93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
SB2943

 

Introduced 2/6/2004, by Mattie Hunter

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c   from Ch. 73, par. 982c

    Amends the Illinois Insurance Code. Changes the Section heading. In provisions requiring insurers providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis, adds coverage for the treatment of substance abuse as defined in this Section. Deletes language that does not require a group health benefit plan to provide coverage for treatment of an addiction to a controlled substance or cannabis that is used in violation of law or mental illness resulting from the use of a controlled substance or cannabis in violation of law. Requires insurers that provide coverage for hospital or medical expenses under a group policy of accident and health insurance or health care plan to cover the treatment of substance abuse under the same terms and conditions as coverage for hospital or medical expenses related to other illnesses and diseases.


LRB093 15990 SAS 41614 b

 

 

A BILL FOR

 

SB2943 LRB093 15990 SAS 41614 b

1     AN ACT concerning insurance coverage.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 370c as follows:
 
6     (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
7     Sec. 370c. Mental health and substance abuse. Mental and
8 emotional disorders.
9     (a) (1) On and after the effective date of this Section,
10 every insurer which delivers, issues for delivery or renews or
11 modifies group A&H policies providing coverage for hospital or
12 medical treatment or services for illness on an
13 expense-incurred basis shall offer to the applicant or group
14 policyholder subject to the insurers standards of
15 insurability, coverage for reasonable and necessary treatment
16 and services for mental, emotional or nervous disorders or
17 conditions, other than serious mental illnesses as defined in
18 item (2) of subsection (b), and the treatment of substance
19 abuse as defined in item (2) of subsection (c), up to the
20 limits provided in the policy for other disorders or
21 conditions, except (i) the insured may be required to pay up to
22 50% of expenses incurred as a result of the treatment or
23 services, and (ii) the annual benefit limit may be limited to
24 the lesser of $10,000 or 25% of the lifetime policy limit.
25     (2) Each insured that is covered for mental, emotional or
26 nervous disorders or conditions shall be free to select the
27 physician licensed to practice medicine in all its branches,
28 licensed clinical psychologist, licensed clinical social
29 worker, or licensed clinical professional counselor of his
30 choice to treat such disorders, and the insurer shall pay the
31 covered charges of such physician licensed to practice medicine
32 in all its branches, licensed clinical psychologist, licensed

 

 

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1 clinical social worker, or licensed clinical professional
2 counselor up to the limits of coverage, provided (i) the
3 disorder or condition treated is covered by the policy, and
4 (ii) the physician, licensed psychologist, licensed clinical
5 social worker, or licensed clinical professional counselor is
6 authorized to provide said services under the statutes of this
7 State and in accordance with accepted principles of his
8 profession.
9     (3) Insofar as this Section applies solely to licensed
10 clinical social workers and licensed clinical professional
11 counselors, those persons who may provide services to
12 individuals shall do so after the licensed clinical social
13 worker or licensed clinical professional counselor has
14 informed the patient of the desirability of the patient
15 conferring with the patient's primary care physician and the
16 licensed clinical social worker or licensed clinical
17 professional counselor has provided written notification to
18 the patient's primary care physician, if any, that services are
19 being provided to the patient. That notification may, however,
20 be waived by the patient on a written form. Those forms shall
21 be retained by the licensed clinical social worker or licensed
22 clinical professional counselor for a period of not less than 5
23 years.
24     (b) (1) An insurer that provides coverage for hospital or
25 medical expenses under a group policy of accident and health
26 insurance or health care plan amended, delivered, issued, or
27 renewed after the effective date of this amendatory Act of the
28 92nd General Assembly shall provide coverage under the policy
29 for treatment of serious mental illness under the same terms
30 and conditions as coverage for hospital or medical expenses
31 related to other illnesses and diseases. The coverage required
32 under this Section must provide for same durational limits,
33 amount limits, deductibles, and co-insurance requirements for
34 serious mental illness as are provided for other illnesses and
35 diseases. This subsection does not apply to coverage provided
36 to employees by employers who have 50 or fewer employees.

 

 

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1     (2) "Serious mental illness" means the following
2 psychiatric illnesses as defined in the most current edition of
3 the Diagnostic and Statistical Manual (DSM) published by the
4 American Psychiatric Association:
5         (A) schizophrenia;
6         (B) paranoid and other psychotic disorders;
7         (C) bipolar disorders (hypomanic, manic, depressive,
8     and mixed);
9         (D) major depressive disorders (single episode or
10     recurrent);
11         (E) schizoaffective disorders (bipolar or depressive);
12         (F) pervasive developmental disorders;
13         (G) obsessive-compulsive disorders;
14         (H) depression in childhood and adolescence; and
15         (I) panic disorder.
16     (3) Upon request of the reimbursing insurer, a provider of
17 treatment of serious mental illness shall furnish medical
18 records or other necessary data that substantiate that initial
19 or continued treatment is at all times medically necessary. An
20 insurer shall provide a mechanism for the timely review by a
21 provider holding the same license and practicing in the same
22 specialty as the patient's provider, who is unaffiliated with
23 the insurer, jointly selected by the patient (or the patient's
24 next of kin or legal representative if the patient is unable to
25 act for himself or herself), the patient's provider, and the
26 insurer in the event of a dispute between the insurer and
27 patient's provider regarding the medical necessity of a
28 treatment proposed by a patient's provider. If the reviewing
29 provider determines the treatment to be medically necessary,
30 the insurer shall provide reimbursement for the treatment.
31 Future contractual or employment actions by the insurer
32 regarding the patient's provider may not be based on the
33 provider's participation in this procedure. Nothing prevents
34 the insured from agreeing in writing to continue treatment at
35 his or her expense. When making a determination of the medical
36 necessity for a treatment modality for serous mental illness,

 

 

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1 an insurer must make the determination in a manner that is
2 consistent with the manner used to make that determination with
3 respect to other diseases or illnesses covered under the
4 policy, including an appeals process.
5     (4) A group health benefit plan:
6         (A) shall provide coverage based upon medical
7     necessity for the following treatment of mental illness in
8     each calendar year;
9             (i) 45 days of inpatient treatment; and
10             (ii) 35 visits for outpatient treatment including
11         group and individual outpatient treatment;
12         (B) may not include a lifetime limit on the number of
13     days of inpatient treatment or the number of outpatient
14     visits covered under the plan; and
15         (C) shall include the same amount limits, deductibles,
16     copayments, and coinsurance factors for serious mental
17     illness as for physical illness.
18     (5) An issuer of a group health benefit plan may not count
19 toward the number of outpatient visits required to be covered
20 under this Section an outpatient visit for the purpose of
21 medication management and shall cover the outpatient visits
22 under the same terms and conditions as it covers outpatient
23 visits for the treatment of physical illness.
24     (6) An issuer of a group health benefit plan may provide or
25 offer coverage required under this Section through a managed
26 care plan.
27     (7) Blank. This Section shall not be interpreted to require
28 a group health benefit plan to provide coverage for treatment
29 of:
30         (A) an addiction to a controlled substance or cannabis
31     that is used in violation of law; or
32         (B) mental illness resulting from the use of a
33     controlled substance or cannabis in violation of law.
34     (8) This subsection (b) is inoperative after December 31,
35 2005.
36     (c)(1) An insurer that provides coverage for hospital or

 

 

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1 medical expenses under a group policy of accident and health
2 insurance or health care plan, amended, delivered, issued, or
3 renewed after the effective date of this amendatory Act of the
4 93rd General Assembly shall provide coverage under the policy
5 for the treatment of substance abuse under the same terms and
6 conditions as coverage for hospital or medical expenses related
7 to other illnesses and diseases. This subsection does not apply
8 to coverage provided to employees by employers who have 2 or
9 fewer employees.
10     (2) "Substance abuse" means any condition or disorder that
11     involves the abuse or addiction to alcohol and/or drugs as
12     defined in the International Classification of Diseases
13     (ICD-9-CM).
14     (3) A group health benefit plan:
15         (A) shall provide the same coverage for the diagnosis,
16     detoxification and treatment of substance abuse on an
17     inpatient, outpatient, or residential treatment basis as
18     for physical illnesses;
19         (B) shall provide coverage for the same durational
20     limits, amount limits, annual limits, lifetime limits,
21     deductibles, copayments and co-insurance requirements for
22     the treatment of substance use as are provided for other
23     illnesses and diseases; and
24         (C) shall not establish any rate, term or condition
25     that places a greater financial burden on an insured for
26     access to the treatment of substance abuse than for access
27     to any other illness or disease.
28 (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02;
29 92-651, eff. 7-11-02.)