by telephone or
facsimile or any other available expeditious method.
(3) If the health carrier or its utilization review
organization fails to provide the documents and
information within the specified timeframe, the assigned
independent review organization may terminate the external
review and make a decision to reverse the adverse
determination or final adverse determination.
(4) Within one business day after making the decision
to terminate the external review and make a decision to
reverse the adverse determination or final adverse
determination under item (3) of this subsection (c), the
independent review organization shall notify the Director,
the health carrier, the covered person, and, if
applicable, the covered person's authorized representative
of its decision to reverse the adverse determination or
final adverse determination.
(d) In addition to the documents and information provided
by the health carrier or its utilization review organization

and any documents and information provided by the covered
person and the covered person's authorized representative, the
independent review organization, to the extent the information
or documents are available and the independent review
organization considers them appropriate, shall consider
information as required by subsection (i) of Section 35 of
this Act in reaching a decision.
(d-5) For expedited external reviews involving mental,
emotional, nervous, or substance use disorders or conditions,
the independent review organization shall consider documents
and information and shall make a decision to uphold or reverse
the adverse determination or final adverse determination
pursuant to subsection (i-5) of Section 35.
(e) As expeditiously as the covered person's medical
condition or circumstances requires, but in no event more than
72 hours after the date of receipt of the request for an
expedited external review, the assigned independent review
organization shall:
(1) make a decision to uphold or reverse the final
adverse determination; and
(2) notify the Director, the health carrier, the
covered person, the covered person's health care provider,
and, if applicable, the covered person's authorized
representative, of the decision.
(f) In reaching a decision, the assigned independent
review organization is not bound by any decisions or

conclusions reached during the health carrier's utilization
review process or the health carrier's internal appeal
process.
(g) Upon receipt of notice of a decision reversing the
adverse determination or final adverse determination, the
health carrier shall immediately approve the coverage that was
the subject of the adverse determination or final adverse
determination.
(h) If the notice provided pursuant to subsection (e) of
this Section was not in writing, then within 48 hours after the
date of providing that notice, the assigned independent review
organization shall provide written confirmation of the
decision to the Director, the health carrier, the covered
person, and, if applicable, the covered person's authorized
representative including the information set forth in
subsection (j) of Section 35 of this Act as applicable.
(i) An expedited external review may not be provided for
retrospective adverse or final adverse determinations.
(j) The assignment by the Director of an approved
independent review organization to conduct an external review
in accordance with this Section shall be done on a random basis
among those independent review organizations approved by the
Director pursuant to this Act.
(Source: P.A. 96-857, eff. 7-1-10; 97-333, eff. 8-12-11;
97-574, eff. 8-26-11.)
Section 99. Effective date. This Act takes effect January

1, 2022, except that this Section and the changes to Section
370c.1 of the Illinois Insurance Code take effect upon
becoming law.