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Public Act 100-0305


 

Public Act 0305 100TH GENERAL ASSEMBLY



 


 
Public Act 100-0305
 
HB1332 EnrolledLRB100 03040 RPS 13045 b

    AN ACT concerning regulation.
 
    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 amendatory
Act of the 97th General Assembly, every insurer which amends,
delivers, issues, or renews group accident and health 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 insurer's
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), consistent
with the parity requirements of Section 370c.1 of this Code.
    (2) Each insured that is covered for mental, emotional,
nervous, or substance use 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, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act 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, licensed clinical professional
counselor, licensed marriage and family therapist, licensed
speech-language pathologist, or other licensed or certified
professional at a program licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act 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,
licensed clinical professional counselor, licensed marriage
and family therapist, licensed speech-language pathologist, or
other licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act 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, licensed clinical professional
counselors, licensed marriage and family therapists, licensed
speech-language pathologists, and other licensed or certified
professionals at programs licensed pursuant to the Illinois
Alcoholism and Other Drug Abuse and Dependency Act, those
persons who may provide services to individuals shall do so
after the licensed clinical social worker, licensed clinical
professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act has informed the patient of the desirability of
the patient conferring with the patient's primary care
physician and the licensed clinical social worker, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act 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, licensed
clinical professional counselor, licensed marriage and family
therapist, licensed speech-language pathologist, or other
licensed or certified professional at a program licensed
pursuant to the Illinois Alcoholism and Other Drug Abuse and
Dependency Act for a period of not less than 5 years.
    (b) (1) An insurer that provides coverage for hospital or
medical expenses under a group or individual policy of accident
and health insurance or health care plan amended, delivered,
issued, or renewed on or after the effective date of this
amendatory Act of the 100th General Assembly this amendatory
Act of the 97th General Assembly shall provide coverage under
the policy for treatment of serious mental illness and
substance use disorders consistent with the parity
requirements of Section 370c.1 of this Code. This subsection
does not apply to any group policy of accident and health
insurance or health care plan for any plan year of a small
employer as defined in Section 5 of the Illinois Health
Insurance Portability and Accountability Act.
    (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;
        (J) post-traumatic stress disorders (acute, chronic,
    or with delayed onset); and
        (K) eating disorders, including, but not limited to,
    anorexia nervosa, and bulimia nervosa, pica, rumination
    disorder, avoidant/restrictive food intake disorder, other
    specified feeding or eating disorder (OSFED), and any other
    eating disorder contained in the most recent version of the
    Diagnostic and Statistical Manual of Mental Disorders
    published by the American Psychiatric Association.
    (2.5) "Substance use disorder" means the following mental
disorders as defined in the most current edition of the
Diagnostic and Statistical Manual (DSM) published by the
American Psychiatric Association:
        (A) substance abuse disorders;
        (B) substance dependence disorders; and
        (C) substance induced disorders.
    (3) Unless otherwise prohibited by federal law and
consistent with the parity requirements of Section 370c.1 of
this Code, the reimbursing insurer, a provider of treatment of
serious mental illness or substance use disorder 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 serious
mental illness or substance use disorder, 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. Medical necessity determinations for
substance use disorders shall be made in accordance with
appropriate patient placement criteria established by the
American Society of Addiction Medicine. No additional criteria
may be used to make medical necessity determinations for
substance use disorders.
    (4) A group health benefit plan amended, delivered, issued,
or renewed on or after the effective date of this amendatory
Act of the 97th General Assembly:
        (A) shall provide coverage based upon medical
    necessity for the treatment of mental illness and substance
    use disorders consistent with the parity requirements of
    Section 370c.1 of this Code; provided, however, that in
    each calendar year coverage shall not be less than the
    following:
            (i) 45 days of inpatient treatment; and
            (ii) beginning on June 26, 2006 (the effective date
        of Public Act 94-921), 60 visits for outpatient
        treatment including group and individual outpatient
        treatment; and
            (iii) for plans or policies delivered, issued for
        delivery, renewed, or modified after January 1, 2007
        (the effective date of Public Act 94-906), 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); and
        (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.
        (C) (Blank).
    (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.
    (5.5) An individual or group health benefit plan amended,
delivered, issued, or renewed on or after the effective date of
this amendatory Act of the 99th General Assembly shall offer
coverage for medically necessary acute treatment services and
medically necessary clinical stabilization services. The
treating provider shall base all treatment recommendations and
the health benefit plan shall base all medical necessity
determinations for substance use disorders in accordance with
the most current edition of the American Society of Addiction
Medicine Patient Placement Criteria.
    As used in this subsection:
    "Acute treatment services" means 24-hour medically
supervised addiction treatment that provides evaluation and
withdrawal management and may include biopsychosocial
assessment, individual and group counseling, psychoeducational
groups, and discharge planning.
    "Clinical stabilization services" means 24-hour treatment,
usually following acute treatment services for substance
abuse, which may include intensive education and counseling
regarding the nature of addiction and its consequences, relapse
prevention, outreach to families and significant others, and
aftercare planning for individuals beginning to engage in
recovery from addiction.
    (6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
    (7) (Blank).
    (8) (Blank).
    (9) With respect to substance use disorders, coverage for
inpatient treatment shall include coverage for treatment in a
residential treatment center licensed by the Department of
Public Health or the Department of Human Services.
    (c) This Section shall not be interpreted to require
coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.15 of this Code.
    (d) The Department shall enforce the requirements of State
and federal parity law, which includes ensuring compliance by
individual and group policies; detecting violations of the law
by individual and group policies proactively monitoring
discriminatory practices; accepting, evaluating, and
responding to complaints regarding such violations; and
ensuring violations are appropriately remedied and deterred.
    (e) Availability of plan information.
        (1) The criteria for medical necessity determinations
    made under a group health plan with respect to mental
    health or substance use disorder benefits (or health
    insurance coverage offered in connection with the plan with
    respect to such benefits) must be made available by the
    plan administrator (or the health insurance issuer
    offering such coverage) to any current or potential
    participant, beneficiary, or contracting provider upon
    request.
        (2) The reason for any denial under a group health plan
    (or health insurance coverage offered in connection with
    such plan) of reimbursement or payment for services with
    respect to mental health or substance use disorder benefits
    in the case of any participant or beneficiary must be made
    available within a reasonable time and in a reasonable
    manner by the plan administrator (or the health insurance
    issuer offering such coverage) to the participant or
    beneficiary upon request.
    (f) As used in this Section, "group policy of accident and
health insurance" and "group health benefit plan" includes (1)
State-regulated employer-sponsored group health insurance
plans written in Illinois and (2) State employee health plans.
(Source: P.A. 99-480, eff. 9-9-15.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 8/24/2017