Full Text of SB2245 99th General Assembly
SB2245 99TH GENERAL ASSEMBLY |
| | 99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016 SB2245 Introduced 1/27/2016, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED: |
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215 ILCS 5/370c | from Ch. 73, par. 982c |
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Amends the Illinois Insurance Code. Requires every insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance, a managed care plan, or a qualified health plan offered for sale through the health insurance marketplace in this State providing coverage for hospital or medical treatment to provide coverage based upon medical necessity for the treatment of eating disorders. Provides that "eating disorder" includes, but is not limited to, anorexia nervosa, bulimia nervosa, pica, rumination disorder, advoidant/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. Effective immediately.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 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 amendatory | 9 | | Act of the 97th General Assembly,
every insurer which amends, | 10 | | delivers, issues, or renews
group accident and health policies | 11 | | providing coverage for hospital or medical treatment or
| 12 | | services for illness on an expense-incurred basis shall offer | 13 | | to the
applicant or group policyholder subject to the insurer's | 14 | | standards of
insurability, coverage for reasonable and | 15 | | necessary treatment and services
for mental, emotional or | 16 | | nervous disorders or conditions, other than serious
mental | 17 | | illnesses as defined in item (2) of subsection (b), consistent | 18 | | with the parity requirements of Section 370c.1 of this Code.
| 19 | | (2) Each insured that is covered for mental, emotional, | 20 | | nervous, or substance use
disorders or conditions shall be free | 21 | | to select the physician licensed to
practice medicine in all | 22 | | its branches, licensed clinical psychologist,
licensed | 23 | | clinical social worker, licensed clinical professional |
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| 1 | | counselor, licensed marriage and family therapist, licensed | 2 | | speech-language pathologist, or other licensed or certified | 3 | | professional at a program licensed pursuant to the Illinois | 4 | | Alcoholism and Other Drug Abuse and Dependency Act of
his | 5 | | choice to treat such disorders, and
the insurer shall pay the | 6 | | covered charges of such physician licensed to
practice medicine | 7 | | in all its branches, licensed clinical psychologist,
licensed | 8 | | clinical social worker, licensed clinical professional | 9 | | counselor, licensed marriage and family therapist, licensed | 10 | | speech-language pathologist, or other licensed or certified | 11 | | professional at a program licensed pursuant to the Illinois | 12 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the | 13 | | limits of coverage, provided (i)
the disorder or condition | 14 | | treated is covered by the policy, and (ii) the
physician, | 15 | | licensed psychologist, licensed clinical social worker, | 16 | | licensed
clinical professional counselor, licensed marriage | 17 | | and family therapist, licensed speech-language pathologist, or | 18 | | other licensed or certified professional at a program licensed | 19 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 20 | | Dependency Act is
authorized to provide said services under the | 21 | | statutes of this State and in
accordance with accepted | 22 | | principles of his profession.
| 23 | | (3) Insofar as this Section applies solely to licensed | 24 | | clinical social
workers, licensed clinical professional | 25 | | counselors, licensed marriage and family therapists, licensed | 26 | | speech-language pathologists, and other licensed or certified |
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| 1 | | professionals at programs licensed pursuant to the Illinois | 2 | | Alcoholism and Other Drug Abuse and Dependency Act, those | 3 | | persons who may
provide services to individuals shall do so
| 4 | | after the licensed clinical social worker, licensed clinical | 5 | | professional
counselor, licensed marriage and family | 6 | | therapist, licensed speech-language pathologist, or other | 7 | | licensed or certified professional at a program licensed | 8 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 9 | | Dependency Act has informed the patient of the
desirability of | 10 | | the patient conferring with the patient's primary care
| 11 | | physician and the licensed clinical social worker, licensed | 12 | | clinical
professional counselor, licensed marriage and family | 13 | | therapist, licensed speech-language pathologist, or other | 14 | | licensed or certified professional at a program licensed | 15 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 16 | | Dependency Act has
provided written
notification to the | 17 | | patient's primary care physician, if any, that services
are | 18 | | being provided to the patient. That notification may, however, | 19 | | be
waived by the patient on a written form. Those forms shall | 20 | | be retained by
the licensed clinical social worker, licensed | 21 | | clinical professional counselor, licensed marriage and family | 22 | | therapist, licensed speech-language pathologist, or other | 23 | | licensed or certified professional at a program licensed | 24 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 25 | | Dependency Act
for a period of not less than 5 years.
| 26 | | (b) (1) An insurer that provides coverage for hospital or |
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| 1 | | medical
expenses under a group policy of accident and health | 2 | | insurance or
health care plan amended, delivered, issued, or | 3 | | renewed on or after the effective
date of this amendatory Act | 4 | | of the 97th General Assembly shall provide coverage
under the | 5 | | policy for treatment of serious mental illness and substance | 6 | | use disorders consistent with the parity requirements of | 7 | | Section 370c.1 of this Code. This subsection does not apply to | 8 | | any group policy of accident and health insurance or health | 9 | | care plan for any plan year of a small employer as defined in | 10 | | Section 5 of the Illinois Health Insurance Portability and | 11 | | Accountability Act.
| 12 | | (1.5) On and after the effective date of this amendatory | 13 | | Act of the 99th General Assembly, every insurer that amends, | 14 | | delivers, issues, or renews a group or individual policy of | 15 | | accident and health insurance, a managed care plan, or a | 16 | | qualified health plan offered for sale through the health | 17 | | insurance marketplace in this State providing coverage for | 18 | | hospital or medical treatment shall provide coverage based upon | 19 | | medical necessity for the treatment of eating disorders | 20 | | consistent with the parity requirements of Section 370c.1 of | 21 | | this Code. | 22 | | For the purposes of this item (1.5), "eating disorder" | 23 | | includes, but is not limited to, anorexia nervosa, bulimia | 24 | | nervosa, pica, rumination disorder, advoidant/restrictive food | 25 | | intake disorder, other specified feeding or eating disorder | 26 | | (OSFED), and any other eating disorder contained in the most |
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| 1 | | recent version of the Diagnostic and Statistical Manual of | 2 | | Mental Disorders published by the American Psychiatric | 3 | | Association. | 4 | | (2) "Serious mental illness" means the following | 5 | | psychiatric illnesses as
defined in the most current edition of | 6 | | the Diagnostic and Statistical Manual
(DSM) published by the | 7 | | American Psychiatric Association:
| 8 | | (A) schizophrenia;
| 9 | | (B) paranoid and other psychotic disorders;
| 10 | | (C) bipolar disorders (hypomanic, manic, depressive, | 11 | | and mixed);
| 12 | | (D) major depressive disorders (single episode or | 13 | | recurrent);
| 14 | | (E) schizoaffective disorders (bipolar or depressive);
| 15 | | (F) pervasive developmental disorders;
| 16 | | (G) obsessive-compulsive disorders;
| 17 | | (H) depression in childhood and adolescence;
| 18 | | (I) panic disorder; | 19 | | (J) post-traumatic stress disorders (acute, chronic, | 20 | | or with delayed onset); and
| 21 | | (K) anorexia nervosa and bulimia nervosa. | 22 | | (2.5) "Substance use disorder" means the following mental | 23 | | disorders as defined in the most current edition of the | 24 | | Diagnostic and Statistical Manual (DSM) published by the | 25 | | American Psychiatric Association: | 26 | | (A) substance abuse disorders; |
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| 1 | | (B) substance dependence disorders; and | 2 | | (C) substance induced disorders. | 3 | | (3) Unless otherwise prohibited by federal law and | 4 | | consistent with the parity requirements of Section 370c.1 of | 5 | | this Code, the reimbursing insurer, a provider of treatment of
| 6 | | serious mental illness or substance use disorder shall furnish | 7 | | medical records or other necessary data
that substantiate that | 8 | | initial or continued treatment is at all times medically
| 9 | | necessary. An insurer shall provide a mechanism for the timely | 10 | | review by a
provider holding the same license and practicing in | 11 | | the same specialty as the
patient's provider, who is | 12 | | unaffiliated with the insurer, jointly selected by
the patient | 13 | | (or the patient's next of kin or legal representative if the
| 14 | | patient is unable to act for himself or herself), the patient's | 15 | | provider, and
the insurer in the event of a dispute between the | 16 | | insurer and patient's
provider regarding the medical necessity | 17 | | of a treatment proposed by a patient's
provider. If the | 18 | | reviewing provider determines the treatment to be medically
| 19 | | necessary, the insurer shall provide reimbursement for the | 20 | | treatment. Future
contractual or employment actions by the | 21 | | insurer regarding the patient's
provider may not be based on | 22 | | the provider's participation in this procedure.
Nothing | 23 | | prevents
the insured from agreeing in writing to continue | 24 | | treatment at his or her
expense. When making a determination of | 25 | | the medical necessity for a treatment
modality for serious | 26 | | mental illness or substance use disorder, an insurer must make |
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| 1 | | the determination in a
manner that is consistent with the | 2 | | manner used to make that determination with
respect to other | 3 | | diseases or illnesses covered under the policy, including an
| 4 | | appeals process. Medical necessity determinations for | 5 | | substance use disorders shall be made in accordance with | 6 | | appropriate patient placement criteria established by the | 7 | | American Society of Addiction Medicine. No additional criteria | 8 | | may be used to make medical necessity determinations for | 9 | | substance use disorders.
| 10 | | (4) A group health benefit plan amended, delivered, issued, | 11 | | or renewed on or after the effective date of this amendatory | 12 | | Act of the 97th General Assembly:
| 13 | | (A) shall provide coverage based upon medical | 14 | | necessity for the
treatment of mental illness and substance | 15 | | use disorders consistent with the parity requirements of | 16 | | Section 370c.1 of this Code; provided, however, that in | 17 | | each calendar year coverage shall not be less than the | 18 | | following:
| 19 | | (i) 45 days of inpatient treatment; and
| 20 | | (ii) beginning on June 26, 2006 (the effective date | 21 | | of Public Act 94-921), 60 visits for outpatient | 22 | | treatment including group and individual
outpatient | 23 | | treatment; and | 24 | | (iii) for plans or policies delivered, issued for | 25 | | delivery, renewed, or modified after January 1, 2007 | 26 | | (the effective date of Public Act 94-906),
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| 1 | | additional outpatient visits for speech therapy for | 2 | | treatment of pervasive developmental disorders that | 3 | | will be in addition to speech therapy provided pursuant | 4 | | to item (ii) of this subparagraph (A); and
| 5 | | (B) may not include a lifetime limit on the number of | 6 | | days of inpatient
treatment or the number of outpatient | 7 | | visits covered under the plan.
| 8 | | (C) (Blank).
| 9 | | (5) An issuer of a group health benefit plan may not count | 10 | | toward the number
of outpatient visits required to be covered | 11 | | under this Section an outpatient
visit for the purpose of | 12 | | medication management and shall cover the outpatient
visits | 13 | | under the same terms and conditions as it covers outpatient | 14 | | visits for
the treatment of physical illness.
| 15 | | (5.5) An individual or group health benefit plan amended, | 16 | | delivered, issued, or renewed on or after the effective date of | 17 | | this amendatory Act of the 99th General Assembly shall offer | 18 | | coverage for medically necessary acute treatment services and | 19 | | medically necessary clinical stabilization services. The | 20 | | treating provider shall base all treatment recommendations and | 21 | | the health benefit plan shall base all medical necessity | 22 | | determinations for substance use disorders in accordance with | 23 | | the most current edition of the American Society of Addiction | 24 | | Medicine Patient Placement Criteria. | 25 | | As used in this subsection: | 26 | | "Acute treatment services" means 24-hour medically |
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| 1 | | supervised addiction treatment that provides evaluation and | 2 | | withdrawal management and may include biopsychosocial | 3 | | assessment, individual and group counseling, psychoeducational | 4 | | groups, and discharge planning. | 5 | | "Clinical stabilization services" means 24-hour treatment, | 6 | | usually following acute treatment services for substance | 7 | | abuse, which may include intensive education and counseling | 8 | | regarding the nature of addiction and its consequences, relapse | 9 | | prevention, outreach to families and significant others, and | 10 | | aftercare planning for individuals beginning to engage in | 11 | | recovery from addiction. | 12 | | (6) An issuer of a group health benefit
plan may provide or | 13 | | offer coverage required under this Section through a
managed | 14 | | care plan.
| 15 | | (7) (Blank).
| 16 | | (8)
(Blank).
| 17 | | (9) With respect to substance use disorders, coverage for | 18 | | inpatient treatment shall include coverage for treatment in a | 19 | | residential treatment center licensed by the Department of | 20 | | Public Health or the Department of Human Services. | 21 | | (c) This Section shall not be interpreted to require | 22 | | coverage for speech therapy or other habilitative services for | 23 | | those individuals covered under Section 356z.15
of this Code. | 24 | | (d) The Department shall enforce the requirements of State | 25 | | and federal parity law, which includes ensuring compliance by | 26 | | individual and group policies; detecting violations of the law |
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| 1 | | by individual and group policies proactively monitoring | 2 | | discriminatory practices; accepting, evaluating, and | 3 | | responding to complaints regarding such violations; and | 4 | | ensuring violations are appropriately remedied and deterred. | 5 | | (e) Availability of plan information. | 6 | | (1) The criteria for medical necessity determinations | 7 | | made under a group health plan with respect to mental | 8 | | health or substance use disorder benefits (or health | 9 | | insurance coverage offered in connection with the plan with | 10 | | respect to such benefits) must be made available by the | 11 | | plan administrator (or the health insurance issuer | 12 | | offering such coverage) to any current or potential | 13 | | participant, beneficiary, or contracting provider upon | 14 | | request. | 15 | | (2) The reason for any denial under a group health plan | 16 | | (or health insurance coverage offered in connection with | 17 | | such plan) of reimbursement or payment for services with | 18 | | respect to mental health or substance use disorder benefits | 19 | | in the case of any participant or beneficiary must be made | 20 | | available within a reasonable time and in a reasonable | 21 | | manner by the plan administrator (or the health insurance | 22 | | issuer offering such coverage) to the participant or | 23 | | beneficiary upon request. | 24 | | (f) As used in this Section, "group policy of accident and | 25 | | health insurance" and "group health benefit plan" includes (1) | 26 | | State-regulated employer-sponsored group health insurance |
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| 1 | | plans written in Illinois and (2) State employee health plans. | 2 | | (Source: P.A. 99-480, eff. 9-9-15.)
| 3 | | Section 99. Effective date. This Act takes effect upon | 4 | | becoming law.
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