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Legislation Signed Into Law

2018

Primary Focus: Compliance: Reporting requirement; Enforcement: Reporting requirement; Mandated Benefit: SUD; Parity: general
Title/Description: Creates reporting requirements for insurers and regulators; Expands accessibility of MAT medications; Extends parity requirements to school group plans
CitationPublic Act 100-1024
Summary: Section 6 amends 5 ILCD 375/6.11 to require school district health plans to comply with the Federal Parity law. Additionally, the bill: Removes barriers to SUD medications by prohibiting prior authorization and step therapy for MAT medications and requires such medication to be placed on the lowest tier; Requires all medical necessity requirements to be made in accordance to ASAM criteria; Creates reporting requirements, including requiring: overseeing regulators to actively enforce provisions of the Federal Parity law and submit to the General Assembly and make public a report detailing all enforcement, oversight, correctional, and educational efforts and actions taken to ensure compliance with MHPAEA and state statutes, including completing and reporting on market conduct examinations and parity compliance audits and health plans to submit detailed parity compliance analyses completed using specified guidelines and processes
Effective Date: 1/1/19
Citation: Enacted through S.B 1707

Primary Focus: Mandated Benefit: Telehealth; Mandated Benefit Provider
Title/Description: Medicaid-Telehealth Services
CitationPublic Act 100-1019
Summary: Public Act 100-1019 amends 305 ILCS 5/5-5.25 by allowing clinical psychologists, clinical social workers, advanced practice registered nurses, and mental health professionals and clinicians acting within their scope of practice to be reimbursed through Medicaid for service offers via telehealth. Additionally, any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service may be reimbursed through Medicaid.
Effective Date: 1/1/18

Primary Focus: Mental Health Screening
Title/Description: Advisory Council on Early Identification and Treatment of Mental Health Conditions Act
Citation: Public Act 100-0184
Summary: Public Act 100-0184 established an Advisory Council on Early Identification and Treatment of Mental Health Conditions Act within the Department of Human Services. Specifically, the Advisory Council shall:
(1) Review and identify evidence-based best practice models and promising practices supported by peer-reviewed literature being implemented in this State and other states on regular screening and early identification of mental health and substance use conditions in children and young adults, including depression, bi-polar disorder, schizophrenia, and other similar conditions, beginning at the age endorsed by the American Academy of Pediatrics, through young adulthood, irrespective of coverage by public or private health insurance, resulting in early treatment;
(2) Identify evidence-based mental health prevention and promotion initiatives;
(3) Identify strategies to enable additional medical providers and community-based providers to implement evidence-based best practices on regular screening, and early identification and treatment of mental health conditions;
(4) Identify barriers to the success of early screening, and identification and treatment of mental health conditions across this State, including but not limited to, treatment access challenges, specific mental health workforce issues, regional challenges, training and knowledge-base needs of providers, provider infrastructure needs, reimbursement and payment issues, and public and private insurance coverage issues;
(5) Based on the findings, develop a set of recommendations and an action plan to address the barriers to early and regular screening and identification of mental health conditions in children, adolescents and young adults in this State;
(6) Complete and deliver the recommendations and action plan to the Governor and the General Assembly within one year of the first meeting of the Advisory Council; and
(7) Upon completion and delivery of the recommendations and action plan to the Governor and General Assembly, the Advisory Council shall be dissolved.
Public Act 100-0184 further discusses the compensation, meeting requirements and qualifications of the Advisory Council, and provides that the Department of Human Services shall provide administrative support.
Effective Date: January 1, 2018
Notes: 405 ILCS 45/1 was deleted by HB 3502, which created Public Act 100-0184.
The Illinois Complied Statutes (ILCS) are a cumulative organization of Public Acts and most, but not all, Public Acts are incorporated in the ILCS. It does not appear that Public Act 100-0184 was incorporated into the ILCS and therefore, it is not referenced in 405 ILCS 45/1.

Primary Focus: Medical Management Limitation
Title/Description: Prohibits the use of prior authorization requirements for certain SUD treatment benefits and sets further medical management and external review guidelines
Citation: 215 ILCS 5/370c
Summary: Adds subsection “g” to prohibit the following plans from imposing prior authorization requirements on specified ASAM level SUD treatment benefits: group health insurance policies, individual health benefit plans, qualified health plans that is offered through the health insurance marketplace, small employer group health plans and large employer group health plans. Furthermore, the law prohibits additional or unrelated diagnosis to be used as a barrier to deny related benefits to a beneficiary with a diagnosis of a SUD. Additionally, the law sets notification requirements, guidelines, and timelines for SUD providers to follow in order inform insurers or managed care organizations of the initiation of treatment and notice of discharge.
Beneficiaries are provided the right to external review and expedited external review pursuant to the Health Carrier External Review Act.
Effective Date: January 1, 2019
Notes: Enacted through  S.682

2017

Primary Focus: Insurance Mandate
Title/Description: Insurance mandate to expand coverage for mental health substance use disorders
Citation: Public Act 100-0305 (Amends Insurance Code Sec. 370c. Mental and emotional disorders).
Summary: Public Act 100-0305 expanded the language of 215 ILCS 5/370c to require insurers that provide coverage for hospital and medical expenses under accident and health insurance or health care plan, for both individual and group policies, to 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 the Code. Public Act 100-0305 also expands the definition of “serious mental illness” to include 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.
Effective Date: August 24, 2017
Notes: 215 ILCS 5/1 was deleted by and 215 ILCS 5/370c was amended by HB 1332, which created Public Act 100-0305.

2015-2016

Primary Focus: Mandated Benefit: Provider
Title/Description: Mental Health and Addiction Parity
Citation: 215 Ill. Comp. Stat. Ann. 5/370c.1
Summary: Every insurer providing accident and health insurance or a qualified health plan offered through the Health Insurance Marketplace providing coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions shall ensure that the financial requirements and treatment limitations applicable to such mental, emotional, nervous, or substance use disorder or condition benefits are no more restrictive than those applied to substantially all hospital and medical benefits covered by the policy and that there are no separate cost-sharing or treatment limitation requirements that are applicable only with respect to mental, emotional, nervous, or substance use disorder or condition benefits.
215 Ill. Comp. Stat. Ann. 5/370c.1 continues on to discuss annual limits, compliance with the federal Mental Health Parity Act, and definitions applicable to the section.
Effective Date: September 9, 2015
Notes: Enacted through HB0001 (99th General Assembly)

2011-2012

Primary Focus: Mandated Benefit: Provider
Title/Description: Mental and Emotional Disorders
Citation: 215 Ill. Comp. Stat. Ann. 5/370c
Summary: Every insurer providing group or individual accident and health policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis shall offer coverage for mental, emotional or nervous disorders or conditions, other than serious mental illnesses.
215 Ill. Comp. Stat. Ann. 5/370c continues on to define “serious mental illness” and other terms used in the section, time limits for treatment, and for medical necessity.
Effective Date: August 18, 2011
Notes: Enacted through HB 1530 (97th General Assembly)

HB 679
Introduced: 2/2011
Sponsor: Sen. Harmon and Rep. Saviano
Status: Signed into Law 8/2012
Summary: This bill changed the state insurance law about autism so that children who were diagnosed with autism spectrum disorders will still be covered for autism treatment even if the diagnostic criteria for these disorders changes and they no longer meet the criteria.

Illinois Parity Law

The sections of the Illinois state insurance laws about parity are the consecutive sections 215 ILCS 5/370c and 215 ILCS 5/370c.1. There is also a separate section, 215 ILCS 5/356z.14, that requires insurance coverage for autism.

Individual plans, Large employer fully-insured plans, and small employer fully-insured plans that provide coverage for behavioral health services must ensure that financial requirements and treatment limitations for behavioral health services are no more restrictive than those in place for other medical services.

Plans cannot use annual maximums and lifetime maximums for behavioral health services or have annual limits and lifetime limits if they aren’t in place for other medical services. If a plan does have these in place for other medical services, they can do either of the following:

  • Make it so that both behavioral health services and other medical services count towards combined limits and maximums

OR

  • Make the limits and maximums for behavioral health services no less than the ones in place for other medical services

For plans that have many different limits and maximums for different categories of medical care, the law requires the Director of the Illinois Department of Insurance to use a mathematical formula to decide what the limits and maximums should be for behavioral health services.

Plans are required to follow the final regulations (pdf | Get Adobe® Reader®)about the Federal Parity Law .

The law also makes clear that treatment limitations includes both quantitative treatment limitations and nonquantitative treatment limitations .

Large employer fully-insured plans are required to cover substance use disorders and “serious mental illness,” which is defined in the law as these conditions:

  1. Schizophrenia
  2. Paranoid and other psychotic disorders
  3. Bipolar disorders (hypomanic, manic, depressive, and mixed)
  4. Major depressive disorders (single episode or recurrent)
  5. Schizoaffective disorders (bipolar or depressive)
  6. Pervasive developmental disorders
  7. Obsessive-compulsive disorders
  8. Depression in childhood and adolescence
  9. Panic disorder
  10. Post-traumatic stress disorders (acute, chronic, or with delayed onset)
  11. Anorexia nervosa and bulimia nervosa

The section of the law about serious mental illness has a very detailed subsection about medical necessity reviews. It states if there is a dispute between an insurance plan and the patient’s provider about whether a certain treatment is medically necessary , a review will be made by another provider in the same specialty as the patient’s provider. This provider will be jointly selected by the patient, the patient’s provider, and the insurance plan. In the vast majority of states, only the insurance plan can select the provider that performs medical necessity reviews.

For substance use disorder medical necessity reviews, plans are required to follow the criteria set by the American Society of Addiction Medicine, and no other criteria.

This section of the law also requires large employer fully-insured plans to cover no less than 45 days of inpatient care and 60 visits of outpatient care for serious mental illness, no matter what coverage is in place for other medical care. These plans must also abide by these coverage floors for any other conditions that are covered. Additionally, if a small employer fully-insured plan covers serious mental illness or any other behavioral health condition, they must abide by these visit and day coverage floors.

This section says there cannot be any lifetime limits for days of inpatient care or visits for outpatient care.

This section of the law also states inpatient care for substance use disorders includes residential treatment .

Autism

This section requires all large employer fully-insured plans , small employer fully-insured plans , and individual plans to cover services for autism for people through age 20. Autism spectrum disorder is defined in the law as conditions considered as pervasive developmental disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM) including autism, Asperger’s disorder, and pervasive developmental disorder not otherwise specified.

There is an annual maximum of $36,000, which must be adjusted for inflation each year. This section of the law says that there cannot be annual limits for outpatient care . Financial requirements cannot be “less favorable” than those in place for other medical care.

Insurance plans are allowed to perform medical necessity reviews and there is no limit on how often they can do this. Many state laws place limits on how often plans are allowed to perform medical necessity reviews for autism patients.

There is also a subsection that says if the definition of autism spectrum disorder changes in future versions of the DSM, patients who were already diagnosed with autism will still be covered, even if they no longer fit the diagnosis.

This section of the law lists the following treatments as approved for autism care:

  • Psychiatric care
  • Psychological care
  • Habilitative or rehabilitative care
  • Therapeutic care, including behavioral, speech, occupational, and physical therapies for improving:
    • self care and feeding
    • pragmatic, receptive, and expressive language
    • cognitive functioning
    • applied behavior analysis, intervention, and modification
    • motor planning
    • sensory processing

There is also a detailed definition of what medically necessary care is considered, including:

  1. Preventing the onset of an illness, condition, injury, disease or disability
  2. Reducing or ameliorating the physical, mental or developmental effects of an illness, condition, injury, disease or disability
  3. Assisting to achieve or maintain maximum functional activity in performing daily activities.

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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