093_SB0601eng

 
SB601 Engrossed                      LRB093 07909 JLS 08100 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 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%
22    of the lifetime policy limit.
23        (2)  Each insured that is covered for  mental,  emotional
24    or  nervous  disorders  or conditions shall be free to select
25    the physician  licensed  to  practice  medicine  in  all  its
26    branches,  licensed  clinical psychologist, licensed clinical
27    social worker, or licensed clinical professional counselor of
28    his or her choice to treat such disorders,  and  the  insurer
29    shall  pay  the covered charges of such physician licensed to
30    practice medicine in  all  its  branches,  licensed  clinical
31    psychologist,  licensed  clinical  social worker, or licensed
 
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 1    clinical professional counselor up to the limits of coverage,
 2    provided (i) the disorder or condition treated is covered  by
 3    the  policy,  and  (ii) the physician, licensed psychologist,
 4    licensed  clinical  social  worker,  or   licensed   clinical
 5    professional counselor is authorized to provide said services
 6    under  the  statutes  of  this  State  and in accordance with
 7    accepted principles of his or her profession.
 8        (3)  Insofar as this Section applies solely  to  licensed
 9    clinical  social  workers  and licensed clinical professional
10    counselors,  those  persons  who  may  provide  services   to
11    individuals  shall  do  so after the licensed clinical social
12    worker  or  licensed  clinical  professional  counselor   has
13    informed  the  patient  of  the  desirability  of the patient
14    conferring with the patient's primary care physician and  the
15    licensed   clinical   social   worker  or  licensed  clinical
16    professional counselor has provided written  notification  to
17    the  patient's  primary care physician, if any, that services
18    are being provided to the patient.   That  notification  may,
19    however,  be  waived by the patient on a written form.  Those
20    forms shall be  retained  by  the  licensed  clinical  social
21    worker  or  licensed  clinical  professional  counselor for a
22    period of not less than 5 years.
23        (b) (1)  An insurer that provides coverage  for  hospital
24    or  medical  expenses  under  a  group policy of accident and
25    health insurance or  health  care  plan  amended,  delivered,
26    issued,   or   renewed  after  the  effective  date  of  this
27    amendatory Act  of  the  93rd  92nd  General  Assembly  shall
28    provide  coverage  under  the policy for treatment of serious
29    mental  illness  under  the  same  terms  and  conditions  as
30    coverage for hospital or medical expenses  related  to  other
31    illnesses  and  diseases.   The  coverage required under this
32    Section must  provide  for  same  durational  limits,  amount
33    limits,   deductibles,   and  co-insurance  requirements  for
34    serious mental illness as are provided  for  other  illnesses
 
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 1    and  diseases.   This  subsection  does not apply to coverage
 2    provided to employees by  employers  who  have  50  or  fewer
 3    employees.
 4        (2)  "Serious   mental   illness"   means  the  following
 5    psychiatric illnesses as defined in the most current  edition
 6    of  the  Diagnostic and Statistical Manual (DSM) published by
 7    the American Psychiatric Association:
 8             (A)  schizophrenia;
 9             (B)  paranoid and other psychotic disorders;
10             (C)  bipolar    disorders     (hypomanic,     manic,
11        depressive, and mixed);
12             (D)  major  depressive  disorders (single episode or
13        recurrent);
14             (E)  schizoaffective    disorders    (bipolar     or
15        depressive);
16             (F)  pervasive developmental disorders;
17             (G)  obsessive-compulsive disorders;
18             (H)  depression in childhood and adolescence; and
19             (I)  panic disorder;.
20             (J)  anorexia  nervosa  (restricting or binge-eating
21        and purging); and
22             (K)  bulimia nervosa (purging or nonpurging).
23        (3)  Upon request of the reimbursing insurer, a  provider
24    of  treatment of serious mental illness shall furnish medical
25    records  or  other  necessary  data  that  substantiate  that
26    initial or continued treatment  is  at  all  times  medically
27    necessary.   An  insurer  shall  provide  a mechanism for the
28    timely review by a provider  holding  the  same  license  and
29    practicing  in  the same specialty as the patient's provider,
30    who is unaffiliated with the insurer, jointly selected by the
31    patient (or the patient's next of kin or legal representative
32    if the patient is unable to act for himself or herself),  the
33    patient's provider, and the insurer in the event of a dispute
34    between  the  insurer  and  patient's  provider regarding the
 
SB601 Engrossed             -4-      LRB093 07909 JLS 08100 b
 1    medical necessity of a  treatment  proposed  by  a  patient's
 2    provider.  If the reviewing provider determines the treatment
 3    to   be   medically  necessary,  the  insurer  shall  provide
 4    reimbursement  for  the  treatment.   Future  contractual  or
 5    employment actions by the  insurer  regarding  the  patient's
 6    provider  may not be based on the provider's participation in
 7    this procedure. Nothing prevents the insured from agreeing in
 8    writing to continue treatment at his or  her  expense.   When
 9    making  a  determination  of  the  medical  necessity  for  a
10    treatment modality for serous mental illness, an insurer must
11    make  the  determination  in a manner that is consistent with
12    the manner used to make that determination  with  respect  to
13    other   diseases  or  illnesses  covered  under  the  policy,
14    including an appeals process.
15        (4)  A group health benefit plan:
16             (A)  shall  provide  coverage  based  upon   medical
17        necessity  for  the following treatment of mental illness
18        in each calendar year;
19                  (i)  45 days of inpatient treatment; and
20                  (ii)  35  visits   for   outpatient   treatment
21             including group and individual outpatient treatment;
22             (B)  may  not include a lifetime limit on the number
23        of  days  of  inpatient  treatment  or  the   number   of
24        outpatient visits covered under the plan; and
25             (C)  shall   include   the   same   amount   limits,
26        deductibles,  copayments,  and  coinsurance  factors  for
27        serious mental illness as for physical illness.
28        (5)  An  issuer  of  a  group health benefit plan may not
29    count toward the number of outpatient visits required  to  be
30    covered  under  this  Section  an  outpatient  visit  for the
31    purpose  of  medication  management  and  shall   cover   the
32    outpatient  visits  under the same terms and conditions as it
33    covers  outpatient  visits  for  the  treatment  of  physical
34    illness.
 
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 1        (6)  An issuer of a group health benefit plan may provide
 2    or offer coverage  required  under  this  Section  through  a
 3    managed care plan.
 4        (7)  This  Section  shall not be interpreted to require a
 5    group health benefit plan to provide coverage  for  treatment
 6    of:
 7             (A)  an  addiction  to  a  controlled  substance  or
 8        cannabis that is used in violation of law; or
 9             (B)  mental  illness  resulting  from  the  use of a
10        controlled substance or cannabis in violation of law.
11        (8)  This subsection (b) is  inoperative  after  December
12    31, 2005.
13    (Source:  P.A.  92-182,  eff.  7-27-01;  92-185, eff. 1-1-02;
14    92-651, eff. 7-11-02.)

15        Section 99.  Effective date.  This Act takes effect  upon
16    becoming law.