Illinois Regulations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Meet the minimum requirements of the Federal parity Law and applicable state law (not for small group)
• Cover all disorders defined as serious mental health in 5/370c(b)(2) (not for small group)
• Include, at a minimum, the outpatient services of psychological testing, neuropsychological testing, electroconvulsive therapy, intensive outpatient programs, and partial hospitalization treatment programs (if it is an in-network program)

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

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

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

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

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

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

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

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

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