Illinois 2025-2026 Regular Session

Illinois House Bill HB3020 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB3020 Introduced , by Rep. Mary Gill SYNOPSIS AS INTRODUCED: 215 ILCS 5/370c from Ch. 73, par. 982c Amends the Illinois Insurance Code. Provides that an individual or group health benefit plan shall not impose any prior authorization requirements on outpatient services for the prevention, screening, diagnosis, or treatment of mental, emotional, nervous, or substance use disorders or conditions. LRB104 08245 BAB 18295 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB3020 Introduced , by Rep. Mary Gill SYNOPSIS AS INTRODUCED: 215 ILCS 5/370c from Ch. 73, par. 982c 215 ILCS 5/370c from Ch. 73, par. 982c Amends the Illinois Insurance Code. Provides that an individual or group health benefit plan shall not impose any prior authorization requirements on outpatient services for the prevention, screening, diagnosis, or treatment of mental, emotional, nervous, or substance use disorders or conditions. LRB104 08245 BAB 18295 b LRB104 08245 BAB 18295 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB3020 Introduced , by Rep. Mary Gill SYNOPSIS AS INTRODUCED:
3	3	215 ILCS 5/370c from Ch. 73, par. 982c 215 ILCS 5/370c from Ch. 73, par. 982c
4	4	215 ILCS 5/370c from Ch. 73, par. 982c
5	5	Amends the Illinois Insurance Code. Provides that an individual or group health benefit plan shall not impose any prior authorization requirements on outpatient services for the prevention, screening, diagnosis, or treatment of mental, emotional, nervous, or substance use disorders or conditions.
6	6	LRB104 08245 BAB 18295 b LRB104 08245 BAB 18295 b
7	7	LRB104 08245 BAB 18295 b
8	8	A BILL FOR
9	9	HB3020LRB104 08245 BAB 18295 b HB3020 LRB104 08245 BAB 18295 b
10	10	HB3020 LRB104 08245 BAB 18295 b
11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Insurance Code is amended by
15	15	5 changing Section 370c as follows:
16	16	6 (215 ILCS 5/370c) (from Ch. 73, par. 982c)
17	17	7 Sec. 370c. Mental and emotional disorders.
18	18	8 (a)(1) On and after January 1, 2022 (the effective date of
19	19	9 Public Act 102-579), every insurer that amends, delivers,
20	20	10 issues, or renews group accident and health policies providing
21	21	11 coverage for hospital or medical treatment or services for
22	22	12 illness on an expense-incurred basis shall provide coverage
23	23	13 for the medically necessary treatment of mental, emotional,
24	24	14 nervous, or substance use disorders or conditions consistent
25	25	15 with the parity requirements of Section 370c.1 of this Code.
26	26	16 (2) Each insured that is covered for mental, emotional,
27	27	17 nervous, or substance use disorders or conditions shall be
28	28	18 free to select the physician licensed to practice medicine in
29	29	19 all its branches, licensed clinical psychologist, licensed
30	30	20 clinical social worker, licensed clinical professional
31	31	21 counselor, licensed marriage and family therapist, licensed
32	32	22 speech-language pathologist, or other licensed or certified
33	33	23 professional at a program licensed pursuant to the Substance
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37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB3020 Introduced , by Rep. Mary Gill SYNOPSIS AS INTRODUCED:
38	38	215 ILCS 5/370c from Ch. 73, par. 982c 215 ILCS 5/370c from Ch. 73, par. 982c
39	39	215 ILCS 5/370c from Ch. 73, par. 982c
40	40	Amends the Illinois Insurance Code. Provides that an individual or group health benefit plan shall not impose any prior authorization requirements on outpatient services for the prevention, screening, diagnosis, or treatment of mental, emotional, nervous, or substance use disorders or conditions.
41	41	LRB104 08245 BAB 18295 b LRB104 08245 BAB 18295 b
42	42	LRB104 08245 BAB 18295 b
43	43	A BILL FOR
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49	49	215 ILCS 5/370c from Ch. 73, par. 982c
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68	68	1 Use Disorder Act of his or her choice to treat such disorders,
69	69	2 and the insurer shall pay the covered charges of such
70	70	3 physician licensed to practice medicine in all its branches,
71	71	4 licensed clinical psychologist, licensed clinical social
72	72	5 worker, licensed clinical professional counselor, licensed
73	73	6 marriage and family therapist, licensed speech-language
74	74	7 pathologist, or other licensed or certified professional at a
75	75	8 program licensed pursuant to the Substance Use Disorder Act up
76	76	9 to the limits of coverage, provided (i) the disorder or
77	77	10 condition treated is covered by the policy, and (ii) the
78	78	11 physician, licensed psychologist, licensed clinical social
79	79	12 worker, licensed clinical professional counselor, licensed
80	80	13 marriage and family therapist, licensed speech-language
81	81	14 pathologist, or other licensed or certified professional at a
82	82	15 program licensed pursuant to the Substance Use Disorder Act is
83	83	16 authorized to provide said services under the statutes of this
84	84	17 State and in accordance with accepted principles of his or her
85	85	18 profession.
86	86	19 (3) Insofar as this Section applies solely to licensed
87	87	20 clinical social workers, licensed clinical professional
88	88	21 counselors, licensed marriage and family therapists, licensed
89	89	22 speech-language pathologists, and other licensed or certified
90	90	23 professionals at programs licensed pursuant to the Substance
91	91	24 Use Disorder Act, those persons who may provide services to
92	92	25 individuals shall do so after the licensed clinical social
93	93	26 worker, licensed clinical professional counselor, licensed
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104	104	1 marriage and family therapist, licensed speech-language
105	105	2 pathologist, or other licensed or certified professional at a
106	106	3 program licensed pursuant to the Substance Use Disorder Act
107	107	4 has informed the patient of the desirability of the patient
108	108	5 conferring with the patient's primary care physician.
109	109	6 (4) "Mental, emotional, nervous, or substance use disorder
110	110	7 or condition" means a condition or disorder that involves a
111	111	8 mental health condition or substance use disorder that falls
112	112	9 under any of the diagnostic categories listed in the mental
113	113	10 and behavioral disorders chapter of the current edition of the
114	114	11 World Health Organization's International Classification of
115	115	12 Disease or that is listed in the most recent version of the
116	116	13 American Psychiatric Association's Diagnostic and Statistical
117	117	14 Manual of Mental Disorders. "Mental, emotional, nervous, or
118	118	15 substance use disorder or condition" includes any mental
119	119	16 health condition that occurs during pregnancy or during the
120	120	17 postpartum period and includes, but is not limited to,
121	121	18 postpartum depression.
122	122	19 (5) Medically necessary treatment and medical necessity
123	123	20 determinations shall be interpreted and made in a manner that
124	124	21 is consistent with and pursuant to subsections (h) through
125	125	22 (t).
126	126	23 (b)(1) (Blank).
127	127	24 (2) (Blank).
128	128	25 (2.5) (Blank).
129	129	26 (3) Unless otherwise prohibited by federal law and
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140	140	1 consistent with the parity requirements of Section 370c.1 of
141	141	2 this Code, the reimbursing insurer that amends, delivers,
142	142	3 issues, or renews a group or individual policy of accident and
143	143	4 health insurance, a qualified health plan offered through the
144	144	5 health insurance marketplace, or a provider of treatment of
145	145	6 mental, emotional, nervous, or substance use disorders or
146	146	7 conditions shall furnish medical records or other necessary
147	147	8 data that substantiate that initial or continued treatment is
148	148	9 at all times medically necessary. An insurer shall provide a
149	149	10 mechanism for the timely review by a provider holding the same
150	150	11 license and practicing in the same specialty as the patient's
151	151	12 provider, who is unaffiliated with the insurer, jointly
152	152	13 selected by the patient (or the patient's next of kin or legal
153	153	14 representative if the patient is unable to act for himself or
154	154	15 herself), the patient's provider, and the insurer in the event
155	155	16 of a dispute between the insurer and patient's provider
156	156	17 regarding the medical necessity of a treatment proposed by a
157	157	18 patient's provider. If the reviewing provider determines the
158	158	19 treatment to be medically necessary, the insurer shall provide
159	159	20 reimbursement for the treatment. Future contractual or
160	160	21 employment actions by the insurer regarding the patient's
161	161	22 provider may not be based on the provider's participation in
162	162	23 this procedure. Nothing prevents the insured from agreeing in
163	163	24 writing to continue treatment at his or her expense. When
164	164	25 making a determination of the medical necessity for a
165	165	26 treatment modality for mental, emotional, nervous, or
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176	176	1 substance use disorders or conditions, an insurer must make
177	177	2 the determination in a manner that is consistent with the
178	178	3 manner used to make that determination with respect to other
179	179	4 diseases or illnesses covered under the policy, including an
180	180	5 appeals process. Medical necessity determinations for
181	181	6 substance use disorders shall be made in accordance with
182	182	7 appropriate patient placement criteria established by the
183	183	8 American Society of Addiction Medicine. No additional criteria
184	184	9 may be used to make medical necessity determinations for
185	185	10 substance use disorders.
186	186	11 (4) A group health benefit plan amended, delivered,
187	187	12 issued, or renewed on or after January 1, 2019 (the effective
188	188	13 date of Public Act 100-1024) or an individual policy of
189	189	14 accident and health insurance or a qualified health plan
190	190	15 offered through the health insurance marketplace amended,
191	191	16 delivered, issued, or renewed on or after January 1, 2019 (the
192	192	17 effective date of Public Act 100-1024):
193	193	18 (A) shall provide coverage based upon medical
194	194	19 necessity for the treatment of a mental, emotional,
195	195	20 nervous, or substance use disorder or condition consistent
196	196	21 with the parity requirements of Section 370c.1 of this
197	197	22 Code; provided, however, that in each calendar year
198	198	23 coverage shall not be less than the following:
199	199	24 (i) 45 days of inpatient treatment; and
200	200	25 (ii) beginning on June 26, 2006 (the effective
201	201	26 date of Public Act 94-921), 60 visits for outpatient
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212	212	1 treatment including group and individual outpatient
213	213	2 treatment; and
214	214	3 (iii) for plans or policies delivered, issued for
215	215	4 delivery, renewed, or modified after January 1, 2007
216	216	5 (the effective date of Public Act 94-906), 20
217	217	6 additional outpatient visits for speech therapy for
218	218	7 treatment of pervasive developmental disorders that
219	219	8 will be in addition to speech therapy provided
220	220	9 pursuant to item (ii) of this subparagraph (A); and
221	221	10 (B) may not include a lifetime limit on the number of
222	222	11 days of inpatient treatment or the number of outpatient
223	223	12 visits covered under the plan.
224	224	13 (C) (Blank).
225	225	14 (5) An issuer of a group health benefit plan or an
226	226	15 individual policy of accident and health insurance or a
227	227	16 qualified health plan offered through the health insurance
228	228	17 marketplace may not count toward the number of outpatient
229	229	18 visits required to be covered under this Section an outpatient
230	230	19 visit for the purpose of medication management and shall cover
231	231	20 the outpatient visits under the same terms and conditions as
232	232	21 it covers outpatient visits for the treatment of physical
233	233	22 illness.
234	234	23 (5.5) An individual or group health benefit plan amended,
235	235	24 delivered, issued, or renewed on or after September 9, 2015
236	236	25 (the effective date of Public Act 99-480) shall offer coverage
237	237	26 for medically necessary acute treatment services and medically
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248	248	1 necessary clinical stabilization services. The treating
249	249	2 provider shall base all treatment recommendations and the
250	250	3 health benefit plan shall base all medical necessity
251	251	4 determinations for substance use disorders in accordance with
252	252	5 the most current edition of the Treatment Criteria for
253	253	6 Addictive, Substance-Related, and Co-Occurring Conditions
254	254	7 established by the American Society of Addiction Medicine. The
255	255	8 treating provider shall base all treatment recommendations and
256	256	9 the health benefit plan shall base all medical necessity
257	257	10 determinations for medication-assisted treatment in accordance
258	258	11 with the most current Treatment Criteria for Addictive,
259	259	12 Substance-Related, and Co-Occurring Conditions established by
260	260	13 the American Society of Addiction Medicine.
261	261	14 As used in this subsection:
262	262	15 "Acute treatment services" means 24-hour medically
263	263	16 supervised addiction treatment that provides evaluation and
264	264	17 withdrawal management and may include biopsychosocial
265	265	18 assessment, individual and group counseling, psychoeducational
266	266	19 groups, and discharge planning.
267	267	20 "Clinical stabilization services" means 24-hour treatment,
268	268	21 usually following acute treatment services for substance
269	269	22 abuse, which may include intensive education and counseling
270	270	23 regarding the nature of addiction and its consequences,
271	271	24 relapse prevention, outreach to families and significant
272	272	25 others, and aftercare planning for individuals beginning to
273	273	26 engage in recovery from addiction.
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284	284	1 (6) An issuer of a group health benefit plan may provide or
285	285	2 offer coverage required under this Section through a managed
286	286	3 care plan.
287	287	4 (6.5) An individual or group health benefit plan amended,
288	288	5 delivered, issued, or renewed on or after the effective date
289	289	6 of this amendatory Act of the 104th General Assembly January
290	290	7 1, 2019 (the effective date of Public Act 100-1024):
291	291	8 (A) shall not impose prior authorization requirements,
292	292	9 including limitations on dosage, other than those
293	293	10 established under the Treatment Criteria for Addictive,
294	294	11 Substance-Related, and Co-Occurring Conditions
295	295	12 established by the American Society of Addiction Medicine,
296	296	13 on a prescription medication approved by the United States
297	297	14 Food and Drug Administration that is prescribed or
298	298	15 administered for the treatment of substance use disorders;
299	299	16 (B) shall not impose any step therapy requirements;
300	300	17 (C) shall place all prescription medications approved
301	301	18 by the United States Food and Drug Administration
302	302	19 prescribed or administered for the treatment of substance
303	303	20 use disorders on, for brand medications, the lowest tier
304	304	21 of the drug formulary developed and maintained by the
305	305	22 individual or group health benefit plan that covers brand
306	306	23 medications and, for generic medications, the lowest tier
307	307	24 of the drug formulary developed and maintained by the
308	308	25 individual or group health benefit plan that covers
309	309	26 generic medications; and
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320	320	1 (D) shall not exclude coverage for a prescription
321	321	2 medication approved by the United States Food and Drug
322	322	3 Administration for the treatment of substance use
323	323	4 disorders and any associated counseling or wraparound
324	324	5 services on the grounds that such medications and services
325	325	6 were court ordered; and .
326	326	7 (E) shall not impose any prior authorization
327	327	8 requirements on outpatient services for the prevention,
328	328	9 screening, diagnosis, or treatment of mental, emotional,
329	329	10 nervous, or substance use disorders or conditions.
330	330	11 (7) (Blank).
331	331	12 (8) (Blank).
332	332	13 (9) With respect to all mental, emotional, nervous, or
333	333	14 substance use disorders or conditions, coverage for inpatient
334	334	15 treatment shall include coverage for treatment in a
335	335	16 residential treatment center certified or licensed by the
336	336	17 Department of Public Health or the Department of Human
337	337	18 Services.
338	338	19 (c) This Section shall not be interpreted to require
339	339	20 coverage for speech therapy or other habilitative services for
340	340	21 those individuals covered under Section 356z.15 of this Code.
341	341	22 (d) With respect to a group or individual policy of
342	342	23 accident and health insurance or a qualified health plan
343	343	24 offered through the health insurance marketplace, the
344	344	25 Department and, with respect to medical assistance, the
345	345	26 Department of Healthcare and Family Services shall each
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356	356	1 enforce the requirements of this Section and Sections 356z.23
357	357	2 and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
358	358	3 Mental Health Parity and Addiction Equity Act of 2008, 42
359	359	4 U.S.C. 18031(j), and any amendments to, and federal guidance
360	360	5 or regulations issued under, those Acts, including, but not
361	361	6 limited to, final regulations issued under the Paul Wellstone
362	362	7 and Pete Domenici Mental Health Parity and Addiction Equity
363	363	8 Act of 2008 and final regulations applying the Paul Wellstone
364	364	9 and Pete Domenici Mental Health Parity and Addiction Equity
365	365	10 Act of 2008 to Medicaid managed care organizations, the
366	366	11 Children's Health Insurance Program, and alternative benefit
367	367	12 plans. Specifically, the Department and the Department of
368	368	13 Healthcare and Family Services shall take action:
369	369	14 (1) proactively ensuring compliance by individual and
370	370	15 group policies, including by requiring that insurers
371	371	16 submit comparative analyses, as set forth in paragraph (6)
372	372	17 of subsection (k) of Section 370c.1, demonstrating how
373	373	18 they design and apply nonquantitative treatment
374	374	19 limitations, both as written and in operation, for mental,
375	375	20 emotional, nervous, or substance use disorder or condition
376	376	21 benefits as compared to how they design and apply
377	377	22 nonquantitative treatment limitations, as written and in
378	378	23 operation, for medical and surgical benefits;
379	379	24 (2) evaluating all consumer or provider complaints
380	380	25 regarding mental, emotional, nervous, or substance use
381	381	26 disorder or condition coverage for possible parity
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392	392	1 violations;
393	393	2 (3) performing parity compliance market conduct
394	394	3 examinations or, in the case of the Department of
395	395	4 Healthcare and Family Services, parity compliance audits
396	396	5 of individual and group plans and policies, including, but
397	397	6 not limited to, reviews of:
398	398	7 (A) nonquantitative treatment limitations,
399	399	8 including, but not limited to, prior authorization
400	400	9 requirements, concurrent review, retrospective review,
401	401	10 step therapy, network admission standards,
402	402	11 reimbursement rates, and geographic restrictions;
403	403	12 (B) denials of authorization, payment, and
404	404	13 coverage; and
405	405	14 (C) other specific criteria as may be determined
406	406	15 by the Department.
407	407	16 The findings and the conclusions of the parity compliance
408	408	17 market conduct examinations and audits shall be made public.
409	409	18 The Director may adopt rules to effectuate any provisions
410	410	19 of the Paul Wellstone and Pete Domenici Mental Health Parity
411	411	20 and Addiction Equity Act of 2008 that relate to the business of
412	412	21 insurance.
413	413	22 (e) Availability of plan information.
414	414	23 (1) The criteria for medical necessity determinations
415	415	24 made under a group health plan, an individual policy of
416	416	25 accident and health insurance, or a qualified health plan
417	417	26 offered through the health insurance marketplace with
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428	428	1 respect to mental health or substance use disorder
429	429	2 benefits (or health insurance coverage offered in
430	430	3 connection with the plan with respect to such benefits)
431	431	4 must be made available by the plan administrator (or the
432	432	5 health insurance issuer offering such coverage) to any
433	433	6 current or potential participant, beneficiary, or
434	434	7 contracting provider upon request.
435	435	8 (2) The reason for any denial under a group health
436	436	9 benefit plan, an individual policy of accident and health
437	437	10 insurance, or a qualified health plan offered through the
438	438	11 health insurance marketplace (or health insurance coverage
439	439	12 offered in connection with such plan or policy) of
440	440	13 reimbursement or payment for services with respect to
441	441	14 mental, emotional, nervous, or substance use disorders or
442	442	15 conditions benefits in the case of any participant or
443	443	16 beneficiary must be made available within a reasonable
444	444	17 time and in a reasonable manner and in readily
445	445	18 understandable language by the plan administrator (or the
446	446	19 health insurance issuer offering such coverage) to the
447	447	20 participant or beneficiary upon request.
448	448	21 (f) As used in this Section, "group policy of accident and
449	449	22 health insurance" and "group health benefit plan" includes (1)
450	450	23 State-regulated employer-sponsored group health insurance
451	451	24 plans written in Illinois or which purport to provide coverage
452	452	25 for a resident of this State; and (2) State employee health
453	453	26 plans.
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464	464	1 (g) (1) As used in this subsection:
465	465	2 "Benefits", with respect to insurers, means the benefits
466	466	3 provided for treatment services for inpatient and outpatient
467	467	4 treatment of substance use disorders or conditions at American
468	468	5 Society of Addiction Medicine levels of treatment 2.1
469	469	6 (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1
470	470	7 (Clinically Managed Low-Intensity Residential), 3.3
471	471	8 (Clinically Managed Population-Specific High-Intensity
472	472	9 Residential), 3.5 (Clinically Managed High-Intensity
473	473	10 Residential), and 3.7 (Medically Monitored Intensive
474	474	11 Inpatient) and OMT (Opioid Maintenance Therapy) services.
475	475	12 "Benefits", with respect to managed care organizations,
476	476	13 means the benefits provided for treatment services for
477	477	14 inpatient and outpatient treatment of substance use disorders
478	478	15 or conditions at American Society of Addiction Medicine levels
479	479	16 of treatment 2.1 (Intensive Outpatient), 2.5 (Partial
480	480	17 Hospitalization), 3.5 (Clinically Managed High-Intensity
481	481	18 Residential), and 3.7 (Medically Monitored Intensive
482	482	19 Inpatient) and OMT (Opioid Maintenance Therapy) services.
483	483	20 "Substance use disorder treatment provider or facility"
484	484	21 means a licensed physician, licensed psychologist, licensed
485	485	22 psychiatrist, licensed advanced practice registered nurse, or
486	486	23 licensed, certified, or otherwise State-approved facility or
487	487	24 provider of substance use disorder treatment.
488	488	25 (2) A group health insurance policy, an individual health
489	489	26 benefit plan, or qualified health plan that is offered through
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500	500	1 the health insurance marketplace, small employer group health
501	501	2 plan, and large employer group health plan that is amended,
502	502	3 delivered, issued, executed, or renewed in this State, or
503	503	4 approved for issuance or renewal in this State, on or after
504	504	5 January 1, 2019 (the effective date of Public Act 100-1023)
505	505	6 shall comply with the requirements of this Section and Section
506	506	7 370c.1. The services for the treatment and the ongoing
507	507	8 assessment of the patient's progress in treatment shall follow
508	508	9 the requirements of 77 Ill. Adm. Code 2060.
509	509	10 (3) Prior authorization shall not be utilized for the
510	510	11 benefits under this subsection. The substance use disorder
511	511	12 treatment provider or facility shall notify the insurer of the
512	512	13 initiation of treatment. For an insurer that is not a managed
513	513	14 care organization, the substance use disorder treatment
514	514	15 provider or facility notification shall occur for the
515	515	16 initiation of treatment of the covered person within 2
516	516	17 business days. For managed care organizations, the substance
517	517	18 use disorder treatment provider or facility notification shall
518	518	19 occur in accordance with the protocol set forth in the
519	519	20 provider agreement for initiation of treatment within 24
520	520	21 hours. If the managed care organization is not capable of
521	521	22 accepting the notification in accordance with the contractual
522	522	23 protocol during the 24-hour period following admission, the
523	523	24 substance use disorder treatment provider or facility shall
524	524	25 have one additional business day to provide the notification
525	525	26 to the appropriate managed care organization. Treatment plans
526	526
527	527
528	528
529	529
530	530
531	531	HB3020 - 14 - LRB104 08245 BAB 18295 b
532	532
533	533
534	534	HB3020- 15 -LRB104 08245 BAB 18295 b HB3020 - 15 - LRB104 08245 BAB 18295 b
535	535	HB3020 - 15 - LRB104 08245 BAB 18295 b
536	536	1 shall be developed in accordance with the requirements and
537	537	2 timeframes established in 77 Ill. Adm. Code 2060. If the
538	538	3 substance use disorder treatment provider or facility fails to
539	539	4 notify the insurer of the initiation of treatment in
540	540	5 accordance with these provisions, the insurer may follow its
541	541	6 normal prior authorization processes.
542	542	7 (4) For an insurer that is not a managed care
543	543	8 organization, if an insurer determines that benefits are no
544	544	9 longer medically necessary, the insurer shall notify the
545	545	10 covered person, the covered person's authorized
546	546	11 representative, if any, and the covered person's health care
547	547	12 provider in writing of the covered person's right to request
548	548	13 an external review pursuant to the Health Carrier External
549	549	14 Review Act. The notification shall occur within 24 hours
550	550	15 following the adverse determination.
551	551	16 Pursuant to the requirements of the Health Carrier
552	552	17 External Review Act, the covered person or the covered
553	553	18 person's authorized representative may request an expedited
554	554	19 external review. An expedited external review may not occur if
555	555	20 the substance use disorder treatment provider or facility
556	556	21 determines that continued treatment is no longer medically
557	557	22 necessary.
558	558	23 If an expedited external review request meets the criteria
559	559	24 of the Health Carrier External Review Act, an independent
560	560	25 review organization shall make a final determination of
561	561	26 medical necessity within 72 hours. If an independent review
562	562
563	563
564	564
565	565
566	566
567	567	HB3020 - 15 - LRB104 08245 BAB 18295 b
568	568
569	569
570	570	HB3020- 16 -LRB104 08245 BAB 18295 b HB3020 - 16 - LRB104 08245 BAB 18295 b
571	571	HB3020 - 16 - LRB104 08245 BAB 18295 b
572	572	1 organization upholds an adverse determination, an insurer
573	573	2 shall remain responsible to provide coverage of benefits
574	574	3 through the day following the determination of the independent
575	575	4 review organization. A decision to reverse an adverse
576	576	5 determination shall comply with the Health Carrier External
577	577	6 Review Act.
578	578	7 (5) The substance use disorder treatment provider or
579	579	8 facility shall provide the insurer with 7 business days'
580	580	9 advance notice of the planned discharge of the patient from
581	581	10 the substance use disorder treatment provider or facility and
582	582	11 notice on the day that the patient is discharged from the
583	583	12 substance use disorder treatment provider or facility.
584	584	13 (6) The benefits required by this subsection shall be
585	585	14 provided to all covered persons with a diagnosis of substance
586	586	15 use disorder or conditions. The presence of additional related
587	587	16 or unrelated diagnoses shall not be a basis to reduce or deny
588	588	17 the benefits required by this subsection.
589	589	18 (7) Nothing in this subsection shall be construed to
590	590	19 require an insurer to provide coverage for any of the benefits
591	591	20 in this subsection.
592	592	21 (h) As used in this Section:
593	593	22 "Generally accepted standards of mental, emotional,
594	594	23 nervous, or substance use disorder or condition care" means
595	595	24 standards of care and clinical practice that are generally
596	596	25 recognized by health care providers practicing in relevant
597	597	26 clinical specialties such as psychiatry, psychology, clinical
598	598
599	599
600	600
601	601
602	602
603	603	HB3020 - 16 - LRB104 08245 BAB 18295 b
604	604
605	605
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607	607	HB3020 - 17 - LRB104 08245 BAB 18295 b
608	608	1 sociology, social work, addiction medicine and counseling, and
609	609	2 behavioral health treatment. Valid, evidence-based sources
610	610	3 reflecting generally accepted standards of mental, emotional,
611	611	4 nervous, or substance use disorder or condition care include
612	612	5 peer-reviewed scientific studies and medical literature,
613	613	6 recommendations of nonprofit health care provider professional
614	614	7 associations and specialty societies, including, but not
615	615	8 limited to, patient placement criteria and clinical practice
616	616	9 guidelines, recommendations of federal government agencies,
617	617	10 and drug labeling approved by the United States Food and Drug
618	618	11 Administration.
619	619	12 "Medically necessary treatment of mental, emotional,
620	620	13 nervous, or substance use disorders or conditions" means a
621	621	14 service or product addressing the specific needs of that
622	622	15 patient, for the purpose of screening, preventing, diagnosing,
623	623	16 managing, or treating an illness, injury, or condition or its
624	624	17 symptoms and comorbidities, including minimizing the
625	625	18 progression of an illness, injury, or condition or its
626	626	19 symptoms and comorbidities in a manner that is all of the
627	627	20 following:
628	628	21 (1) in accordance with the generally accepted
629	629	22 standards of mental, emotional, nervous, or substance use
630	630	23 disorder or condition care;
631	631	24 (2) clinically appropriate in terms of type,
632	632	25 frequency, extent, site, and duration; and
633	633	26 (3) not primarily for the economic benefit of the
634	634
635	635
636	636
637	637
638	638
639	639	HB3020 - 17 - LRB104 08245 BAB 18295 b
640	640
641	641
642	642	HB3020- 18 -LRB104 08245 BAB 18295 b HB3020 - 18 - LRB104 08245 BAB 18295 b
643	643	HB3020 - 18 - LRB104 08245 BAB 18295 b
644	644	1 insurer, purchaser, or for the convenience of the patient,
645	645	2 treating physician, or other health care provider.
646	646	3 "Utilization review" means either of the following:
647	647	4 (1) prospectively, retrospectively, or concurrently
648	648	5 reviewing and approving, modifying, delaying, or denying,
649	649	6 based in whole or in part on medical necessity, requests
650	650	7 by health care providers, insureds, or their authorized
651	651	8 representatives for coverage of health care services
652	652	9 before, retrospectively, or concurrently with the
653	653	10 provision of health care services to insureds.
654	654	11 (2) evaluating the medical necessity, appropriateness,
655	655	12 level of care, service intensity, efficacy, or efficiency
656	656	13 of health care services, benefits, procedures, or
657	657	14 settings, under any circumstances, to determine whether a
658	658	15 health care service or benefit subject to a medical
659	659	16 necessity coverage requirement in an insurance policy is
660	660	17 covered as medically necessary for an insured.
661	661	18 "Utilization review criteria" means patient placement
662	662	19 criteria or any criteria, standards, protocols, or guidelines
663	663	20 used by an insurer to conduct utilization review.
664	664	21 (i)(1) Every insurer that amends, delivers, issues, or
665	665	22 renews a group or individual policy of accident and health
666	666	23 insurance or a qualified health plan offered through the
667	667	24 health insurance marketplace in this State and Medicaid
668	668	25 managed care organizations providing coverage for hospital or
669	669	26 medical treatment on or after January 1, 2023 shall, pursuant
670	670
671	671
672	672
673	673
674	674
675	675	HB3020 - 18 - LRB104 08245 BAB 18295 b
676	676
677	677
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679	679	HB3020 - 19 - LRB104 08245 BAB 18295 b
680	680	1 to subsections (h) through (s), provide coverage for medically
681	681	2 necessary treatment of mental, emotional, nervous, or
682	682	3 substance use disorders or conditions.
683	683	4 (2) An insurer shall not set a specific limit on the
684	684	5 duration of benefits or coverage of medically necessary
685	685	6 treatment of mental, emotional, nervous, or substance use
686	686	7 disorders or conditions or limit coverage only to alleviation
687	687	8 of the insured's current symptoms.
688	688	9 (3) All utilization review conducted by the insurer
689	689	10 concerning diagnosis, prevention, and treatment of insureds
690	690	11 diagnosed with mental, emotional, nervous, or substance use
691	691	12 disorders or conditions shall be conducted in accordance with
692	692	13 the requirements of subsections (k) through (w).
693	693	14 (4) An insurer that authorizes a specific type of
694	694	15 treatment by a provider pursuant to this Section shall not
695	695	16 rescind or modify the authorization after that provider
696	696	17 renders the health care service in good faith and pursuant to
697	697	18 this authorization for any reason, including, but not limited
698	698	19 to, the insurer's subsequent cancellation or modification of
699	699	20 the insured's or policyholder's contract, or the insured's or
700	700	21 policyholder's eligibility. Nothing in this Section shall
701	701	22 require the insurer to cover a treatment when the
702	702	23 authorization was granted based on a material
703	703	24 misrepresentation by the insured, the policyholder, or the
704	704	25 provider. Nothing in this Section shall require Medicaid
705	705	26 managed care organizations to pay for services if the
706	706
707	707
708	708
709	709
710	710
711	711	HB3020 - 19 - LRB104 08245 BAB 18295 b
712	712
713	713
714	714	HB3020- 20 -LRB104 08245 BAB 18295 b HB3020 - 20 - LRB104 08245 BAB 18295 b
715	715	HB3020 - 20 - LRB104 08245 BAB 18295 b
716	716	1 individual was not eligible for Medicaid at the time the
717	717	2 service was rendered. Nothing in this Section shall require an
718	718	3 insurer to pay for services if the individual was not the
719	719	4 insurer's enrollee at the time services were rendered. As used
720	720	5 in this paragraph, "material" means a fact or situation that
721	721	6 is not merely technical in nature and results in or could
722	722	7 result in a substantial change in the situation.
723	723	8 (j) An insurer shall not limit benefits or coverage for
724	724	9 medically necessary services on the basis that those services
725	725	10 should be or could be covered by a public entitlement program,
726	726	11 including, but not limited to, special education or an
727	727	12 individualized education program, Medicaid, Medicare,
728	728	13 Supplemental Security Income, or Social Security Disability
729	729	14 Insurance, and shall not include or enforce a contract term
730	730	15 that excludes otherwise covered benefits on the basis that
731	731	16 those services should be or could be covered by a public
732	732	17 entitlement program. Nothing in this subsection shall be
733	733	18 construed to require an insurer to cover benefits that have
734	734	19 been authorized and provided for a covered person by a public
735	735	20 entitlement program. Medicaid managed care organizations are
736	736	21 not subject to this subsection.
737	737	22 (k) An insurer shall base any medical necessity
738	738	23 determination or the utilization review criteria that the
739	739	24 insurer, and any entity acting on the insurer's behalf,
740	740	25 applies to determine the medical necessity of health care
741	741	26 services and benefits for the diagnosis, prevention, and
742	742
743	743
744	744
745	745
746	746
747	747	HB3020 - 20 - LRB104 08245 BAB 18295 b
748	748
749	749
750	750	HB3020- 21 -LRB104 08245 BAB 18295 b HB3020 - 21 - LRB104 08245 BAB 18295 b
751	751	HB3020 - 21 - LRB104 08245 BAB 18295 b
752	752	1 treatment of mental, emotional, nervous, or substance use
753	753	2 disorders or conditions on current generally accepted
754	754	3 standards of mental, emotional, nervous, or substance use
755	755	4 disorder or condition care. All denials and appeals shall be
756	756	5 reviewed by a professional with experience or expertise
757	757	6 comparable to the provider requesting the authorization.
758	758	7 (l) In conducting utilization review of all covered health
759	759	8 care services for the diagnosis, prevention, and treatment of
760	760	9 mental, emotional, and nervous disorders or conditions, an
761	761	10 insurer shall apply the criteria and guidelines set forth in
762	762	11 the most recent version of the treatment criteria developed by
763	763	12 an unaffiliated nonprofit professional association for the
764	764	13 relevant clinical specialty or, for Medicaid managed care
765	765	14 organizations, criteria and guidelines determined by the
766	766	15 Department of Healthcare and Family Services that are
767	767	16 consistent with generally accepted standards of mental,
768	768	17 emotional, nervous or substance use disorder or condition
769	769	18 care. Pursuant to subsection (b), in conducting utilization
770	770	19 review of all covered services and benefits for the diagnosis,
771	771	20 prevention, and treatment of substance use disorders an
772	772	21 insurer shall use the most recent edition of the patient
773	773	22 placement criteria established by the American Society of
774	774	23 Addiction Medicine.
775	775	24 (m) In conducting utilization review relating to level of
776	776	25 care placement, continued stay, transfer, discharge, or any
777	777	26 other patient care decisions that are within the scope of the
778	778
779	779
780	780
781	781
782	782
783	783	HB3020 - 21 - LRB104 08245 BAB 18295 b
784	784
785	785
786	786	HB3020- 22 -LRB104 08245 BAB 18295 b HB3020 - 22 - LRB104 08245 BAB 18295 b
787	787	HB3020 - 22 - LRB104 08245 BAB 18295 b
788	788	1 sources specified in subsection (l), an insurer shall not
789	789	2 apply different, additional, conflicting, or more restrictive
790	790	3 utilization review criteria than the criteria set forth in
791	791	4 those sources. For all level of care placement decisions, the
792	792	5 insurer shall authorize placement at the level of care
793	793	6 consistent with the assessment of the insured using the
794	794	7 relevant patient placement criteria as specified in subsection
795	795	8 (l). If that level of placement is not available, the insurer
796	796	9 shall authorize the next higher level of care. In the event of
797	797	10 disagreement, the insurer shall provide full detail of its
798	798	11 assessment using the relevant criteria as specified in
799	799	12 subsection (l) to the provider of the service and the patient.
800	800	13 If an insurer purchases or licenses utilization review
801	801	14 criteria pursuant to this subsection, the insurer shall verify
802	802	15 and document before use that the criteria were developed in
803	803	16 accordance with subsection (k).
804	804	17 (n) In conducting utilization review that is outside the
805	805	18 scope of the criteria as specified in subsection (l) or
806	806	19 relates to the advancements in technology or in the types or
807	807	20 levels of care that are not addressed in the most recent
808	808	21 versions of the sources specified in subsection (l), an
809	809	22 insurer shall conduct utilization review in accordance with
810	810	23 subsection (k).
811	811	24 (o) This Section does not in any way limit the rights of a
812	812	25 patient under the Medical Patient Rights Act.
813	813	26 (p) This Section does not in any way limit early and
814	814
815	815
816	816
817	817
818	818
819	819	HB3020 - 22 - LRB104 08245 BAB 18295 b
820	820
821	821
822	822	HB3020- 23 -LRB104 08245 BAB 18295 b HB3020 - 23 - LRB104 08245 BAB 18295 b
823	823	HB3020 - 23 - LRB104 08245 BAB 18295 b
824	824	1 periodic screening, diagnostic, and treatment benefits as
825	825	2 defined under 42 U.S.C. 1396d(r).
826	826	3 (q) To ensure the proper use of the criteria described in
827	827	4 subsection (l), every insurer shall do all of the following:
828	828	5 (1) Educate the insurer's staff, including any third
829	829	6 parties contracted with the insurer to review claims,
830	830	7 conduct utilization reviews, or make medical necessity
831	831	8 determinations about the utilization review criteria.
832	832	9 (2) Make the educational program available to other
833	833	10 stakeholders, including the insurer's participating or
834	834	11 contracted providers and potential participants,
835	835	12 beneficiaries, or covered lives. The education program
836	836	13 must be provided at least once a year, in-person or
837	837	14 digitally, or recordings of the education program must be
838	838	15 made available to the aforementioned stakeholders.
839	839	16 (3) Provide, at no cost, the utilization review
840	840	17 criteria and any training material or resources to
841	841	18 providers and insured patients upon request. For
842	842	19 utilization review criteria not concerning level of care
843	843	20 placement, continued stay, transfer, discharge, or other
844	844	21 patient care decisions used by the insurer pursuant to
845	845	22 subsection (m), the insurer may place the criteria on a
846	846	23 secure, password-protected website so long as the access
847	847	24 requirements of the website do not unreasonably restrict
848	848	25 access to insureds or their providers. No restrictions
849	849	26 shall be placed upon the insured's or treating provider's
850	850
851	851
852	852
853	853
854	854
855	855	HB3020 - 23 - LRB104 08245 BAB 18295 b
856	856
857	857
858	858	HB3020- 24 -LRB104 08245 BAB 18295 b HB3020 - 24 - LRB104 08245 BAB 18295 b
859	859	HB3020 - 24 - LRB104 08245 BAB 18295 b
860	860	1 access right to utilization review criteria obtained under
861	861	2 this paragraph at any point in time, including before an
862	862	3 initial request for authorization.
863	863	4 (4) Track, identify, and analyze how the utilization
864	864	5 review criteria are used to certify care, deny care, and
865	865	6 support the appeals process.
866	866	7 (5) Conduct interrater reliability testing to ensure
867	867	8 consistency in utilization review decision making that
868	868	9 covers how medical necessity decisions are made; this
869	869	10 assessment shall cover all aspects of utilization review
870	870	11 as defined in subsection (h).
871	871	12 (6) Run interrater reliability reports about how the
872	872	13 clinical guidelines are used in conjunction with the
873	873	14 utilization review process and parity compliance
874	874	15 activities.
875	875	16 (7) Achieve interrater reliability pass rates of at
876	876	17 least 90% and, if this threshold is not met, immediately
877	877	18 provide for the remediation of poor interrater reliability
878	878	19 and interrater reliability testing for all new staff
879	879	20 before they can conduct utilization review without
880	880	21 supervision.
881	881	22 (8) Maintain documentation of interrater reliability
882	882	23 testing and the remediation actions taken for those with
883	883	24 pass rates lower than 90% and submit to the Department of
884	884	25 Insurance or, in the case of Medicaid managed care
885	885	26 organizations, the Department of Healthcare and Family
886	886
887	887
888	888
889	889
890	890
891	891	HB3020 - 24 - LRB104 08245 BAB 18295 b
892	892
893	893
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895	895	HB3020 - 25 - LRB104 08245 BAB 18295 b
896	896	1 Services the testing results and a summary of remedial
897	897	2 actions as part of parity compliance reporting set forth
898	898	3 in subsection (k) of Section 370c.1.
899	899	4 (r) This Section applies to all health care services and
900	900	5 benefits for the diagnosis, prevention, and treatment of
901	901	6 mental, emotional, nervous, or substance use disorders or
902	902	7 conditions covered by an insurance policy, including
903	903	8 prescription drugs.
904	904	9 (s) This Section applies to an insurer that amends,
905	905	10 delivers, issues, or renews a group or individual policy of
906	906	11 accident and health insurance or a qualified health plan
907	907	12 offered through the health insurance marketplace in this State
908	908	13 providing coverage for hospital or medical treatment and
909	909	14 conducts utilization review as defined in this Section,
910	910	15 including Medicaid managed care organizations, and any entity
911	911	16 or contracting provider that performs utilization review or
912	912	17 utilization management functions on an insurer's behalf.
913	913	18 (t) If the Director determines that an insurer has
914	914	19 violated this Section, the Director may, after appropriate
915	915	20 notice and opportunity for hearing, by order, assess a civil
916	916	21 penalty between $1,000 and $5,000 for each violation. Moneys
917	917	22 collected from penalties shall be deposited into the Parity
918	918	23 Advancement Fund established in subsection (i) of Section
919	919	24 370c.1.
920	920	25 (u) An insurer shall not adopt, impose, or enforce terms
921	921	26 in its policies or provider agreements, in writing or in
922	922
923	923
924	924
925	925
926	926
927	927	HB3020 - 25 - LRB104 08245 BAB 18295 b
928	928
929	929
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931	931	HB3020 - 26 - LRB104 08245 BAB 18295 b
932	932	1 operation, that undermine, alter, or conflict with the
933	933	2 requirements of this Section.
934	934	3 (v) The provisions of this Section are severable. If any
935	935	4 provision of this Section or its application is held invalid,
936	936	5 that invalidity shall not affect other provisions or
937	937	6 applications that can be given effect without the invalid
938	938	7 provision or application.
939	939	8 (w) Beginning January 1, 2026, coverage for inpatient
940	940	9 mental health treatment at participating hospitals shall
941	941	10 comply with the following requirements:
942	942	11 (1) Subject to paragraphs (2) and (3) of this
943	943	12 subsection, no policy shall require prior authorization
944	944	13 for admission for such treatment at any participating
945	945	14 hospital.
946	946	15 (2) Coverage provided under this subsection also shall
947	947	16 not be subject to concurrent review for the first 72
948	948	17 hours, provided that the hospital must notify the insurer
949	949	18 of both the admission and the initial treatment plan
950	950	19 within 48 hours of admission. A discharge plan must be
951	951	20 fully developed and continuity services prepared to meet
952	952	21 the patient's needs and the patient's community preference
953	953	22 upon release. Nothing in this paragraph supersedes a
954	954	23 health maintenance organization's referral requirement for
955	955	24 services from nonparticipating providers upon a patient's
956	956	25 discharge from a hospital.
957	957	26 (3) Treatment provided under this subsection may be
958	958
959	959
960	960
961	961
962	962
963	963	HB3020 - 26 - LRB104 08245 BAB 18295 b
964	964
965	965
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967	967	HB3020 - 27 - LRB104 08245 BAB 18295 b
968	968	1 reviewed retrospectively. If coverage is denied
969	969	2 retrospectively, neither the insurer nor the participating
970	970	3 hospital shall bill, and the insured shall not be liable,
971	971	4 for any treatment under this subsection through the date
972	972	5 the adverse determination is issued, other than any
973	973	6 copayment, coinsurance, or deductible for the stay through
974	974	7 that date as applicable under the policy. Coverage shall
975	975	8 not be retrospectively denied for the first 72 hours of
976	976	9 treatment at a participating hospital except:
977	977	10 (A) upon reasonable determination that the
978	978	11 inpatient mental health treatment was not provided;
979	979	12 (B) upon determination that the patient receiving
980	980	13 the treatment was not an insured, enrollee, or
981	981	14 beneficiary under the policy;
982	982	15 (C) upon material misrepresentation by the patient
983	983	16 or health care provider. In this item (C), "material"
984	984	17 means a fact or situation that is not merely technical
985	985	18 in nature and results or could result in a substantial
986	986	19 change in the situation; or
987	987	20 (D) upon determination that a service was excluded
988	988	21 under the terms of coverage. In that case, the
989	989	22 limitation to billing for a copayment, coinsurance, or
990	990	23 deductible shall not apply.
991	991	24 (4) Nothing in this subsection shall be construed to
992	992	25 require a policy to cover any health care service excluded
993	993	26 under the terms of coverage.
994	994
995	995
996	996
997	997
998	998
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1000	1000
1001	1001
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1003	1003	HB3020 - 28 - LRB104 08245 BAB 18295 b
1004	1004	1 (x) Notwithstanding any provision of this Section, nothing
1005	1005	2 shall require the medical assistance program under Article V
1006	1006	3 of the Illinois Public Aid Code to violate any applicable
1007	1007	4 federal laws, regulations, or grant requirements or any State
1008	1008	5 or federal consent decrees. Nothing in subsection (w) shall
1009	1009	6 prevent the Department of Healthcare and Family Services from
1010	1010	7 requiring a health care provider to use specified level of
1011	1011	8 care, admission, continued stay, or discharge criteria,
1012	1012	9 including, but not limited to, those under Section 5-5.23 of
1013	1013	10 the Illinois Public Aid Code, as long as the Department of
1014	1014	11 Healthcare and Family Services does not require a health care
1015	1015	12 provider to seek prior authorization or concurrent review from
1016	1016	13 the Department of Healthcare and Family Services, a Medicaid
1017	1017	14 managed care organization, or a utilization review
1018	1018	15 organization under the circumstances expressly prohibited by
1019	1019	16 subsection (w). Nothing in this Section prohibits a health
1020	1020	17 plan, including a Medicaid managed care organization, from
1021	1021	18 conducting reviews for fraud, waste, or abuse and reporting
1022	1022	19 suspected fraud, waste, or abuse according to State and
1023	1023	20 federal requirements.
1024	1024	21 (y) Children's Mental Health. Nothing in this Section
1025	1025	22 shall suspend the screening and assessment requirements for
1026	1026	23 mental health services for children participating in the
1027	1027	24 State's medical assistance program as required in Section
1028	1028	25 5-5.23 of the Illinois Public Aid Code.
1029	1029	26 (Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;
1030	1030
1031	1031
1032	1032
1033	1033
1034	1034
1035	1035	HB3020 - 28 - LRB104 08245 BAB 18295 b
1036	1036
1037	1037
1038	1038	HB3020- 29 -LRB104 08245 BAB 18295 b HB3020 - 29 - LRB104 08245 BAB 18295 b
1039	1039	HB3020 - 29 - LRB104 08245 BAB 18295 b
1040	1040
1041	1041
1042	1042
1043	1043
1044	1044
1045	1045	HB3020 - 29 - LRB104 08245 BAB 18295 b