93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB4778

 

Introduced 02/04/04, by Carole Pankau

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/370c   from Ch. 73, par. 982c

    Amends the Illinois Insurance Code. Provides that services provided by a licensed marriage and family therapist shall be covered on the same basis as services provided by licensed clinical social workers. Effective immediately.


LRB093 15980 SAS 41604 b

 

 

A BILL FOR

 

HB4778 LRB093 15980 SAS 41604 b

1     AN ACT concerning insurance coverage.
 
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 or
10 modifies group A&H policies providing coverage for hospital or
11 medical treatment or services for illness on an
12 expense-incurred basis shall offer to the applicant or group
13 policyholder subject to the insurers standards of
14 insurability, coverage for reasonable and necessary treatment
15 and services for mental, emotional or nervous disorders or
16 conditions, other than serious mental illnesses as defined in
17 item (2) of subsection (b), up to the limits provided in the
18 policy for other disorders or conditions, except (i) the
19 insured may be required to pay up to 50% of expenses incurred
20 as a result of the treatment or services, and (ii) the annual
21 benefit limit may be limited to the lesser of $10,000 or 25% of
22 the lifetime policy limit.
23     (2)  Each insured that is covered for mental, emotional or
24 nervous disorders or conditions shall be free to select the
25 physician licensed to practice medicine in all its branches,
26 licensed clinical psychologist, licensed clinical social
27 worker, or licensed clinical professional counselor, or
28 licensed marriage and family therapist of his choice to treat
29 such disorders, and the insurer shall pay the covered charges
30 of such physician licensed to practice medicine in all its
31 branches, licensed clinical psychologist, licensed clinical
32 social worker, or licensed clinical professional counselor, or

 

 

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1 licensed marriage and family therapist up to the limits of
2 coverage, provided (i) the disorder or condition treated is
3 covered by the policy, and (ii) the physician, licensed
4 psychologist, licensed clinical social worker, or licensed
5 clinical professional counselor, or licensed marriage and
6 family therapist is authorized to provide said services under
7 the statutes of this State and in accordance with accepted
8 principles of his profession.
9     (3)  Insofar as this Section applies solely to licensed
10 clinical social workers, and licensed clinical professional
11 counselors, and licensed marriage and family therapists, those
12 persons who may provide services to individuals shall do so
13 after the licensed clinical social worker, or licensed clinical
14 professional counselor, or licensed marriage and family
15 therapist has informed the patient of the desirability of the
16 patient conferring with the patient's primary care physician
17 and the licensed clinical social worker, or licensed clinical
18 professional counselor, or licensed marriage and family
19 therapist has provided written notification to the patient's
20 primary care physician, if any, that services are being
21 provided to the patient. That notification may, however, be
22 waived by the patient on a written form. Those forms shall be
23 retained by the licensed clinical social worker, or licensed
24 clinical professional counselor, or licensed marriage and
25 family therapist for a period of not less than 5 years.
26     (b) (1)  An insurer that provides coverage for hospital or
27 medical expenses under a group policy of accident and health
28 insurance or health care plan amended, delivered, issued, or
29 renewed after the effective date of this amendatory Act of the
30 92nd General Assembly shall provide coverage under the policy
31 for treatment of serious mental illness under the same terms
32 and conditions as coverage for hospital or medical expenses
33 related to other illnesses and diseases. The coverage required
34 under this Section must provide for same durational limits,
35 amount limits, deductibles, and co-insurance requirements for
36 serious mental illness as are provided for other illnesses and

 

 

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1 diseases. This subsection does not apply to coverage provided
2 to employees by employers who have 50 or fewer employees.
3     (2)  "Serious mental illness" means the following
4 psychiatric illnesses as defined in the most current edition of
5 the Diagnostic and Statistical Manual (DSM) published by the
6 American Psychiatric Association:
7         (A)  schizophrenia;
8         (B)  paranoid and other psychotic disorders;
9         (C)  bipolar disorders (hypomanic, manic, depressive,
10     and mixed);
11         (D)  major depressive disorders (single episode or
12     recurrent);
13         (E)  schizoaffective disorders (bipolar or
14     depressive);
15         (F)  pervasive developmental disorders;
16         (G)  obsessive-compulsive disorders;
17         (H)  depression in childhood and adolescence; and
18         (I)  panic disorder.
19     (3)  Upon request of the reimbursing insurer, a provider of
20 treatment of serious mental illness shall furnish medical
21 records or other necessary data that substantiate that initial
22 or continued treatment is at all times medically necessary. An
23 insurer shall provide a mechanism for the timely review by a
24 provider holding the same license and practicing in the same
25 specialty as the patient's provider, who is unaffiliated with
26 the insurer, jointly selected by the patient (or the patient's
27 next of kin or legal representative if the patient is unable to
28 act for himself or herself), the patient's provider, and the
29 insurer in the event of a dispute between the insurer and
30 patient's provider regarding the medical necessity of a
31 treatment proposed by a patient's provider. If the reviewing
32 provider determines the treatment to be medically necessary,
33 the insurer shall provide reimbursement for the treatment.
34 Future contractual or employment actions by the insurer
35 regarding the patient's provider may not be based on the
36 provider's participation in this procedure. Nothing prevents

 

 

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1 the insured from agreeing in writing to continue treatment at
2 his or her expense. When making a determination of the medical
3 necessity for a treatment modality for serous mental illness,
4 an insurer must make the determination in a manner that is
5 consistent with the manner used to make that determination with
6 respect to other diseases or illnesses covered under the
7 policy, including an appeals process.
8     (4)  A group health benefit plan:
9         (A)  shall provide coverage based upon medical
10     necessity for the following treatment of mental illness in
11     each calendar year;
12             (i)  45 days of inpatient treatment; and
13             (ii)  35 visits for outpatient treatment including
14         group and individual outpatient treatment;
15         (B)  may not include a lifetime limit on the number of
16     days of inpatient treatment or the number of outpatient
17     visits covered under the plan; and
18         (C)  shall include the same amount limits,
19     deductibles, copayments, and coinsurance factors for
20     serious mental illness as for physical illness.
21     (5)  An issuer of a group health benefit plan may not count
22 toward the number of outpatient visits required to be covered
23 under this Section an outpatient visit for the purpose of
24 medication management and shall cover the outpatient visits
25 under the same terms and conditions as it covers outpatient
26 visits for the treatment of physical illness.
27     (6)  An issuer of a group health benefit plan may provide
28 or offer coverage required under this Section through a managed
29 care plan.
30     (7)  This Section shall not be interpreted to require a
31 group health benefit plan to provide coverage for treatment of:
32         (A)  an addiction to a controlled substance or
33     cannabis that is used in violation of law; or
34         (B)  mental illness resulting from the use of a
35     controlled substance or cannabis in violation of law.
36     (8)  This subsection (b) is inoperative after December 31,

 

 

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1 2005.
2 (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02;
3 92-651, eff. 7-11-02.)
 
4     Section 99. Effective date. This Act takes effect upon
5 becoming law.