HB 4475

Abstract

Amends the Illinois Insurance Code. Provides that the amendatory Act may be referred to as the Strengthening Mental Health and Substance Use Parity Act. Provides that a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025, or any third-party administrator administering the behavioral health benefits for the insurer, shall cover all out-of-network medically necessary mental health and substance use benefits and services (inpatient and outpatient) as if they were in-network for purposes of cost sharing for the insured. Provides that the insured has the right to select the provider or facility of their choice and the modality, whether the care is provided via in-person visit or telehealth, for medically necessary care. Sets forth minimum reimbursement rates for certain behavioral health benefits. Sets forth provisions concerning responsibility for compliance with parity requirements; coverage and payment for multiple covered mental health and substance use services, mental health or substance use services provided under the supervision of a licensed mental health or substance treatment provider, and 60-minute individual psychotherapy; timely credentialing of mental health and substance use providers; Department of Insurance enforcement and rulemaking; civil penalties; and other matters. Amends the Illinois Administrative Procedure Act to authorize emergency rulemaking. Effective immediately. House Committee Amendment No. 1 Deletes reference to: 5 ILCS 100/5-45.55 new Adds reference to: 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Replaces everything after the enacting clause. Provides that the amendatory Act may be referred to as the Strengthening Mental Health and Substance Use Parity Act. Amends the Illinois Insurance Code. Provides that for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2026, or any contracted third party administering the behavioral health benefits for the insurer, reimbursement for in-network mental health and substance use disorder treatment services delivered by Illinois providers and facilities must be, on average, at least as favorable as professional services provided by in-network primary care providers. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2025, or a contracted third party administering the behavioral health benefits for the insurer, to cover all medically necessary mental health or substance use disorder services received by the same insured on the same day from the same or different mental health or substance use provider or facility for both outpatient and inpatient care. Requires coverage of medically necessary mental health or substance use disorder services provided by behavioral health trainees under certain circumstances. Requires coverage of medically necessary 60-minute psychotherapy billed using the CPT Code 90837 for Individual Therapy. Sets forth provisions concerning timely contracting for becoming a participating mental health or substance use disorder treatment provider, enforcement, and rulemaking. Amends the Health Maintenance Organization Act to require health maintenance organizations to comply with the provisions of the Illinois Insurance Code added by the amendatory Act. Effective immediately. House Floor Amendment No. 2 Replaces everything after the enacting clause. Reinserts the provisions of the bill, as amended by House Amendment No. 1, with the following changes. Provides that for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2026, or any contracted third party administering the behavioral health benefits for the insurer, reimbursement for in-network mental health and substance use disorder treatment services delivered by Illinois providers and facilities must be equal to or greater than 141% of the Medicare rate for the mental health or substance use disorder service delivered (rather than on average, at least as favorable as professional services provided by in-network primary care providers). Removes language providing that reimbursement rates for services paid to Illinois mental health and substance use disorder treatment providers and facilities do not meet the required standard unless the reimbursement rates are, on average, equal to or greater than 141% of the Medicare reimbursement rate for the same service. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 (rather than $5,000) for each violation. Excludes health care plans serving Medicaid populations that provide, arrange for, pay for, or reimburse the cost of any health care service for persons who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Makes other changes. Effective immediately.