Bill Text: IL HB2438 | 2019-2020 | 101st General Assembly | Enrolled
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Amends the Illinois Insurance Code. In provisions concerning mental and emotional disorders, provides that "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. Effective immediately.
Spectrum: Moderate Partisan Bill (Democrat 15-4)
Status: (Passed) 2019-08-16 - Public Act . . . . . . . . . 101-0386 [HB2438 Detail]
Download: Illinois-2019-HB2438-Enrolled.html
Bill Title: Amends the Illinois Insurance Code. In provisions concerning mental and emotional disorders, provides that "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. Effective immediately.
Spectrum: Moderate Partisan Bill (Democrat 15-4)
Status: (Passed) 2019-08-16 - Public Act . . . . . . . . . 101-0386 [HB2438 Detail]
Download: Illinois-2019-HB2438-Enrolled.html
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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | ||||||
5 | changing Section 370c as follows:
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6 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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7 | Sec. 370c. Mental and emotional disorders.
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8 | (a)(1) On and after the effective date of this amendatory | ||||||
9 | Act of the 101st General Assembly this amendatory Act of the | ||||||
10 | 100th General Assembly ,
every insurer that amends, delivers, | ||||||
11 | issues, or renews
group accident and health policies providing | ||||||
12 | coverage for hospital or medical treatment or
services for | ||||||
13 | illness on an expense-incurred basis shall provide coverage for | ||||||
14 | reasonable and necessary treatment and services
for mental, | ||||||
15 | emotional, nervous, or substance use disorders or conditions | ||||||
16 | consistent with the parity requirements of Section 370c.1 of | ||||||
17 | this Code.
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18 | (2) Each insured that is covered for mental, emotional, | ||||||
19 | nervous, or substance use
disorders or conditions shall be free | ||||||
20 | to select the physician licensed to
practice medicine in all | ||||||
21 | its branches, licensed clinical psychologist,
licensed | ||||||
22 | clinical social worker, licensed clinical professional | ||||||
23 | counselor, licensed marriage and family therapist, licensed |
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1 | speech-language pathologist, or other licensed or certified | ||||||
2 | professional at a program licensed pursuant to the Substance | ||||||
3 | Use Disorder Illinois Alcoholism and Other Drug Abuse and | ||||||
4 | Dependency Act of
his choice to treat such disorders, and
the | ||||||
5 | insurer shall pay the covered charges of such physician | ||||||
6 | licensed to
practice medicine in all its branches, licensed | ||||||
7 | clinical psychologist,
licensed clinical social worker, | ||||||
8 | licensed clinical professional counselor, licensed marriage | ||||||
9 | and family therapist, licensed speech-language pathologist, or | ||||||
10 | other licensed or certified professional at a program licensed | ||||||
11 | pursuant to the Substance Use Disorder Illinois Alcoholism and | ||||||
12 | Other Drug Abuse and Dependency Act up
to the limits of | ||||||
13 | coverage, provided (i)
the disorder or condition treated is | ||||||
14 | covered by the policy, and (ii) the
physician, licensed | ||||||
15 | psychologist, licensed clinical social worker, licensed
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16 | clinical professional counselor, licensed marriage and family | ||||||
17 | therapist, licensed speech-language pathologist, or other | ||||||
18 | licensed or certified professional at a program licensed | ||||||
19 | pursuant to the Substance Use Disorder Illinois Alcoholism and | ||||||
20 | Other Drug Abuse and Dependency Act is
authorized to provide | ||||||
21 | said services under the statutes of this State and in
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22 | accordance with accepted principles of his profession.
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23 | (3) Insofar as this Section applies solely to licensed | ||||||
24 | clinical social
workers, licensed clinical professional | ||||||
25 | counselors, licensed marriage and family therapists, licensed | ||||||
26 | speech-language pathologists, and other licensed or certified |
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1 | professionals at programs licensed pursuant to the Substance | ||||||
2 | Use Disorder Illinois Alcoholism and Other Drug Abuse and | ||||||
3 | Dependency Act, those persons who may
provide services to | ||||||
4 | individuals shall do so
after the licensed clinical social | ||||||
5 | worker, licensed clinical professional
counselor, licensed | ||||||
6 | marriage and family therapist, licensed speech-language | ||||||
7 | pathologist, or other licensed or certified professional at a | ||||||
8 | program licensed pursuant to the Substance Use Disorder | ||||||
9 | Illinois Alcoholism and Other Drug Abuse and Dependency Act has | ||||||
10 | informed the patient of the
desirability of the patient | ||||||
11 | conferring with the patient's primary care
physician.
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12 | (4) "Mental, emotional, nervous, or substance use disorder | ||||||
13 | or condition" means a condition or disorder that involves a | ||||||
14 | mental health condition or substance use disorder that falls | ||||||
15 | under any of the diagnostic categories listed in the mental and | ||||||
16 | behavioral disorders chapter of the current edition of the | ||||||
17 | International Classification of Disease or that is listed in | ||||||
18 | the most recent version of the Diagnostic and Statistical | ||||||
19 | Manual of Mental Disorders. "Mental, emotional, nervous, or | ||||||
20 | substance use disorder or condition" includes any mental health | ||||||
21 | condition that occurs during pregnancy or during the postpartum | ||||||
22 | period and includes, but is not limited to, postpartum | ||||||
23 | depression. | ||||||
24 | (b)(1) (Blank).
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25 | (2) (Blank).
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26 | (2.5) (Blank). |
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1 | (3) Unless otherwise prohibited by federal law and | ||||||
2 | consistent with the parity requirements of Section 370c.1 of | ||||||
3 | this Code, the reimbursing insurer that amends, delivers, | ||||||
4 | issues, or renews a group or individual policy of accident and | ||||||
5 | health insurance, a qualified health plan offered through the | ||||||
6 | health insurance marketplace, or a provider of treatment of | ||||||
7 | mental, emotional, nervous,
or substance use disorders or | ||||||
8 | conditions shall furnish medical records or other necessary | ||||||
9 | data
that substantiate that initial or continued treatment is | ||||||
10 | at all times medically
necessary. An insurer shall provide a | ||||||
11 | mechanism for the timely review by a
provider holding the same | ||||||
12 | license and practicing in the same specialty as the
patient's | ||||||
13 | provider, who is unaffiliated with the insurer, jointly | ||||||
14 | selected by
the patient (or the patient's next of kin or legal | ||||||
15 | representative if the
patient is unable to act for himself or | ||||||
16 | herself), the patient's provider, and
the insurer in the event | ||||||
17 | of a dispute between the insurer and patient's
provider | ||||||
18 | regarding the medical necessity of a treatment proposed by a | ||||||
19 | patient's
provider. If the reviewing provider determines the | ||||||
20 | treatment to be medically
necessary, the insurer shall provide | ||||||
21 | reimbursement for the treatment. Future
contractual or | ||||||
22 | employment actions by the insurer regarding the patient's
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23 | provider may not be based on the provider's participation in | ||||||
24 | this procedure.
Nothing prevents
the insured from agreeing in | ||||||
25 | writing to continue treatment at his or her
expense. When | ||||||
26 | making a determination of the medical necessity for a treatment
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1 | modality for mental, emotional, nervous, or substance use | ||||||
2 | disorders or conditions, an insurer must make the determination | ||||||
3 | in a
manner that is consistent with the manner used to make | ||||||
4 | that determination with
respect to other diseases or illnesses | ||||||
5 | covered under the policy, including an
appeals process. Medical | ||||||
6 | necessity determinations for substance use disorders shall be | ||||||
7 | made in accordance with appropriate patient placement criteria | ||||||
8 | established by the American Society of Addiction Medicine. No | ||||||
9 | additional criteria may be used to make medical necessity | ||||||
10 | determinations for substance use disorders.
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11 | (4) A group health benefit plan amended, delivered, issued, | ||||||
12 | or renewed on or after January 1, 2019 ( the effective date of | ||||||
13 | Public Act 100-1024) this amendatory Act of the 100th General | ||||||
14 | Assembly or an individual policy of accident and health | ||||||
15 | insurance or a qualified health plan offered through the health | ||||||
16 | insurance marketplace amended, delivered, issued, or renewed | ||||||
17 | on or after January 1, 2019 ( the effective date of Public Act | ||||||
18 | 100-1024) this amendatory Act of the 100th General Assembly :
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19 | (A) shall provide coverage based upon medical | ||||||
20 | necessity for the
treatment of a mental, emotional, | ||||||
21 | nervous, or substance use disorder or condition consistent | ||||||
22 | with the parity requirements of Section 370c.1 of this | ||||||
23 | Code; provided, however, that in each calendar year | ||||||
24 | coverage shall not be less than the following:
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25 | (i) 45 days of inpatient treatment; and
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26 | (ii) beginning on June 26, 2006 (the effective date |
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1 | of Public Act 94-921), 60 visits for outpatient | ||||||
2 | treatment including group and individual
outpatient | ||||||
3 | treatment; and | ||||||
4 | (iii) for plans or policies delivered, issued for | ||||||
5 | delivery, renewed, or modified after January 1, 2007 | ||||||
6 | (the effective date of Public Act 94-906),
20 | ||||||
7 | additional outpatient visits for speech therapy for | ||||||
8 | treatment of pervasive developmental disorders that | ||||||
9 | will be in addition to speech therapy provided pursuant | ||||||
10 | to item (ii) of this subparagraph (A); and
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11 | (B) may not include a lifetime limit on the number of | ||||||
12 | days of inpatient
treatment or the number of outpatient | ||||||
13 | visits covered under the plan.
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14 | (C) (Blank).
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15 | (5) An issuer of a group health benefit plan or an | ||||||
16 | individual policy of accident and health insurance or a | ||||||
17 | qualified health plan offered through the health insurance | ||||||
18 | marketplace may not count toward the number
of outpatient | ||||||
19 | visits required to be covered under this Section an outpatient
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20 | visit for the purpose of medication management and shall cover | ||||||
21 | the outpatient
visits under the same terms and conditions as it | ||||||
22 | covers outpatient visits for
the treatment of physical illness.
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23 | (5.5) An individual or group health benefit plan amended, | ||||||
24 | delivered, issued, or renewed on or after September 9, 2015 | ||||||
25 | ( the effective date of Public Act 99-480) this amendatory Act | ||||||
26 | of the 99th General Assembly shall offer coverage for medically |
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1 | necessary acute treatment services and medically necessary | ||||||
2 | clinical stabilization services. The treating provider shall | ||||||
3 | base all treatment recommendations and the health benefit plan | ||||||
4 | shall base all medical necessity determinations for substance | ||||||
5 | use disorders in accordance with the most current edition of | ||||||
6 | the Treatment Criteria for Addictive, Substance-Related, and | ||||||
7 | Co-Occurring Conditions established by the American Society of | ||||||
8 | Addiction Medicine. The treating provider shall base all | ||||||
9 | treatment recommendations and the health benefit plan shall | ||||||
10 | base all medical necessity determinations for | ||||||
11 | medication-assisted treatment in accordance with the most | ||||||
12 | current Treatment Criteria for Addictive, Substance-Related, | ||||||
13 | and Co-Occurring Conditions established by the American | ||||||
14 | Society of Addiction Medicine. | ||||||
15 | As used in this subsection: | ||||||
16 | "Acute treatment services" means 24-hour medically | ||||||
17 | supervised addiction treatment that provides evaluation and | ||||||
18 | withdrawal management and may include biopsychosocial | ||||||
19 | assessment, individual and group counseling, psychoeducational | ||||||
20 | groups, and discharge planning. | ||||||
21 | "Clinical stabilization services" means 24-hour treatment, | ||||||
22 | usually following acute treatment services for substance | ||||||
23 | abuse, which may include intensive education and counseling | ||||||
24 | regarding the nature of addiction and its consequences, relapse | ||||||
25 | prevention, outreach to families and significant others, and | ||||||
26 | aftercare planning for individuals beginning to engage in |
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1 | recovery from addiction. | ||||||
2 | (6) An issuer of a group health benefit
plan may provide or | ||||||
3 | offer coverage required under this Section through a
managed | ||||||
4 | care plan.
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5 | (6.5) An individual or group health benefit plan amended, | ||||||
6 | delivered, issued, or renewed on or after January 1, 2019 ( the | ||||||
7 | effective date of Public Act 100-1024) this amendatory Act of | ||||||
8 | the 100th General Assembly : | ||||||
9 | (A) shall not impose prior authorization requirements, | ||||||
10 | other than those established under the Treatment Criteria | ||||||
11 | for Addictive, Substance-Related, and Co-Occurring | ||||||
12 | Conditions established by the American Society of | ||||||
13 | Addiction Medicine, on a prescription medication approved | ||||||
14 | by the United States Food and Drug Administration that is | ||||||
15 | prescribed or administered for the treatment of substance | ||||||
16 | use disorders; | ||||||
17 | (B) shall not impose any step therapy requirements, | ||||||
18 | other than those established under the Treatment Criteria | ||||||
19 | for Addictive, Substance-Related, and Co-Occurring | ||||||
20 | Conditions established by the American Society of | ||||||
21 | Addiction Medicine, before authorizing coverage for a | ||||||
22 | prescription medication approved by the United States Food | ||||||
23 | and Drug Administration that is prescribed or administered | ||||||
24 | for the treatment of substance use disorders; | ||||||
25 | (C) shall place all prescription medications approved | ||||||
26 | by the United States Food and Drug Administration |
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1 | prescribed or administered for the treatment of substance | ||||||
2 | use disorders on, for brand medications, the lowest tier of | ||||||
3 | the drug formulary developed and maintained by the | ||||||
4 | individual or group health benefit plan that covers brand | ||||||
5 | medications and, for generic medications, the lowest tier | ||||||
6 | of the drug formulary developed and maintained by the | ||||||
7 | individual or group health benefit plan that covers generic | ||||||
8 | medications; and | ||||||
9 | (D) shall not exclude coverage for a prescription | ||||||
10 | medication approved by the United States Food and Drug | ||||||
11 | Administration for the treatment of substance use | ||||||
12 | disorders and any associated counseling or wraparound | ||||||
13 | services on the grounds that such medications and services | ||||||
14 | were court ordered. | ||||||
15 | (7) (Blank).
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16 | (8)
(Blank).
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17 | (9) With respect to all mental, emotional, nervous, or | ||||||
18 | substance use disorders or conditions, coverage for inpatient | ||||||
19 | treatment shall include coverage for treatment in a residential | ||||||
20 | treatment center certified or licensed by the Department of | ||||||
21 | Public Health or the Department of Human Services. | ||||||
22 | (c) This Section shall not be interpreted to require | ||||||
23 | coverage for speech therapy or other habilitative services for | ||||||
24 | those individuals covered under Section 356z.15
of this Code. | ||||||
25 | (d) With respect to a group or individual policy of | ||||||
26 | accident and health insurance or a qualified health plan |
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1 | offered through the health insurance marketplace, the | ||||||
2 | Department and, with respect to medical assistance, the | ||||||
3 | Department of Healthcare and Family Services shall each enforce | ||||||
4 | the requirements of this Section and Sections 356z.23 and | ||||||
5 | 370c.1 of this Code, the Paul Wellstone and Pete Domenici | ||||||
6 | Mental Health Parity and Addiction Equity Act of 2008, 42 | ||||||
7 | U.S.C. 18031(j), and any amendments to, and federal guidance or | ||||||
8 | regulations issued under, those Acts, including, but not | ||||||
9 | limited to, final regulations issued under the Paul Wellstone | ||||||
10 | and Pete Domenici Mental Health Parity and Addiction Equity Act | ||||||
11 | of 2008 and final regulations applying the Paul Wellstone and | ||||||
12 | Pete Domenici Mental Health Parity and Addiction Equity Act of | ||||||
13 | 2008 to Medicaid managed care organizations, the Children's | ||||||
14 | Health Insurance Program, and alternative benefit plans. | ||||||
15 | Specifically, the Department and the Department of Healthcare | ||||||
16 | and Family Services shall take action: | ||||||
17 | (1) proactively ensuring compliance by individual and | ||||||
18 | group policies, including by requiring that insurers | ||||||
19 | submit comparative analyses, as set forth in paragraph (6) | ||||||
20 | of subsection (k) of Section 370c.1, demonstrating how they | ||||||
21 | design and apply nonquantitative treatment limitations, | ||||||
22 | both as written and in operation, for mental, emotional, | ||||||
23 | nervous, or substance use disorder or condition benefits as | ||||||
24 | compared to how they design and apply nonquantitative | ||||||
25 | treatment limitations, as written and in operation, for | ||||||
26 | medical and surgical benefits; |
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1 | (2) evaluating all consumer or provider complaints | ||||||
2 | regarding mental, emotional, nervous, or substance use | ||||||
3 | disorder or condition coverage for possible parity | ||||||
4 | violations; | ||||||
5 | (3) performing parity compliance market conduct | ||||||
6 | examinations or, in the case of the Department of | ||||||
7 | Healthcare and Family Services, parity compliance audits | ||||||
8 | of individual and group plans and policies, including, but | ||||||
9 | not limited to, reviews of: | ||||||
10 | (A) nonquantitative treatment limitations, | ||||||
11 | including, but not limited to, prior authorization | ||||||
12 | requirements, concurrent review, retrospective review, | ||||||
13 | step therapy, network admission standards, | ||||||
14 | reimbursement rates, and geographic restrictions; | ||||||
15 | (B) denials of authorization, payment, and | ||||||
16 | coverage; and | ||||||
17 | (C) other specific criteria as may be determined by | ||||||
18 | the Department. | ||||||
19 | The findings and the conclusions of the parity compliance | ||||||
20 | market conduct examinations and audits shall be made public. | ||||||
21 | The Director may adopt rules to effectuate any provisions | ||||||
22 | of the Paul Wellstone and Pete Domenici Mental Health Parity | ||||||
23 | and Addiction Equity Act of 2008 that relate to the business of | ||||||
24 | insurance. | ||||||
25 | (e) Availability of plan information. | ||||||
26 | (1) The criteria for medical necessity determinations |
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1 | made under a group health plan, an individual policy of | ||||||
2 | accident and health insurance, or a qualified health plan | ||||||
3 | offered through the health insurance marketplace with | ||||||
4 | respect to mental health or substance use disorder benefits | ||||||
5 | (or health insurance coverage offered in connection with | ||||||
6 | the plan with respect to such benefits) must be made | ||||||
7 | available by the plan administrator (or the health | ||||||
8 | insurance issuer offering such coverage) to any current or | ||||||
9 | potential participant, beneficiary, or contracting | ||||||
10 | provider upon request. | ||||||
11 | (2) The reason for any denial under a group health | ||||||
12 | benefit plan, an individual policy of accident and health | ||||||
13 | insurance, or a qualified health plan offered through the | ||||||
14 | health insurance marketplace (or health insurance coverage | ||||||
15 | offered in connection with such plan or policy) of | ||||||
16 | reimbursement or payment for services with respect to | ||||||
17 | mental, emotional, nervous, or substance use disorders or | ||||||
18 | conditions benefits in the case of any participant or | ||||||
19 | beneficiary must be made available within a reasonable time | ||||||
20 | and in a reasonable manner and in readily understandable | ||||||
21 | language by the plan administrator (or the health insurance | ||||||
22 | issuer offering such coverage) to the participant or | ||||||
23 | beneficiary upon request. | ||||||
24 | (f) As used in this Section, "group policy of accident and | ||||||
25 | health insurance" and "group health benefit plan" includes (1) | ||||||
26 | State-regulated employer-sponsored group health insurance |
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1 | plans written in Illinois or which purport to provide coverage | ||||||
2 | for a resident of this State; and (2) State employee health | ||||||
3 | plans. | ||||||
4 | (g) (1) As used in this subsection: | ||||||
5 | "Benefits", with respect to insurers, means
the benefits | ||||||
6 | provided for treatment services for inpatient and outpatient | ||||||
7 | treatment of substance use disorders or conditions at American | ||||||
8 | Society of Addiction Medicine levels of treatment 2.1 | ||||||
9 | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | ||||||
10 | (Clinically Managed Low-Intensity Residential), 3.3 | ||||||
11 | (Clinically Managed Population-Specific High-Intensity | ||||||
12 | Residential), 3.5 (Clinically Managed High-Intensity | ||||||
13 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
14 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
15 | "Benefits", with respect to managed care organizations, | ||||||
16 | means the benefits provided for treatment services for | ||||||
17 | inpatient and outpatient treatment of substance use disorders | ||||||
18 | or conditions at American Society of Addiction Medicine levels | ||||||
19 | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | ||||||
20 | Hospitalization), 3.5 (Clinically Managed High-Intensity | ||||||
21 | Residential), and 3.7 (Medically Monitored Intensive | ||||||
22 | Inpatient) and OMT (Opioid Maintenance Therapy) services. | ||||||
23 | "Substance use disorder treatment provider or facility" | ||||||
24 | means a licensed physician, licensed psychologist, licensed | ||||||
25 | psychiatrist, licensed advanced practice registered nurse, or | ||||||
26 | licensed, certified, or otherwise State-approved facility or |
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1 | provider of substance use disorder treatment. | ||||||
2 | (2) A group health insurance policy, an individual health | ||||||
3 | benefit plan, or qualified health plan that is offered through | ||||||
4 | the health insurance marketplace, small employer group health | ||||||
5 | plan, and large employer group health plan that is amended, | ||||||
6 | delivered, issued, executed, or renewed in this State, or | ||||||
7 | approved for issuance or renewal in this State, on or after | ||||||
8 | January 1, 2019 ( the effective date of Public Act 100-1023) | ||||||
9 | this amendatory Act of the 100th General Assembly shall comply | ||||||
10 | with the requirements of this Section and Section 370c.1. The | ||||||
11 | services for the treatment and the ongoing assessment of the | ||||||
12 | patient's progress in treatment shall follow the requirements | ||||||
13 | of 77 Ill. Adm. Code 2060. | ||||||
14 | (3) Prior authorization shall not be utilized for the | ||||||
15 | benefits under this subsection. The substance use disorder | ||||||
16 | treatment provider or facility shall notify the insurer of the | ||||||
17 | initiation of treatment. For an insurer that is not a managed | ||||||
18 | care organization, the substance use disorder treatment | ||||||
19 | provider or facility notification shall occur for the | ||||||
20 | initiation of treatment of the covered person within 2 business | ||||||
21 | days. For managed care organizations, the substance use | ||||||
22 | disorder treatment provider or facility notification shall | ||||||
23 | occur in accordance with the protocol set forth in the provider | ||||||
24 | agreement for initiation of treatment within 24 hours. If the | ||||||
25 | managed care organization is not capable of accepting the | ||||||
26 | notification in accordance with the contractual protocol |
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1 | during the 24-hour period following admission, the substance | ||||||
2 | use disorder treatment provider or facility shall have one | ||||||
3 | additional business day to provide the notification to the | ||||||
4 | appropriate managed care organization. Treatment plans shall | ||||||
5 | be developed in accordance with the requirements and timeframes | ||||||
6 | established in 77 Ill. Adm. Code 2060. If the substance use | ||||||
7 | disorder treatment provider or facility fails to notify the | ||||||
8 | insurer of the initiation of treatment in accordance with these | ||||||
9 | provisions, the insurer may follow its normal prior | ||||||
10 | authorization processes. | ||||||
11 | (4) For an insurer that is not a managed care organization, | ||||||
12 | if an insurer determines that benefits are no longer medically | ||||||
13 | necessary, the insurer shall notify the covered person, the | ||||||
14 | covered person's authorized representative, if any, and the | ||||||
15 | covered person's health care provider in writing of the covered | ||||||
16 | person's right to request an external review pursuant to the | ||||||
17 | Health Carrier External Review Act. The notification shall | ||||||
18 | occur within 24 hours following the adverse determination. | ||||||
19 | Pursuant to the requirements of the Health Carrier External | ||||||
20 | Review Act, the covered person or the covered person's | ||||||
21 | authorized representative may request an expedited external | ||||||
22 | review.
An expedited external review may not occur if the | ||||||
23 | substance use disorder treatment provider or facility | ||||||
24 | determines that continued treatment is no longer medically | ||||||
25 | necessary. Under this subsection, a request for expedited | ||||||
26 | external review must be initiated within 24 hours following the |
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1 | adverse determination notification by the insurer. Failure to | ||||||
2 | request an expedited external review within 24 hours shall | ||||||
3 | preclude a covered person or a covered person's authorized | ||||||
4 | representative from requesting an expedited external review. | ||||||
5 | If an expedited external review request meets the criteria | ||||||
6 | of the Health Carrier External Review Act, an independent | ||||||
7 | review organization shall make a final determination of medical | ||||||
8 | necessity within 72 hours. If an independent review | ||||||
9 | organization upholds an adverse determination, an insurer | ||||||
10 | shall remain responsible to provide coverage of benefits | ||||||
11 | through the day following the determination of the independent | ||||||
12 | review organization. A decision to reverse an adverse | ||||||
13 | determination shall comply with the Health Carrier External | ||||||
14 | Review Act. | ||||||
15 | (5) The substance use disorder treatment provider or | ||||||
16 | facility shall provide the insurer with 7 business days' | ||||||
17 | advance notice of the planned discharge of the patient from the | ||||||
18 | substance use disorder treatment provider or facility and | ||||||
19 | notice on the day that the patient is discharged from the | ||||||
20 | substance use disorder treatment provider or facility. | ||||||
21 | (6) The benefits required by this subsection shall be | ||||||
22 | provided to all covered persons with a diagnosis of substance | ||||||
23 | use disorder or conditions. The presence of additional related | ||||||
24 | or unrelated diagnoses shall not be a basis to reduce or deny | ||||||
25 | the benefits required by this subsection. | ||||||
26 | (7) Nothing in this subsection shall be construed to |
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1 | require an insurer to provide coverage for any of the benefits | ||||||
2 | in this subsection. | ||||||
3 | (Source: P.A. 99-480, eff. 9-9-15; 100-305, eff. 8-24-17; | ||||||
4 | 100-1023, eff. 1-1-19; 100-1024, eff. 1-1-19; revised | ||||||
5 | 10-18-18.)
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6 | Section 99. Effective date. This Act takes effect upon | ||||||
7 | becoming law.
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