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| Public Act 103-0094
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| SB1568 Enrolled | LRB103 28639 BMS 55020 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
changing Section 370c.1 as follows:
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(215 ILCS 5/370c.1) |
Sec. 370c.1. Mental, emotional, nervous, or substance use |
disorder or condition parity. |
(a) On and after July 23, 2021 (the effective date of |
Public Act 102-135), 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 prior to policy issuance |
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 |
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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 |
September 9, 2015 (the effective date of Public Act |
99-480) 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, |
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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, |
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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 |
September 9, 2015 (the effective date of Public Act |
99-480) 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 |
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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 |
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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). |
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"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.
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(h) The Department of Insurance shall implement the |
following education initiatives: |
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(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 |
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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 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 |
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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. |
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(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 |
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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: |
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(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. |
(j-5) The Department of Insurance shall collect the |
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following information: |
(1) The number of employment disability insurance |
plans offered in this State, including, but not limited |
to: |
(A) individual short-term policies; |
(B) individual long-term policies; |
(C) group short-term policies; and |
(D) group long-term policies. |
(2) The number of policies referenced in paragraph (1) |
of this subsection that limit mental health and substance |
use disorder benefits. |
(3) The average defined benefit period for the |
policies referenced in paragraph (1) of this subsection, |
both for those policies that limit and those policies that |
have no limitation on mental health and substance use |
disorder benefits. |
(4) Whether the policies referenced in paragraph (1) |
of this subsection are purchased on a voluntary or |
non-voluntary basis. |
(5) The identities of the individuals, entities, or a |
combination of the 2, that assume the cost associated with |
covering the policies referenced in paragraph (1) of this |
subsection. |
(6) The average defined benefit period for plans that |
cover physical disability and mental health and substance |
abuse without limitation, including, but not limited to: |
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(A) individual short-term policies; |
(B) individual long-term policies; |
(C) group short-term policies; and |
(D) group long-term policies. |
(7) The average premiums for disability income |
insurance issued in this State for: |
(A) individual short-term policies that limit |
mental health and substance use disorder benefits; |
(B) individual long-term policies that limit |
mental health and substance use disorder benefits; |
(C) group short-term policies that limit mental |
health and substance use disorder benefits; |
(D) group long-term policies that limit mental |
health and substance use disorder benefits; |
(E) individual short-term policies that include |
mental health and substance use disorder benefits |
without limitation; |
(F) individual long-term policies that include |
mental health and substance use disorder benefits |
without limitation; |
(G) group short-term policies that include mental |
health and substance use disorder benefits without |
limitation; and |
(H) group long-term policies that include mental |
health and substance use disorder benefits without |
limitation. |
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The Department shall present its findings regarding |
information collected under this subsection (j-5) to the |
General Assembly no later than April 30, 2024. Information |
regarding a specific insurance provider's contributions to the |
Department's report shall be exempt from disclosure under |
paragraph (t) of subsection (1) of Section 7 of the Freedom of |
Information Act. The aggregated information gathered by the |
Department shall not be exempt from disclosure under paragraph |
(t) of subsection (1) of Section 7 of the Freedom of |
Information Act. |
(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, |
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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 |
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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 |
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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. |
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(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 |
January 1, 2019 (the effective date of Public Act 100-1024) |
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 |
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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. 102-135, eff. 7-23-21; 102-579, eff. 8-25-21; |
102-813, eff. 5-13-22.)
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