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    AN ACT concerning insurance coverage. 

 
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    Be it enacted by the People of the State of Illinois, 
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represented in the General Assembly: 


 
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    Section 5. The Illinois Insurance Code is amended by 
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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 
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modifies
group A&H policies providing coverage for hospital or 
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medical treatment or
services for illness on an 
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expense-incurred basis shall offer to the
applicant or group 
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policyholder subject to the insurers standards of

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insurability, coverage for reasonable and necessary treatment 
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and services
for mental, emotional or nervous disorders or 
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conditions, other than serious
mental illnesses as defined in 
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item (2) of subsection (b), up to the limits
provided in the 
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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 
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as a result
of the treatment or services, and (ii) the annual 
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benefit limit may be
limited to the lesser of $10,000 or 25% of 
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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 
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physician licensed to
practice medicine in all its branches, 
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licensed clinical psychologist,
licensed clinical social 
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worker, or licensed clinical professional counselor, or 
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licensed marriage and family therapist of
his choice to treat 
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such disorders, and
the insurer shall pay the covered charges 
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of such physician licensed to
practice medicine in all its 
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branches, licensed clinical psychologist,
licensed clinical 
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social worker, or licensed clinical professional counselor, or 
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licensed marriage and family therapist up
to the limits of 
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coverage, provided (i)
the disorder or condition treated is 
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covered by the policy, and (ii) the
physician, licensed 
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psychologist, licensed clinical social worker, or licensed

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clinical professional counselor, or licensed marriage and 
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family therapist is
authorized to provide said services under 
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the statutes of this State and in
accordance with accepted 
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principles of his profession.

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    (3) Insofar as this Section applies solely to licensed 
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clinical social
workers,
and licensed clinical professional 
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counselors, and licensed marriage and family therapists, those 
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persons who may
provide services to individuals shall do so

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after the licensed clinical social worker,
or licensed clinical 
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professional
counselor, or licensed marriage and family 
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therapist has informed the patient of the
desirability of the 
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patient conferring with the patient's primary care
physician 
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and the licensed clinical social worker,
or licensed clinical

 


 






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professional counselor, or licensed marriage and family 
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therapist has
provided written
notification to the patient's 
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primary care physician, if any, that services
are being 
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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 
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retained by
the licensed clinical social worker,
or licensed 
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clinical professional counselor, or licensed marriage and 
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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 
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medical
expenses under a group policy of accident and health 
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insurance or
health care plan amended, delivered, issued, or 
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renewed after the effective
date of this amendatory Act of the 
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92nd General Assembly shall provide coverage
under the policy 
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for treatment of serious mental illness under the same terms

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

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    (2) "Serious mental illness" means the following 
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psychiatric illnesses as
defined in the most current edition of 
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the Diagnostic and Statistical Manual
(DSM) published by the 
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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, 
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    and mixed);


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        (D) major depressive disorders (single episode or 
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    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
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        (J) post-traumatic stress disorders (acute, chronic, 
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    or with delayed onset).


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    (3) Upon request of the reimbursing insurer, a provider of 
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treatment of
serious mental illness shall furnish medical 
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records or other necessary data
that substantiate that initial 
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or continued treatment is at all times medically
necessary.  An 
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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 
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specialty as the
patient's provider, who is unaffiliated with 
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the insurer, jointly selected by
the patient (or the patient's 
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next of kin or legal representative if the
patient is unable to 
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act for himself or herself), the patient's provider, and
the 
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insurer in the event of a dispute between the insurer and 
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patient's
provider regarding the medical necessity of a 
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treatment proposed by a patient's
provider.  If the reviewing 
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provider determines the treatment to be medically
necessary, 
 


 






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the insurer shall provide reimbursement for the treatment.  
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Future
contractual or employment actions by the insurer 
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regarding the patient's
provider may not be based on the 
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provider's participation in this procedure.
Nothing prevents

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the insured from agreeing in writing to continue treatment at 
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his or her
expense.  When making a determination of the medical 
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necessity for a treatment
modality for serous mental illness, 
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an insurer must make the determination in a
manner that is 
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consistent with the manner used to make that determination with

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respect to other diseases or illnesses covered under the 
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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 
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    necessity for the following
treatment of mental illness in 
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    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 
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        of Public Act 94-921)
this amendatory Act of the 94th 
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        General Assembly, 60 visits for outpatient treatment 
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        including group and individual
outpatient treatment; 
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        and
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            (iii) for plans or policies delivered, issued for 
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        delivery, renewed, or modified after January 1, 2007 
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        (the effective date of Public Act 94-906)
this 
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        amendatory Act of the 94th General Assembly,
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        additional outpatient visits for speech therapy for 
 


 






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        treatment of pervasive developmental disorders that 
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        will be in addition to speech therapy provided pursuant 
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        to item (ii) of this subparagraph (A);



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


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

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    (5) An issuer of a group health benefit plan may not count 
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toward the number
of outpatient visits required to be covered 
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under this Section an outpatient
visit for the purpose of 
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medication management and shall cover the outpatient
visits 
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under the same terms and conditions as it covers outpatient 
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visits for
the treatment of physical illness.

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

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


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


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        (B) mental illness resulting from the use of a 
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    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; 
 


 






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94-906, eff. 1-1-07; 94-921, eff. 6-26-06; revised 8-3-06.)



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