Bill Text: IL HB4633 | 2019-2020 | 101st General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that an insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services for illness entered into on or after January 1, 2021 shall ensure that the insured have timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions. Provides that network adequacy standards for timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions must satisfy specified minimum requirements. Provides that if there is no in-network facility or provider available for an insured to receive timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions in accordance with the minimum network adequacy standards, the insurer shall provide necessary exceptions to its network to ensure admission and treatment with a provider or at a treatment facility in accordance with those network adequacy standards. Effective immediately.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2020-06-23 - Rule 19(b) / Re-referred to Rules Committee [HB4633 Detail]

Download: Illinois-2019-HB4633-Introduced.html

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101ST GENERAL ASSEMBLY State of Illinois 2019 and 2020 HB4633 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
215 ILCS 5/370c from Ch. 73, par. 982c
Amends the Illinois Insurance Code. Provides that an insurer that amends, delivers, issues, or renews group accident and health policies providing coverage for hospital or medical treatment or services for illness entered into on or after January 1, 2021 shall ensure that the insured have timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions. Provides that network adequacy standards for timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions must satisfy specified minimum requirements. Provides that if there is no in-network facility or provider available for an insured to receive timely and proximate access to treatment for mental, emotional, nervous, or substance use disorders or conditions in accordance with the minimum network adequacy standards, the insurer shall provide necessary exceptions to its network to ensure admission and treatment with a provider or at a treatment facility in accordance with those network adequacy standards. Effective immediately.
LRB101 17909 BMS 69642 b
A BILL FOR
HB4633 LRB101 17909 BMS 69642 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a)(1) On and after August 16, 2019 January 1, 2019 (the
effective date of Public Act 101-386 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 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

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speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Substance
Use Disorder 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 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 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

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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
International Classification of Disease or that is listed in
the most recent version of the 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.
(b) Notwithstanding the requirements provided in
subsection (d) of Section 10 of the Network Adequacy and
Transparency Act, every insurer that amends, delivers, issues,
or renews group accident and health policies providing coverage
for hospital or medical treatment or services for illness
entered into on or after January 1, 2021 shall ensure that
insureds have timely and proximate access to treatment for
mental, emotional, nervous, or substance use disorders or

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conditions. Insurers shall use a comparable process, strategy,
evidentiary standard, and other factors in the development and
application of the network adequacy standards for timely and
proximate access to treatment for mental, emotional, nervous,
or substance use disorders or conditions and those for the
access to treatment for medical and surgical conditions. As
such, the network adequacy standards for timely and proximate
access shall equally be applied to treatment facilities and
providers for mental, emotional, nervous, or substance use
disorders or conditions and specialists providing medical or
surgical benefits pursuant to the parity requirements of
Section 370c.1 of this Code and the federal Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of
2008. Notwithstanding the foregoing, the network adequacy
standards for timely and proximate access to treatment for
mental, emotional, nervous, or substance use disorders or
conditions shall, at a minimum, satisfy the following
requirements:
(1) For insureds residing in Counties of Cook, DuPage,
Kane, Lake, McHenry, and Will, network adequacy standards
for timely and proximate access to treatment for mental,
emotional, nervous, or substance use disorders or
conditions means an insured shall not have to travel longer
than 30 minutes or 30 miles from the insured's residence to
receive outpatient treatment for mental, emotional,
nervous, or substance use disorders or conditions.

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Insureds shall not be required to wait longer than 10
business days between requesting an initial or repeat
appointment and being seen by the facility or provider of
mental, emotional, nervous, or substance use disorders or
conditions outpatient treatment.
(2) For insureds residing in Illinois counties other
than those counties listed in paragraph (1) of this
subsection, network adequacy standards for timely and
proximate access to treatment for mental, emotional,
nervous, or substance use disorders or conditions means an
insured shall not have to travel longer than 60 minutes or
60 miles from the insured's residence to receive outpatient
treatment for mental, emotional, nervous, or substance use
disorders or conditions. Insureds shall not be required to
wait longer than 10 business days between requesting an
initial or repeat appointment and being seen by the
facility or provider of mental, emotional, nervous, or
substance use disorders or conditions outpatient
treatment.
(2.5) For insureds residing in all Illinois counties,
network adequacy standards for timely and proximate access
to treatment for mental, emotional, nervous, or substance
use disorders or conditions means an insured shall not have
to travel longer than 60 minutes or 60 miles from the
insured's residence to receive inpatient or residential
treatment for mental, emotional, nervous, or substance use

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disorders or conditions.
(2.7) If there is no in-network facility or provider
available for an insured to receive timely and proximate
access to treatment for mental, emotional, nervous, or
substance use disorders or conditions in accordance with
the network adequacy standards outlined in this
subsection, the insurer shall provide necessary exceptions
to its network to ensure admission and treatment with a
provider or at a treatment facility in accordance with the
network adequacy standards in this subsection.
(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

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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

HB4633 - 8 - LRB101 17909 BMS 69642 b
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

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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

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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):

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(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

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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

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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;

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(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

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(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:

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"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

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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

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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

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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.
(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.)

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Section 99. Effective date. This Act takes effect upon
becoming law.