Rep. Laura Fine

Filed: 3/24/2017

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1332

2    AMENDMENT NO. ______. Amend House Bill 1332 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing 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 amendatory
9Act of the 97th General Assembly, every insurer which amends,
10delivers, issues, or renews group accident and health policies
11providing coverage for hospital or medical treatment or
12services for illness on an expense-incurred basis shall offer
13to the applicant or group policyholder subject to the insurer's
14standards of insurability, coverage for reasonable and
15necessary treatment and services for mental, emotional or
16nervous disorders or conditions, other than serious mental

 

 

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1illnesses as defined in item (2) of subsection (b), consistent
2with the parity requirements of Section 370c.1 of this Code.
3    (2) Each insured that is covered for mental, emotional,
4nervous, or substance use disorders or conditions shall be free
5to select the physician licensed to practice medicine in all
6its branches, licensed clinical psychologist, licensed
7clinical social worker, licensed clinical professional
8counselor, licensed marriage and family therapist, licensed
9speech-language pathologist, or other licensed or certified
10professional at a program licensed pursuant to the Illinois
11Alcoholism and Other Drug Abuse and Dependency Act of his
12choice to treat such disorders, and the insurer shall pay the
13covered charges of such physician licensed to practice medicine
14in all its branches, licensed clinical psychologist, licensed
15clinical social worker, licensed clinical professional
16counselor, licensed marriage and family therapist, licensed
17speech-language pathologist, or other licensed or certified
18professional at a program licensed pursuant to the Illinois
19Alcoholism and Other Drug Abuse and Dependency Act up to the
20limits of coverage, provided (i) the disorder or condition
21treated is covered by the policy, and (ii) the physician,
22licensed psychologist, licensed clinical social worker,
23licensed clinical professional counselor, licensed marriage
24and family therapist, licensed speech-language pathologist, or
25other licensed or certified professional at a program licensed
26pursuant to the Illinois Alcoholism and Other Drug Abuse and

 

 

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1Dependency Act is authorized to provide said services under the
2statutes of this State and in accordance with accepted
3principles of his profession.
4    (3) Insofar as this Section applies solely to licensed
5clinical social workers, licensed clinical professional
6counselors, licensed marriage and family therapists, licensed
7speech-language pathologists, and other licensed or certified
8professionals at programs licensed pursuant to the Illinois
9Alcoholism and Other Drug Abuse and Dependency Act, those
10persons who may provide services to individuals shall do so
11after the licensed clinical social worker, licensed clinical
12professional counselor, licensed marriage and family
13therapist, licensed speech-language pathologist, or other
14licensed or certified professional at a program licensed
15pursuant to the Illinois Alcoholism and Other Drug Abuse and
16Dependency Act has informed the patient of the desirability of
17the patient conferring with the patient's primary care
18physician and the licensed clinical social worker, licensed
19clinical professional counselor, licensed marriage and family
20therapist, licensed speech-language pathologist, or other
21licensed or certified professional at a program licensed
22pursuant to the Illinois Alcoholism and Other Drug Abuse and
23Dependency Act has provided written notification to the
24patient's primary care physician, if any, that services are
25being provided to the patient. That notification may, however,
26be waived by the patient on a written form. Those forms shall

 

 

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1be retained by the licensed clinical social worker, licensed
2clinical professional counselor, licensed marriage and family
3therapist, licensed speech-language pathologist, or other
4licensed or certified professional at a program licensed
5pursuant to the Illinois Alcoholism and Other Drug Abuse and
6Dependency Act for a period of not less than 5 years.
7    (b) (1) An insurer that provides coverage for hospital or
8medical expenses under a group policy of accident and health
9insurance or health care plan amended, delivered, issued, or
10renewed on or after the effective date of this amendatory Act
11of the 97th General Assembly shall provide coverage under the
12policy for treatment of serious mental illness and substance
13use disorders consistent with the parity requirements of
14Section 370c.1 of this Code. This subsection does not apply to
15any group policy of accident and health insurance or health
16care plan for any plan year of a small employer as defined in
17Section 5 of the Illinois Health Insurance Portability and
18Accountability Act.
19    (1.5) On and after the effective date of this amendatory
20Act of the 100th General Assembly, every insurer that amends,
21delivers, issues, or renews a group or individual policy of
22accident and health insurance, a managed care plan, or a
23qualified health plan offered for sale through the health
24insurance marketplace in this State providing coverage for
25hospital or medical treatment shall provide coverage based upon
26medical necessity for the treatment of eating disorders

 

 

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1consistent with the parity requirements of Section 370c.1 of
2this Code.
3    For the purposes of this item (1.5), "eating disorder"
4includes, but is not limited to, anorexia nervosa, bulimia
5nervosa, pica, rumination disorder, avoidant/restrictive food
6intake disorder, other specified feeding or eating disorder
7(OSFED), and any other eating disorder contained in the most
8recent version of the Diagnostic and Statistical Manual of
9Mental Disorders published by the American Psychiatric
10Association.
11    (2) "Serious mental illness" means the following
12psychiatric illnesses as defined in the most current edition of
13the Diagnostic and Statistical Manual (DSM) published by the
14American Psychiatric Association:
15        (A) schizophrenia;
16        (B) paranoid and other psychotic disorders;
17        (C) bipolar disorders (hypomanic, manic, depressive,
18    and mixed);
19        (D) major depressive disorders (single episode or
20    recurrent);
21        (E) schizoaffective disorders (bipolar or depressive);
22        (F) pervasive developmental disorders;
23        (G) obsessive-compulsive disorders;
24        (H) depression in childhood and adolescence;
25        (I) panic disorder;
26        (J) post-traumatic stress disorders (acute, chronic,

 

 

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1    or with delayed onset); and
2        (K) eating disorders, including, but not limited to,
3    anorexia nervosa, and bulimia nervosa, pica, rumination
4    disorder, avoidant/restrictive food intake disorder, other
5    specified feeding or eating disorder (OSFED), and any other
6    eating disorder contained in the most recent version of the
7    Diagnostic and Statistical Manual of Mental Disorders
8    published by the American Psychiatric Association.
9    (2.5) "Substance use disorder" means the following mental
10disorders as defined in the most current edition of the
11Diagnostic and Statistical Manual (DSM) published by the
12American Psychiatric Association:
13        (A) substance abuse disorders;
14        (B) substance dependence disorders; and
15        (C) substance induced disorders.
16    (3) Unless otherwise prohibited by federal law and
17consistent with the parity requirements of Section 370c.1 of
18this Code, the reimbursing insurer, a provider of treatment of
19serious mental illness or substance use disorder shall furnish
20medical records or other necessary data that substantiate that
21initial or continued treatment is at all times medically
22necessary. An insurer shall provide a mechanism for the timely
23review by a provider holding the same license and practicing in
24the same specialty as the patient's provider, who is
25unaffiliated with the insurer, jointly selected by the patient
26(or the patient's next of kin or legal representative if the

 

 

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1patient is unable to act for himself or herself), the patient's
2provider, and the insurer in the event of a dispute between the
3insurer and patient's provider regarding the medical necessity
4of a treatment proposed by a patient's provider. If the
5reviewing provider determines the treatment to be medically
6necessary, the insurer shall provide reimbursement for the
7treatment. Future contractual or employment actions by the
8insurer regarding the patient's provider may not be based on
9the provider's participation in this procedure. Nothing
10prevents the insured from agreeing in writing to continue
11treatment at his or her expense. When making a determination of
12the medical necessity for a treatment modality for serious
13mental illness or substance use disorder, an insurer must make
14the determination in a manner that is consistent with the
15manner used to make that determination with respect to other
16diseases or illnesses covered under the policy, including an
17appeals process. Medical necessity determinations for
18substance use disorders shall be made in accordance with
19appropriate patient placement criteria established by the
20American Society of Addiction Medicine. No additional criteria
21may be used to make medical necessity determinations for
22substance use disorders.
23    (4) A group health benefit plan amended, delivered, issued,
24or renewed on or after the effective date of this amendatory
25Act of the 97th General Assembly:
26        (A) shall provide coverage based upon medical

 

 

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1    necessity for the treatment of mental illness and substance
2    use disorders consistent with the parity requirements of
3    Section 370c.1 of this Code; provided, however, that in
4    each calendar year coverage shall not be less than the
5    following:
6            (i) 45 days of inpatient treatment; and
7            (ii) beginning on June 26, 2006 (the effective date
8        of Public Act 94-921), 60 visits for outpatient
9        treatment including group and individual outpatient
10        treatment; and
11            (iii) for plans or policies delivered, issued for
12        delivery, renewed, or modified after January 1, 2007
13        (the effective date of Public Act 94-906), 20
14        additional outpatient visits for speech therapy for
15        treatment of pervasive developmental disorders that
16        will be in addition to speech therapy provided pursuant
17        to item (ii) of this subparagraph (A); and
18        (B) may not include a lifetime limit on the number of
19    days of inpatient treatment or the number of outpatient
20    visits covered under the plan.
21        (C) (Blank).
22    (5) An issuer of a group health benefit plan may not count
23toward the number of outpatient visits required to be covered
24under this Section an outpatient visit for the purpose of
25medication management and shall cover the outpatient visits
26under the same terms and conditions as it covers outpatient

 

 

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1visits for the treatment of physical illness.
2    (5.5) An individual or group health benefit plan amended,
3delivered, issued, or renewed on or after the effective date of
4this amendatory Act of the 99th General Assembly shall offer
5coverage for medically necessary acute treatment services and
6medically necessary clinical stabilization services. The
7treating provider shall base all treatment recommendations and
8the health benefit plan shall base all medical necessity
9determinations for substance use disorders in accordance with
10the most current edition of the American Society of Addiction
11Medicine Patient Placement Criteria.
12    As used in this subsection:
13    "Acute treatment services" means 24-hour medically
14supervised addiction treatment that provides evaluation and
15withdrawal management and may include biopsychosocial
16assessment, individual and group counseling, psychoeducational
17groups, and discharge planning.
18    "Clinical stabilization services" means 24-hour treatment,
19usually following acute treatment services for substance
20abuse, which may include intensive education and counseling
21regarding the nature of addiction and its consequences, relapse
22prevention, outreach to families and significant others, and
23aftercare planning for individuals beginning to engage in
24recovery from addiction.
25    (6) An issuer of a group health benefit plan may provide or
26offer coverage required under this Section through a managed

 

 

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1care plan.
2    (7) (Blank).
3    (8) (Blank).
4    (9) With respect to substance use disorders, coverage for
5inpatient treatment shall include coverage for treatment in a
6residential treatment center licensed by the Department of
7Public Health or the Department of Human Services.
8    (c) This Section shall not be interpreted to require
9coverage for speech therapy or other habilitative services for
10those individuals covered under Section 356z.15 of this Code.
11    (d) The Department shall enforce the requirements of State
12and federal parity law, which includes ensuring compliance by
13individual and group policies; detecting violations of the law
14by individual and group policies proactively monitoring
15discriminatory practices; accepting, evaluating, and
16responding to complaints regarding such violations; and
17ensuring violations are appropriately remedied and deterred.
18    (e) Availability of plan information.
19        (1) The criteria for medical necessity determinations
20    made under a group health plan with respect to mental
21    health or substance use disorder benefits (or health
22    insurance coverage offered in connection with the plan with
23    respect to such benefits) must be made available by the
24    plan administrator (or the health insurance issuer
25    offering such coverage) to any current or potential
26    participant, beneficiary, or contracting provider upon

 

 

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1    request.
2        (2) The reason for any denial under a group health plan
3    (or health insurance coverage offered in connection with
4    such plan) of reimbursement or payment for services with
5    respect to mental health or substance use disorder benefits
6    in the case of any participant or beneficiary must be made
7    available within a reasonable time and in a reasonable
8    manner by the plan administrator (or the health insurance
9    issuer offering such coverage) to the participant or
10    beneficiary upon request.
11    (f) As used in this Section, "group policy of accident and
12health insurance" and "group health benefit plan" includes (1)
13State-regulated employer-sponsored group health insurance
14plans written in Illinois and (2) State employee health plans.
15(Source: P.A. 99-480, eff. 9-9-15.)
 
16    Section 99. Effective date. This Act takes effect upon
17becoming law.".