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HB 4585

Illinois House•House Floor Calendar

Summary

HB 4585, “INS CD-SUBSTANCE USE TREATMENT”, was introduced in the House on Jan 23, 2026 by Rep. Lindsey LaPointe (D) with 5 co-sponsors. It was referred to Rules, and last saw action on Apr 17, 2026: House Floor Amendment No. 1 Rule 19(c) / Re-referred to Rules Committee.

Record

Text

HB 4585 has 5 co-sponsors and 1 roll call.

hb4585/introduced.txt
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Full Text of HB4585
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	HB4585 - 104th General Assembly
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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4585
Introduced 2/3/2026, by Rep. Lindsey LaPointe
SYNOPSIS AS INTRODUCED:
215 ILCS 5/370c	  from Ch. 73, par. 982c
Amends the Illinois Insurance Code. Provides that coverage for treatment in a residential treatment center shall include residential coverage for the diagnosis and treatment of substance use disorders. Provides that this coverage shall include unlimited medically necessary treatment for substance use disorder treatment services provided in residential settings. Prohibits the coverage from applying financial requirements or treatment limitations to residential substance use disorder benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to other medical and surgical benefits covered by the policy. Sets forth provisions concerning cost sharing; application of coverage requirements; prior authorization; clinical review; discharge plans; other forms of utilization review; and the criteria for medical necessity determinations.
LRB104 17523 BAB 30950 b
A BILL FOR
		HB4585		LRB104 17523 BAB 30950 b
    AN ACT concerning regulation.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
    Sec. 370c. Mental and emotional disorders.
    (a)(1) On and after January 1, 2022 (the effective date of
Public Act 102-579), every insurer that amends, delivers,
issues, or renews group accident and health policies providing
coverage for hospital or medical treatment or services for
illness shall provide coverage for the medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions consistent with the parity
requirements of Section 370c.1 of this Code.
    (2) Each insured that is covered for mental, emotional,
nervous, or substance use disorders or conditions shall be
free to select the physician licensed to practice medicine in
all its branches, licensed clinical psychologist, licensed
clinical social worker, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Substance
		HB4585	- 2 -	LRB104 17523 BAB 30950 b
Use Disorder Act of his or her choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act up
to the limits of coverage, provided (i) the disorder or
condition treated is covered by the policy, and (ii) the
physician, licensed psychologist, licensed clinical social
worker, licensed clinical professional counselor, licensed
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his or her
profession.
    (3) Insofar as this Section applies solely to licensed
clinical social workers, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Substance
Use Disorder Act, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker, licensed clinical professional counselor, licensed
		HB4585	- 3 -	LRB104 17523 BAB 30950 b
marriage and family therapist, licensed speech-language
pathologist, or other licensed or certified professional at a
program licensed pursuant to the Substance Use Disorder Act
has informed the patient of the desirability of the patient
conferring with the patient's primary care physician.
    (4) "Mental, emotional, nervous, or substance use disorder
or condition" means a condition or disorder that involves a
mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the current edition of the
World Health Organization's International Classification of
Disease or that is listed in the most recent version of the
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders. "Mental, emotional, nervous, or
substance use disorder or condition" includes any mental
health condition that occurs during pregnancy or during the
postpartum period and includes, but is not limited to,
postpartum depression.
    (5) Medically necessary treatment and medical necessity
determinations shall be interpreted and made in a manner that
is consistent with and pursuant to subsections (h) through
(y).
    (b)(1) (Blank).
    (2) (Blank).
    (2.5) (Blank).
    (3) Unless otherwise prohibited by federal law and
		HB4585	- 4 -	LRB104 17523 BAB 30950 b
consistent with the parity requirements of Section 370c.1 of
this Code, the insurer that amends, delivers, issues, or
renews a group or individual policy of accident and health
insurance, a qualified health plan offered through the health
insurance marketplace, or a provider of treatment of mental,
emotional, nervous, or substance use disorders or conditions
shall furnish medical records or other necessary data that
substantiate that initial or continued treatment is at all
times medically necessary. Nothing in this paragraph (3)
supersedes the prohibition on prior authorization requirements
to the extent provided under subsections (g) and (w) and
subparagraph (A) of paragraph (6.5) of this subsection.
Nothing prevents the insured from agreeing in writing to
continue treatment at his or her expense. When making a
determination of the medical necessity for a treatment
modality for mental, emotional, nervous, or substance use
disorders or conditions, an insurer must make the
determination in a manner that is consistent with the manner
used to make that determination with respect to other diseases
or illnesses covered under the policy, including an appeals
process. Medical necessity determinations for substance use
disorders shall be made in accordance with appropriate patient
placement criteria established by the American Society of
Addiction Medicine. No additional criteria may be used to make
medical necessity determinations for substance use disorders.
    (4) A group health benefit plan amended, delivered,
		HB4585	- 5 -	LRB104 17523 BAB 30950 b
issued, or renewed on or after January 1, 2019 (the effective
date of Public Act 100-1024) or an individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
        (A) shall provide coverage based upon medical
    necessity for the treatment of a mental, emotional,
    nervous, or substance use disorder or condition consistent
    with the parity requirements of Section 370c.1 of this
    Code; provided, however, that in each calendar year
    coverage shall not be less than the following:
            (i) 45 days of inpatient treatment; and
            (ii) beginning on June 26, 2006 (the effective
        date of Public Act 94-921), 60 visits for outpatient
        treatment including group and individual outpatient
        treatment; and
            (iii) for plans or policies delivered, issued for
        delivery, renewed, or modified after January 1, 2007
        (the effective date of Public Act 94-906), 20
        additional outpatient visits for speech therapy for
        treatment of pervasive developmental disorders that
        will be in addition to speech therapy provided
        pursuant to item (ii) of this subparagraph (A); and
        (B) may not include a lifetime limit on the number of
    days of inpatient treatment or the number of outpatient
		HB4585	- 6 -	LRB104 17523 BAB 30950 b
    visits covered under the plan.
        (C) (Blank).
    (5) An issuer of a group health benefit plan or an
individual policy of accident and health insurance or a
qualified health plan offered through the health insurance
marketplace may not count toward the number of outpatient
visits required to be covered under this Section an outpatient
visit for the purpose of medication management and shall cover
the outpatient visits under the same terms and conditions as
it covers outpatient visits for the treatment of physical
illness.
    (5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after September 9, 2015
(the effective date of Public Act 99-480) shall offer coverage
for medically necessary acute treatment services and medically
necessary clinical stabilization services. The treating
provider shall base all treatment recommendations and the
health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the Treatment Criteria for
Addictive, Substance-Related, and Co-Occurring Conditions
established by the American Society of Addiction Medicine. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for medication-assisted treatment in accordance
with the most current Treatment Criteria for Addictive,
		HB4585	- 7 -	LRB104 17523 BAB 30950 b
Substance-Related, and Co-Occurring Conditions established by
the American Society of Addiction Medicine.
    As used in this subsection:
    "Acute treatment services" means 24-hour medically
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial
assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
    "Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences,
relapse prevention, outreach to families and significant
others, and aftercare planning for individuals beginning to
engage in recovery from addiction.
    "Prior authorization" has the meaning given to that term
in Section 15 of the Prior Authorization Reform Act.
    (6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
    (6.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after January 1, 2019 (the
effective date of Public Act 100-1024):
        (A) shall not impose prior authorization requirements,
    including limitations on dosage, other than those
    established under the Treatment Criteria for Addictive,
		HB4585	- 8 -	LRB104 17523 BAB 30950 b
    Substance-Related, and Co-Occurring Conditions
    established by the American Society of Addiction Medicine,
    on a prescription medication approved by the United States
    Food and Drug Administration that is prescribed or
    administered for the treatment of substance use disorders;
        (B) shall not impose any step therapy requirements;
        (C) shall place all prescription medications approved
    by the United States Food and Drug Administration
    prescribed or administered for the treatment of substance
    use disorders on, for brand medications, the lowest tier
    of the drug formulary developed and maintained by the
    individual or group health benefit plan that covers brand
    medications and, for generic medications, the lowest tier
    of the drug formulary developed and maintained by the
    individual or group health benefit plan that covers
    generic medications; and
        (D) shall not exclude coverage for a prescription
    medication approved by the United States Food and Drug
    Administration for the treatment of substance use
    disorders and any associated counseling or wraparound
    services on the grounds that such medications and services
    were court ordered.
    (7) (Blank).
    (8) (Blank).
    (9) With respect to all mental, emotional, nervous, or
substance use disorders or conditions, coverage for inpatient
		HB4585	- 9 -	LRB104 17523 BAB 30950 b
treatment shall include coverage for treatment in a
residential treatment center certified or licensed by the
Department of Public Health or the Department of Human
Services.
        (A) Coverage for treatment in a residential treatment 
    center shall include residential coverage for the 
    diagnosis and treatment of substance use disorders, 
    including at American Society of Addiction Medicine levels 
    of treatment 3.5 (Clinically Managed High-Intensity 
    Residential) and 3.7 (Medically Managed Residential). This 
    coverage shall include unlimited medically necessary 
    treatment for substance use disorder treatment services 
    provided in residential settings. This coverage shall not 
    apply financial requirements or treatment limitations, 
    including concurrent or utilization review requirements, 
    to residential substance use disorder benefits that are 
    more restrictive than the predominant financial 
    requirements and treatment limitations applied to other 
    medical and surgical benefits covered by the policy.
        (B) Coverage for treatment in a residential treatment 
    center may be subject to annual deductibles, coinsurance, 
    or other cost sharing that is consistent with those 
    imposed on other benefits covered by the policy.
        (C) This paragraph (9) shall apply to facilities in 
    this State that are licensed, certified, or otherwise 
    authorized and participating in a provider network. 
		HB4585	- 10 -	LRB104 17523 BAB 30950 b
    Coverage for treatment in a residential treatment center 
    shall not be subject to prior authorization and shall not 
    be subject to concurrent utilization review during the 
    first 3 days of American Society of Addiction Medicine 
    Level 3.7 and the first 28 days of American Society of 
    Addiction Medicine Level 3.5 residential admission, so 
    long as the facility notifies the insurer of both the 
    admission and the initial treatment plan within 3 business 
    days after admission. The facility shall perform clinical 
    review of the patient, including consultation with the 
    insurer at or just prior to the 14th day of treatment to 
    ensure that the facility is using the American Society of 
    Addiction Medicine review tool to ensure that the 
    residential treatment is medically necessary for the 
    patient.
        (D) Prior to discharge, the facility shall provide the 
    patient and the insurer with a written discharge plan, 
    which shall describe arrangements for additional services 
    needed following discharge from the residential facility, 
    as determined using the evidence-based and peer-reviewed 
    clinical review tool used by the insurer and designated by 
    the relevant Illinois State agencies. Prior to discharge, 
    the facility shall indicate to the insurer whether 
    services included in the discharge plan are secured or 
    determined to be reasonably available.
        (E) Any utilization review of treatment provided in a 
		HB4585	- 11 -	LRB104 17523 BAB 30950 b
    residential treatment center may include a review of all 
    services provided during such residential treatment, 
    including all services provided during the first 35 days 
    of residential treatment. The insurer shall only deny 
    coverage for any portion of the initial 35-day residential 
    treatment on the basis that the treatment was not 
    medically necessary if the residential treatment was 
    contrary to the evidence-based and peer-reviewed clinical 
    review tool used by the insurer and designated by the 
    relevant Illinois State agencies. An insured shall not 
    have any financial obligation to the facility for any 
    treatment under this subparagraph (E), other than any 
    copayment, coinsurance, or deductible otherwise required 
    under the policy.
        (F) The criteria for medical necessity determinations 
    under the policy with respect to residential substance use 
    disorder benefits shall be made available by the insurer 
    to any insured, prospective insured, or in-network 
    provider upon request.
    (c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
    (d) With respect to a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace, the
Department and, with respect to medical assistance, the
		HB4585	- 12 -	LRB104 17523 BAB 30950 b
Department of Healthcare and Family Services shall each
enforce the requirements of this Section and Sections 356z.23
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, 42
U.S.C. 18031(j), and any amendments to, and federal guidance
or regulations issued under, those Acts, including, but not
limited to, final regulations issued under the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 and final regulations applying the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 to Medicaid managed care organizations, the
Children's Health Insurance Program, and alternative benefit
plans. Specifically, the Department and the Department of
Healthcare and Family Services shall take action:
        (1) proactively ensuring compliance by individual and
    group policies, including by requiring that insurers
    submit comparative analyses, as set forth in paragraph (6)
    of subsection (k) of Section 370c.1, demonstrating how
    they design and apply nonquantitative treatment
    limitations, both as written and in operation, for mental,
    emotional, nervous, or substance use disorder or condition
    benefits as compared to how they design and apply
    nonquantitative treatment limitations, as written and in
    operation, for medical and surgical benefits;
        (2) evaluating all consumer or provider complaints
    regarding mental, emotional, nervous, or substance use
		HB4585	- 13 -	LRB104 17523 BAB 30950 b
    disorder or condition coverage for possible parity
    violations;
        (3) performing parity compliance market conduct
    examinations or, in the case of the Department of
    Healthcare and Family Services, parity compliance audits
    of individual and group plans and policies, including, but
    not limited to, reviews of:
            (A) nonquantitative treatment limitations,
        including, but not limited to, prior authorization
        requirements, concurrent review, retrospective review,
        step therapy, network admission standards,
        reimbursement rates, and geographic restrictions;
            (B) denials of authorization, payment, and
        coverage; and
            (C) other specific criteria as may be determined
        by the Department.
    The findings and the conclusions of the parity compliance
market conduct examinations and audits shall be made public.
    The Director may adopt rules to effectuate any provisions
of the Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act of 2008 that relate to the business of
insurance.
    (e) Availability of plan information.
        (1) The criteria for medical necessity determinations
    made under a group health plan, an individual policy of
    accident and health insurance, or a qualified health plan
		HB4585	- 14 -	LRB104 17523 BAB 30950 b
    offered through the health insurance marketplace with
    respect to mental health or substance use disorder
    benefits (or health insurance coverage offered in
    connection with the plan with respect to such benefits)
    must be made available by the plan administrator (or the
    health insurance issuer offering such coverage) to any
    current or potential participant, beneficiary, or
    contracting provider upon request.
        (2) The reason for any denial under a group health
    benefit plan, an individual policy of accident and health
    insurance, or a qualified health plan offered through the
    health insurance marketplace (or health insurance coverage
    offered in connection with such plan or policy) of
    reimbursement or payment for services with respect to
    mental, emotional, nervous, or substance use disorders or
    conditions benefits in the case of any participant or
    beneficiary must be made available within a reasonable
    time and in a reasonable manner and in readily
    understandable language by the plan administrator (or the
    health insurance issuer offering such coverage) to the
    participant or beneficiary upon request.
    (f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois or which purport to provide coverage
for a resident of this State; and (2) State, county,
		HB4585	- 15 -	LRB104 17523 BAB 30950 b
municipal, or school district employee health plans.
References to an insurer include all plans described in this
subsection.
    (g) (1) As used in this subsection:
    "Benefits", with respect to insurers that are not Medicaid
managed care organizations, means the benefits provided for
treatment services for inpatient and outpatient treatment of
substance use disorders or conditions at American Society of
Addiction Medicine levels of treatment 2.1 (Intensive
Outpatient), 2.5 (High-Intensity Outpatient), 3.1 (Clinically
Managed Low-Intensity Residential), 3.5 (Clinically Managed
High-Intensity Residential), and 3.7 (Medically Managed
Residential) and OMT (Opioid Maintenance Therapy) services.
    "Benefits", with respect to Medicaid managed care
organizations, means the benefits provided for treatment
services for inpatient and outpatient treatment of substance
use disorders or conditions at American Society of Addiction
Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5
(High-Intensity Outpatient), 3.5 (Clinically Managed
High-Intensity Residential), and 3.7 (Medically Managed
Residential) and OMT (Opioid Maintenance Therapy) services.
    "Substance use disorder treatment provider or facility"
means a licensed physician, licensed psychologist, licensed
psychiatrist, licensed advanced practice registered nurse, or
licensed, certified, or otherwise State-approved facility or
provider of substance use disorder treatment.
		HB4585	- 16 -	LRB104 17523 BAB 30950 b
    (2) A group health insurance policy, an individual health
benefit plan, or qualified health plan that is offered through
the health insurance marketplace, small employer group health
plan, and large employer group health plan that is amended,
delivered, issued, executed, or renewed in this State, or
approved for issuance or renewal in this State, on or after
January 1, 2019 (the effective date of Public Act 100-1023)
shall comply with the requirements of this Section and Section
370c.1. The services for the treatment and the ongoing
assessment of the patient's progress in treatment shall follow
the requirements of 77 Ill. Adm. Code 2060.
    (3) Prior authorization shall not be utilized for the
benefits under this subsection. Except to the extent
prohibited by Section 370c.1 with respect to treatment
limitations in a benefit classification or subclassification,
the insurer may require the substance use disorder treatment
provider or facility to notify the insurer of the initiation
of treatment. For an insurer that is not a Medicaid managed
care organization, the substance use disorder treatment
provider or facility may be required to give notification for
the initiation of treatment of the covered person within 2
business days. For Medicaid managed care organizations, the
substance use disorder treatment provider or facility may be
required to give notification in accordance with the protocol
set forth in the provider agreement for initiation of
treatment within 24 hours. If the Medicaid managed care
		HB4585	- 17 -	LRB104 17523 BAB 30950 b
organization is not capable of accepting the notification in
accordance with the contractual protocol during the 24-hour
period following admission, the substance use disorder
treatment provider or facility shall have one additional
business day to provide the notification to the appropriate
managed care organization. Treatment plans shall be developed
in accordance with the requirements and timeframes established
in 77 Ill. Adm. Code 2060. No such coverage shall be subject to
concurrent review prior to the applicable notification
deadline. If coverage is denied retrospectively, neither the
provider or facility nor the insurer shall bill, and the
covered individual shall not be liable, for any treatment
under this subsection through the date the adverse
determination is issued, other than any copayment,
coinsurance, or deductible for the treatment or stay through
that date as applicable under the policy. Coverage shall not
be retrospectively denied for benefits that were furnished at
a participating substance use disorder facility prior to the
applicable notification deadline except for the following:
        (A) upon reasonable determination that the benefits
    were not provided;
        (B) upon determination that the patient receiving the
    treatment was not an insured, enrollee, or beneficiary
    under the policy;
        (C) upon material misrepresentation by the patient or
    provider. As used in this subparagraph (C), "material"
		HB4585	- 18 -	LRB104 17523 BAB 30950 b
    means a fact or situation that is not merely technical in
    nature and results or could result in a substantial change
    in the situation;
        (D) upon determination that a service was excluded
    under the terms of coverage. For situations that qualify
    under this subparagraph (D), the limitation to billing for
    a copayment, coinsurance, or deductible shall not apply;
        (E) upon determination that a service was not
    medically necessary consistent with subsections (h)
    through (n); or
        (F) upon determination that the patient did not
    consent to the treatment and that there was no court order
    mandating the treatment.
    (4) For an insurer that is not a Medicaid managed care
organization, if an insurer determines that benefits are no
longer medically necessary, the insurer shall notify the
covered person, the covered person's authorized
representative, if any, and the covered person's health care
provider in writing of the covered person's right to request
an external review pursuant to the Health Carrier External
Review Act. The notification shall occur within 24 hours
following the adverse determination.
    Pursuant to the requirements of the Health Carrier
External Review Act, the covered person or the covered
person's authorized representative may request an expedited
external review. An expedited external review may not occur if
		HB4585	- 19 -	LRB104 17523 BAB 30950 b
the substance use disorder treatment provider or facility
determines that continued treatment is no longer medically
necessary.
    If an expedited external review request meets the criteria
of the Health Carrier External Review Act, an independent
review organization shall make a final determination of
medical necessity within 72 hours. If an independent review
organization upholds an adverse determination, an insurer
shall remain responsible to provide coverage of benefits
through the day following the determination of the independent
review organization. A decision to reverse an adverse
determination shall comply with the Health Carrier External
Review Act.
    (5) The substance use disorder treatment provider or
facility shall provide the insurer with 7 business days'
advance notice of the planned discharge of the patient from
the substance use disorder treatment provider or facility and
notice on the day that the patient is discharged from the
substance use disorder treatment provider or facility.
    (6) The benefits required by this subsection shall be
provided to all covered persons with a diagnosis of substance
use disorder or conditions. The presence of additional related
or unrelated diagnoses shall not be a basis to reduce or deny
the benefits required by this subsection.
    (7) Nothing in this subsection shall be construed to
require an insurer to provide coverage for any of the benefits
		HB4585	- 20 -	LRB104 17523 BAB 30950 b
in this subsection.
    (8) Any concurrent or retrospective review permitted by
this subsection must be consistent with the utilization review
provisions in subsections (h) through (n).
    (h) As used in this Section:
    "Generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care" means
standards of care and clinical practice that are generally
recognized by health care providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, social work, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
reflecting generally accepted standards of mental, emotional,
nervous, or substance use disorder or condition care include
peer-reviewed scientific studies and medical literature,
recommendations of nonprofit health care provider professional
associations and specialty societies, including, but not
limited to, patient placement criteria and clinical practice
guidelines, recommendations of federal government agencies,
and drug labeling approved by the United States Food and Drug
Administration.
    "Medically necessary treatment of mental, emotional,
nervous, or substance use disorders or conditions" means a
service or product addressing the specific needs of that
patient, for the purpose of screening, preventing, diagnosing,
managing, or treating an illness, injury, or condition or its
		HB4585	- 21 -	LRB104 17523 BAB 30950 b
symptoms and comorbidities, including minimizing the
progression of an illness, injury, or condition or its
symptoms and comorbidities in a manner that is all of the
following:
        (1) in accordance with the generally accepted
    standards of mental, emotional, nervous, or substance use
    disorder or condition care;
        (2) clinically appropriate in terms of type,
    frequency, extent, site, and duration; and
        (3) not primarily for the economic benefit of the
    insurer, purchaser, or for the convenience of the patient,
    treating physician, or other health care provider.
    "Utilization review" means either of the following:
        (1) prospectively, retrospectively, or concurrently
    reviewing and approving, modifying, delaying, or denying,
    based in whole or in part on medical necessity, requests
    by health care providers, insureds, or their authorized
    representatives for coverage of health care services
    before, retrospectively, or concurrently with the
    provision of health care services to insureds.
        (2) evaluating the medical necessity, appropriateness,
    level of care, service intensity, efficacy, or efficiency
    of health care services, benefits, procedures, or
    settings, under any circumstances, to determine whether a
    health care service or benefit subject to a medical
    necessity coverage requirement in an insurance policy is
		HB4585	- 22 -	LRB104 17523 BAB 30950 b
    covered as medically necessary for an insured.
    "Utilization review criteria" means patient placement
criteria or any criteria, standards, protocols, or guidelines
used by an insurer to conduct utilization review.
    (i)(1) Every insurer that amends, delivers, issues, or
renews a group or individual policy of accident and health
insurance or a qualified health plan offered through the
health insurance marketplace in this State and Medicaid
managed care organizations providing coverage for hospital or
medical treatment on or after January 1, 2023 shall, pursuant
to subsections (h) through (s), provide coverage for medically
necessary treatment of mental, emotional, nervous, or
substance use disorders or conditions.
    (2) An insurer shall not set a specific limit on the
duration of benefits or coverage of medically necessary
treatment of mental, emotional, nervous, or substance use
disorders or conditions or limit coverage only to alleviation
of the insured's current symptoms.
    (3) All utilization review conducted by the insurer
concerning diagnosis, prevention, and treatment of insureds
diagnosed with mental, emotional, nervous, or substance use
disorders or conditions shall be conducted in accordance with
the requirements of subsections (k) through (w).
    (4) An insurer that authorizes a specific type of
treatment by a provider pursuant to this Section shall not
rescind or modify the authorization after that provider
		HB4585	- 23 -	LRB104 17523 BAB 30950 b
renders the health care service in good faith and pursuant to
this authorization for any reason, including, but not limited
to, the insurer's subsequent cancellation or modification of
the insured's or policyholder's contract, or the insured's or
policyholder's eligibility. Nothing in this Section shall
require the insurer to cover a treatment when the
authorization was granted based on a material
misrepresentation by the insured, the policyholder, or the
provider. Nothing in this Section shall require Medicaid
managed care organizations to pay for services if the
individual was not eligible for Medicaid at the time the
service was rendered. Nothing in this Section shall require an
insurer to pay for services if the individual was not the
insurer's enrollee at the time services were rendered. As used
in this paragraph, "material" means a fact or situation that
is not merely technical in nature and results in or could
result in a substantial change in the situation.
    (j) An insurer shall not limit benefits or coverage for
medically necessary services on the basis that those services
should be or could be covered by a public entitlement program,
including, but not limited to, special education or an
individualized education program, Medicaid, Medicare,
Supplemental Security Income, or Social Security Disability
Insurance, and shall not include or enforce a contract term
that excludes otherwise covered benefits on the basis that
those services should be or could be covered by a public
		HB4585	- 24 -	LRB104 17523 BAB 30950 b
entitlement program. Nothing in this subsection shall be
construed to require an insurer to cover benefits that have
been authorized and provided for a covered person by a public
entitlement program. Medicaid managed care organizations are
not subject to this subsection.
    (k) An insurer shall base any medical necessity
determination or the utilization review criteria that the
insurer, and any entity acting on the insurer's behalf,
applies to determine the medical necessity of health care
services and benefits for the diagnosis, prevention, and
treatment of mental, emotional, nervous, or substance use
disorders or conditions on current generally accepted
standards of mental, emotional, nervous, or substance use
disorder or condition care. All denials and appeals shall be
reviewed by a professional with experience or expertise
comparable to the provider requesting the authorization.
    (l) In conducting utilization review of all covered health
care services for the diagnosis, prevention, and treatment of
mental, emotional, and nervous disorders or conditions, an
insurer shall apply the criteria and guidelines set forth in
the most recent version of the treatment criteria developed by
an unaffiliated nonprofit professional association for the
relevant clinical specialty or, for Medicaid managed care
organizations, criteria and guidelines determined by the
Department of Healthcare and Family Services that are
consistent with generally accepted standards of mental,
		HB4585	- 25 -	LRB104 17523 BAB 30950 b
emotional, nervous or substance use disorder or condition
care. Pursuant to subsection (b), in conducting utilization
review of all covered services and benefits for the diagnosis,
prevention, and treatment of substance use disorders an
insurer shall use the most recent edition of the patient
placement criteria established by the American Society of
Addiction Medicine.
    (m) In conducting utilization review relating to level of
care placement, continued stay, transfer, discharge, or any
other patient care decisions that are within the scope of the
sources specified in subsection (l), an insurer shall not
apply different, additional, conflicting, or more restrictive
utilization review criteria than the criteria set forth in
those sources. For all level of care placement decisions, the
insurer shall authorize placement at the level of care
consistent with the assessment of the insured using the
relevant patient placement criteria as specified in subsection
(l). If that level of placement is not available, the insurer
shall authorize the next higher level of care. In the event of
disagreement, the insurer shall provide full detail of its
assessment using the relevant criteria as specified in
subsection (l) to the provider of the service and the patient.
    If an insurer purchases or licenses utilization review
criteria pursuant to this subsection, the insurer shall verify
and document before use that the criteria were developed in
accordance with subsection (k).
		HB4585	- 26 -	LRB104 17523 BAB 30950 b
    (n) In conducting utilization review that is outside the
scope of the criteria as specified in subsection (l) or
relates to the advancements in technology or in the types or
levels of care that are not addressed in the most recent
versions of the sources specified in subsection (l), an
insurer shall conduct utilization review in accordance with
subsection (k).
    (o) This Section does not in any way limit the rights of a
patient under the Medical Patient Rights Act.
    (p) This Section does not in any way limit early and
periodic screening, diagnostic, and treatment benefits as
defined under 42 U.S.C. 1396d(r).
    (q) To ensure the proper use of the criteria described in
subsection (l), every insurer shall do all of the following:
        (1) Educate the insurer's staff, including any third
    parties contracted with the insurer to review claims,
    conduct utilization reviews, or make medical necessity
    determinations about the utilization review criteria.
        (2) Make the educational program available to other
    stakeholders, including the insurer's participating or
    contracted providers and potential participants,
    beneficiaries, or covered lives. The education program
    must be provided at least once a year, in-person or
    digitally, or recordings of the education program must be
    made available to the aforementioned stakeholders.
        (3) Provide, at no cost, the utilization review
		HB4585	- 27 -	LRB104 17523 BAB 30950 b
    criteria and any training material or resources to
    providers and insured patients upon request. For
    utilization review criteria not concerning level of care
    placement, continued stay, transfer, discharge, or other
    patient care decisions used by the insurer pursuant to
    subsection (m), the insurer may place the criteria on a
    secure, password-protected website so long as the access
    requirements of the website do not unreasonably restrict
    access to insureds or their providers. No restrictions
    shall be placed upon the insured's or treating provider's
    access right to utilization review criteria obtained under
    this paragraph at any point in time, including before an
    initial request for authorization.
        (4) Track, identify, and analyze how the utilization
    review criteria are used to certify care, deny care, and
    support the appeals process.
        (5) Conduct interrater reliability testing to ensure
    consistency in utilization review decision making that
    covers how medical necessity decisions are made; this
    assessment shall cover all aspects of utilization review
    as defined in subsection (h).
        (6) Run interrater reliability reports about how the
    clinical guidelines are used in conjunction with the
    utilization review process and parity compliance
    activities.
        (7) Achieve interrater reliability pass rates of at
		HB4585	- 28 -	LRB104 17523 BAB 30950 b
    least 90% and, if this threshold is not met, immediately
    provide for the remediation of poor interrater reliability
    and interrater reliability testing for all new staff
    before they can conduct utilization review without
    supervision.
        (8) Maintain documentation of interrater reliability
    testing and the remediation actions taken for those with
    pass rates lower than 90% and submit to the Department of
    Insurance or, in the case of Medicaid managed care
    organizations, the Department of Healthcare and Family
    Services the testing results and a summary of remedial
    actions as part of parity compliance reporting set forth
    in subsection (k) of Section 370c.1.
    (r) This Section applies to all health care services and
benefits for the diagnosis, prevention, and treatment of
mental, emotional, nervous, or substance use disorders or
conditions covered by an insurance policy, including
prescription drugs.
    (s) This Section applies to an insurer that amends,
delivers, issues, or renews a group or individual policy of
accident and health insurance or a qualified health plan
offered through the health insurance marketplace in this State
providing coverage for hospital or medical treatment and
conducts utilization review as defined in this Section,
including Medicaid managed care organizations, and any entity
or contracting provider that performs utilization review or
		HB4585	- 29 -	LRB104 17523 BAB 30950 b
utilization management functions on an insurer's behalf.
    (t) If the Director determines that an insurer has
violated this Section, the Director may, after appropriate
notice and opportunity for hearing, by order, assess a civil
penalty between $1,000 and $5,000 for each violation. Moneys
collected from penalties shall be deposited into the Parity
Advancement Fund established in subsection (i) of Section
370c.1.
    (u) An insurer shall not adopt, impose, or enforce terms
in its policies or provider agreements, in writing or in
operation, that undermine, alter, or conflict with the
requirements of this Section.
    (v) The provisions of this Section are severable. If any
provision of this Section or its application is held invalid,
that invalidity shall not affect other provisions or
applications that can be given effect without the invalid
provision or application.
    (w) Beginning January 1, 2026, coverage for medically
necessary treatment of mental, emotional, or nervous disorders
or conditions shall comply with the following requirements:
        (1) No policy shall require prior authorization for
    outpatient or partial hospitalization services for
    treatment of mental, emotional, or nervous disorders or
    conditions provided by a physician licensed to practice
    medicine in all branches, a licensed clinical
    psychologist, a licensed clinical social worker, a
		HB4585	- 30 -	LRB104 17523 BAB 30950 b
    licensed clinical professional counselor, a licensed
    marriage and family therapist, a licensed speech-language
    pathologist, or any other type of licensed, certified, or
    legally authorized provider, including trainees working
    under the supervision of a licensed health care
    professional listed under this subsection, or facility
    whose outpatient or partial hospitalization services the
    policy covers for treatment of mental, emotional, or
    nervous disorders or conditions. Such coverage may be
    subject to concurrent and retrospective review consistent
    with the utilization review provisions in subsections (h)
    through (n) and Section 370c.1. Nothing in this paragraph
    (1) supersedes a health maintenance organization's
    referral requirement for services from nonparticipating
    providers. An insurer may require providers or facilities
    to notify the insurer of the initiation of treatment as
    specified in this subsection, except to the extent
    prohibited by Section 370c.1 with respect to treatment
    limitations in a benefit classification or
    subclassification. No such coverage shall be subject to
    concurrent review for any services furnished before an
    applicable notification deadline, subject to the
    following:
            (A) In the case of outpatient treatment, for an
        insurer that is not a Medicaid managed care
        organization, the insurer may set a notification
		HB4585	- 31 -	LRB104 17523 BAB 30950 b
        deadline of 2 business days after the initiation of
        the covered person's treatment. A Medicaid managed
        care organization may set a deadline of 24 hours after
        the initiation of treatment. If the Medicaid managed
        care organization is not capable of accepting the
        notification in accordance with the contractual
        protocol within the 24-hour period following
        initiation, the treatment provider or facility shall
        have one additional business day to provide the
        notification to the Medicaid managed care
        organization.
            (B) In the case of a partial hospitalization
        program, for an insurer that is not a Medicaid managed
        care organization, the insurer may set a notification
        deadline of 48 hours after the initiation of the
        covered person's treatment. A Medicaid managed care
        organization may set a deadline of 24 hours after the
        initiation of treatment. If the Medicaid managed care
        organization is not capable of accepting the
        notification in accordance with the contractual
        protocol during the 24-hour period following
        initiation, the treatment provider or facility shall
        have one additional business day to provide the
        notification to the Medicaid managed care
        organization.
        (2) No policy shall require prior authorization for
		HB4585	- 32 -	LRB104 17523 BAB 30950 b
    inpatient treatment at a hospital for mental, emotional,
    or nervous disorders or conditions at a participating
    provider. Additionally, no such coverage shall be subject
    to concurrent review for the first 72 hours after
    admission, provided that the provider must notify the
    insurer of both the admission and the initial treatment
    plan within 48 hours of admission. A discharge plan must
    be fully developed and continuity services prepared to
    meet the patient's needs and the patient's community
    preference upon release. Recommended level of care
    placements identified in the discharge plan shall comply
    with generally accepted standards of care, as defined in
    subsection (h).
            (A) If the provider satisfies the conditions of
        paragraph (2), then the insurer shall approve coverage
        of the recommended level of care, if applicable, upon
        discharge subject to concurrent review.
            (B) Nothing in this paragraph supersedes a health
        maintenance organization's referral requirement for
        services from nonparticipating providers upon a
        patient's discharge from a hospital or facility.
            (C) Concurrent review for such coverage must be
        consistent with the utilization review provisions in
        subsections (h) through (n).
            (D) In this subsection, residential treatment that
        is not otherwise identified in the discharge plan is
		HB4585	- 33 -	LRB104 17523 BAB 30950 b
        not inpatient hospitalization.
        (3) Treatment provided under this subsection may be
    reviewed retrospectively. If coverage is denied
    retrospectively, neither the insurer nor the participating
    provider shall bill, and the insured shall not be liable,
    for any treatment under this subsection through the date
    the adverse determination is issued, other than any
    copayment, coinsurance, or deductible for the stay through
    that date as applicable under the policy. Coverage shall
    not be retrospectively denied for the first 72 hours of
    admission to inpatient hospitalization for treatment of
    mental, emotional, or nervous disorders or conditions, or
    before the applicable deadline under paragraph (1) of this
    subsection for outpatient treatment or partial
    hospitalization programs, at a participating provider
    except:
            (A) upon reasonable determination that the
        inpatient mental health treatment was not provided;
            (B) upon determination that the patient receiving
        the treatment was not an insured, enrollee, or
        beneficiary under the policy;
            (C) upon material misrepresentation by the patient
        or health care provider. In this item (C), "material"
        means a fact or situation that is not merely technical
        in nature and results or could result in a substantial
        change in the situation;
		HB4585	- 34 -	LRB104 17523 BAB 30950 b
            (D) upon determination that a service was excluded
        under the terms of coverage. In that case, the
        limitation to billing for a copayment, coinsurance, or
        deductible shall not apply;
            (E) for outpatient treatment or partial
        hospitalization programs only, upon determination that
        a service was not medically necessary consistent with
        subsections (h) through (n); or
             (F) upon determination that the patient did not
        consent to the treatment and that there was no court
        order mandating the treatment.
        Nothing in this subsection shall be construed to
    require a policy to cover any health care service excluded
    under the terms of coverage.
        This subsection does not apply to coverage for any
    prescription or over-the-counter drug.
        Nothing in this subsection shall be construed to
    require the medical assistance program to reimburse for
    services not covered by the medical assistance program as
    authorized by the Illinois Public Aid Code or the
    Children's Health Insurance Program Act.
    (x) Notwithstanding any provision of this Section, nothing
shall require the medical assistance program under Article V
of the Illinois Public Aid Code or the Children's Health
Insurance Program Act to violate any applicable federal laws,
regulations, or grant requirements, including requirements for
		HB4585	- 35 -	LRB104 17523 BAB 30950 b
utilization management, or any State or federal consent
decrees. Nothing in subsection (g) or (w) shall prevent the
Department of Healthcare and Family Services from requiring a
health care provider to use specified level of care,
admission, continued stay, or discharge criteria, including,
but not limited to, those under Section 5-5.23 of the Illinois
Public Aid Code, as long as the Department of Healthcare and
Family Services, subject to applicable federal laws,
regulations, or grant requirements, including requirements for
utilization management, does not require a health care
provider to seek prior authorization or concurrent review from
the Department of Healthcare and Family Services, a Medicaid
managed care organization, or a utilization review
organization under the circumstances expressly prohibited by
subsections (g) and (w). Nothing in this Section prohibits a
health plan, including a Medicaid managed care organization,
from conducting reviews for medical necessity, clinical
appropriateness, safety, fraud, waste, or abuse and reporting
suspected fraud, waste, or abuse according to State and
federal requirements. Nothing in this Section limits the
authority of the Department of Healthcare and Family Services
or another State agency, or a Medicaid managed care
organization on the State agency's behalf, to (i) implement or
require programs, services, screenings, assessments, tools, or
reviews to comply with applicable federal law, federal
regulation, federal grant requirements, any State or federal
		HB4585	- 36 -	LRB104 17523 BAB 30950 b
consent decrees or court orders, or any applicable case law,
such as Olmstead v. L.C., 527 U.S. 581 (1999), or (ii)
administer or require programs, services, screenings,
assessments, tools, or reviews established under State or
federal laws, rules, or regulations in compliance with State
or federal laws, rules, or regulations, including, but not
limited to, the Children's Mental Health Act and the Mental
Health and Developmental Disabilities Administrative Act.
    (y) (Blank).
(Source: P.A. 103-426, eff. 8-4-23; 103-650, eff. 1-1-25;
103-1040, eff. 8-9-24; 104-28, eff. 1-1-26; 104-417, eff.
8-15-25.)

Amends the Illinois Insurance Code. Provides that coverage for treatment in a residential treatment center shall include residential coverage for the diagnosis and treatment of substance use disorders. Provides that this coverage shall include unlimited medically necessary treatment for substance use disorder treatment services provided in residential settings. Prohibits the coverage from applying financial requirements or treatment limitations to residential substance use disorder benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to other medical and surgical benefits covered by the policy. Sets forth provisions concerning cost sharing; application of coverage requirements; prior authorization; clinical review; discharge plans; other forms of utilization review; and the criteria for medical necessity determinations.

Sponsors

Rep. Lindsey LaPointe (D) sponsors HB 4585, and 5 members have co-sponsored it.

Committees

HB 4585 went before 2 committees: Rules and Insurance.

Rules
Rules
Referred to · Feb 3, 2026 · 5,290 Bills
Insurance
Insurance
Referred to · Feb 11, 2026

History

HB 4585 has taken 18 actions since Jan 23, 2026, the latest on Apr 17, 2026.

ChamberAction
Apr 17, 2026
House
Added Co-Sponsor Rep. Dagmara Avelar
Apr 17, 2026
House
Rule 19(a) / Re-referred to Rules Committee
Apr 17, 2026
House
House Floor Amendment No. 1 Rule 19(c) / Re-referred to Rules Committee
Apr 15, 2026
House
House Floor Amendment No. 1 Rules Refers to Insurance Committee
Apr 14, 2026
House
House Floor Amendment No. 1 Filed with Clerk by Rep. Lindsey LaPointe

Votes

HB 4585 went to 1 roll call in the House, the latest on Mar 24, 2026 at 9–6.

ChamberQuestion
Yea
Nay
Mar 24, 2026
House
House Insurance Committee
9
6

Source: ilga.gov · legiscan.com