State of Illinois
92nd General Assembly

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HB0111 Engrossed                              LRB9200848JSpcA

 1        AN  ACT  to amend the Illinois Insurance Code by changing
 2    Section 370c and adding Section 370c-1.

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

 5        Section  5.  The  Illinois  Insurance  Code is amended by
 6    changing Section 370c and adding Section 370c-1 as follows:

 7        (215 ILCS 5/370c) (from Ch. 73, par. 982c)
 8        Sec. 370c.  Mental and emotional disorders.
 9        (1) On and after the  effective  date  of  this  Section,
10    every  insurer  which delivers, issues for delivery or renews
11    or  modifies  group  A&H  policies  providing  coverage   for
12    hospital  or  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  subject  to
18    Section  370c-1,  up to the limits provided in the policy for
19    other disorders or conditions, except (i) the insured may  be
20    required to pay up to 50% of expenses incurred as a result of
21    the  treatment or services, and (ii) the annual benefit limit
22    may be limited to  the  lesser  of  $10,000  or  25%  of  the
23    lifetime policy limit.
24        (2)  Each  insured  that is covered for mental, emotional
25    or nervous disorders or conditions shall be  free  to  select
26    the  physician  licensed  to  practice  medicine  in  all its
27    branches,  licensed  clinical   psychologist,   or   licensed
28    clinical social worker of his choice to treat such disorders,
29    and  the  insurer  shall  pay  the  covered  charges  of such
30    physician licensed to practice medicine in all its  branches,
31    licensed  clinical  psychologist, or licensed clinical social
HB0111 Engrossed            -2-               LRB9200848JSpcA
 1    worker up  to  the  limits  of  coverage,  provided  (i)  the
 2    disorder  or  condition treated is covered by the policy, and
 3    (ii)  the  physician,  licensed  psychologist,  or   licensed
 4    clinical social worker is authorized to provide said services
 5    under  the  statutes  of  this  State  and in accordance with
 6    accepted principles of his profession.
 7        Insofar  as  this  Section  applies  solely  to  licensed
 8    clinical  social  workers,  those  persons  who  may  provide
 9    services to  individuals  shall  do  so  after  the  licensed
10    clinical  social  worker  has  informed  the  patient  of the
11    desirability of the patient  conferring  with  the  patient's
12    primary  care  physician  and  the  licensed  clinical social
13    worker has provided written  notification  to  the  patient's
14    primary  care  physician,  if  any,  that  services are being
15    provided to the patient.  That notification may, however,  be
16    waived  by  the patient on a written form.  Those forms shall
17    be retained by the licensed  clinical  social  worker  for  a
18    period of not less than 5 years.
19    (Source: P.A. 86-1434.)

20        (215 ILCS 5/370c-1 new)
21        Sec. 370c-1.  Coverage for serious mental illness.
22        (a)  An  insurer  that  provides coverage for hospital or
23    medical expenses  under  a  group  or  individual  policy  of
24    accident  and  health  insurance or health care plan amended,
25    delivered, issued, or renewed after  the  effective  date  of
26    this  amendatory  Act  of  the  92nd  General  Assembly shall
27    provide coverage under the policy for  treatment  of  serious
28    mental  illness  under  the  same  terms  and  conditions  as
29    coverage  for  hospital  or medical expenses related to other
30    illnesses and diseases.  The  coverage  required  under  this
31    Section  must  provide  the  same  durational  limits, amount
32    limits,  deductibles,  and  co-insurance   requirements   for
33    serious  mental  illness  as are provided for other illnesses
HB0111 Engrossed            -3-               LRB9200848JSpcA
 1    and diseases.
 2        (b)  "Serious mental illness" means any mental  disorders
 3    that   are  caused  by  factors  including  a  biological  or
 4    physiological disorder of the brain or  psychosocial  factors
 5    that  substantially  limit  the life activities of the person
 6    with the illness.  Examples include, but are not limited  to,
 7    the following as described in the most current edition of the
 8    Diagnostic  and  Statistical  Manual  (DSM)  published by the
 9    American Psychiatric Association:
10             (1)  Schizophrenia.
11             (2)  Pervasive developmental disorder.
12             (3)  Autistic disorders.
13             (4)  Schizoaffective disorder.
14             (5)  Delusional disorder.
15             (6)  Bipolar disorder.
16             (7)  Major depression.
17             (8)  Obsessive compulsive disorder.
18             (9)  Panic disorder.
19        (c)  Upon request of the reimbursing insurer, a  provider
20    of  treatment of serious mental illness shall furnish medical
21    records  or  other  necessary  data  that  substantiate  that
22    initial or continued treatment  is  at  all  times  medically
23    necessary.   An  insurer  shall  provide  a mechanism for the
24    timely review by a provider  holding  the  same  license  and
25    practicing  in  the same specialty as the patient's provider,
26    who is unaffiliated with the insurer, jointly selected by the
27    patient (or the patient's next of kin or legal representative
28    if the patient is unable to act for himself or herself),  the
29    patient's provider, and the insurer in the event of a dispute
30    between  the  insurer  and  patient's  provider regarding the
31    medical necessity of a  treatment  proposed  by  a  patient's
32    provider.  If the reviewing provider determines the treatment
33    to   be   medically  necessary,  the  insurer  shall  provide
34    reimbursement  for  the  treatment.   Future  contractual  or
HB0111 Engrossed            -4-               LRB9200848JSpcA
 1    employment actions by the  insurer  regarding  the  patient's
 2    provider  shall  not be based on the provider's participation
 3    in  this  procedure.    Nothing  prevents  the  insured  from
 4    agreeing in writing to  continue  treatment  at  his  or  her
 5    expense.
 6        When  making a determination of the medical necessity for
 7    a treatment modality for serious mental illness,  an  insurer
 8    must  make  the  determination in a manner that is consistent
 9    with the manner used to make that determination with  respect
10    to  other  diseases  or  illnesses  covered under the policy,
11    including an appeals process.
12        (d)  Inpatient   coverage   under   this   Section   when
13    continuous hospitalization  is  medically  necessary  may  be
14    limited to 90 consecutive days.

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