Illinois to Require Insurance Coverage for Mental Health and Substance Use Disorders | Chicago News

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A new law signed last week by Governor JB Pritzker will require health insurers to cover medically necessary services and treatment for mental, emotional, nervous or substance use disorders and conditions.

“I am proud and inspired to be a part of the bold changes to our mental health services in Illinois that will help all Illinois residents receive the essential services and care they need, no matter where they are. of residence or their socio-economic status, ”said the governor. JB Pritzker said in a statement upon signing the legislation. “Mental health care is health care. It’s medically necessary, it’s life-saving, and it can help deal with the systemic trauma that has held back many communities for too long.

Illinois is now the third state in the country to pass such legislation, which its supporters say is needed more than ever. California and Oregon have passed similar legislation.

“We are at a critical time when the need for mental health care is greater than ever,” said David Applegate, director of policy at Illinois Kennedy Forum. “Our communities are really facing two public health crises right now: the COVID-19 pandemic, and then the current mental health and addiction crisis which has been significantly worsened by the pandemic.”

About 4 in 10 adults reported anxiety or depressive disorders during the pandemic, compared to 1 in 10 adults before the pandemic, according to a Kaiser Family Foundation report.

“Despite an increase in needs, too often what we have seen in the past is that people are unable to access care when their health plan decides not to pay for the care they need and refuse their treatment, ”Applegate said. “People are forced to pay thousands of dollars for care or forgo care altogether. “

Right now, insurance coverage decisions are opaque, according to Heather O’Donnell, senior vice president of public policy and advocacy for Thresholds, an organization that serves people with mental illnesses and substance use disorders.

“When an insurance company says you don’t qualify, it’s important to understand the criteria they’re using,” she said. “Now more than ever, we need to understand why an insurance company can refuse care recommended by a doctor or health care provider. “

The legislation, which comes into force on January 1, 2023, seeks to make coverage decisions more transparent by establishing clear definitions and standards for when services and treatments are deemed medically necessary.

The law also requires all Medicaid-managed care organizations and commercial insurers to use publicly available guidelines issued by nonprofit clinical companies to determine what constitutes a medical necessity.

“Basically when a doctor says it’s the right thing to do, insurers can’t deny it,” Illinois representative Deb Conroy said of the legislation she sponsored. “Now they are waiting for someone to be seriously ill and in crisis to cover it up.”

Under the new law, insurers will be prohibited from limiting benefits to acute short-term treatment or from refusing to cover certain types of care.

“An insurance company can’t say they’ll only cover six treatment sessions when a doctor says (someone) needs 12,” Conroy said.

And if an insurer denies coverage, people can appeal those decisions, which advocates say is vital.

“We see every day, now, that sometimes many patients are wrongly denied care, and a provider can help get documents or justify why they are eligible for a service,” O’Donnell said. . “An appeal process is crucial to ensure that an insurance company has not missed anything. “

The Illinois Medicaid Health Plans Association, which represents health plans that participate in Medicaid managed care in Illinois, supports the legislation.

“From our perspective, mental health parity is one piece of the behavioral health puzzle, and we look forward to working with Leader Conroy and (Senator Laura) Fine and the provider community to continue to strengthen the access to behavioral health for Medicaid members, ”said Samantha Olds Frey, CEO of the Illinois Association of Medicaid Health Plans.

Consistent and transparent guidelines will also make it easier for providers to submit the necessary documentation to insurers for coverage, according to Olds Frey.

“We don’t want the provider community to feel frustrated and say, ‘We don’t know what criteria you are looking at,'” she said, adding that the lack of clinical documentation is one of the main reasons for which people are denied coverage. “We think it’s in everyone’s best interest to make sure there is a clear process for suppliers to get this information and to make sure we get all the information we need. “

Not only does the legislation remove barriers to accessing care, it also helps de-stigmatize mental health and substance abuse disorders, according to Applegate.

“Mental health care is health care, and it should not be stigmatized or viewed differently,” he said. “If I’m going to get treatment for a broken leg, my health insurance pays and takes care of it, no questions asked. … It should be the same if you go to the doctor and suffer from depression or anxiety or if you have an addiction.

Contact Kristen Thometz: @kristenthometz | (773) 509-5452 | [email protected]

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Justin D. O'Neill

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