HEALTH CARE & treatment ACCESS

ILLINOIS LEGISLATION:

Generally Accepted Standards of Behavioral Health Care Act - PA 102-0579 (2021)

  • Amends the Illinois Insurance Code and requires that all health plans in Illinois follow generally accepted standards of mental health care (best practices agreed upon by clinical experts) when making medical necessity determinations and use medical necessity criteria/guidelines reflecting these standards

    • Provides that an insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public program. 

    • Provides that an insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in the treatment criteria.

    • Provides that the Director may, after appropriate notice and opportunity for hearing, assess a civil penalty between $1,000 and $5,000 for each violation. 

    • Effective January 1, 2022, except that specified provisions take effect immediately.

Heroin Crisis Act - PA 99-0480 (2016)
  • Medicaid coverage: 

    • Removes the prior authorization requirements for medication assisted treatment (MAT) for alcohol or opioid use disorders. It also eliminates lifetime limits, including the one-year lifetime limit for buprenorphine and related medications.

    • Requires coverage of all FDA-approved MAT for alcohol and opioid use disorders. In particular, methadone will now be covered for opioid use disorders once obtaining federal approval for the change.

    • Requires coverage for naloxone. Certain pharmacist training provisions for naloxone only must be completed prior to going into effect.

    • Applies Illinois mental health and substance use disorder (SUD) parity requirements to Medicaid, requiring that mental health and SUD benefits are comparable to – meaning the copays, number of visits and the like – other medical benefits.

  • Private Insurance Coverage:
    • Expands parity requirements to include coverage for naloxone.

    • Expands parity requirements to include acute and crisis inpatient treatment such as medically supervised withdrawal management and stabilization. 

    • Requires insurance plans to publish their SUD treatment and medication policies. 

    • Applies Illinois mental health and SUD parity requirements to most private insurance plans, requiring that mental health and SUD benefits are comparable to other medical benefits.

Source: Heartland Alliance