INS-ENFORCEMENT MENTAL HEALTH

Illinois General Assembly - Full Text of SB3024

Select Language

×

The Illinois General Assembly offers the Google Translate™ service for visitor convenience. In no way should it be considered accurate as to the translation of any content herein.

Visitors of the Illinois General Assembly website are encouraged to use other translation services available on the internet.

The English language version is always the official and authoritative version of this website.

NOTE: To return to the original English language version, select the "Show Original" button on the Google Translate™ menu bar at the top of the window.

Choose Language

English

Afrikaans

Albanian

Arabic

Armenian

Azerbaijani

Basque

Bengali

Bosnian

Catalan

Croatian

Czech

Danish

Dutch

Esperanto

Estonian

Filipino

Finnish

French

Galician

Georgian

German

Greek

Gujarati

Haitian Creole

Hausa

Hawaiian

Hebrew

Hindi

Hungarian

Icelandic

Indonesian

Interlingua

Interlingue

Inuktitut

Irish

Italian

Japanese

Javanese

Kannada

Khmer

Korean

Latin

Latvian

Lithuanian

Luxembourgish

Macedonian

Malagasy

Malayalam

Maltese

Maori

Marathi

Myanmar

Nepali

Norwegian

Odia

Pashto

Punjabi

Romanian

Russian

Samoan

Sango

Sanskrit

Sardinian

Sindhi

Sinhala

Slovak

Slovenian

Somali

Southern Sotho

Spanish

Sundanese

Swahili

Swedish

Tamil

Telugu

Thai

Tigrinya

Tonga

Turkish

Ukrainian

Urdu

Vietnamese

Welsh

Xhosa

Yiddish

Yoruba

Zulu

Powered by
Translate

Close

Illinois General Assembly

Top Navigation Bar

Translate

Learn

Select General Assembly

Search the 104th General Assembly

Enter search terms for legislation, members, committees, or schedules.

ILGA.GOV

LEGISLATION & LAWS

Bills & Resolutions

Public Acts

Illinois Compiled Statutes

Illinois Constitution

Search Legislation

Glossary

Guide

Reports & Inquiry

Legislative Reports

Special Reports

FTP Site

Legislator Lookup

Capitol Complex Phone Numbers

Rules & Regulations

Illinois Register

Administrative Rules

Senate

Members

Schedules

Committees

Request for Remote Testimony

Journals

Transcripts

Rules

Audio/Video

FOIA Information

Senate Employment Opportunities

Media Guidelines

House

Members

Schedules

Committees

Submit testimony for House Committees

Journals

Transcripts

Rules

Audio/Video

FOIA Information

House Employment Opportunities

Log In

Mobile Top Bar

Search the 104th General Assembly

Enter keywords to search the Illinois General Assembly website.

Full Text of SB3024

Home

Legislation

Full Text

SB3024 - 104th General Assembly

Bill Status

Full Text

Votes

Witness Slips

Select Menu

Bill Status

Full Text

Votes

Witness Slips

Printer Friendly Version

Introduced

Printer Friendly Version

Introduced

Open PDF

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
SB3024

Introduced 1/28/2026, by Sen. Mike Simmons

SYNOPSIS AS INTRODUCED:

215 ILCS 5/370c

from Ch. 73, par. 982c

Amends the Illinois Insurance Code. Requires a group or individual
policy of accident and health insurance or a managed care plan that is
amended, delivered, issued, or renewed on or after January 1, 2027 to cover
up to 12 mental health provider visits per plan year, with no visitation
restrictions, if a local or State emergency is declared due to immigration
enforcement activity and the insured has experienced loss, trauma, or
displacement due to such activity. Provides that the coverage shall not be
subject to deductibles, copayments, or other forms of cost sharing.
Effective immediately.
LRB104 18555 BAB 31998 b

A BILL FOR

SB3024
LRB104 18555 BAB 31998 b
1

AN ACT concerning regulation.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The Illinois Insurance Code is amended by
5
changing Section 370c as follows:

6

(215 ILCS 5/370c)

(from Ch. 73, par. 982c)
7

Sec. 370c.
Mental and emotional disorders.
8

(a)(1) On and after January 1, 2022 (the effective date of
9
Public Act 102-579), every insurer that amends, delivers,
10
issues, or renews group accident and health policies providing
11
coverage for hospital or medical treatment or services for
12
illness shall provide coverage for the medically necessary
13
treatment of mental, emotional, nervous, or substance use
14
disorders or conditions consistent with the parity
15
requirements of Section 370c.1 of this Code.
16

(2) Each insured that is covered for mental, emotional,
17
nervous, or substance use disorders or conditions shall be
18
free to select the physician licensed to practice medicine in
19
all its branches, licensed clinical psychologist, licensed
20
clinical social worker, licensed clinical professional
21
counselor, licensed marriage and family therapist, licensed
22
speech-language pathologist, or other licensed or certified
23
professional at a program licensed pursuant to the Substance

SB3024
- 2 -
LRB104 18555 BAB 31998 b
1
Use Disorder Act of his or her choice to treat such disorders,
2
and the insurer shall pay the covered charges of such
3
physician licensed to practice medicine in all its branches,
4
licensed clinical psychologist, 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 Act up
9
to the limits of coverage, provided (i) the disorder or
10
condition treated is covered by the policy, and (ii) the
11
physician, licensed psychologist, licensed clinical social
12
worker, licensed clinical professional counselor, licensed
13
marriage and family therapist, licensed speech-language
14
pathologist, or other licensed or certified professional at a
15
program licensed pursuant to the Substance Use Disorder Act is
16
authorized to provide said services under the statutes of this
17
State and in accordance with accepted principles of his or her
18
profession.
19

(3) Insofar as this Section applies solely to licensed
20
clinical social workers, licensed clinical professional
21
counselors, licensed marriage and family therapists, licensed
22
speech-language pathologists, and other licensed or certified
23
professionals at programs licensed pursuant to the Substance
24
Use Disorder Act, those persons who may provide services to
25
individuals shall do so after the licensed clinical social
26
worker, licensed clinical professional counselor, licensed

SB3024
- 3 -
LRB104 18555 BAB 31998 b
1
marriage and family therapist, licensed speech-language
2
pathologist, or other licensed or certified professional at a
3
program licensed pursuant to the Substance Use Disorder Act
4
has informed the patient of the desirability of the patient
5
conferring with the patient's primary care physician.
6

(4) "Mental, emotional, nervous, or substance use disorder
7
or condition" means a condition or disorder that involves a
8
mental health condition or substance use disorder that falls
9
under any of the diagnostic categories listed in the mental
10
and behavioral disorders chapter of the current edition of the
11
World Health Organization's International Classification of
12
Disease or that is listed in the most recent version of the
13
American Psychiatric Association's Diagnostic and Statistical
14
Manual of Mental Disorders. "Mental, emotional, nervous, or
15
substance use disorder or condition" includes any mental
16
health condition that occurs during pregnancy or during the
17
postpartum period and includes, but is not limited to,
18
postpartum depression.
19

(5) Medically necessary treatment and medical necessity
20
determinations shall be interpreted and made in a manner that
21
is consistent with and pursuant to subsections (h) through
22
(y).
23

(b)(1) (Blank).
24

(2) (Blank).
25

(2.5) (Blank).
26

(3) Unless otherwise prohibited by federal law and

SB3024
- 4 -
LRB104 18555 BAB 31998 b
1
consistent with the parity requirements of Section 370c.1 of
2
this Code, the insurer that amends, delivers, issues, or
3
renews a group or individual policy of accident and health
4
insurance, a qualified health plan offered through the health
5
insurance marketplace, or a provider of treatment of mental,
6
emotional, nervous, or substance use disorders or conditions
7
shall furnish medical records or other necessary data that
8
substantiate that initial or continued treatment is at all
9
times medically necessary. Nothing in this paragraph (3)
10
supersedes the prohibition on prior authorization requirements
11
to the extent provided under subsections (g) and (w) and
12
subparagraph (A) of paragraph (6.5) of this subsection.
13
Nothing prevents the insured from agreeing in writing to
14
continue treatment at his or her expense. When making a
15
determination of the medical necessity for a treatment
16
modality for mental, emotional, nervous, or substance use
17
disorders or conditions, an insurer must make the
18
determination in a manner that is consistent with the manner
19
used to make that determination with respect to other diseases
20
or illnesses covered under the policy, including an appeals
21
process. Medical necessity determinations for substance use
22
disorders shall be made in accordance with appropriate patient
23
placement criteria established by the American Society of
24
Addiction Medicine. No additional criteria may be used to make
25
medical necessity determinations for substance use disorders.
26

(4) A group health benefit plan amended, delivered,

SB3024
- 5 -
LRB104 18555 BAB 31998 b
1
issued, or renewed on or after January 1, 2019 (the effective
2
date of Public Act 100-1024) or an individual policy of
3
accident and health insurance or a qualified health plan
4
offered through the health insurance marketplace amended,
5
delivered, issued, or renewed on or after January 1, 2019 (the
6
effective date of Public Act 100-1024):
7

(A) shall provide coverage based upon medical
8

necessity for the treatment of a mental, emotional,
9

nervous, or substance use disorder or condition consistent
10

with the parity requirements of Section 370c.1 of this
11

Code; provided, however, that in each calendar year
12

coverage shall not be less than the following:
13

(i) 45 days of inpatient treatment; and
14

(ii) beginning on June 26, 2006 (the effective
15

date of Public Act 94-921), 60 visits for outpatient
16

treatment including group and individual outpatient
17

treatment; and
18

(iii) for plans or policies delivered, issued for
19

delivery, renewed, or modified after January 1, 2007
20

(the effective date of Public Act 94-906), 20
21

additional outpatient visits for speech therapy for
22

treatment of pervasive developmental disorders that
23

will be in addition to speech therapy provided
24

pursuant to item (ii) of this subparagraph (A); and
25

(B) may not include a lifetime limit on the number of
26

days of inpatient treatment or the number of outpatient

SB3024
- 6 -
LRB104 18555 BAB 31998 b
1

visits covered under the plan.
2

(C) (Blank).
3

(5) An issuer of a group health benefit plan or an
4
individual policy of accident and health insurance or a
5
qualified health plan offered through the health insurance
6
marketplace may not count toward the number of outpatient
7
visits required to be covered under this Section an outpatient
8
visit for the purpose of medication management and shall cover
9
the outpatient visits under the same terms and conditions as
10
it covers outpatient visits for the treatment of physical
11
illness.
12

(5.5) An individual or group health benefit plan amended,
13
delivered, issued, or renewed on or after September 9, 2015
14
(the effective date of Public Act 99-480) shall offer coverage
15
for medically necessary acute treatment services and medically
16
necessary clinical stabilization services. The treating
17
provider shall base all treatment recommendations and the
18
health benefit plan shall base all medical necessity
19
determinations for substance use disorders in accordance with
20
the most current edition of the Treatment Criteria for
21
Addictive, Substance-Related, and Co-Occurring Conditions
22
established by the American Society of Addiction Medicine. The
23
treating provider shall base all treatment recommendations and
24
the health benefit plan shall base all medical necessity
25
determinations for medication-assisted treatment in accordance
26
with the most current Treatment Criteria for Addictive,

SB3024
- 7 -
LRB104 18555 BAB 31998 b
1
Substance-Related, and Co-Occurring Conditions established by
2
the American Society of Addiction Medicine.
3

As used in this subsection:
4

"Acute treatment services" means 24-hour medically
5
supervised addiction treatment that provides evaluation and
6
withdrawal management and may include biopsychosocial
7
assessment, individual and group counseling, psychoeducational
8
groups, and discharge planning.
9

"Clinical stabilization services" means 24-hour treatment,
10
usually following acute treatment services for substance
11
abuse, which may include intensive education and counseling
12
regarding the nature of addiction and its consequences,
13
relapse prevention, outreach to families and significant
14
others, and aftercare planning for individuals beginning to
15
engage in recovery from addiction.
16

"Prior authorization" has the meaning given to that term
17
in Section 15 of the Prior Authorization Reform Act.
18

(6) An issuer of a group health benefit plan may provide or
19
offer coverage required under this Section through a managed
20
care plan.
21

(6.5) An individual or group health benefit plan amended,
22
delivered, issued, or renewed on or after January 1, 2019 (the
23
effective date of Public Act 100-1024):
24

(A) shall not impose prior authorization requirements,
25

including limitations on dosage, other than those
26

established under the Treatment Criteria for Addictive,

SB3024
- 8 -
LRB104 18555 BAB 31998 b
1

Substance-Related, and Co-Occurring Conditions
2

established by the American Society of Addiction Medicine,
3

on a prescription medication approved by the United States
4

Food and Drug Administration that is prescribed or
5

administered for the treatment of substance use disorders;
6

(B) shall not impose any step therapy requirements;
7

(C) shall place all prescription medications approved
8

by the United States Food and Drug Administration
9

prescribed or administered for the treatment of substance
10

use disorders on, for brand medications, the lowest tier
11

of the drug formulary developed and maintained by the
12

individual or group health benefit plan that covers brand
13

medications and, for generic medications, the lowest tier
14

of the drug formulary developed and maintained by the
15

individual or group health benefit plan that covers
16

generic medications; and
17

(D) shall not exclude coverage for a prescription
18

medication approved by the United States Food and Drug
19

Administration for the treatment of substance use
20

disorders and any associated counseling or wraparound
21

services on the grounds that such medications and services
22

were court ordered.
23

(7) (Blank).
24

(8) (Blank).
25

(9) With respect to all mental, emotional, nervous, or
26
substance use disorders or conditions, coverage for inpatient

SB3024
- 9 -
LRB104 18555 BAB 31998 b
1
treatment shall include coverage for treatment in a
2
residential treatment center certified or licensed by the
3
Department of Public Health or the Department of Human
4
Services.
5

(10) A group or individual policy of accident and health
6
insurance or a managed care plan that is amended, delivered,
7
issued, or renewed on or after January 1, 2027 shall cover up
8
to 12 mental health provider visits per plan year, with no
9
visitation restrictions, if a local or State emergency is
10
declared due to immigration enforcement activity and the
11
insured has experienced loss, trauma, or displacement due to
12
such activity. The coverage shall not be subject to
13
deductibles, copayments, or other forms of cost sharing.

14

(c) This Section shall not be interpreted to require
15
coverage for speech therapy or other habilitative services for
16
those individuals covered under Section 356z.15 of this Code.
17

(d) With respect to a group or individual policy of
18
accident and health insurance or a qualified health plan
19
offered through the health insurance marketplace, the
20
Department and, with respect to medical assistance, the
21
Department of Healthcare and Family Services shall each
22
enforce the requirements of this Section and Sections 356z.23
23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
24
Mental Health Parity and Addiction Equity Act of 2008, 42
25
U.S.C. 18031(j), and any amendments to, and federal guidance
26
or regulations issued under, those Acts, including, but not

SB3024
- 10 -
LRB104 18555 BAB 31998 b
1
limited to, final regulations issued under the Paul Wellstone
2
and Pete Domenici Mental Health Parity and Addiction Equity
3
Act of 2008 and final regulations applying the Paul Wellstone
4
and Pete Domenici Mental Health Parity and Addiction Equity
5
Act of 2008 to Medicaid managed care organizations, the
6
Children's Health Insurance Program, and alternative benefit
7
plans. Specifically, the Department and the Department of
8
Healthcare and Family Services shall take action:
9

(1) proactively ensuring compliance by individual and
10

group policies, including by requiring that insurers
11

submit comparative analyses, as set forth in paragraph (6)
12

of subsection (k) of Section 370c.1, demonstrating how
13

they design and apply nonquantitative treatment
14

limitations, both as written and in operation, for mental,
15

emotional, nervous, or substance use disorder or condition
16

benefits as compared to how they design and apply
17

nonquantitative treatment limitations, as written and in
18

operation, for medical and surgical benefits;
19

(2) evaluating all consumer or provider complaints
20

regarding mental, emotional, nervous, or substance use
21

disorder or condition coverage for possible parity
22

violations;
23

(3) performing parity compliance market conduct
24

examinations or, in the case of the Department of
25

Healthcare and Family Services, parity compliance audits
26

of individual and group plans and policies, including, but

SB3024
- 11 -
LRB104 18555 BAB 31998 b
1

not limited to, reviews of:
2

(A) nonquantitative treatment limitations,
3

including, but not limited to, prior authorization
4

requirements, concurrent review, retrospective review,
5

step therapy, network admission standards,
6

reimbursement rates, and geographic restrictions;
7

(B) denials of authorization, payment, and
8

coverage; and
9

(C) other specific criteria as may be determined
10

by the Department.
11

The findings and the conclusions of the parity compliance
12
market conduct examinations and audits shall be made public.
13

The Director may adopt rules to effectuate any provisions
14
of the Paul Wellstone and Pete Domenici Mental Health Parity
15
and Addiction Equity Act of 2008 that relate to the business of
16
insurance.
17

(e) Availability of plan information.
18

(1) The criteria for medical necessity determinations
19

made under a group health plan, an individual policy of
20

accident and health insurance, or a qualified health plan
21

offered through the health insurance marketplace with
22

respect to mental health or substance use disorder
23

benefits (or health insurance coverage offered in
24

connection with the plan with respect to such benefits)
25

must be made available by the plan administrator (or the
26

health insurance issuer offering such coverage) to any

SB3024
- 12 -
LRB104 18555 BAB 31998 b
1

current or potential participant, beneficiary, or
2

contracting provider upon request.
3

(2) The reason for any denial under a group health
4

benefit plan, an individual policy of accident and health
5

insurance, or a qualified health plan offered through the
6

health insurance marketplace (or health insurance coverage
7

offered in connection with such plan or policy) of
8

reimbursement or payment for services with respect to
9

mental, emotional, nervous, or substance use disorders or
10

conditions benefits in the case of any participant or
11

beneficiary must be made available within a reasonable
12

time and in a reasonable manner and in readily
13

understandable language by the plan administrator (or the
14

health insurance issuer offering such coverage) to the
15

participant or beneficiary upon request.
16

(f) As used in this Section, "group policy of accident and
17
health insurance" and "group health benefit plan" includes (1)
18
State-regulated employer-sponsored group health insurance
19
plans written in Illinois or which purport to provide coverage
20
for a resident of this State; and (2) State, county,
21
municipal, or school district employee health plans.
22
References to an insurer include all plans described in this
23
subsection.
24

(g) (1) As used in this subsection:
25

"Benefits", with respect to insurers that are not Medicaid
26
managed care organizations, means the benefits provided for

SB3024
- 13 -
LRB104 18555 BAB 31998 b
1
treatment services for inpatient and outpatient treatment of
2
substance use disorders or conditions at American Society of
3
Addiction Medicine levels of treatment 2.1 (Intensive
4
Outpatient), 2.5 (High-Intensity Outpatient), 3.1 (Clinically
5
Managed Low-Intensity Residential), 3.5 (Clinically Managed
6
High-Intensity Residential), and 3.7 (Medically Managed
7
Residential) and OMT (Opioid Maintenance Therapy) services.
8

"Benefits", with respect to Medicaid managed care
9
organizations, means the benefits provided for treatment
10
services for inpatient and outpatient treatment of substance
11
use disorders or conditions at American Society of Addiction
12
Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5
13
(High-Intensity Outpatient), 3.5 (Clinically Managed
14
High-Intensity Residential), and 3.7 (Medically Managed
15
Residential) and OMT (Opioid Maintenance Therapy) services.
16

"Substance use disorder treatment provider or facility"
17
means a licensed physician, licensed psychologist, licensed
18
psychiatrist, licensed advanced practice registered nurse, or
19
licensed, certified, or otherwise State-approved facility or
20
provider of substance use disorder treatment.
21

(2) A group health insurance policy, an individual health
22
benefit plan, or qualified health plan that is offered through
23
the health insurance marketplace, small employer group health
24
plan, and large employer group health plan that is amended,
25
delivered, issued, executed, or renewed in this State, or
26
approved for issuance or renewal in this State, on or after

SB3024
- 14 -
LRB104 18555 BAB 31998 b
1
January 1, 2019 (the effective date of Public Act 100-1023)
2
shall comply with the requirements of this Section and Section
3
370c.1. The services for the treatment and the ongoing
4
assessment of the patient's progress in treatment shall follow
5
the requirements of 77 Ill. Adm. Code 2060.
6

(3) Prior authorization shall not be utilized for the
7
benefits under this subsection. Except to the extent
8
prohibited by Section 370c.1 with respect to treatment
9
limitations in a benefit classification or subclassification,
10
the insurer may require the substance use disorder treatment
11
provider or facility to notify the insurer of the initiation
12
of treatment. For an insurer that is not a Medicaid managed
13
care organization, the substance use disorder treatment
14
provider or facility may be required to give notification for
15
the initiation of treatment of the covered person within 2
16
business days. For Medicaid managed care organizations, the
17
substance use disorder treatment provider or facility may be
18
required to give notification in accordance with the protocol
19
set forth in the provider agreement for initiation of
20
treatment within 24 hours. If the Medicaid managed care
21
organization is not capable of accepting the notification in
22
accordance with the contractual protocol during the 24-hour
23
period following admission, the substance use disorder
24
treatment provider or facility shall have one additional
25
business day to provide the notification to the appropriate
26
managed care organization. Treatment plans shall be developed

SB3024
- 15 -
LRB104 18555 BAB 31998 b
1
in accordance with the requirements and timeframes established
2
in 77 Ill. Adm. Code 2060. No such coverage shall be subject to
3
concurrent review prior to the applicable notification
4
deadline. If coverage is denied retrospectively, neither the
5
provider or facility nor the insurer shall bill, and the
6
covered individual shall not be liable, for any treatment
7
under this subsection through the date the adverse
8
determination is issued, other than any copayment,
9
coinsurance, or deductible for the treatment or stay through
10
that date as applicable under the policy. Coverage shall not
11
be retrospectively denied for benefits that were furnished at
12
a participating substance use disorder facility prior to the
13
applicable notification deadline except for the following:
14

(A) upon reasonable determination that the benefits
15

were not provided;
16

(B) upon determination that the patient receiving the
17

treatment was not an insured, enrollee, or beneficiary
18

under the policy;
19

(C) upon material misrepresentation by the patient or
20

provider. As used in this subparagraph (C), "material"
21

means a fact or situation that is not merely technical in
22

nature and results or could result in a substantial change
23

in the situation;
24

(D) upon determination that a service was excluded
25

under the terms of coverage. For situations that qualify
26

under this subparagraph (D), the limitation to billing for

SB3024
- 16 -
LRB104 18555 BAB 31998 b
1

a copayment, coinsurance, or deductible shall not apply;
2

(E) upon determination that a service was not
3

medically necessary consistent with subsections (h)
4

through (n); or
5

(F) upon determination that the patient did not
6

consent to the treatment and that there was no court order
7

mandating the treatment.
8

(4) For an insurer that is not a Medicaid managed care
9
organization, if an insurer determines that benefits are no
10
longer medically necessary, the insurer shall notify the
11
covered person, the covered person's authorized
12
representative, if any, and the covered person's health care
13
provider in writing of the covered person's right to request
14
an external review pursuant to the Health Carrier External
15
Review Act. The notification shall occur within 24 hours
16
following the adverse determination.
17

Pursuant to the requirements of the Health Carrier
18
External Review Act, the covered person or the covered
19
person's authorized representative may request an expedited
20
external review. An expedited external review may not occur if
21
the substance use disorder treatment provider or facility
22
determines that continued treatment is no longer medically
23
necessary.
24

If an expedited external review request meets the criteria
25
of the Health Carrier External Review Act, an independent
26
review organization shall make a final determination of

SB3024
- 17 -
LRB104 18555 BAB 31998 b
1
medical necessity within 72 hours. If an independent review
2
organization upholds an adverse determination, an insurer
3
shall remain responsible to provide coverage of benefits
4
through the day following the determination of the independent
5
review organization. A decision to reverse an adverse
6
determination shall comply with the Health Carrier External
7
Review Act.
8

(5) The substance use disorder treatment provider or
9
facility shall provide the insurer with 7 business days'
10
advance notice of the planned discharge of the patient from
11
the substance use disorder treatment provider or facility and
12
notice on the day that the patient is discharged from the
13
substance use disorder treatment provider or facility.
14

(6) The benefits required by this subsection shall be
15
provided to all covered persons with a diagnosis of substance
16
use disorder or conditions. The presence of additional related
17
or unrelated diagnoses shall not be a basis to reduce or deny
18
the benefits required by this subsection.
19

(7) Nothing in this subsection shall be construed to
20
require an insurer to provide coverage for any of the benefits
21
in this subsection.
22

(8) Any concurrent or retrospective review permitted by
23
this subsection must be consistent with the utilization review
24
provisions in subsections (h) through (n).
25

(h) As used in this Section:
26

"Generally accepted standards of mental, emotional,

SB3024
- 18 -
LRB104 18555 BAB 31998 b
1
nervous, or substance use disorder or condition care" means
2
standards of care and clinical practice that are generally
3
recognized by health care providers practicing in relevant
4
clinical specialties such as psychiatry, psychology, clinical
5
sociology, social work, addiction medicine and counseling, and
6
behavioral health treatment. Valid, evidence-based sources
7
reflecting generally accepted standards of mental, emotional,
8
nervous, or substance use disorder or condition care include
9
peer-reviewed scientific studies and medical literature,
10
recommendations of nonprofit health care provider professional
11
associations and specialty societies, including, but not
12
limited to, patient placement criteria and clinical practice
13
guidelines, recommendations of federal government agencies,
14
and drug labeling approved by the United States Food and Drug
15
Administration.
16

"Medically necessary treatment of mental, emotional,
17
nervous, or substance use disorders or conditions" means a
18
service or product addressing the specific needs of that
19
patient, for the purpose of screening, preventing, diagnosing,
20
managing, or treating an illness, injury, or condition or its
21
symptoms and comorbidities, including minimizing the
22
progression of an illness, injury, or condition or its
23
symptoms and comorbidities in a manner that is all of the
24
following:
25

(1) in accordance with the generally accepted
26

standards of mental, emotional, nervous, or substance use

SB3024
- 19 -
LRB104 18555 BAB 31998 b
1

disorder or condition care;
2

(2) clinically appropriate in terms of type,
3

frequency, extent, site, and duration; and
4

(3) not primarily for the economic benefit of the
5

insurer, purchaser, or for the convenience of the patient,
6

treating physician, or other health care provider.
7

"Utilization review" means either of the following:
8

(1) prospectively, retrospectively, or concurrently
9

reviewing and approving, modifying, delaying, or denying,
10

based in whole or in part on medical necessity, requests
11

by health care providers, insureds, or their authorized
12

representatives for coverage of health care services
13

before, retrospectively, or concurrently with the
14

provision of health care services to insureds.
15

(2) evaluating the medical necessity, appropriateness,
16

level of care, service intensity, efficacy, or efficiency
17

of health care services, benefits, procedures, or
18

settings, under any circumstances, to determine whether a
19

health care service or benefit subject to a medical
20

necessity coverage requirement in an insurance policy is
21

covered as medically necessary for an insured.
22

"Utilization review criteria" means patient placement
23
criteria or any criteria, standards, protocols, or guidelines
24
used by an insurer to conduct utilization review.
25

(i)(1) Every insurer that amends, delivers, issues, or
26
renews a group or individual policy of accident and health

SB3024
- 20 -
LRB104 18555 BAB 31998 b
1
insurance or a qualified health plan offered through the
2
health insurance marketplace in this State and Medicaid
3
managed care organizations providing coverage for hospital or
4
medical treatment on or after January 1, 2023 shall, pursuant
5
to subsections (h) through (s), provide coverage for medically
6
necessary treatment of mental, emotional, nervous, or
7
substance use disorders or conditions.
8

(2) An insurer shall not set a specific limit on the
9
duration of benefits or coverage of medically necessary
10
treatment of mental, emotional, nervous, or substance use
11
disorders or conditions or limit coverage only to alleviation
12
of the insured's current symptoms.
13

(3) All utilization review conducted by the insurer
14
concerning diagnosis, prevention, and treatment of insureds
15
diagnosed with mental, emotional, nervous, or substance use
16
disorders or conditions shall be conducted in accordance with
17
the requirements of subsections (k) through (w).
18

(4) An insurer that authorizes a specific type of
19
treatment by a provider pursuant to this Section shall not
20
rescind or modify the authorization after that provider
21
renders the health care service in good faith and pursuant to
22
this authorization for any reason, including, but not limited
23
to, the insurer's subsequent cancellation or modification of
24
the insured's or policyholder's contract, or the insured's or
25
policyholder's eligibility. Nothing in this Section shall
26
require the insurer to cover a treatment when the

SB3024
- 21 -
LRB104 18555 BAB 31998 b
1
authorization was granted based on a material
2
misrepresentation by the insured, the policyholder, or the
3
provider. Nothing in this Section shall require Medicaid
4
managed care organizations to pay for services if the
5
individual was not eligible for Medicaid at the time the
6
service was rendered. Nothing in this Section shall require an
7
insurer to pay for services if the individual was not the
8
insurer's enrollee at the time services were rendered. As used
9
in this paragraph, "material" means a fact or situation that
10
is not merely technical in nature and results in or could
11
result in a substantial change in the situation.
12

(j) An insurer shall not limit benefits or coverage for
13
medically necessary services on the basis that those services
14
should be or could be covered by a public entitlement program,
15
including, but not limited to, special education or an
16
individualized education program, Medicaid, Medicare,
17
Supplemental Security Income, or Social Security Disability
18
Insurance, and shall not include or enforce a contract term
19
that excludes otherwise covered benefits on the basis that
20
those services should be or could be covered by a public
21
entitlement program. Nothing in this subsection shall be
22
construed to require an insurer to cover benefits that have
23
been authorized and provided for a covered person by a public
24
entitlement program. Medicaid managed care organizations are
25
not subject to this subsection.
26

(k) An insurer shall base any medical necessity

SB3024
- 22 -
LRB104 18555 BAB 31998 b
1
determination or the utilization review criteria that the
2
insurer, and any entity acting on the insurer's behalf,
3
applies to determine the medical necessity of health care
4
services and benefits for the diagnosis, prevention, and
5
treatment of mental, emotional, nervous, or substance use
6
disorders or conditions on current generally accepted
7
standards of mental, emotional, nervous, or substance use
8
disorder or condition care. All denials and appeals shall be
9
reviewed by a professional with experience or expertise
10
comparable to the provider requesting the authorization.
11

(l) In conducting utilization review of all covered health
12
care services for the diagnosis, prevention, and treatment of
13
mental, emotional, and nervous disorders or conditions, an
14
insurer shall apply the criteria and guidelines set forth in
15
the most recent version of the treatment criteria developed by
16
an unaffiliated nonprofit professional association for the
17
relevant clinical specialty or, for Medicaid managed care
18
organizations, criteria and guidelines determined by the
19
Department of Healthcare and Family Services that are
20
consistent with generally accepted standards of mental,
21
emotional, nervous or substance use disorder or condition
22
care. Pursuant to subsection (b), in conducting utilization
23
review of all covered services and benefits for the diagnosis,
24
prevention, and treatment of substance use disorders an
25
insurer shall use the most recent edition of the patient
26
placement criteria established by the American Society of

SB3024
- 23 -
LRB104 18555 BAB 31998 b
1
Addiction Medicine.
2

(m) In conducting utilization review relating to level of
3
care placement, continued stay, transfer, discharge, or any
4
other patient care decisions that are within the scope of the
5
sources specified in subsection (l), an insurer shall not
6
apply different, additional, conflicting, or more restrictive
7
utilization review criteria than the criteria set forth in
8
those sources. For all level of care placement decisions, the
9
insurer shall authorize placement at the level of care
10
consistent with the assessment of the insured using the
11
relevant patient placement criteria as specified in subsection
12
(l). If that level of placement is not available, the insurer
13
shall authorize the next higher level of care. In the event of
14
disagreement, the insurer shall provide full detail of its
15
assessment using the relevant criteria as specified in
16
subsection (l) to the provider of the service and the patient.
17

If an insurer purchases or licenses utilization review
18
criteria pursuant to this subsection, the insurer shall verify
19
and document before use that the criteria were developed in
20
accordance with subsection (k).
21

(n) In conducting utilization review that is outside the
22
scope of the criteria as specified in subsection (l) or
23
relates to the advancements in technology or in the types or
24
levels of care that are not addressed in the most recent
25
versions of the sources specified in subsection (l), an
26
insurer shall conduct utilization review in accordance with

SB3024
- 24 -
LRB104 18555 BAB 31998 b
1
subsection (k).
2

(o) This Section does not in any way limit the rights of a
3
patient under the Medical Patient Rights Act.
4

(p) This Section does not in any way limit early and
5
periodic screening, diagnostic, and treatment benefits as
6
defined under 42 U.S.C. 1396d(r).
7

(q) To ensure the proper use of the criteria described in
8
subsection (l), every insurer shall do all of the following:
9

(1) Educate the insurer's staff, including any third
10

parties contracted with the insurer to review claims,
11

conduct utilization reviews, or make medical necessity
12

determinations about the utilization review criteria.
13

(2) Make the educational program available to other
14

stakeholders, including the insurer's participating or
15

contracted providers and potential participants,
16

beneficiaries, or covered lives. The education program
17

must be provided at least once a year, in-person or
18

digitally, or recordings of the education program must be
19

made available to the aforementioned stakeholders.
20

(3) Provide, at no cost, the utilization review
21

criteria and any training material or resources to
22

providers and insured patients upon request. For
23

utilization review criteria not concerning level of care
24

placement, continued stay, transfer, discharge, or other
25

patient care decisions used by the insurer pursuant to
26

subsection (m), the insurer may place the criteria on a

SB3024
- 25 -
LRB104 18555 BAB 31998 b
1

secure, password-protected website so long as the access
2

requirements of the website do not unreasonably restrict
3

access to insureds or their providers. No restrictions
4

shall be placed upon the insured's or treating provider's
5

access right to utilization review criteria obtained under
6

this paragraph at any point in time, including before an
7

initial request for authorization.
8

(4) Track, identify, and analyze how the utilization
9

review criteria are used to certify care, deny care, and
10

support the appeals process.
11

(5) Conduct interrater reliability testing to ensure
12

consistency in utilization review decision making that
13

covers how medical necessity decisions are made; this
14

assessment shall cover all aspects of utilization review
15

as defined in subsection (h).
16

(6) Run interrater reliability reports about how the
17

clinical guidelines are used in conjunction with the
18

utilization review process and parity compliance
19

activities.
20

(7) Achieve interrater reliability pass rates of at
21

least 90% and, if this threshold is not met, immediately
22

provide for the remediation of poor interrater reliability
23

and interrater reliability testing for all new staff
24

before they can conduct utilization review without
25

supervision.
26

(8) Maintain documentation of interrater reliability

SB3024
- 26 -
LRB104 18555 BAB 31998 b
1

testing and the remediation actions taken for those with
2

pass rates lower than 90% and submit to the Department of
3

Insurance or, in the case of Medicaid managed care
4

organizations, the Department of Healthcare and Family
5

Services the testing results and a summary of remedial
6

actions as part of parity compliance reporting set forth
7

in subsection (k) of Section 370c.1.
8

(r) This Section applies to all health care services and
9
benefits for the diagnosis, prevention, and treatment of
10
mental, emotional, nervous, or substance use disorders or
11
conditions covered by an insurance policy, including
12
prescription drugs.
13

(s) This Section applies to an insurer that amends,
14
delivers, issues, or renews a group or individual policy of
15
accident and health insurance or a qualified health plan
16
offered through the health insurance marketplace in this State
17
providing coverage for hospital or medical treatment and
18
conducts utilization review as defined in this Section,
19
including Medicaid managed care organizations, and any entity
20
or contracting provider that performs utilization review or
21
utilization management functions on an insurer's behalf.
22

(t) If the Director determines that an insurer has
23
violated this Section, the Director may, after appropriate
24
notice and opportunity for hearing, by order, assess a civil
25
penalty between $1,000 and $5,000 for each violation. Moneys
26
collected from penalties shall be deposited into the Parity

SB3024
- 27 -
LRB104 18555 BAB 31998 b
1
Advancement Fund established in subsection (i) of Section
2
370c.1.
3

(u) An insurer shall not adopt, impose, or enforce terms
4
in its policies or provider agreements, in writing or in
5
operation, that undermine, alter, or conflict with the
6
requirements of this Section.
7

(v) The provisions of this Section are severable. If any
8
provision of this Section or its application is held invalid,
9
that invalidity shall not affect other provisions or
10
applications that can be given effect without the invalid
11
provision or application.
12

(w) Beginning January 1, 2026, coverage for medically
13
necessary treatment of mental, emotional, or nervous disorders
14
or conditions shall comply with the following requirements:
15

(1) No policy shall require prior authorization for
16

outpatient or partial hospitalization services for
17

treatment of mental, emotional, or nervous disorders or
18

conditions provided by a physician licensed to practice
19

medicine in all branches, a licensed clinical
20

psychologist, a licensed clinical social worker, a
21

licensed clinical professional counselor, a licensed
22

marriage and family therapist, a licensed speech-language
23

pathologist, or any other type of licensed, certified, or
24

legally authorized provider, including trainees working
25

under the supervision of a licensed health care
26

professional listed under this subsection, or facility

SB3024
- 28 -
LRB104 18555 BAB 31998 b
1

whose outpatient or partial hospitalization services the
2

policy covers for treatment of mental, emotional, or
3

nervous disorders or conditions. Such coverage may be
4

subject to concurrent and retrospective review consistent
5

with the utilization review provisions in subsections (h)
6

through (n) and Section 370c.1. Nothing in this paragraph
7

(1) supersedes a health maintenance organization's
8

referral requirement for services from nonparticipating
9

providers. An insurer may require providers or facilities
10

to notify the insurer of the initiation of treatment as
11

specified in this subsection, except to the extent
12

prohibited by Section 370c.1 with respect to treatment
13

limitations in a benefit classification or
14

subclassification. No such coverage shall be subject to
15

concurrent review for any services furnished before an
16

applicable notification deadline, subject to the
17

following:
18

(A) In the case of outpatient treatment, for an
19

insurer that is not a Medicaid managed care
20

organization, the insurer may set a notification
21

deadline of 2 business days after the initiation of
22

the covered person's treatment. A Medicaid managed
23

care organization may set a deadline of 24 hours after
24

the initiation of treatment. If the Medicaid managed
25

care organization is not capable of accepting the
26

notification in accordance with the contractual

SB3024
- 29 -
LRB104 18555 BAB 31998 b
1

protocol within the 24-hour period following
2

initiation, the treatment provider or facility shall
3

have one additional business day to provide the
4

notification to the Medicaid managed care
5

organization.
6

(B) In the case of a partial hospitalization
7

program, for an insurer that is not a Medicaid managed
8

care organization, the insurer may set a notification
9

deadline of 48 hours after the initiation of the
10

covered person's treatment. A Medicaid managed care
11

organization may set a deadline of 24 hours after the
12

initiation of treatment. If the Medicaid managed care
13

organization is not capable of accepting the
14

notification in accordance with the contractual
15

protocol during the 24-hour period following
16

initiation, the treatment provider or facility shall
17

have one additional business day to provide the
18

notification to the Medicaid managed care
19

organization.
20

(2) No policy shall require prior authorization for
21

inpatient treatment at a hospital for mental, emotional,
22

or nervous disorders or conditions at a participating
23

provider. Additionally, no such coverage shall be subject
24

to concurrent review for the first 72 hours after
25

admission, provided that the provider must notify the
26

insurer of both the admission and the initial treatment

SB3024
- 30 -
LRB104 18555 BAB 31998 b
1

plan within 48 hours of admission. A discharge plan must
2

be fully developed and continuity services prepared to
3

meet the patient's needs and the patient's community
4

preference upon release. Recommended level of care
5

placements identified in the discharge plan shall comply
6

with generally accepted standards of care, as defined in
7

subsection (h).
8

(A) If the provider satisfies the conditions of
9

paragraph (2), then the insurer shall approve coverage
10

of the recommended level of care, if applicable, upon
11

discharge subject to concurrent review.
12

(B) Nothing in this paragraph supersedes a health
13

maintenance organization's referral requirement for
14

services from nonparticipating providers upon a
15

patient's discharge from a hospital or facility.
16

(C) Concurrent review for such coverage must be
17

consistent with the utilization review provisions in
18

subsections (h) through (n).
19

(D) In this subsection, residential treatment that
20

is not otherwise identified in the discharge plan is
21

not inpatient hospitalization.
22

(3) Treatment provided under this subsection may be
23

reviewed retrospectively. If coverage is denied
24

retrospectively, neither the insurer nor the participating
25

provider shall bill, and the insured shall not be liable,
26

for any treatment under this subsection through the date

SB3024
- 31 -
LRB104 18555 BAB 31998 b
1

the adverse determination is issued, other than any
2

copayment, coinsurance, or deductible for the stay through
3

that date as applicable under the policy. Coverage shall
4

not be retrospectively denied for the first 72 hours of
5

admission to inpatient hospitalization for treatment of
6

mental, emotional, or nervous disorders or conditions, or
7

before the applicable deadline under paragraph (1) of this
8

subsection for outpatient treatment or partial
9

hospitalization programs, at a participating provider
10

except:
11

(A) upon reasonable determination that the
12

inpatient mental health treatment was not provided;
13

(B) upon determination that the patient receiving
14

the treatment was not an insured, enrollee, or
15

beneficiary under the policy;
16

(C) upon material misrepresentation by the patient
17

or health care provider. In this item (C), "material"
18

means a fact or situation that is not merely technical
19

in nature and results or could result in a substantial
20

change in the situation;
21

(D) upon determination that a service was excluded
22

under the terms of coverage. In that case, the
23

limitation to billing for a copayment, coinsurance, or
24

deductible shall not apply;
25

(E) for outpatient treatment or partial
26

hospitalization programs only, upon determination that

SB3024
- 32 -
LRB104 18555 BAB 31998 b
1

a service was not medically necessary consistent with
2

subsections (h) through (n); or
3

(F) upon determination that the patient did not
4

consent to the treatment and that there was no court
5

order mandating the treatment.
6

Nothing in this subsection shall be construed to
7

require a policy to cover any health care service excluded
8

under the terms of coverage.
9

This subsection does not apply to coverage for any
10

prescription or over-the-counter drug.
11

Nothing in this subsection shall be construed to
12

require the medical assistance program to reimburse for
13

services not covered by the medical assistance program as
14

authorized by the Illinois Public Aid Code or the
15

Children's Health Insurance Program Act.
16

(x) Notwithstanding any provision of this Section, nothing
17
shall require the medical assistance program under Article V
18
of the Illinois Public Aid Code or the Children's Health
19
Insurance Program Act to violate any applicable federal laws,
20
regulations, or grant requirements, including requirements for
21
utilization management, or any State or federal consent
22
decrees. Nothing in subsection (g) or (w) shall prevent the
23
Department of Healthcare and Family Services from requiring a
24
health care provider to use specified level of care,
25
admission, continued stay, or discharge criteria, including,
26
but not limited to, those under Section 5-5.23 of the Illinois

SB3024
- 33 -
LRB104 18555 BAB 31998 b
1
Public Aid Code, as long as the Department of Healthcare and
2
Family Services, subject to applicable federal laws,
3
regulations, or grant requirements, including requirements for
4
utilization management, does not require a health care
5
provider to seek prior authorization or concurrent review from
6
the Department of Healthcare and Family Services, a Medicaid
7
managed care organization, or a utilization review
8
organization under the circumstances expressly prohibited by
9
subsections (g) and (w). Nothing in this Section prohibits a
10
health plan, including a Medicaid managed care organization,
11
from conducting reviews for medical necessity, clinical
12
appropriateness, safety, fraud, waste, or abuse and reporting
13
suspected fraud, waste, or abuse according to State and
14
federal requirements. Nothing in this Section limits the
15
authority of the Department of Healthcare and Family Services
16
or another State agency, or a Medicaid managed care
17
organization on the State agency's behalf, to (i) implement or
18
require programs, services, screenings, assessments, tools, or
19
reviews to comply with applicable federal law, federal
20
regulation, federal grant requirements, any State or federal
21
consent decrees or court orders, or any applicable case law,
22
such as Olmstead v. L.C., 527 U.S. 581 (1999), or (ii)
23
administer or require programs, services, screenings,
24
assessments, tools, or reviews established under State or
25
federal laws, rules, or regulations in compliance with State
26
or federal laws, rules, or regulations, including, but not

SB3024
- 34 -
LRB104 18555 BAB 31998 b
1
limited to, the Children's Mental Health Act and the Mental
2
Health and Developmental Disabilities Administrative Act.
3

(y) (Blank).
4
(Source: P.A. 103-426, eff. 8-4-23; 103-650, eff. 1-1-25;
5
103-1040, eff. 8-9-24; 104-28, eff. 1-1-26; 104-417, eff.
6
8-15-25
.)

7

Section 99.
Effective date.
This Act takes effect upon
8
becoming law.

Footer

Disclaimer

This site is maintained for the Illinois General Assembly by the
Legislative Information System, 705 Stratton Building, Springfield, Illinois 62706.

Contact ILGA Webmaster

ILGA.gov uses cookies to ensure you get the best experience on our website. By continuing to browse ILGA.gov you consent to our use of cookies.
Read About Cookies

ILGA.GOV

2026 ILGA.gov | All Rights Reserved |
ADA

|
Disclaimers
|
Learn

This site is maintained for the Illinois General Assembly by the
Legislative Information System, 705 Stratton Building, Springfield, Illinois 62706.
Contact ILGA Webmaster

ILGA.gov uses cookies to ensure you get the best experience on our website. By continuing to browse ILGA.gov you consent to our use of cookies.
Read About Cookies

ILGA.GOV

2026 ILGA.gov | All Rights Reserved |
ADA

|
Disclaimers
|
Learn