093_HB1493eng

 
HB1493 Engrossed                     LRB093 07907 JLS 08098 b

 1        AN ACT concerning insurance.

 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  or  through  a  health   maintenance
13    organization,  as  defined  in  Section  1-2  of  the  Health
14    Maintenance  Organization Act shall offer to the applicant or
15    group policyholder  subject  to  the  insurers  standards  of
16    insurability, coverage for reasonable and necessary treatment
17    and  services  for  mental, emotional or nervous disorders or
18    conditions, other than serious mental illnesses as defined in
19    item (2) of subsection (b), up to the limits provided in  the
20    policy  for  other  disorders  or  conditions, except (i) the
21    insured may be required to pay up to 50% of expenses incurred
22    as a result of the treatment or services, and (ii) the annual
23    benefit limit may be limited to the lesser of $10,000 or  25%
24    of the lifetime policy limit.
25        (2)  Each  insured  that is covered for mental, emotional
26    or nervous disorders or conditions shall be  free  to  select
27    the  physician  licensed  to  practice  medicine  in  all its
28    branches, licensed clinical psychologist,  licensed  clinical
29    social worker, or licensed clinical professional counselor of
30    his  or  her  choice to treat such disorders, and the insurer
31    shall pay the covered charges of such physician  licensed  to
 
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 1    practice  medicine  in  all  its  branches, licensed clinical
 2    psychologist, licensed clinical social  worker,  or  licensed
 3    clinical professional counselor up to the limits of coverage,
 4    provided  (i) the disorder or condition treated is covered by
 5    the policy, and (ii) the  physician,  licensed  psychologist,
 6    licensed   clinical   social  worker,  or  licensed  clinical
 7    professional counselor is authorized to provide said services
 8    under the statutes of  this  State  and  in  accordance  with
 9    accepted principles of his or her profession.
10        (3)  Insofar  as  this Section applies solely to licensed
11    clinical social workers and  licensed  clinical  professional
12    counselors,   those  persons  who  may  provide  services  to
13    individuals shall do so after the  licensed  clinical  social
14    worker   or  licensed  clinical  professional  counselor  has
15    informed the patient  of  the  desirability  of  the  patient
16    conferring  with the patient's primary care physician and the
17    licensed  clinical  social  worker   or   licensed   clinical
18    professional  counselor  has provided written notification to
19    the patient's primary care physician, if any,  that  services
20    are  being  provided  to the patient.  That notification may,
21    however, be waived by the patient on a written  form.   Those
22    forms  shall  be  retained  by  the  licensed clinical social
23    worker or licensed  clinical  professional  counselor  for  a
24    period of not less than 5 years.
25        (b) (1)  An  insurer  that provides coverage for hospital
26    or medical expenses under a  group  policy  of  accident  and
27    health  insurance, through a health maintenance organization,
28    as  defined  in  Section  1-2  of  the   Health   Maintenance
29    Organization  Act,  or  health  care plan amended, delivered,
30    issued,  or  renewed  after  the  effective  date   of   this
31    amendatory  Act  of  the  93rd  92nd  General  Assembly shall
32    provide coverage under the policy for  treatment  of  serious
33    mental  illness  under  the  same  terms  and  conditions  as
34    coverage  for  hospital  or medical expenses related to other
 
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 1    illnesses and diseases.  The  coverage  required  under  this
 2    Section  must  provide  for  same  durational  limits, amount
 3    limits,  deductibles,  and  co-insurance   requirements   for
 4    serious  mental  illness  as are provided for other illnesses
 5    and diseases.  This subsection does  not  apply  to  coverage
 6    provided  to  employees  by  employers  who  have 50 or fewer
 7    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             (J)  anorexia nervosa (restricting  or  binge-eating
25        and purging); and
26             (K)  bullemia nervosa (purging or nonpurging).
27        (3)  Upon  request of the reimbursing insurer, a provider
28    of treatment of serious mental illness shall furnish  medical
29    records  or  other  necessary  data  that  substantiate  that
30    initial  or  continued  treatment  is  at all times medically
31    necessary.  An insurer shall  provide  a  mechanism  for  the
32    timely  review  by  a  provider  holding the same license and
33    practicing in the same specialty as the  patient's  provider,
34    who is unaffiliated with the insurer, jointly selected by the
 
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 1    patient (or the patient's next of kin or legal representative
 2    if  the patient is unable to act for himself or herself), the
 3    patient's provider, and the insurer in the event of a dispute
 4    between the insurer  and  patient's  provider  regarding  the
 5    medical  necessity  of  a  treatment  proposed by a patient's
 6    provider.  If the reviewing provider determines the treatment
 7    to  be  medically  necessary,  the  insurer   shall   provide
 8    reimbursement  for  the  treatment.   Future  contractual  or
 9    employment  actions  by  the  insurer regarding the patient's
10    provider may not be based on the provider's participation  in
11    this procedure. Nothing prevents the insured from agreeing in
12    writing  to  continue  treatment at his or her expense.  When
13    making  a  determination  of  the  medical  necessity  for  a
14    treatment modality for serous mental illness, an insurer must
15    make the determination in a manner that  is  consistent  with
16    the  manner  used  to make that determination with respect to
17    other  diseases  or  illnesses  covered  under  the   policy,
18    including an appeals process.
19        (4)  A group health benefit plan:
20             (A)  shall   provide  coverage  based  upon  medical
21        necessity for the following treatment of  mental  illness
22        in each calendar year;
23                  (i)  45 days of inpatient treatment; and
24                  (ii)  35   visits   for   outpatient  treatment
25             including group and individual outpatient treatment;
26             (B)  may not include a lifetime limit on the  number
27        of   days   of  inpatient  treatment  or  the  number  of
28        outpatient visits covered under the plan; and
29             (C)  shall   include   the   same   amount   limits,
30        deductibles,  copayments,  and  coinsurance  factors  for
31        serious mental illness as for physical illness.
32        (5)  An issuer of a group health  benefit  plan  may  not
33    count  toward  the number of outpatient visits required to be
34    covered under  this  Section  an  outpatient  visit  for  the
 
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 1    purpose   of   medication  management  and  shall  cover  the
 2    outpatient visits under the same terms and conditions  as  it
 3    covers  outpatient  visits  for  the  treatment  of  physical
 4    illness.
 5        (6)  An issuer of a group health benefit plan may provide
 6    or  offer  coverage  required  under  this  Section through a
 7    managed care plan.
 8        (7)  This Section shall not be interpreted to  require  a
 9    group  health  benefit plan to provide coverage for treatment
10    of:
11             (A)  an  addiction  to  a  controlled  substance  or
12        cannabis that is used in violation of law; or
13             (B)  mental illness resulting  from  the  use  of  a
14        controlled substance or cannabis in violation of law.
15        (8)  This  subsection  (b)  is inoperative after December
16    31, 2005.
17    (Source: P.A. 92-182,  eff.  7-27-01;  92-185,  eff.  1-1-02;
18    92-651, eff. 7-11-02.)

19        Section  10.  The  Health Maintenance Organization Act is
20    amended by changing Section 5-3 as follows:

21        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
22        Sec. 5-3.  Insurance Code provisions.
23        (a)  Health Maintenance Organizations shall be subject to
24    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
25    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
26    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
27    356y,  356z.2,  367i, 368a, 370c, 401, 401.1, 402, 403, 403A,
28    408, 408.2, 409,  412,  444,  and  444.1,  paragraph  (c)  of
29    subsection  (2)  of  Section 367, and Articles IIA, VIII 1/2,
30    XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of  the  Illinois
31    Insurance Code.
32        (b)  For  purposes of the Illinois Insurance Code, except
 
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 1    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
 2    Health  Maintenance Organizations in the following categories
 3    are deemed to be "domestic companies":
 4             (1)  a  corporation  authorized  under  the   Dental
 5        Service  Plan  Act or the Voluntary Health Services Plans
 6        Act;
 7             (2)  a corporation organized under the laws of  this
 8        State; or
 9             (3)  a  corporation  organized  under  the  laws  of
10        another  state, 30% or more of the enrollees of which are
11        residents of this State, except a corporation subject  to
12        substantially  the  same  requirements  in  its  state of
13        organization as is a  "domestic  company"  under  Article
14        VIII 1/2 of the Illinois Insurance Code.
15        (c)  In  considering  the merger, consolidation, or other
16    acquisition of control of a Health  Maintenance  Organization
17    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
18             (1)  the  Director  shall give primary consideration
19        to the continuation of  benefits  to  enrollees  and  the
20        financial  conditions  of the acquired Health Maintenance
21        Organization after the merger,  consolidation,  or  other
22        acquisition of control takes effect;
23             (2)(i)  the  criteria specified in subsection (1)(b)
24        of Section 131.8 of the Illinois Insurance Code shall not
25        apply and (ii) the Director, in making his  determination
26        with  respect  to  the  merger,  consolidation,  or other
27        acquisition of control, need not take  into  account  the
28        effect  on  competition  of the merger, consolidation, or
29        other acquisition of control;
30             (3)  the Director shall have the  power  to  require
31        the following information:
32                  (A)  certification by an independent actuary of
33             the   adequacy   of   the  reserves  of  the  Health
34             Maintenance Organization sought to be acquired;
 
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 1                  (B)  pro forma financial statements  reflecting
 2             the combined balance sheets of the acquiring company
 3             and the Health Maintenance Organization sought to be
 4             acquired  as of the end of the preceding year and as
 5             of a date 90 days prior to the acquisition, as  well
 6             as   pro   forma   financial  statements  reflecting
 7             projected combined  operation  for  a  period  of  2
 8             years;
 9                  (C)  a  pro  forma  business  plan detailing an
10             acquiring  party's  plans  with   respect   to   the
11             operation  of  the  Health  Maintenance Organization
12             sought to be acquired for a period of not less  than
13             3 years; and
14                  (D)  such  other  information  as  the Director
15             shall require.
16        (d)  The provisions of Article VIII 1/2 of  the  Illinois
17    Insurance  Code  and this Section 5-3 shall apply to the sale
18    by any health maintenance organization of greater than 10% of
19    its enrollee population  (including  without  limitation  the
20    health  maintenance organization's right, title, and interest
21    in and to its health care certificates).
22        (e)  In considering any management  contract  or  service
23    agreement  subject to Section 141.1 of the Illinois Insurance
24    Code, the Director (i) shall, in  addition  to  the  criteria
25    specified  in  Section  141.2 of the Illinois Insurance Code,
26    take into account the effect of the  management  contract  or
27    service   agreement   on  the  continuation  of  benefits  to
28    enrollees  and  the  financial  condition   of   the   health
29    maintenance  organization to be managed or serviced, and (ii)
30    need not take into  account  the  effect  of  the  management
31    contract or service agreement on competition.
32        (f)  Except  for  small employer groups as defined in the
33    Small Employer Rating, Renewability  and  Portability  Health
34    Insurance  Act and except for medicare supplement policies as
 
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 1    defined in Section 363 of  the  Illinois  Insurance  Code,  a
 2    Health  Maintenance Organization may by contract agree with a
 3    group or other enrollment unit to effect  refunds  or  charge
 4    additional premiums under the following terms and conditions:
 5             (i)  the  amount  of, and other terms and conditions
 6        with respect to, the refund or additional premium are set
 7        forth in the group or enrollment unit contract agreed  in
 8        advance of the period for which a refund is to be paid or
 9        additional  premium  is to be charged (which period shall
10        not be less than one year); and
11             (ii)  the amount of the refund or additional premium
12        shall  not  exceed  20%   of   the   Health   Maintenance
13        Organization's profitable or unprofitable experience with
14        respect  to  the  group  or other enrollment unit for the
15        period (and, for  purposes  of  a  refund  or  additional
16        premium,  the profitable or unprofitable experience shall
17        be calculated taking into account a pro rata share of the
18        Health  Maintenance  Organization's  administrative   and
19        marketing  expenses,  but shall not include any refund to
20        be made or additional premium to be paid pursuant to this
21        subsection (f)).  The Health Maintenance Organization and
22        the  group  or  enrollment  unit  may  agree   that   the
23        profitable  or  unprofitable experience may be calculated
24        taking into account the refund period and the immediately
25        preceding 2 plan years.
26        The  Health  Maintenance  Organization  shall  include  a
27    statement in the evidence of coverage issued to each enrollee
28    describing the possibility of a refund or additional premium,
29    and upon request of any group or enrollment unit, provide  to
30    the group or enrollment unit a description of the method used
31    to   calculate  (1)  the  Health  Maintenance  Organization's
32    profitable experience with respect to the group or enrollment
33    unit and the resulting refund to the group or enrollment unit
34    or (2) the  Health  Maintenance  Organization's  unprofitable
 
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 1    experience  with  respect to the group or enrollment unit and
 2    the resulting additional premium to be paid by the  group  or
 3    enrollment unit.
 4        In   no  event  shall  the  Illinois  Health  Maintenance
 5    Organization  Guaranty  Association  be  liable  to  pay  any
 6    contractual obligation of an insolvent  organization  to  pay
 7    any refund authorized under this Section.
 8    (Source: P.A.  91-357,  eff.  7-29-99;  91-406,  eff. 1-1-00;
 9    91-549, eff. 8-14-99; 91-605,  eff.  12-14-99;  91-788,  eff.
10    6-9-00; 92-764, eff. 1-1-03.)

11        Section  99.  Effective date.  This Act takes effect upon
12    becoming law.