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Public Act 095-0972
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| HB0953 Enrolled |
LRB095 03888 KBJ 23921 b |
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AN ACT concerning insurance coverage.
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Be it enacted by the People of the State of Illinois, |
represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
changing
Section 370c as follows:
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(215 ILCS 5/370c) (from Ch. 73, par. 982c)
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Sec. 370c. Mental and emotional disorders.
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(a) (1) On and after the effective date of this Section,
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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
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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
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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.
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(2) Each insured that is covered for mental, emotional or |
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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, or |
licensed marriage and family therapist 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, or |
licensed marriage and family therapist 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
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clinical professional counselor, or licensed marriage and |
family therapist is
authorized to provide said services under |
the statutes of this State and in
accordance with accepted |
principles of his profession.
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(3) Insofar as this Section applies solely to licensed |
clinical social
workers,
and licensed clinical professional |
counselors, and licensed marriage and family therapists, those |
persons who may
provide services to individuals shall do so
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after the licensed clinical social worker,
or licensed clinical |
professional
counselor, or licensed marriage and family |
therapist 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
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professional counselor, or licensed marriage and family |
therapist 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
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waived by the patient on a written form. Those forms shall be |
retained by
the licensed clinical social worker,
or licensed |
clinical professional counselor, or licensed marriage and |
family therapist
for a period of not less than 5 years.
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(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
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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.
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(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:
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(A) schizophrenia;
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(B) paranoid and other psychotic disorders;
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(C) bipolar disorders (hypomanic, manic, depressive, |
and mixed);
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(D) major depressive disorders (single episode or |
recurrent);
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(E) schizoaffective disorders (bipolar or depressive);
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(F) pervasive developmental disorders;
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(G) obsessive-compulsive disorders;
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(H) depression in childhood and adolescence;
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(I) panic disorder; and |
(J) post-traumatic stress disorders (acute, chronic, |
or with delayed onset).
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(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
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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, |
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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
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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
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respect to other diseases or illnesses covered under the |
policy, including an
appeals process.
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(4) A group health benefit plan:
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(A) shall provide coverage based upon medical |
necessity for the following
treatment of mental illness in |
each calendar year:
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(i) 45 days of inpatient treatment; and
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(ii) beginning on June 26, 2006 (the effective date |
of Public Act 94-921)
this amendatory Act of the 94th |
General Assembly, 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)
this |
amendatory Act of the 94th General Assembly,
20 |
additional outpatient visits for speech therapy for |
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treatment of pervasive developmental disorders that |
will be in addition to speech therapy provided pursuant |
to item (ii) of this subparagraph (A);
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(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
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(C) shall include the same amount limits, deductibles, |
copayments, and
coinsurance factors for serious mental |
illness as for physical illness.
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(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.
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(6) An issuer of a group health benefit
plan may provide or |
offer coverage required under this Section through a
managed |
care plan.
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(7) This Section shall not be interpreted to require a |
group health benefit
plan to provide coverage for treatment of:
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(A) an addiction to a controlled substance or cannabis |
that is used in
violation of law; or
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(B) mental illness resulting from the use of a |
controlled substance or
cannabis in violation of law.
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(8)
(Blank).
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(Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; |