Healthcare (Mental Health)

Amends the Mental Health and Developmental Disabilities Code. Expands the definition of "developmental disability" to include a disability attributable to Prader-Willi syndrome. Amends the Developmental Disability and Mental Disability Services Act. Expands the definition of "severe and multiple impairments" to include a substantial disability attributable to Prader-Willi syndrome. Exempts persons diagnosed with Prader-Willi syndrome from any assessment or evaluation to measure cognitive functioning or IQ for purposes of making determinations on whether such persons have severe and multiple impairments eligible for home and community-based services for persons with developmental disabilities. Amends the Statute on Statutes. Provides that, except where the context indicates otherwise: (i) in any rule, contract, or other document the term "developmental disability" shall include a disability attributable to Prader-Willi syndrome; and (ii) whenever there is a reference in any Act to "development disability" the term shall be construed to include a disability attributable to Prader-Willi syndrome.

Amends the Community Mental Health Act. Authorizes any public library district to construct, repair, operate, maintain, and regulate community mental health facilities. Provides that a public library district authorized to levy an annual tax under the Act shall establish a community mental health board whose members are appointed by the president of the public library district's board of trustees.

Amends the Illinois Insurance Code. Provides that, when a beneficiary, insured, or enrollee receives mental health services from a nonparticipating provider or a nonparticipating health care facility, the health insurance issuer shall ensure that the beneficiary, insured, or enrollee shall incur no greater out-of-pocket costs than the beneficiary, insured, or enrollee would have incurred with a participating provider or a participating health care facility. Requires any cost-sharing requirements to be applied as though the mental health services had been received from a participating provider or a participating health care facility. Provides that, if the cost sharing for the same item or service furnished by a participating provider would have been a flat-dollar copayment, that amount shall be the cost-sharing amount unless the provider has billed a lesser total amount. Provides that administrative requirements or limitations shall be no greater than those applicable to emergency services received from a participating provider or a participating health care facility. Permits a beneficiary, insured, or enrollee receiving ongoing mental health services from a nonparticipating provider to continue treatment with the nonparticipating provider for up to one year from the start of services or one year after the effective date of the amendatory Act, whichever is later, as if the mental health services were provided by a participating provider. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, the Voluntary Health Services Plans Act, and the Illinois Public Aid Code to require coverage under those provisions. Effective January 1, 2027.

Amends the Illinois Insurance Code. Provides that 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, 2026, shall not impose any prior authorization or utilization management controls on covered behavioral health services. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, and the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Insurance and the Department of Healthcare and Family Services to establish a process for receiving complaints from providers and covered individuals for violations of the mandate. Grants the Department of Insurance and the Department of Healthcare and Family Services the authority to issue cease and desist orders and administrative fines. Amends the Prior Authorization Reform Act. Provides that the Department of Healthcare and Family Services shall adopt rules consistent with the Act. Provisions amending the Prior Authorization Reform Act are effective immediately.

Amends the Illinois Insurance Code. Provides that all group and individual health insurance policies issued, delivered, amended, or renewed in Illinois that provide coverage for medical or surgical conditions shall also provide coverage for crisis services, regardless of any difference in billing codes used for such services. Provides that coverage for crisis services may not be denied or restricted based on the modality or setting of the services; and that crisis services shall be covered whether delivered in person, through telehealth, or in a residential or outpatient setting, to the extent that such services are covered in other settings or modalities under the policy. Makes conforming changes to the State Employees Group Insurance Act of 1971, the Illinois Municipal Code, the School Code, the Health Maintenance Organization Act, the Telehealth Act, and the Illinois Public Aid Code. Amends the Strengthening and Transforming Behavioral Health Crisis Care in Illinois Act. Renames the Act the Crisis Continuum Sustainability Act. Provides that on or before December 31, 2028, and every 5 years thereafter, the Department of Human Services shall, subject to available funding and in collaboration with relevant stakeholders and State bodies, develop and submit a Statewide Crisis Continuum Strategic Plan to the Office of the Governor and the General Assembly, with the goal of ensuring every Illinoisan has timely access to appropriate and supportive behavioral health response during a behavioral health crisis. Requires the strategic plan to identify statewide goals, key stakeholders, and performance metrics for expanding access to behavioral health crisis continuum services across Illinois; address gaps in service delivery; and other matters.

Amends the Mental Health and Developmental Disabilities Code. Makes changes to a provision concerning initial Department of Human Services investigations of a facility employee's alleged abuse, neglect, or financial exploitation of a recipient of mental health or developmental disability services. Expands the provision to include allegations of material obstruction of an investigation, physical abuse, sexual abuse, non-de minimis financial exploitation (such as financial exploitation totaling a cumulative value equal to or greater than $100), or egregious neglect. Adds provisions concerning Department investigations where a facility employee is the perpetrator of, at most, neglect, de minimis financial exploitation (such as financial exploitation totaling a cumulative value of less than $100), or mental abuse.

Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs for FDA-approved prescription drugs that treat mental illness, requires the Department of Healthcare and Family Services and managed care organizations to report quarterly on compliance with the specified prohibitions beginning with dates of service on and after July 1, 2025. Requires the Department to post on its website a report on fee-for-service prescriptions and the reports from each managed care organization. Sets forth the information that must be contained in the quarterly reports, including, but not limited to: (i) the number of denied prescriptions and estimated net cost to the State for those covered prescriptions summarized by each of the allowed categories specified in the Code; (ii) the number of denied prescriptions and estimated net cost to the State for those prescriptions summarized by each of the non-allowed categories specified in the Code; and (iii) the number of denied prescriptions and estimated gross cost to the State for those prescriptions summarized by any other reason not specified in the Code. Requires the Department to sanction those managed care organizations that do not file the required reports. Effective immediately.

Amends the Illinois Insurance Code. Provides that an individual or group health benefit plan shall not impose any prior authorization requirements on outpatient services for the prevention, screening, diagnosis, or treatment of mental, emotional, nervous, or substance use disorders or conditions.

Creates the Psychiatric Residential Treatment Facilities (PRTF) Act. Requires the Department of Healthcare and Family Services to establish an Illinois Psychiatric Residential Treatment Facilities (PRTF) program that is family-driven, youth-guided, and trauma-informed, and includes youth and family involvement in all aspects of care planning. Requires the Department to submit a State Plan Amendment, by January 1, 2026, to the Centers for Medicare and Medicaid Services to establish coverage of federally authorized, medically necessary inpatient psychiatric services delivered by a certified PRTF to medical assistance beneficiaries under 21 years of age. Provides that the Department shall adopt rules to implement the PRTF program that at a minimum shall include: (i) certification and participation requirements for PRTF providers in compliance with all applicable federal laws, regulations, requirements, and policies; (ii) monitoring and oversight of PRTF services; (iii) a limit on allowable beds at any one PRTF, not to exceed 40 total beds; and other matters. Requires the Department to establish, and update as needed, a methodology for completing a statewide PRTF capacity analysis for the purposes of identifying capacity needs for PRTF services under the Illinois Medical Assistance Program. Requires the Department to establish a PRTF Advisory Committee responsible for reviewing and providing guidance on the Department's policies and implementations of the PRTF program. Requires the Department to publish on its website counts of reported emergency safety interventions and serious occurrences by State fiscal year and quarter. Makes conforming changes to the Specialized Mental Health Rehabilitation Act of 2013, the Child Care Act of 1969, and other various Acts. Effective immediately.

Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs for FDA-approved prescription drugs that treat mental illness, requires the Department of Healthcare and Family Services and managed care organizations to report quarterly on compliance with the specified prohibitions beginning with dates of service on and after July 1, 2025. Requires the Department to post on its website a report on fee-for-service prescriptions and the reports from each managed care organization. Sets forth the information that must be contained in the quarterly reports, including, but not limited to: (i) the number of denied prescriptions and estimated net cost to the State for those covered prescriptions summarized by each of the allowed categories specified in the Code; (ii) the number of denied prescriptions and estimated net cost to the State for those prescriptions summarized by each of the non-allowed categories specified in the Code; and (iii) the number of denied prescriptions and estimated gross cost to the State for those prescriptions summarized by any other reason not specified in the Code. Requires the Department to sanction those managed care organizations that do not file the required reports. Effective immediately.