Illinois

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

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

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

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

OR

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

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

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

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

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

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

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

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

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

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

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

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.