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

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: REGULATION-TECH

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

Download: Illinois-2017-HB0068-House_Amendment_005.html

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Rep. Lou Lang

Filed: 5/28/2018

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AMENDMENT TO HOUSE BILL 68
AMENDMENT NO. ______. Amend House Bill 68, AS AMENDED, by
replacing everything after the enacting clause with the
following:
"Section 5. The State Employees Group Insurance Act of 1971
is amended by changing Section 6.11 as follows:
(5 ILCS 375/6.11)
Sec. 6.11. Required health benefits; Illinois Insurance
Code requirements. The program of health benefits shall provide
the post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t of
the Illinois Insurance Code. The program of health benefits
shall provide the coverage required under Sections 356g,
356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.17, 356z.22, and 356z.25, and 356z.26 of

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the Illinois Insurance Code. The program of health benefits
must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c,
and 370c.1 of the Illinois Insurance Code. The Department of
Insurance shall enforce the requirements of this Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; revised 10-3-17.)
Section 10. The State Finance Act is amended by changing
Section 5.872 as follows:
(30 ILCS 105/5.872)
Sec. 5.872. The Parity Advancement Education Fund.
(Source: P.A. 99-480, eff. 9-9-15; 99-642, eff. 7-28-16.)
Section 15. The Counties Code is amended by changing
Section 5-1069.3 as follows:
(55 ILCS 5/5-1069.3)
Sec. 5-1069.3. Required health benefits. If a county,
including a home rule county, is a self-insurer for purposes of

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providing health insurance coverage for its employees, the
coverage shall include coverage for the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.22, and 356z.25, and 356z.26 of the
Illinois Insurance Code. The coverage shall comply with
Sections 155.22a, 355b, 356z.19, and 370c of the Illinois
Insurance Code. The Department of Insurance shall enforce the
requirements of this Section. The requirement that health
benefits be covered as provided in this Section is an exclusive
power and function of the State and is a denial and limitation
under Article VII, Section 6, subsection (h) of the Illinois
Constitution. A home rule county to which this Section applies
must comply with every provision of this Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; revised 10-5-17.)
Section 20. The Illinois Municipal Code is amended by

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changing Section 10-4-2.3 as follows:
(65 ILCS 5/10-4-2.3)
Sec. 10-4-2.3. Required health benefits. If a
municipality, including a home rule municipality, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the coverage shall include coverage
for the post-mastectomy care benefits required to be covered by
a policy of accident and health insurance under Section 356t
and the coverage required under Sections 356g, 356g.5,
356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and
356z.25, and 356z.26 of the Illinois Insurance Code. The
coverage shall comply with Sections 155.22a, 355b, 356z.19, and
370c of the Illinois Insurance Code. The Department of
Insurance shall enforce the requirements of this Section. The
requirement that health benefits be covered as provided in this
is an exclusive power and function of the State and is a denial
and limitation under Article VII, Section 6, subsection (h) of
the Illinois Constitution. A home rule municipality to which
this Section applies must comply with every provision of this
Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on

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Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; revised 10-5-17.)
Section 25. The School Code is amended by changing Section
10-22.3f as follows:
(105 ILCS 5/10-22.3f)
Sec. 10-22.3f. Required health benefits. Insurance
protection and benefits for employees shall provide the
post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t and
the coverage required under Sections 356g, 356g.5, 356g.5-1,
356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
356z.13, 356z.14, 356z.15, 356z.22, and 356z.25, and 356z.26 of
the Illinois Insurance Code. Insurance policies shall comply
with Section 356z.19 of the Illinois Insurance Code. The
coverage shall comply with Sections 155.22a, and 355b, and 370c
of the Illinois Insurance Code. The Department of Insurance
shall enforce the requirements of this Section.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for

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whatever reason, is unauthorized.
(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
revised 9-25-17.)
Section 30. The Illinois Insurance Code is amended by
changing Sections 370c and 370c.1 as follows:
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after the effective date of this amendatory
Act of the 100th General Assembly the effective date of this
amendatory Act of the 97th General Assembly, every insurer that
which amends, delivers, issues, or renews group accident and
health policies providing coverage for hospital or medical
treatment or services for illness on an expense-incurred basis
shall provide offer to the applicant or group policyholder
subject to the insurer's standards of insurability, coverage
for reasonable and necessary treatment and services for mental,
emotional, or nervous, or substance use disorders or
conditions, other than serious mental illnesses as defined in
item (2) of subsection (b), consistent with the parity
requirements of Section 370c.1 of this Code.
(2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be free
to select the physician licensed to practice medicine in all
its branches, licensed clinical psychologist, licensed

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clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act of his
choice to treat such disorders, and the insurer shall pay the
covered charges of such physician licensed to practice medicine
in all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act up to the
limits of coverage, provided (i) the disorder or condition
treated is covered by the policy, and (ii) the physician,
licensed psychologist, licensed clinical social worker,
licensed clinical professional counselor, licensed marriage
and family therapist, licensed speech-language pathologist, or
other licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act is authorized to provide said services under the
statutes of this State and in accordance with accepted
principles of his profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed

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speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act, those
persons who may provide services to individuals shall do so
after the licensed clinical social worker, licensed clinical
professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act has informed the patient of the desirability of
the patient conferring with the patient's primary care
physician and the licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act has provided written notification to the
patient's primary care physician, if any, that services are
being provided to the patient. That notification may, however,
be waived by the patient on a written form. Those forms shall
be retained by the licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act for a period of not less than 5 years.

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(4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental and
behavioral disorders chapter of the current edition of the
International Classification of Disease or that is listed in
the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders.
(b)(1) (Blank). An insurer that provides coverage for
hospital or medical expenses under a group or individual policy
of accident and health insurance or health care plan amended,
delivered, issued, or renewed on or after the effective date of
this amendatory Act of the 100th General Assembly shall provide
coverage under the policy for treatment of serious mental
illness and substance use disorders consistent with the parity
requirements of Section 370c.1 of this Code. This subsection
does not apply to any group policy of accident and health
insurance or health care plan for any plan year of a small
employer as defined in Section 5 of the Illinois Health
Insurance Portability and Accountability Act.
(2) (Blank). "Serious mental illness" means the following
psychiatric illnesses as defined in the most current edition of
the Diagnostic and Statistical Manual (DSM) published by the
American Psychiatric Association:
(A) schizophrenia;
(B) paranoid and other psychotic disorders;

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(C) bipolar disorders (hypomanic, manic, depressive,
and mixed);
(D) major depressive disorders (single episode or
recurrent);
(E) schizoaffective disorders (bipolar or depressive);
(F) pervasive developmental disorders;
(G) obsessive-compulsive disorders;
(H) depression in childhood and adolescence;
(I) panic disorder;
(J) post-traumatic stress disorders (acute, chronic,
or with delayed onset); and
(K) eating disorders, including, but not limited to,
anorexia nervosa, bulimia nervosa, pica, rumination
disorder, avoidant/restrictive food intake disorder, other
specified feeding or eating disorder (OSFED), and any other
eating disorder contained in the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders
published by the American Psychiatric Association.
(2.5) (Blank). "Substance use disorder" means the
following mental disorders as defined in the most current
edition of the Diagnostic and Statistical Manual (DSM)
published by the American Psychiatric Association:
(A) substance abuse disorders;
(B) substance dependence disorders; and
(C) substance induced disorders.
(3) Unless otherwise prohibited by federal law and

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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, serious mental illness or
substance use disorders or conditions disorder shall furnish
medical records or other necessary data that substantiate that
initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the timely
review by a provider holding the same license and practicing in
the same specialty as the patient's provider, who is
unaffiliated with the insurer, jointly selected by the patient
(or the patient's next of kin or legal representative if the
patient is unable to act for himself or herself), the patient's
provider, and the insurer in the event of a dispute between the
insurer and patient's provider regarding the medical necessity
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,

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emotional, nervous, serious mental illness or substance use
disorders or conditions disorder, an insurer must make the
determination in a manner that is consistent with the manner
used to make that determination with respect to other diseases
or illnesses covered under the policy, including an appeals
process. Medical necessity determinations for substance use
disorders shall be made in accordance with appropriate patient
placement criteria established by the American Society of
Addiction Medicine. No additional criteria may be used to make
medical necessity determinations for substance use disorders.
(4) A group health benefit plan amended, delivered, issued,
or renewed on or after the effective date of this amendatory
Act of the 100th General Assembly or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after the effective date of
this amendatory Act of the 100th General Assembly the effective
date of this amendatory Act of the 97th General Assembly:
(A) shall provide coverage based upon medical
necessity for the treatment of a mental, emotional,
nervous, or mental illness and substance use disorder or
condition disorders consistent with the parity
requirements of Section 370c.1 of this Code; provided,
however, that in each calendar year coverage shall not be
less than the following:
(i) 45 days of inpatient treatment; and

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(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 the effective date of
this amendatory Act of the 99th General Assembly shall offer

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coverage for medically necessary acute treatment services and
medically necessary clinical stabilization services. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine
Patient Placement Criteria. The treating provider shall base
all treatment recommendations and the health benefit plan shall
base all medical necessity determinations for
medication-assisted treatment in accordance with the most
current Treatment Criteria for Addictive, Substance-Related,
and Co-Occurring Conditions established by the American
Society of Addiction Medicine.
As used in this subsection:
"Acute treatment services" means 24-hour medically
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

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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 the effective date of
this amendatory Act of the 100th General Assembly:
(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

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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

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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;

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(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.
(d) The Department shall enforce the requirements of State
and federal parity law, which includes ensuring compliance by

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individual and group policies; detecting violations of the law
by individual and group policies proactively monitoring
discriminatory practices; accepting, evaluating, and
responding to complaints regarding such violations; and
ensuring violations are appropriately remedied and deterred.
(e) Availability of plan information.
(1) The criteria for medical necessity determinations
made under a group health plan, an individual policy of
accident and health insurance, or a qualified health plan
offered through the health insurance marketplace with
respect to mental health or substance use disorder benefits
(or health insurance coverage offered in connection with
the plan with respect to such benefits) must be made
available by the plan administrator (or the health
insurance issuer offering such coverage) to any current or
potential participant, beneficiary, or contracting
provider upon request.
(2) The reason for any denial under a group health
benefit plan, an individual policy of accident and health
insurance, or a qualified health plan offered through the
health insurance marketplace (or health insurance coverage
offered in connection with such plan or policy) of
reimbursement or payment for services with respect to
mental, emotional, nervous, health or substance use
disorders or conditions disorder benefits in the case of
any participant or beneficiary must be made available

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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.
(Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17.)
(215 ILCS 5/370c.1)
Sec. 370c.1. Mental, emotional, nervous, or substance use
disorder or condition health and addiction parity.
(a) On and after the effective date of this amendatory Act
of the 99th General Assembly, every insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the Health Insurance Marketplace in this State
providing coverage for hospital or medical treatment and for
the treatment of mental, emotional, nervous, or substance use
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

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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

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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

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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

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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.

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

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"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

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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 2016. By January 1, 2018
the Department shall issue a report to the General Assembly
on the success of the Consumer Education Campaign, which
shall indicate whether additional training is necessary or
would be recommended.
(2) The Department, in coordination with the
Department of Human Services and the Department of
Healthcare and Family Services, shall convene a working
group of health care insurance carriers, mental health
advocacy groups, substance abuse patient advocacy groups,

10000HB0068ham005 - 28 - LRB100 03757 SMS 40938 a
and mental health physician groups for the purpose of
discussing issues related to the treatment and coverage of
mental, emotional, nervous, or substance use abuse
disorders or conditions and compliance with parity
obligations under State and federal law. Compliance shall
be measured, tracked, and shared during the meetings of the
working group and mental illness. The working group shall
meet once before January 1, 2016 and shall meet
semiannually thereafter. The Department shall issue an
annual report to the General Assembly that includes a list
of the health care insurance carriers, mental health
advocacy groups, substance abuse patient advocacy groups,
and mental health physician groups that participated in the
working group meetings, details on the issues and topics
covered, and any legislative recommendations developed by
the working group.
(3) Not later than August 1 of each year, the
Department, in conjunction with the Department of
Healthcare and Family Services, shall issue a joint report
to the General Assembly and provide an educational
presentation to the General Assembly. The report and
presentation shall:
(A) Cover the methodology the Departments use to
check for compliance with the federal Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008, 42 U.S.C. 18031(j), and any federal

10000HB0068ham005 - 29 - LRB100 03757 SMS 40938 a
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 non-quantitative treatment
limitations; and
(iv) a summary of the basis for the final
decision rendered in each market conduct
examination and audit.

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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 Education Fund is created as a
special fund in the State treasury. Moneys from fines and
penalties collected from insurers for violations of this
Section shall be deposited into the Fund. Moneys deposited into
the Fund for appropriation by the General Assembly to the
Department of Insurance shall be used for the purpose of
providing financial support of the Consumer Education
Campaign, parity compliance advocacy, and other initiatives
that support parity implementation and enforcement on behalf of
consumers.
(j) The Department of Insurance and the Department of
Healthcare and Family Services shall convene and provide

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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

10000HB0068ham005 - 32 - LRB100 03757 SMS 40938 a
also develop the format and provide any needed definitions for
reporting requirements in subjection (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

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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

10000HB0068ham005 - 34 - LRB100 03757 SMS 40938 a
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

10000HB0068ham005 - 35 - LRB100 03757 SMS 40938 a
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;

10000HB0068ham005 - 36 - LRB100 03757 SMS 40938 a
(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

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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

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the head of the applicable State agency and posted on the
Auditor General's website.
(Source: P.A. 99-480, eff. 9-9-15.)
Section 99. Effective date. This Act takes effect January
1, 2019.".