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HB1085 Enrolled LRB104 05991 BAB 16024 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 Counties Code is amended by changing
5 Section 5-1069.3 as follows:
6 (55 ILCS 5/5-1069.3)
7 Sec. 5-1069.3. Required health benefits. If a county,
8 including a home rule county, is a self-insurer for purposes
9 of providing health insurance coverage for its employees, the
10 coverage shall include coverage for the post-mastectomy care
11 benefits required to be covered by a policy of accident and
12 health insurance under Section 356t and the coverage required
13 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
14 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
15 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
16 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
17 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
18 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
19 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
20 356z.74, and 356z.77 of the Illinois Insurance Code. The
21 coverage shall comply with Sections 155.22a, 355b, 356z.19,
22 and 370c, and 370c.4 of the Illinois Insurance Code. The
23 Department of Insurance shall enforce the requirements of this
HB1085 Enrolled -2- LRB104 05991 BAB 16024 b
1 Section. The requirement that health benefits be covered as
2 provided in this Section is an exclusive power and function of
3 the State and is a denial and limitation under Article VII,
4 Section 6, subsection (h) of the Illinois Constitution. A home
5 rule county to which this Section applies must comply with
6 every provision of this Section.
7 Rulemaking authority to implement Public Act 95-1045, if
8 any, is conditioned on the rules being adopted in accordance
9 with all provisions of the Illinois Administrative Procedure
10 Act and all rules and procedures of the Joint Committee on
11 Administrative Rules; any purported rule not so adopted, for
12 whatever reason, is unauthorized.
13 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
14 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
15 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
16 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
17 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
18 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
19 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
20 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
21 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
22 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
23 revised 11-26-24.)
24 Section 10. The Illinois Municipal Code is amended by
25 changing Section 10-4-2.3 as follows:
HB1085 Enrolled -3- LRB104 05991 BAB 16024 b
1 (65 ILCS 5/10-4-2.3)
2 Sec. 10-4-2.3. Required health benefits. If a
3 municipality, including a home rule municipality, is a
4 self-insurer for purposes of providing health insurance
5 coverage for its employees, the coverage shall include
6 coverage for the post-mastectomy care benefits required to be
7 covered by a policy of accident and health insurance under
8 Section 356t and the coverage required under Sections 356g,
9 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
10 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
11 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
12 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
13 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
14 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
15 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, and
16 356z.77 of the Illinois Insurance Code. The coverage shall
17 comply with Sections 155.22a, 355b, 356z.19, and 370c, and
18 370c.4 of the Illinois Insurance Code. The Department of
19 Insurance shall enforce the requirements of this Section. The
20 requirement that health benefits be covered as provided in
21 this is an exclusive power and function of the State and is a
22 denial and limitation under Article VII, Section 6, subsection
23 (h) of the Illinois Constitution. A home rule municipality to
24 which this Section applies must comply with every provision of
25 this Section.
HB1085 Enrolled -4- LRB104 05991 BAB 16024 b
1 Rulemaking authority to implement Public Act 95-1045, if
2 any, is conditioned on the rules being adopted in accordance
3 with all provisions of the Illinois Administrative Procedure
4 Act and all rules and procedures of the Joint Committee on
5 Administrative Rules; any purported rule not so adopted, for
6 whatever reason, is unauthorized.
7 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
8 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
9 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
10 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
11 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
12 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
13 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
14 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
15 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
16 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
17 revised 11-26-24.)
18 Section 15. The School Code is amended by changing Section
19 10-22.3f as follows:
20 (105 ILCS 5/10-22.3f)
21 Sec. 10-22.3f. Required health benefits. Insurance
22 protection and benefits for employees shall provide the
23 post-mastectomy care benefits required to be covered by a
24 policy of accident and health insurance under Section 356t and
HB1085 Enrolled -5- LRB104 05991 BAB 16024 b
1 the coverage required under Sections 356g, 356g.5, 356g.5-1,
2 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
3 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
4 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
5 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
6 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
7 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
8 356z.71, 356z.74, and 356z.77 of the Illinois Insurance Code.
9 Insurance policies shall comply with Section 356z.19 of the
10 Illinois Insurance Code. The coverage shall comply with
11 Sections 155.22a, 355b, and 370c, and 370c.4 of the Illinois
12 Insurance Code. The Department of Insurance shall enforce the
13 requirements of this Section.
14 Rulemaking authority to implement Public Act 95-1045, if
15 any, is conditioned on the rules being adopted in accordance
16 with all provisions of the Illinois Administrative Procedure
17 Act and all rules and procedures of the Joint Committee on
18 Administrative Rules; any purported rule not so adopted, for
19 whatever reason, is unauthorized.
20 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
21 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
22 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
23 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
24 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
25 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
26 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
HB1085 Enrolled -6- LRB104 05991 BAB 16024 b
1 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
2 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
3 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
4 Section 20. The Illinois Insurance Code is amended by
5 adding Section 370c.4 as follows:
6 (215 ILCS 5/370c.4 new)
7 Sec. 370c.4. Mental health and substance use parity.
8 (a) In this Section:
9 "Application" means a person's or facility's application
10 to become a participating provider with an insurer in at least
11 one of the insurer's provider networks.
12 "Applying provider" means a provider or facility that has
13 submitted a completed application to become a participating
14 provider or facility with an insurer.
15 "Behavioral health trainee" means any person: (1) engaged
16 in the provision of mental health or substance use disorder
17 clinical services as part of that person's supervised course
18 of study while enrolled in a master's or doctoral psychology,
19 social work, counseling, or marriage or family therapy program
20 or as a postdoctoral graduate working toward licensure; and
21 (2) who is working toward clinical State licensure under the
22 clinical supervision of a fully licensed mental health or
23 substance use disorder treatment provider.
24 "Completed application" means a person's or facility's
HB1085 Enrolled -7- LRB104 05991 BAB 16024 b
1 application to become a participating provider that has been
2 submitted to the insurer and includes all the required
3 information for the application to be considered by the
4 insurer according to the insurer's policies and procedures for
5 verifying a provider's or facility's credentials.
6 "Contracting process" means the process by which a mental
7 health or substance use disorder treatment provider or
8 facility makes a completed application with an insurer to
9 become a participating provider with the insurer until the
10 effective date of a final contract between the provider or
11 facility and the insurer. "Contracting process" includes the
12 process of verifying a provider's credentials.
13 "Participating provider" means any mental health or
14 substance use disorder treatment provider that has a contract
15 to provide mental health or substance use disorder services
16 with an insurer.
17 (b) Consistent with the principles of the federal Mental
18 Health Parity and Addiction Equity Act of 2008, and for the
19 purposes of strengthening network adequacy for mental health
20 and substance use disorder services and lowering
21 out-of-network utilization, provider reimbursement rates
22 subject to this Section shall comply with the reimbursement
23 rate floors for all in-network mental health and substance use
24 disorder services, including inpatient services, outpatient
25 services, office visits, and residential care, delivered by
26 Illinois providers and facilities using the Illinois data in
HB1085 Enrolled -8- LRB104 05991 BAB 16024 b
1 the Research Triangle Institute International's study,
2 Behavioral Health Parity - Pervasive Disparities in Access to
3 In-Network Care Continue, Mark, T.L., & Parish, W. (April
4 2024). The reimbursement rate floors for in-network mental
5 health and substance use disorder services requires that
6 reimbursement for each service, classified by Healthcare
7 Common Procedure Coding System (HCPCS) codes, Current
8 Procedural Terminology (CPT) codes, Ambulatory Payment
9 Classifications (APC), Enhanced Ambulatory Patient Groups
10 (EAPG), Medicare Severity Diagnosis Related Groups (MS-DRG),
11 All Patient Refined Diagnosis Related Groups (APR-DRG), and
12 base payment rates with adjusters and applicable outliers must
13 be equal to or greater than the dollar amounts applicable
14 under this subsection on the date of service for the
15 geographic location. The reimbursement rate floor for each
16 Healthcare Common Procedure Coding System (HCPCS) code,
17 Current Procedural Terminology (CPT) code, Ambulatory Payment
18 Classification (APC), Enhanced Ambulatory Patient Group
19 (EAPG), Medicare Severity Diagnosis Related Group (MS-DRG),
20 All Patient Refined Diagnosis Related Group (APR-DRG), and
21 base payment rate with adjusters and applicable outliers shall
22 apply to all group or individual policies of accident and
23 health insurance or managed care plans that are amended,
24 delivered, issued, or renewed on or after January 1, 2027, or
25 any contracted third party administering the behavioral health
26 benefits for the insurer.
HB1085 Enrolled -9- LRB104 05991 BAB 16024 b
1 (1) Except as otherwise provided in this subsection,
2 the reimbursement rate floor for each Healthcare Common
3 Procedure Coding System (HCPCS) code, Current Procedural
4 Terminology (CPT) code, Ambulatory Payment Classification
5 (APC), Enhanced Ambulatory Patient Group (EAPG), Medicare
6 Severity Diagnosis Related Group (MS-DRG), All Patient
7 Refined Diagnosis Related Group (APR-DRG), and base
8 payment rate with adjusters and applicable outliers for a
9 mental health or substance use disorder service shall be
10 equal to the following dollar amount:
11 (A)(i) the average reimbursement percentage for
12 Illinois All Medical/Surgical Clinicians, as listed on
13 the first line of Appendix C-13, page C-52 of the
14 Research Triangle Institute International study, plus;
15 (ii) half of the difference between the
16 average reimbursement percentage and the
17 percentage at the 75th percentile for Illinois All
18 Medical/Surgical Clinicians, as listed in the
19 first line in Appendix C-13, page C-52, multiplied
20 by;
21 (B) the same source of the benchmark rate that was
22 used to calculate the percentages in items (i) and
23 (ii) of subparagraph (A), using the updated benchmark
24 rate for medical/surgical clinicians for the same
25 Healthcare Common Procedure Coding System (HCPCS) or
26 Current Procedural Terminology (CPT) code in effect on
HB1085 Enrolled - 10 - LRB104 05991 BAB 16024 b
1 the date of service for the geographic location,
2 except that:
3 (i) the source of the benchmark rate for a
4 hospital inpatient service shall follow the
5 formula set out by the same federal health care
6 program for the acute inpatient operating
7 prospective payment system in effect on the date
8 of service for the geographic location using all
9 applicable adjusters and outliers; and
10 (ii) the source of the benchmark rate for a
11 hospital outpatient service shall follow the
12 formula set out by the same federal health care
13 program for the hospital outpatient services
14 prospective payment system in effect on the date
15 of service for the geographic location using all
16 applicable adjusters and outliers.
17 Calculation of the benchmark rate shall adhere to
18 the methodologies used in the Research Triangle
19 Institution International study using comparable
20 benefits within the same classification.
21 (2) If the rate benchmark set by this subsection is
22 tied to a federal health care program, a rate floor dollar
23 amount shall take effect on the date the federal health
24 care program's benchmark rate takes effect. However, for
25 any year that the benchmark rate decreases for any
26 Healthcare Common Procedure Coding System (HCPCS) code,
HB1085 Enrolled - 11 - LRB104 05991 BAB 16024 b
1 Current Procedural Terminology (CPT) code, Ambulatory
2 Payment Classification (APC), Enhanced Ambulatory Patient
3 Group (EAPG), Medicare Severity Diagnosis Related Group
4 (MS-DRG), All Patient Refined Diagnosis Related Group
5 (APR-DRG), and base payment rate with adjusters and
6 applicable outliers, the reimbursement rate floor for the
7 purposes of this Section shall remain at the level it was
8 the previous year. Notwithstanding any other provision of
9 this Section, all rate floor dollar amounts in effect on
10 January 1, 2027 shall be equal to the amount described in
11 paragraph (1). The Department has the authority to enforce
12 and monitor the reimbursement rate floor set pursuant to
13 this Section.
14 (c) A group or individual policy of accident and health
15 insurance or managed care plan that is amended, delivered,
16 issued, or renewed on or after January 1, 2027, or any
17 contracted third party administering the behavioral health
18 benefits for the insurer, shall cover all medically necessary
19 mental health or substance use disorder services received by
20 the same insured on the same day from the same or different
21 mental health or substance use provider or facility for both
22 outpatient and inpatient care.
23 (d) A group or individual policy of accident and health
24 insurance or managed care plan that is amended, delivered,
25 issued, or renewed on or after January 1, 2027, or any
26 contracted third party administering the behavioral health
HB1085 Enrolled - 12 - LRB104 05991 BAB 16024 b
1 benefits for the insurer, shall cover any medically necessary
2 mental health or substance use disorder service provided by a
3 behavioral health trainee when the trainee is working toward
4 clinical State licensure and is under the supervision of a
5 fully licensed mental health or substance use disorder
6 treatment provider who is a physician licensed to practice
7 medicine in all its branches, licensed clinical psychologist,
8 licensed clinical social worker, licensed clinical
9 professional counselor, licensed marriage and family
10 therapist, licensed speech-language pathologist, or other
11 licensed or certified professional at a program licensed
12 pursuant to the Substance Use Disorder Act who is engaged in
13 treating mental, emotional, nervous, or substance use
14 disorders or conditions. Services provided by the trainee must
15 be billed under the supervising clinician's rendering National
16 Provider Identifier.
17 (e) A group or individual policy of accident and health
18 insurance or managed care plan that is amended, delivered,
19 issued, or renewed on or after January 1, 2027, or any
20 contracted third party administering the behavioral health
21 benefits for the insurer, shall:
22 (1) cover medically necessary 60-minute psychotherapy
23 billed using the Current Procedural Terminology Code 90837
24 for Individual Therapy;
25 (2) not impose more onerous documentation requirements
26 on the provider than is required for other psychotherapy
HB1085 Enrolled - 13 - LRB104 05991 BAB 16024 b
1 Current Procedural Terminology (CPT) codes; and
2 (3) not audit the use of Current Procedural
3 Terminology Code 90837 any more frequently than audits for
4 the use of other psychotherapy Current Procedural
5 Terminology (CPT) codes.
6 (f)(1) Any group or individual policy of accident and
7 health insurance or managed care plan that is amended,
8 delivered, issued, or renewed on or after January 1, 2027, or
9 any contracted third party administering the behavioral health
10 benefits for the insurer, shall complete the contracting
11 process with a mental health or substance use disorder
12 treatment provider or facility for becoming a participating
13 provider in the insurer's network, including the verification
14 of the provider's credentials, within 60 days from the date of
15 a completed application to the insurer to become a
16 participating provider. Nothing in this paragraph (1),
17 however, presumes or establishes a contract between an insurer
18 and a provider.
19 (2) Any group or individual policy of accident and health
20 insurance or managed care plan that is amended, delivered,
21 issued, or renewed on or after January 1, 2027, or any
22 contracted third party administering the behavioral health
23 benefits for the insurer, shall reimburse a participating
24 mental health or substance use disorder treatment provider or
25 facility at the contracted reimbursement rate for any
26 medically necessary services provided to an insured from the
HB1085 Enrolled - 14 - LRB104 05991 BAB 16024 b
1 date of submission of the provider's or facility's completed
2 application to become a participating provider with the
3 insurer up to the effective date of the provider's contract.
4 The provider's claims for such services shall be reimbursed
5 only when submitted after the effective date of the provider's
6 contract with the insurer. This paragraph (2) does not apply
7 to a provider that does not have a completed contract with an
8 insurer. If a provider opts to submit claims for medically
9 necessary mental health or substance use disorder services
10 pursuant to this paragraph (2), the provider must notify the
11 insured following submission of the claims to the insurer that
12 the services provided to the insured may be treated as
13 in-network services.
14 (3) Any group or individual policy of accident and health
15 insurance or managed care plan that is amended, delivered,
16 issued, or renewed on or after January 1, 2027, or any
17 contracted third party administering the behavioral health
18 benefits for the insurer, shall cover any medically necessary
19 mental health or substance use disorder service provided by a
20 fully licensed mental health or substance use disorder
21 treatment provider affiliated with a mental health or
22 substance use disorder treatment group practice who has
23 submitted a completed application to become a participating
24 provider with an insurer who is delivering services under the
25 supervision of another fully licensed participating mental
26 health or substance use disorder treatment provider within the
HB1085 Enrolled - 15 - LRB104 05991 BAB 16024 b
1 same group practice up to the effective date of the applying
2 provider's contract with the insurer as a participating
3 provider. Services provided by the applying provider must be
4 billed under the supervising licensed provider's rendering
5 National Provider Identifier.
6 (4) Upon request, an insurer, or any contracted third
7 party administering the behavioral health benefits for the
8 insurer, shall provide an applying provider with the insurer's
9 credentialing policies and procedures. An insurer, or any
10 contracted third party administering the behavioral health
11 benefits for the insurer, shall post the following
12 nonproprietary information on its website and make that
13 information available to all applicants:
14 (A) a list of the information required to be included
15 in an application;
16 (B) a checklist of the materials that must be
17 submitted in the credentialing process; and
18 (C) designated contact information of a network
19 representative, including a designated point of contact,
20 an email address, and a telephone number, to which an
21 applicant may address any credentialing inquiries.
22 (g) The Department has the same authority to enforce this
23 Section as it has to enforce compliance with Sections 370c and
24 370c.1. Additionally, if the Department determines that an
25 insurer or any contracted third party administering the
26 behavioral health benefits for the insurer has violated this
HB1085 Enrolled - 16 - LRB104 05991 BAB 16024 b
1 Section, the Department shall, after appropriate notice and
2 opportunity for hearing in accordance with Section 402, by
3 order assess a civil penalty of $1,000 for each violation. The
4 Department shall establish any processes or procedures
5 necessary to monitor compliance with this Section.
6 (h) At the end of 2 years, 7 years, and 12 years following
7 the implementation of subsection (b) of this Section, the
8 Department shall review the impact of this Section on network
9 adequacy for mental health and substance use disorder
10 treatment and access to affordable mental health and substance
11 use care. By no later than December 31, 2030, December 31,
12 2035, and December 31, 2040, the Department shall submit a
13 report in each of those years to the General Assembly that
14 includes its analyses and findings. For the purpose of
15 evaluating trends in network adequacy, the Department is
16 granted the authority to examine out-of-network utilization
17 and out-of-pocket costs for insureds for mental health and
18 substance use disorder treatment and services for all plans to
19 compare with in-network utilization for purposes of evaluating
20 access to care. The Department shall conduct an analysis of
21 the impact, if any, of the reimbursement rate floor for mental
22 health and substance use disorder services on health insurance
23 premiums across the State-regulated health insurance markets,
24 taking into consideration the need to expand network adequacy
25 to improve access to care.
26 (i) The Department of Insurance shall adopt any rules
HB1085 Enrolled - 17 - LRB104 05991 BAB 16024 b
1 necessary to implement this Section by no later than September
2 1, 2026.
3 (j) This Section does not apply to a health care plan
4 serving Medicaid populations that provides, arranges for, pays
5 for, or reimburses the cost of any health care service for
6 persons who are enrolled under the Illinois Public Aid Code or
7 under the Children's Health Insurance Program Act.
8 Section 99. Effective date. This Act takes effect June 1,
9 2026.Every fact on this page links to its source, starting with the official bill record.