Public Act 094-0906
 
HB4125 Enrolled LRB094 13838 LJB 48711 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
 
    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
    Sec. 370c. Mental and emotional disorders.
    (a) (1) On and after the effective date of this Section,
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
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
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.
    (2) Each insured that is covered for mental, emotional or
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 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 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 clinical professional counselor is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his
profession.
    (3) Insofar as this Section applies solely to licensed
clinical social workers and licensed clinical professional
counselors, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker or licensed clinical professional counselor 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
professional counselor 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 waived by the patient on a written form. Those forms shall
be retained by the licensed clinical social worker or licensed
clinical professional counselor for a period of not less than 5
years.
    (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
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.
    (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:
        (A) schizophrenia;
        (B) paranoid and other psychotic disorders;
        (C) bipolar disorders (hypomanic, manic, depressive,
    and mixed);
        (D) major depressive disorders (single episode or
    recurrent);
        (E) schizoaffective disorders (bipolar or depressive);
        (F) pervasive developmental disorders;
        (G) obsessive-compulsive disorders;
        (H) depression in childhood and adolescence;
        (I) panic disorder; and
        (J) post-traumatic stress disorders (acute, chronic,
    or with delayed onset).
    (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
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,
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
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
respect to other diseases or illnesses covered under the
policy, including an appeals process.
    (4) A group health benefit plan:
        (A) shall provide coverage based upon medical
    necessity for the following treatment of mental illness in
    each calendar year: ;
            (i) 45 days of inpatient treatment; and
            (ii) 35 visits for outpatient treatment including
        group and individual outpatient treatment; and
            (iii) for plans or policies delivered, issued for
        delivery, renewed, or modified after the effective
        date of this amendatory Act of the 94th General
        Assembly, 20 additional outpatient visits for speech
        therapy for treatment of pervasive developmental
        disorders that will be in addition to speech therapy
        provided pursuant to item (ii) of this subparagraph
        (A);
        (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
        (C) shall include the same amount limits, deductibles,
    copayments, and coinsurance factors for serious mental
    illness as for physical illness.
    (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.
    (6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
    (7) This Section shall not be interpreted to require a
group health benefit plan to provide coverage for treatment of:
        (A) an addiction to a controlled substance or cannabis
    that is used in violation of law; or
        (B) mental illness resulting from the use of a
    controlled substance or cannabis in violation of law.
    (8) (Blank).
(Source: P.A. 94-402, eff. 8-2-05; P.A. 94-584, eff. 8-15-05;
revised 8-19-05.)
 
    Section 10. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
 
    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
    Sec. 5-3. Insurance Code provisions.
    (a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
356y, 356z.2, 356z.4, 356z.5, 356z.6, 364.01, 367.2, 367.2-5,
367i, 368a, 368b, 368c, 368d, 368e, 370c, 401, 401.1, 402, 403,
403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,
XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
Insurance Code.
    (b) For purposes of the Illinois Insurance Code, except for
Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
Maintenance Organizations in the following categories are
deemed to be "domestic companies":
        (1) a corporation authorized under the Dental Service
    Plan Act or the Voluntary Health Services Plans Act;
        (2) a corporation organized under the laws of this
    State; or
        (3) a corporation organized under the laws of another
    state, 30% or more of the enrollees of which are residents
    of this State, except a corporation subject to
    substantially the same requirements in its state of
    organization as is a "domestic company" under Article VIII
    1/2 of the Illinois Insurance Code.
    (c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
        (1) the Director shall give primary consideration to
    the continuation of benefits to enrollees and the financial
    conditions of the acquired Health Maintenance Organization
    after the merger, consolidation, or other acquisition of
    control takes effect;
        (2)(i) the criteria specified in subsection (1)(b) of
    Section 131.8 of the Illinois Insurance Code shall not
    apply and (ii) the Director, in making his determination
    with respect to the merger, consolidation, or other
    acquisition of control, need not take into account the
    effect on competition of the merger, consolidation, or
    other acquisition of control;
        (3) the Director shall have the power to require the
    following information:
            (A) certification by an independent actuary of the
        adequacy of the reserves of the Health Maintenance
        Organization sought to be acquired;
            (B) pro forma financial statements reflecting the
        combined balance sheets of the acquiring company and
        the Health Maintenance Organization sought to be
        acquired as of the end of the preceding year and as of
        a date 90 days prior to the acquisition, as well as pro
        forma financial statements reflecting projected
        combined operation for a period of 2 years;
            (C) a pro forma business plan detailing an
        acquiring party's plans with respect to the operation
        of the Health Maintenance Organization sought to be
        acquired for a period of not less than 3 years; and
            (D) such other information as the Director shall
        require.
    (d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including without limitation the health
maintenance organization's right, title, and interest in and to
its health care certificates).
    (e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code, take
into account the effect of the management contract or service
agreement on the continuation of benefits to enrollees and the
financial condition of the health maintenance organization to
be managed or serviced, and (ii) need not take into account the
effect of the management contract or service agreement on
competition.
    (f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a Health
Maintenance Organization may by contract agree with a group or
other enrollment unit to effect refunds or charge additional
premiums under the following terms and conditions:
        (i) the amount of, and other terms and conditions with
    respect to, the refund or additional premium are set forth
    in the group or enrollment unit contract agreed in advance
    of the period for which a refund is to be paid or
    additional premium is to be charged (which period shall not
    be less than one year); and
        (ii) the amount of the refund or additional premium
    shall not exceed 20% of the Health Maintenance
    Organization's profitable or unprofitable experience with
    respect to the group or other enrollment unit for the
    period (and, for purposes of a refund or additional
    premium, the profitable or unprofitable experience shall
    be calculated taking into account a pro rata share of the
    Health Maintenance Organization's administrative and
    marketing expenses, but shall not include any refund to be
    made or additional premium to be paid pursuant to this
    subsection (f)). The Health Maintenance Organization and
    the group or enrollment unit may agree that the profitable
    or unprofitable experience may be calculated taking into
    account the refund period and the immediately preceding 2
    plan years.
    The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and the
resulting additional premium to be paid by the group or
enrollment unit.
    In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
(Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853,
eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)

Effective Date: 1/1/2007