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This page lists some of the action toward parity compliance undertaken by Illinois regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org

Actions in the Regulatory Arena

2018

Primary Focus: Medical Payment
Agency: Department of Healthcare and Family Services
Title/Description: Medical Payment
Citation: 41 Ill. Reg. 7526
Summary: Allows Licensed Clinical Psychologists (LCPs) and Licensed Clinical Social Workers (LCSWs) to bill for services he or she personally provides or that are provided under his or her supervision. Payment shall be made to LCPs for the following services: psychological and neuropsychological testing; diagnostic evaluation; and therapeutic services provided in the office, home or community setting. Payment shall be made to LCSWs for the following services: diagnostic evaluation; and therapeutic services provided in the office, home or community setting. Direct supervision is not required under ILL. ADMIN. CODE tit. 89, § 140.400.
Effective Date: June 15, 2017
Notes: ILL. ADMIN. CODE tit. 89, § 140.

4/2016

The Illinois Department of Insurance launched a consumer education awareness campaign (pdf | Get Adobe® Reader®) in partnership with other state agencies and healthcare organizations to help Illinois families across the state navigate health insurance coverage for behavioral health disorders. The Department of Insurance developed a consumer toolkit (pdf | Get Adobe® Reader®) as part of this campaign. It also held five in-person trainings (pdf | Get Adobe® Reader®) on health insurance coverage for consumers and providers. The program included live presentations from state agencies involved in parity implementation and enforcement and a question and answer session.

03/2016

The Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®)detailing the instructions to become an Illinois Qualified Health Plan for the 2017 Plan Year. Under the instructions, the Department will confirm that all qualified health plans’ benefit design complies with the Federal Parity Law and applicable state laws.

03/2016

The Illinois Department of Insurance issued a press release (pdf | Get Adobe® Reader®) encouraging individuals to contact the Office of Consumer Health Insurance if they need help navigating their mental health and substance use disorder coverage.

02/2016

The Illinois Department of Insurance issued a fact sheet that provides information about mental health and substance use disorderinsurance coverage. The fact sheet outlines which plans are under purview of the Federal Parity Law and applicable state parity laws. The sheet defines:

  • The different types of health insurance plans and how they relate to new mandates under the Affordable Care Act
  • The significant provisions of the Federal Parity Law, interim final rules, final rules, and the Affordable Care Act
  • The benchmark plan’s definition of and covered benefits for mental health and substance use disorders
  • Coverage and benefits under the Illinois state law for large group, small group, and individual plans
  • The interaction between the federal parity law, state law, and the Affordable Care Act and how this impacts different insurance plans

02/2016

The Illinois Department of Insurance released a FAQ (pdf | Get Adobe® Reader®) on mental health parity that provides consumers with information about how the Federal Parity Law and applicable state parity law impact their insurance plan. The FAQ defines serious mental illness, substance use disorder, quantitative treatment limitations , and non-quantitative treatment limitations. It also encourages individuals to contact the Department if they are interested in having a complaint reviewed or questions answered.

01/2016

The Illinois Department of Insurance issued a fact sheet (pdf | Get Adobe® Reader®) to provide consumers with information on insurance coverage for autism spectrum disorders under the Affordable Care Act (ACA)and Illinois Insurance Code. The fact sheet provides information on how the ACA impacts coverage despite pre-existing conditions, autism screening, lifetime limits and annual limits , and coverage under age 26. It also provides information on plans that must comply with and covered treatments under the Autism Mandate in Illinois State law.

02/2015

The Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®)detailing the instructions to become an Illinois Qualified Health Planfor the 2016 Plan Year. Under the instructions, the Department will confirm that all qualified health plans’ benefit design complies with the Federal Parity Law and applicable state laws.

02/2015

The Illinois Department of Insurance updated their webpage on insurance coverage for autism to provide detailed information on the Affordable Care Act and Illinois Insurance Code. The page includes information on who is covered under the Federal Parity Law and applicable state law, benefit package treatments requirements, and treatment limitations.

01/2015

The Illinois Department of Insurance released their 2014 annual report (pdf | Get Adobe® Reader®) which comprehensively details their work over the past year. The report includes three actions related to parityreleased in 2014:

  • Company Bulletin 2014-06 reminded insurance companies of the prevention and parity requirements within the ACA
  • Company Bulletin 2014-10 provided insurance companies guidance regarding compliance with the nondiscrimination provisions applicable to transgender persons in the Affordable Care Act , the Illinois Human Rights Act, and the Illinois Mental Health Parity Act
  • 50 Ill. Adm. Code 5421 – Health Maintenance Organizations – was a 2013 amendment that went into effect on November 25, 2014. The amendment states that there may be other standards in addition to the basic health care services outlined in the regulation under the ACA and the federal parity law

12/2014

The Illinois Department of Insurance issued a fact sheet (pdf | Get Adobe® Reader®) on provider networks. In the network adequacy standards, the Department includes timely access to a sufficient number of mental health in-network providers.

11/2014

On November 25, 2014, an amended Section of the Illinois Administrative Code became effective. This section on minimum standards applies to HMOs. According to the amendment, minimum standards have to be medically necessary as determined by the primary care physician, and by the HMO’s Medical Director if the HMO requires Director approval. The relevant parity provisions state:

  • Emergency treatment includes outpatient visits and referrals for emergency mental health problems
  • 45 days inpatient mental health care are allowed per year
  • Care in a day hospital, residential non-hospital or intensive outpatient mode may be substituted on a two-to-one basis for inpatient hospital services if determined to be appropriate by the primary care physician
  • 60 individual outpatient mental health care visits for each enrollee are allowed each year
  • Group outpatient mental health care visits may be substituted on a two-to-one basis for individual mental health care visits if determined to be appropriate by the primary care physician
  • Diagnosis, detoxification and inpatient or outpatient treatment of drug or alcohol abuse or addiction are covered
  • Inpatient rehabilitation services are covered for up to 45 days per year
  • Care in a day hospital, residential non-hospital or intensive outpatient treatment mode may be substituted on a two-to-one basis for inpatient hospital services if determined to be appropriate by the primary care physician
  • 60 individual outpatient care visits are covered for each enrollee each year
  • Group outpatient care visits may be substituted on a two-to-one basis for individual outpatient visits if determined to be appropriate by the primary care physician (this section does not require that prolonged rehabilitation services be part of Basic Health Care Services)
  • Additional minimum standards may apply under the ACA and the Federal Parity Law .

07/2014

The Illinois Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®) providing insurance companies guidance on the nondiscrimination provisions applicable to transgender persons under the Affordable Care Act , the Illinois Human Rights Act, and the Illinois parity act. The bulletin interprets that mental conditions under Illinois state law include gender dysphoria and gender identity disorder. This clarification extends the Illinois parity act to these disorders.

5/2014

The Illinois Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®) to plans reminding them that they must comply with the Federal Parity Law. It specified that any behavioral health coverage must be at parity with coverage for other medical care for any behavioral health service covered.

01/2014

The 2014 Benchmark Plan Affordable Care Act Benchmark template requires plans meet the requirements of the state mental health parity act. These include benefits for serious mental illness, according to medical necessity and, as a minimum, 45 days of inpatient treatment, 60 days of care and an additional 20 outpatient visits for speech therapy for the treatment of pervasive developmental disorders (Note – these limits may not be in compliance with the Federal Parity Law if they are more restrictive than the comparable physical health standard)

01/2014

Primary Focus: Mandated Benefit: Provider
Agency: Department of Insurance
Title/Description: Essential Health Benefits
Citation: Ill. Admin. Code tit. 50, § 2001.11
Summary: A health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that the coverage includes an essential health benefits (EHB) package.  EHB includes mental health and substance use disorder services, including behavioral health treatment.
Effective Date: January 2, 2014
Notes: N/A

2014

The Illinois Department of Insurance submitted the 2014 annual report (pdf | Get Adobe® Reader®) to the Governor. In the section outlining the work completed by the Legal Division, the report summarizes the Bulletin that provided guidance to insurers on complying with the nondiscrimination provisions applicable to transgender persons found in the Affordable Care Act, the Illinois Human Rights Act, and the Illinois Parity Act. The report also summarizes another bulletin that provided guidance on the Federal Parity Law.

03/2013

The Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®)briefly explaining a non-exhaustive checklist insurers can follow to become a qualified health plan on the Illinois Health Insurance Marketplace. At the end of the month, the Department released a bulletin (pdf | Get Adobe® Reader®) with detailed guidelines for the qualified health plan application process. According to the guidelines, the Department of Insurance will confirm the benefit design complies with the Federal Parity Law.

The Department also issued Review Requirements Checklists (pdf | Get Adobe® Reader®) that are available on their website. The review requirements for group health maintenance organizations, catastrophic plans, individual HMO policies, individual and small group accident and health insurance explain these requirements in detail. These documents were updated on 03/2016. The requirements include –

3/2011

The Illinois Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®) that notified individual plans and small employer fully-insured plans that the annual maximum for autism coverage had been adjusted to $38,527 to account for inflation. It informed large employer fully-insured plans that they must comply with the Federal Parity Law, and therefore may not be able to impose the annual maximum for individuals with autism, regardless of the annual maximum language in Illinois law.

01/2011

The Illinois Department of Insurance issued a press release (pdf | Get Adobe® Reader®) acknowledging ambiguities within the Federal Parity Law and stated that they will respond to any questions.

10/2010

The Illinois Department of Insurance issued a bulletin (pdf | Get Adobe® Reader®) reminding individual plans and group health insurance policies that they must comply with the Autism Mandate (Section 356z.14 of Illinois Insurance Code). The law established an annual maximum benefit of $36,000 for the mandated coverage and required the Director to adjust this benefit for inflation. (Note – This law is not particularly relevant because, under state law, autism is defined as a serious mental illness. This means that autism is a covered under the Federal Parity Law in Illinois, making the maximum benefit inapplicable to the majority of insurance plans).

06/2010

The Illinois Department of Insurance released a document with general information on the interaction between Illinois Law and the Affordable Care Act. Within the document, they detail the difference in mandated insurance coverage for mental health services between the Illinois Law and the ACA.

01/2010

The Office of Consumer Health Insurance issued their 2009 Annual Report. (pdf | Get Adobe® Reader®) The report summarizes the [[term 5 “Federal Parity Law” and applicable state law. It explains that the Federal Parity Law does not preempt state law and that, instead, both laws will be integrated to preserve the features that best protect consumers.

10/2009

The Illinois Department of Insurance released a fact sheet (pdf | Get Adobe® Reader®) with information on the new Illinois law requiring insurance companies to provide coverage for the diagnosis and treatment of autism up to an annual limit of $36,000. (Note – This law is not particularly relevant because, under state law, autism is defined as a serious mental illness. This means that autism is a covered under the Federal Parity Law in Illinois, making the maximum benefit inapplicable to the majority of insurance plans).

07/2009

In 2009, the Illinois Department of Insurance conducted a series of market conduct examinations investigating insurers for compliance with the state autism law (215 ILCS 5/356z.14) and dependent benefit (under 215 ILCS 5/356.12) requirements. The insurers investigated include Aetna Life Insurance, (pdf | Get Adobe® Reader®) Connecticut General Life Insurance, (pdf | Get Adobe® Reader®) Principal Life Insurance,(pdf | Get Adobe® Reader®) United HealthCare, (pdf | Get Adobe® Reader®) Unicare Health Insurance Company, (pdf | Get Adobe® Reader®) Humana Insurance Company, (pdf | Get Adobe® Reader®) and Health Care Service Corporation.(pdf | Get Adobe® Reader®) The results of the examination include:

  • The Department found that only United HealthCare Insurance Company could not affirm compliance with the state autism law. This is the only company found to be noncompliant
  • The Department recommended that Connecticut General Life Insurance, Principal Life Insurance, United HealthCare, Humana, and Health Care Service Corporation switch from a manual to an automatic processing system to identify speech, occupational and physical therapy related claims
  • The Department recommended that Connecticut General Life Insurance, United HealthCare, and Humana change their process for identifying claims that may fall under the state autism law. Since many claims eligible for payment under this law may be submitted without an autism diagnostic code, they recommend that the Company capture all claims submitted for an individual that has had at least one claim with an autism diagnostic code
  • The Department recommended further investigation into the Health Care Service Corporation’s underwriting and record keeping practices to ensure that they are keeping appropriate information and data

01/2009

The Office of Consumer Health Insurance issued their 2008 Annual Report. (pdf | Get Adobe® Reader®) The report summarizes the Federal Parity Law and applicable state law/ It explains that the Federal Parity Law does not preempt state law and that, instead, both laws will be integrated to preserve the features that best protect consumers.

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 may use 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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