HB0953 Enrolled LRB095 03888 KBJ 23921 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

 

 

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1 nervous disorders or conditions shall be free to select the
2 physician licensed to practice medicine in all its branches,
3 licensed clinical psychologist, licensed clinical social
4 worker, or licensed clinical professional counselor, or
5 licensed marriage and family therapist of his choice to treat
6 such disorders, and the insurer shall pay the covered charges
7 of such physician licensed to practice medicine in all its
8 branches, licensed clinical psychologist, licensed clinical
9 social worker, or licensed clinical professional counselor, or
10 licensed marriage and family therapist up to the limits of
11 coverage, provided (i) the disorder or condition treated is
12 covered by the policy, and (ii) the physician, licensed
13 psychologist, licensed clinical social worker, or licensed
14 clinical professional counselor, or licensed marriage and
15 family therapist is authorized to provide said services under
16 the statutes of this State and in accordance with accepted
17 principles of his profession.
18     (3) Insofar as this Section applies solely to licensed
19 clinical social workers, and licensed clinical professional
20 counselors, and licensed marriage and family therapists, those
21 persons who may provide services to individuals shall do so
22 after the licensed clinical social worker, or licensed clinical
23 professional counselor, or licensed marriage and family
24 therapist has informed the patient of the desirability of the
25 patient conferring with the patient's primary care physician
26 and the licensed clinical social worker, or licensed clinical

 

 

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1 professional counselor, or licensed marriage and family
2 therapist has provided written notification to the patient's
3 primary care physician, if any, that services are being
4 provided to the patient. That notification may, however, be
5 waived by the patient on a written form. Those forms shall be
6 retained by the licensed clinical social worker, or licensed
7 clinical professional counselor, or licensed marriage and
8 family therapist for a period of not less than 5 years.
9     (b) (1) An insurer that provides coverage for hospital or
10 medical expenses under a group policy of accident and health
11 insurance or health care plan amended, delivered, issued, or
12 renewed after the effective date of this amendatory Act of the
13 92nd General Assembly shall provide coverage under the policy
14 for treatment of serious mental illness under the same terms
15 and conditions as coverage for hospital or medical expenses
16 related to other illnesses and diseases. The coverage required
17 under this Section must provide for same durational limits,
18 amount limits, deductibles, and co-insurance requirements for
19 serious mental illness as are provided for other illnesses and
20 diseases. This subsection does not apply to coverage provided
21 to employees by employers who have 50 or fewer employees.
22     (2) "Serious mental illness" means the following
23 psychiatric illnesses as defined in the most current edition of
24 the Diagnostic and Statistical Manual (DSM) published by the
25 American Psychiatric Association:
26         (A) schizophrenia;

 

 

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1         (B) paranoid and other psychotic disorders;
2         (C) bipolar disorders (hypomanic, manic, depressive,
3     and mixed);
4         (D) major depressive disorders (single episode or
5     recurrent);
6         (E) schizoaffective disorders (bipolar or depressive);
7         (F) pervasive developmental disorders;
8         (G) obsessive-compulsive disorders;
9         (H) depression in childhood and adolescence;
10         (I) panic disorder; and
11         (J) post-traumatic stress disorders (acute, chronic,
12     or with delayed onset).
13     (3) Upon request of the reimbursing insurer, a provider of
14 treatment of serious mental illness shall furnish medical
15 records or other necessary data that substantiate that initial
16 or continued treatment is at all times medically necessary. An
17 insurer shall provide a mechanism for the timely review by a
18 provider holding the same license and practicing in the same
19 specialty as the patient's provider, who is unaffiliated with
20 the insurer, jointly selected by the patient (or the patient's
21 next of kin or legal representative if the patient is unable to
22 act for himself or herself), the patient's provider, and the
23 insurer in the event of a dispute between the insurer and
24 patient's provider regarding the medical necessity of a
25 treatment proposed by a patient's provider. If the reviewing
26 provider determines the treatment to be medically necessary,

 

 

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1 the insurer shall provide reimbursement for the treatment.
2 Future contractual or employment actions by the insurer
3 regarding the patient's provider may not be based on the
4 provider's participation in this procedure. Nothing prevents
5 the insured from agreeing in writing to continue treatment at
6 his or her expense. When making a determination of the medical
7 necessity for a treatment modality for serous mental illness,
8 an insurer must make the determination in a manner that is
9 consistent with the manner used to make that determination with
10 respect to other diseases or illnesses covered under the
11 policy, including an appeals process.
12     (4) A group health benefit plan:
13         (A) shall provide coverage based upon medical
14     necessity for the following treatment of mental illness in
15     each calendar year:
16             (i) 45 days of inpatient treatment; and
17             (ii) beginning on June 26, 2006 (the effective date
18         of Public Act 94-921) this amendatory Act of the 94th
19         General Assembly, 60 visits for outpatient treatment
20         including group and individual outpatient treatment;
21         and
22             (iii) for plans or policies delivered, issued for
23         delivery, renewed, or modified after January 1, 2007
24         (the effective date of Public Act 94-906) this
25         amendatory Act of the 94th General Assembly, 20
26         additional outpatient visits for speech therapy for

 

 

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1         treatment of pervasive developmental disorders that
2         will be in addition to speech therapy provided pursuant
3         to item (ii) of this subparagraph (A);
4         (B) may not include a lifetime limit on the number of
5     days of inpatient treatment or the number of outpatient
6     visits covered under the plan; and
7         (C) shall include the same amount limits, deductibles,
8     copayments, and coinsurance factors for serious mental
9     illness as for physical illness.
10     (5) An issuer of a group health benefit plan may not count
11 toward the number of outpatient visits required to be covered
12 under this Section an outpatient visit for the purpose of
13 medication management and shall cover the outpatient visits
14 under the same terms and conditions as it covers outpatient
15 visits for the treatment of physical illness.
16     (6) An issuer of a group health benefit plan may provide or
17 offer coverage required under this Section through a managed
18 care plan.
19     (7) This Section shall not be interpreted to require a
20 group health benefit plan to provide coverage for treatment of:
21         (A) an addiction to a controlled substance or cannabis
22     that is used in violation of law; or
23         (B) mental illness resulting from the use of a
24     controlled substance or cannabis in violation of law.
25     (8) (Blank).
26 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;

 

 

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1 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; revised 8-3-06.)
 
2     Section 99. Effective date. This Act takes effect upon
3 becoming law.