Rep. Laura Fine

Filed: 4/12/2017

 

 


 

 


 
10000HB1332ham004LRB100 03040 SMS 25026 a

1
AMENDMENT TO HOUSE BILL 1332

2    AMENDMENT NO. ______. Amend House Bill 1332, AS AMENDED, by
3replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Illinois Insurance Code is amended by
6changing Section 370c as follows:
 
7    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
8    Sec. 370c. Mental and emotional disorders.
9    (a) (1) On and after the effective date of this amendatory
10Act of the 97th General Assembly, every insurer which amends,
11delivers, issues, or renews group accident and health policies
12providing coverage for hospital or medical treatment or
13services for illness on an expense-incurred basis shall offer
14to the applicant or group policyholder subject to the insurer's
15standards of insurability, coverage for reasonable and
16necessary treatment and services for mental, emotional or

 

 

10000HB1332ham004- 2 -LRB100 03040 SMS 25026 a

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

 

 

10000HB1332ham004- 3 -LRB100 03040 SMS 25026 a

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

 

 

10000HB1332ham004- 4 -LRB100 03040 SMS 25026 a

1be waived by the patient on a written form. Those forms shall
2be retained by the licensed clinical social worker, licensed
3clinical professional counselor, licensed marriage and family
4therapist, licensed speech-language pathologist, or other
5licensed or certified professional at a program licensed
6pursuant to the Illinois Alcoholism and Other Drug Abuse and
7Dependency Act for a period of not less than 5 years.
8    (b) (1) An insurer that provides coverage for hospital or
9medical expenses under a group or individual policy of accident
10and health insurance or health care plan amended, delivered,
11issued, or renewed on or after the effective date of this
12amendatory Act of the 100th General Assembly this amendatory
13Act of the 97th General Assembly shall provide coverage under
14the policy for treatment of serious mental illness and
15substance use disorders consistent with the parity
16requirements of Section 370c.1 of this Code. This subsection
17does not apply to any group policy of accident and health
18insurance or health care plan for any plan year of a small
19employer as defined in Section 5 of the Illinois Health
20Insurance Portability and Accountability Act.
21    (2) "Serious mental illness" means the following
22psychiatric illnesses as defined in the most current edition of
23the Diagnostic and Statistical Manual (DSM) published by the
24American Psychiatric Association:
25        (A) schizophrenia;
26        (B) paranoid and other psychotic disorders;

 

 

10000HB1332ham004- 5 -LRB100 03040 SMS 25026 a

1        (C) bipolar disorders (hypomanic, manic, depressive,
2    and mixed);
3        (D) major depressive disorders (single episode or
4    recurrent);
5        (E) schizoaffective disorders (bipolar or depressive);
6        (F) pervasive developmental disorders;
7        (G) obsessive-compulsive disorders;
8        (H) depression in childhood and adolescence;
9        (I) panic disorder;
10        (J) post-traumatic stress disorders (acute, chronic,
11    or with delayed onset); and
12        (K) eating disorders, including, but not limited to,
13    anorexia nervosa, and bulimia nervosa, pica, rumination
14    disorder, avoidant/restrictive food intake disorder, other
15    specified feeding or eating disorder (OSFED), and any other
16    eating disorder contained in the most recent version of the
17    Diagnostic and Statistical Manual of Mental Disorders
18    published by the American Psychiatric Association.
19    (2.5) "Substance use disorder" means the following mental
20disorders as defined in the most current edition of the
21Diagnostic and Statistical Manual (DSM) published by the
22American Psychiatric Association:
23        (A) substance abuse disorders;
24        (B) substance dependence disorders; and
25        (C) substance induced disorders.
26    (3) Unless otherwise prohibited by federal law and

 

 

10000HB1332ham004- 6 -LRB100 03040 SMS 25026 a

1consistent with the parity requirements of Section 370c.1 of
2this Code, the reimbursing insurer, a provider of treatment of
3serious mental illness or substance use disorder shall furnish
4medical records or other necessary data that substantiate that
5initial or continued treatment is at all times medically
6necessary. An insurer shall provide a mechanism for the timely
7review by a provider holding the same license and practicing in
8the same specialty as the patient's provider, who is
9unaffiliated with the insurer, jointly selected by the patient
10(or the patient's next of kin or legal representative if the
11patient is unable to act for himself or herself), the patient's
12provider, and the insurer in the event of a dispute between the
13insurer and patient's provider regarding the medical necessity
14of a treatment proposed by a patient's provider. If the
15reviewing provider determines the treatment to be medically
16necessary, the insurer shall provide reimbursement for the
17treatment. Future contractual or employment actions by the
18insurer regarding the patient's provider may not be based on
19the provider's participation in this procedure. Nothing
20prevents the insured from agreeing in writing to continue
21treatment at his or her expense. When making a determination of
22the medical necessity for a treatment modality for serious
23mental illness or substance use disorder, an insurer must make
24the determination in a manner that is consistent with the
25manner used to make that determination with respect to other
26diseases or illnesses covered under the policy, including an

 

 

10000HB1332ham004- 7 -LRB100 03040 SMS 25026 a

1appeals process. Medical necessity determinations for
2substance use disorders shall be made in accordance with
3appropriate patient placement criteria established by the
4American Society of Addiction Medicine. No additional criteria
5may be used to make medical necessity determinations for
6substance use disorders.
7    (4) A group health benefit plan amended, delivered, issued,
8or renewed on or after the effective date of this amendatory
9Act of the 97th General Assembly:
10        (A) shall provide coverage based upon medical
11    necessity for the treatment of mental illness and substance
12    use disorders consistent with the parity requirements of
13    Section 370c.1 of this Code; provided, however, that in
14    each calendar year coverage shall not be less than the
15    following:
16            (i) 45 days of inpatient treatment; and
17            (ii) beginning on June 26, 2006 (the effective date
18        of Public Act 94-921), 60 visits for outpatient
19        treatment including group and individual outpatient
20        treatment; and
21            (iii) for plans or policies delivered, issued for
22        delivery, renewed, or modified after January 1, 2007
23        (the effective date of Public Act 94-906), 20
24        additional outpatient visits for speech therapy for
25        treatment of pervasive developmental disorders that
26        will be in addition to speech therapy provided pursuant

 

 

10000HB1332ham004- 8 -LRB100 03040 SMS 25026 a

1        to item (ii) of this subparagraph (A); and
2        (B) may not include a lifetime limit on the number of
3    days of inpatient treatment or the number of outpatient
4    visits covered under the plan.
5        (C) (Blank).
6    (5) An issuer of a group health benefit plan may not count
7toward the number of outpatient visits required to be covered
8under this Section an outpatient visit for the purpose of
9medication management and shall cover the outpatient visits
10under the same terms and conditions as it covers outpatient
11visits for the treatment of physical illness.
12    (5.5) An individual or group health benefit plan amended,
13delivered, issued, or renewed on or after the effective date of
14this amendatory Act of the 99th General Assembly shall offer
15coverage for medically necessary acute treatment services and
16medically necessary clinical stabilization services. The
17treating provider shall base all treatment recommendations and
18the health benefit plan shall base all medical necessity
19determinations for substance use disorders in accordance with
20the most current edition of the American Society of Addiction
21Medicine Patient Placement Criteria.
22    As used in this subsection:
23    "Acute treatment services" means 24-hour medically
24supervised addiction treatment that provides evaluation and
25withdrawal management and may include biopsychosocial
26assessment, individual and group counseling, psychoeducational

 

 

10000HB1332ham004- 9 -LRB100 03040 SMS 25026 a

1groups, and discharge planning.
2    "Clinical stabilization services" means 24-hour treatment,
3usually following acute treatment services for substance
4abuse, which may include intensive education and counseling
5regarding the nature of addiction and its consequences, relapse
6prevention, outreach to families and significant others, and
7aftercare planning for individuals beginning to engage in
8recovery from addiction.
9    (6) An issuer of a group health benefit plan may provide or
10offer coverage required under this Section through a managed
11care plan.
12    (7) (Blank).
13    (8) (Blank).
14    (9) With respect to substance use disorders, coverage for
15inpatient treatment shall include coverage for treatment in a
16residential treatment center licensed by the Department of
17Public Health or the Department of Human Services.
18    (c) This Section shall not be interpreted to require
19coverage for speech therapy or other habilitative services for
20those individuals covered under Section 356z.15 of this Code.
21    (d) The Department shall enforce the requirements of State
22and federal parity law, which includes ensuring compliance by
23individual and group policies; detecting violations of the law
24by individual and group policies proactively monitoring
25discriminatory practices; accepting, evaluating, and
26responding to complaints regarding such violations; and

 

 

10000HB1332ham004- 10 -LRB100 03040 SMS 25026 a

1ensuring violations are appropriately remedied and deterred.
2    (e) Availability of plan information.
3        (1) The criteria for medical necessity determinations
4    made under a group health plan with respect to mental
5    health or substance use disorder benefits (or health
6    insurance coverage offered in connection with the plan with
7    respect to such benefits) must be made available by the
8    plan administrator (or the health insurance issuer
9    offering such coverage) to any current or potential
10    participant, beneficiary, or contracting provider upon
11    request.
12        (2) The reason for any denial under a group health plan
13    (or health insurance coverage offered in connection with
14    such plan) of reimbursement or payment for services with
15    respect to mental health or substance use disorder benefits
16    in the case of any participant or beneficiary must be made
17    available within a reasonable time and in a reasonable
18    manner by the plan administrator (or the health insurance
19    issuer offering such coverage) to the participant or
20    beneficiary upon request.
21    (f) As used in this Section, "group policy of accident and
22health insurance" and "group health benefit plan" includes (1)
23State-regulated employer-sponsored group health insurance
24plans written in Illinois and (2) State employee health plans.
25(Source: P.A. 99-480, eff. 9-9-15.)
 

 

 

10000HB1332ham004- 11 -LRB100 03040 SMS 25026 a

1    Section 99. Effective date. This Act takes effect upon
2becoming law.".