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92_HB4213
LRB9211352JSpc
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 and emotional disorders.
8 (a) (1) On and after the effective date of this Section,
9 every insurer which delivers, issues for delivery or renews
10 or modifies group A&H policies providing coverage for
11 hospital or medical treatment or services for illness on an
12 expense-incurred basis shall offer to the applicant or group
13 policyholder subject to the insurers standards of
14 insurability, coverage for reasonable and necessary treatment
15 and services for mental, emotional or nervous disorders or
16 conditions, other than serious mental illnesses as defined in
17 item (2) of subsection (b), up to the limits provided in the
18 policy for other disorders or conditions, except (i) the
19 insured may be required to pay up to 50% of expenses incurred
20 as a result of the treatment or services, and (ii) the annual
21 benefit limit may be limited to the lesser of $10,000 or 25%
22 of the lifetime policy limit.
23 (2) Each insured that is covered for mental, emotional
24 or nervous disorders or conditions shall be free to select
25 the physician licensed to practice medicine in all its
26 branches, licensed clinical psychologist, licensed clinical
27 social worker, or licensed clinical professional counselor,
28 or licensed marriage and family therapist of his choice to
29 treat such disorders, and the insurer shall pay the covered
30 charges of such physician licensed to practice medicine in
31 all its branches, licensed clinical psychologist, licensed
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1 clinical social worker, or licensed clinical professional
2 counselor, or licensed marriage and family therapist up to
3 the limits of coverage, provided (i) the disorder or
4 condition treated is covered by the policy, and (ii) the
5 physician, licensed psychologist, licensed clinical social
6 worker, or licensed clinical professional counselor, or
7 licensed marriage and family therapist is authorized to
8 provide said services under the statutes of this State and in
9 accordance with accepted principles of his profession.
10 (3) Insofar as this Section applies solely to licensed
11 clinical social workers, and licensed clinical professional
12 counselors, and licensed marriage and family therapists,
13 those persons who may provide services to individuals shall
14 do so after the licensed clinical social worker, or licensed
15 clinical professional counselor, or licensed marriage and
16 family therapist has informed the patient of the desirability
17 of the patient conferring with the patient's primary care
18 physician and the licensed clinical social worker, or
19 licensed clinical professional counselor, or licensed
20 marriage and family therapist has provided written
21 notification to the patient's primary care physician, if any,
22 that services are being provided to the patient. That
23 notification may, however, be waived by the patient on a
24 written form. Those forms shall be retained by the licensed
25 clinical social worker, or licensed clinical professional
26 counselor, or licensed marriage and family therapist for a
27 period of not less than 5 years.
28 (b) (1) An insurer that provides coverage for hospital
29 or medical expenses under a group policy of accident and
30 health insurance or health care plan amended, delivered,
31 issued, or renewed after the effective date of this
32 amendatory Act of the 92nd General Assembly shall provide
33 coverage under the policy for treatment of serious mental
34 illness under the same terms and conditions as coverage for
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1 hospital or medical expenses related to other illnesses and
2 diseases. The coverage required under this Section must
3 provide for same durational limits, amount limits,
4 deductibles, and co-insurance requirements for serious mental
5 illness as are provided for other illnesses and diseases.
6 This subsection does not apply to coverage provided to
7 employees by employers who have 50 or fewer employees.
8 (2) "Serious mental illness" means the following
9 psychiatric illnesses as defined in the most current edition
10 of the Diagnostic and Statistical Manual (DSM) published by
11 the American Psychiatric Association:
12 (A) schizophrenia;
13 (B) paranoid and other psychotic disorders;
14 (C) bipolar disorders (hypomanic, manic,
15 depressive, and mixed);
16 (D) major depressive disorders (single episode or
17 recurrent);
18 (E) schizoaffective disorders (bipolar or
19 depressive);
20 (F) pervasive developmental disorders;
21 (G) obsessive-compulsive disorders;
22 (H) depression in childhood and adolescence; and
23 (I) panic disorder.
24 (3) Upon request of the reimbursing insurer, a provider
25 of treatment of serious mental illness shall furnish medical
26 records or other necessary data that substantiate that
27 initial or continued treatment is at all times medically
28 necessary. An insurer shall provide a mechanism for the
29 timely review by a provider holding the same license and
30 practicing in the same specialty as the patient's provider,
31 who is unaffiliated with the insurer, jointly selected by the
32 patient (or the patient's next of kin or legal representative
33 if the patient is unable to act for himself or herself), the
34 patient's provider, and the insurer in the event of a dispute
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1 between the insurer and patient's provider regarding the
2 medical necessity of a treatment proposed by a patient's
3 provider. If the reviewing provider determines the treatment
4 to be medically necessary, the insurer shall provide
5 reimbursement for the treatment. Future contractual or
6 employment actions by the insurer regarding the patient's
7 provider may not be based on the provider's participation in
8 this procedure. Nothing prevents the insured from agreeing in
9 writing to continue treatment at his or her expense. When
10 making a determination of the medical necessity for a
11 treatment modality for serous mental illness, an insurer must
12 make the determination in a manner that is consistent with
13 the manner used to make that determination with respect to
14 other diseases or illnesses covered under the policy,
15 including an appeals process.
16 (4) A group health benefit plan:
17 (A) shall provide coverage based upon medical
18 necessity for the following treatment of mental illness
19 in each calendar year;
20 (i) 45 days of inpatient treatment; and
21 (ii) 35 visits for outpatient treatment
22 including group and individual outpatient treatment;
23 (B) may not include a lifetime limit on the number
24 of days of inpatient treatment or the number of
25 outpatient visits covered under the plan; and
26 (C) shall include the same amount limits,
27 deductibles, copayments, and coinsurance factors for
28 serious mental illness as for physical illness.
29 (5) An issuer of a group health benefit plan may not
30 count toward the number of outpatient visits required to be
31 covered under this Section an outpatient visit for the
32 purpose of medication management and shall cover the
33 outpatient visits under the same terms and conditions as it
34 covers outpatient visits for the treatment of physical
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1 illness.
2 (6) An issuer of a group health benefit plan may provide
3 or offer coverage required under this Section through a
4 managed care plan.
5 (7) This Section shall not be interpreted to require a
6 group health benefit plan to provide coverage for treatment
7 of:
8 (A) an addiction to a controlled substance or
9 cannabis that is used in violation of law; or
10 (B) mental illness resulting from the use of a
11 controlled substance or cannabis in violation of law.
12 (8) This subsection (b) is inoperative after December
13 31, 2005.
14 (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02;
15 revised 9-18-01.)
16 Section 99. Effective date. This Act takes effect upon
17 becoming law.