Public Act 094-0921
 		





HB4202 Enrolled
LRB094 14922 LJB 49994 b






    AN ACT concerning insurance.

 
    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 the effective date of this Section,

every insurer which delivers, issues for delivery or renews or 
modifies
group A&H policies providing coverage for hospital or 
medical treatment or
services for illness on an 
expense-incurred basis shall offer to the
applicant or group 
policyholder subject to the insurers standards of

insurability, coverage for reasonable and necessary treatment 
and services
for mental, emotional or nervous disorders or 
conditions, other than serious
mental illnesses as defined in 
item (2) of subsection (b), up to the limits
provided in the 
policy for other disorders or conditions, except (i) the

insured may be required to pay up to 50% of expenses incurred 
as a result
of the treatment or services, and (ii) the annual 
benefit limit may be
limited to the lesser of $10,000 or 25% of 
the lifetime policy limit.

    (2) Each insured that is covered for mental, emotional or 
nervous
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, or licensed clinical professional counselor of
his 
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, or licensed clinical professional 
counselor 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, or licensed
clinical professional counselor is

authorized to provide said services under the statutes of this 
State and in
accordance with accepted principles of his 
profession.

    (3) Insofar as this Section applies solely to licensed 
clinical social
workers and licensed clinical professional 
counselors, those persons who may
provide services to 
individuals shall do so
after the licensed clinical social 
worker or licensed clinical professional
counselor has 
informed the patient of the
desirability of the patient 
conferring with the patient's primary care
physician and the 
licensed clinical social worker or licensed clinical

professional counselor has
provided written
notification to 
the patient's primary care physician, if any, that services
are 
being provided to the patient.  That notification may, however, 
be
waived by the patient on a written form.  Those forms shall 
be retained by
the licensed clinical social worker or licensed 
clinical professional counselor
for a period of not less than 5 
years.

    (b) (1) An insurer that provides coverage for hospital or 
medical
expenses under a group policy of accident and health 
insurance or
health care plan amended, delivered, issued, or 
renewed after the effective
date of this amendatory Act of the 
92nd General Assembly shall provide coverage
under the policy 
for treatment of serious mental illness under the same terms

and conditions as coverage for hospital or medical expenses 
related to other
illnesses and diseases.  The coverage required 
under this Section must provide
for same durational limits, 
amount limits, deductibles, and co-insurance
requirements for 
serious mental illness as are provided for other illnesses
and 
diseases.  This subsection does not apply to coverage provided 
to
employees by employers who have 50 or fewer employees.

    (2) "Serious mental illness" means the following 
psychiatric illnesses as
defined in the most current edition of 
the Diagnostic and Statistical Manual
(DSM) published by the 
American Psychiatric Association:


        (A) schizophrenia;


        (B) paranoid and other psychotic disorders;


        (C) bipolar disorders (hypomanic, manic, depressive, 
    and mixed);


        (D) major depressive disorders (single episode or 
    recurrent);


        (E) schizoaffective disorders (bipolar or depressive);


        (F) pervasive developmental disorders;


        (G) obsessive-compulsive disorders;


        (H) depression in childhood and adolescence;


        (I) panic disorder; and
        (J) post-traumatic stress disorders (acute, chronic, 
    or with delayed onset).


    (3) Upon request of the reimbursing insurer, a provider of 
treatment of
serious mental illness shall furnish medical 
records or other necessary data
that substantiate that initial 
or continued treatment is at all times medically
necessary.  An 
insurer shall provide a mechanism for the timely review by a

provider holding the same license and practicing in the same 
specialty as the
patient's provider, who is unaffiliated with 
the insurer, jointly selected by
the patient (or the patient's 
next of kin or legal representative if the
patient is unable to 
act for himself or herself), the patient's provider, and
the 
insurer in the event of a dispute between the insurer and 
patient's
provider regarding the medical necessity of a 
treatment proposed by a patient's
provider.  If the reviewing 
provider determines the treatment to be medically
necessary, 
the insurer shall provide reimbursement for the treatment.  
Future
contractual or employment actions by the insurer 
regarding the patient's
provider may not be based on the 
provider's participation in this procedure.
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 serous mental illness, 
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.

    (4) A group health benefit plan:


        (A) shall provide coverage based upon medical 
    necessity for the following
treatment of mental illness in 
    each calendar year;


            (i) 45 days of inpatient treatment; and


            (ii) beginning on the effective date of this 
        amendatory Act of the 94th General Assembly, 60
35 
        visits for outpatient treatment including group and 
        individual
outpatient treatment;


        (B) may not include a lifetime limit on the number of 
    days of inpatient
treatment or the number of outpatient 
    visits covered under the plan; and


        (C) shall include the same amount limits, deductibles, 
    copayments, and
coinsurance factors for serious mental 
    illness as for physical illness.

    (5) An issuer of a group health benefit plan 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.

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

    (7) This Section shall not be interpreted to require a 
group health benefit
plan to provide coverage for treatment of:


        (A) an addiction to a controlled substance or cannabis 
    that is used in
violation of law; or


        (B) mental illness resulting from the use of a 
    controlled substance or
cannabis in violation of law.

    (8)
(Blank).

(Source: P.A. 94-402, eff. 8-2-05; P.A. 94-584, eff. 8-15-05; 
revised 8-19-05.)

 

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