093_HB1493

 
                                     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  or  individual  accident  and  health  A&H
11    policies providing coverage for hospital or medical treatment
12    or  services  for  illness  on  an  expense-incurred basis or
13    through a health  maintenance  organization,  as  defined  in
14    Section  1-2 of the Health Maintenance Organization Act shall
15    offer to the applicant or group policyholder subject  to  the
16    insurers  standards  of insurability, coverage for reasonable
17    and necessary treatment and services for mental, emotional or
18    nervous disorders or conditions, other  than  serious  mental
19    illnesses as defined in item (2) of subsection (b), up to the
20    limits   provided  in  the  policy  for  other  disorders  or
21    conditions, except (i) the insured may be required to pay  up
22    to  50%  of expenses incurred as a result of the treatment or
23    services, and (ii) the annual benefit limit may be limited to
24    the lesser of $10,000 or 25% 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 or individual policy of
27    accident and health insurance, through a  health  maintenance
28    organization,  as  defined  in  Section  1-2  of  the  Health
29    Maintenance  Organization  Act,  or health care plan amended,
30    delivered, issued, or renewed after  the  effective  date  of
31    this  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);
26             (K)  bullemia nervosa (purging or nonpurging); and
27             (L)  post-traumatic stress disorder (acute, chronic,
28        or with delayed onset).
29        (3)  Upon  request of the reimbursing insurer, a provider
30    of treatment of serious mental illness shall furnish  medical
31    records  or  other  necessary  data  that  substantiate  that
32    initial  or  continued  treatment  is  at all times medically
33    necessary.  An insurer shall  provide  a  mechanism  for  the
34    timely  review  by  a  provider  holding the same license and
 
                            -4-      LRB093 07907 JLS 08098 b
 1    practicing in the same specialty as the  patient's  provider,
 2    who is unaffiliated with the insurer, jointly selected by the
 3    patient (or the patient's next of kin or legal representative
 4    if  the patient is unable to act for himself or herself), the
 5    patient's provider, and the insurer in the event of a dispute
 6    between the insurer  and  patient's  provider  regarding  the
 7    medical  necessity  of  a  treatment  proposed by a patient's
 8    provider.  If the reviewing provider determines the treatment
 9    to  be  medically  necessary,  the  insurer   shall   provide
10    reimbursement  for  the  treatment.   Future  contractual  or
11    employment  actions  by  the  insurer regarding the patient's
12    provider may not be based on the provider's participation  in
13    this procedure. Nothing prevents the insured from agreeing in
14    writing  to  continue  treatment at his or her expense.  When
15    making  a  determination  of  the  medical  necessity  for  a
16    treatment modality for serous mental illness, an insurer must
17    make the determination in a manner that  is  consistent  with
18    the  manner  used  to make that determination with respect to
19    other  diseases  or  illnesses  covered  under  the   policy,
20    including an appeals process.
21        (4)  A group health benefit plan:
22             (A)  shall   provide  coverage  based  upon  medical
23        necessity for the following treatment of  mental  illness
24        in each calendar year;
25                  (i)  45 days of inpatient treatment; and
26                  (ii)  60  35  visits  for  outpatient treatment
27             including group and individual outpatient treatment;
28             (B)  may not include a lifetime limit on the  number
29        of   days   of  inpatient  treatment  or  the  number  of
30        outpatient visits covered under the plan; and
31             (C)  shall   include   the   same   amount   limits,
32        deductibles,  copayments,  and  coinsurance  factors  for
33        serious mental illness as for physical illness.
34        (5)  An issuer of a group health  benefit  plan  may  not
 
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 1    count  toward  the number of outpatient visits required to be
 2    covered under  this  Section  an  outpatient  visit  for  the
 3    purpose   of   medication  management  and  shall  cover  the
 4    outpatient visits under the same terms and conditions  as  it
 5    covers  outpatient  visits  for  the  treatment  of  physical
 6    illness.
 7        (6)  An issuer of a group health benefit plan may provide
 8    or  offer  coverage  required  under  this  Section through a
 9    managed care plan.
10        (7)  This Section shall not be interpreted to  require  a
11    group  health  benefit plan to provide coverage for treatment
12    of:
13             (A)  an  addiction  to  a  controlled  substance  or
14        cannabis that is used in violation of law; or
15             (B)  mental illness resulting  from  the  use  of  a
16        controlled substance or cannabis in violation of law.
17        (8)  This  subsection  (b)  is inoperative after December
18    31, 2005.
19    (Source: P.A. 92-182,  eff.  7-27-01;  92-185,  eff.  1-1-02;
20    92-651, eff. 7-11-02.)

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

23        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
24        Sec. 5-3.  Insurance Code provisions.
25        (a)  Health Maintenance Organizations shall be subject to
26    the provisions of Sections 133, 134, 137, 140, 141.1,  141.2,
27    141.3,  143,  143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
28    154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v,  356w,  356x,
29    356y,  356z.2,  367i, 368a, 370c, 401, 401.1, 402, 403, 403A,
30    408, 408.2, 409,  412,  444,  and  444.1,  paragraph  (c)  of
31    subsection  (2)  of  Section 367, and Articles IIA, VIII 1/2,
32    XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of  the  Illinois
 
                            -6-      LRB093 07907 JLS 08098 b
 1    Insurance Code.
 2        (b)  For  purposes of the Illinois Insurance Code, except
 3    for Sections 444 and 444.1 and Articles XIII  and  XIII  1/2,
 4    Health  Maintenance Organizations in the following categories
 5    are deemed to be "domestic companies":
 6             (1)  a  corporation  authorized  under  the   Dental
 7        Service  Plan  Act or the Voluntary Health Services Plans
 8        Act;
 9             (2)  a corporation organized under the laws of  this
10        State; or
11             (3)  a  corporation  organized  under  the  laws  of
12        another  state, 30% or more of the enrollees of which are
13        residents of this State, except a corporation subject  to
14        substantially  the  same  requirements  in  its  state of
15        organization as is a  "domestic  company"  under  Article
16        VIII 1/2 of the Illinois Insurance Code.
17        (c)  In  considering  the merger, consolidation, or other
18    acquisition of control of a Health  Maintenance  Organization
19    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20             (1)  the  Director  shall give primary consideration
21        to the continuation of  benefits  to  enrollees  and  the
22        financial  conditions  of the acquired Health Maintenance
23        Organization after the merger,  consolidation,  or  other
24        acquisition of control takes effect;
25             (2)(i)  the  criteria specified in subsection (1)(b)
26        of Section 131.8 of the Illinois Insurance Code shall not
27        apply and (ii) the Director, in making his  determination
28        with  respect  to  the  merger,  consolidation,  or other
29        acquisition of control, need not take  into  account  the
30        effect  on  competition  of the merger, consolidation, or
31        other acquisition of control;
32             (3)  the Director shall have the  power  to  require
33        the following information:
34                  (A)  certification by an independent actuary of
 
                            -7-      LRB093 07907 JLS 08098 b
 1             the   adequacy   of   the  reserves  of  the  Health
 2             Maintenance Organization sought to be acquired;
 3                  (B)  pro forma financial statements  reflecting
 4             the combined balance sheets of the acquiring company
 5             and the Health Maintenance Organization sought to be
 6             acquired  as of the end of the preceding year and as
 7             of a date 90 days prior to the acquisition, as  well
 8             as   pro   forma   financial  statements  reflecting
 9             projected combined  operation  for  a  period  of  2
10             years;
11                  (C)  a  pro  forma  business  plan detailing an
12             acquiring  party's  plans  with   respect   to   the
13             operation  of  the  Health  Maintenance Organization
14             sought to be acquired for a period of not less  than
15             3 years; and
16                  (D)  such  other  information  as  the Director
17             shall require.
18        (d)  The provisions of Article VIII 1/2 of  the  Illinois
19    Insurance  Code  and this Section 5-3 shall apply to the sale
20    by any health maintenance organization of greater than 10% of
21    its enrollee population  (including  without  limitation  the
22    health  maintenance organization's right, title, and interest
23    in and to its health care certificates).
24        (e)  In considering any management  contract  or  service
25    agreement  subject to Section 141.1 of the Illinois Insurance
26    Code, the Director (i) shall, in  addition  to  the  criteria
27    specified  in  Section  141.2 of the Illinois Insurance Code,
28    take into account the effect of the  management  contract  or
29    service   agreement   on  the  continuation  of  benefits  to
30    enrollees  and  the  financial  condition   of   the   health
31    maintenance  organization to be managed or serviced, and (ii)
32    need not take into  account  the  effect  of  the  management
33    contract or service agreement on competition.
34        (f)  Except  for  small employer groups as defined in the
 
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 1    Small Employer Rating, Renewability  and  Portability  Health
 2    Insurance  Act and except for medicare supplement policies as
 3    defined in Section 363 of  the  Illinois  Insurance  Code,  a
 4    Health  Maintenance Organization may by contract agree with a
 5    group or other enrollment unit to effect  refunds  or  charge
 6    additional premiums under the following terms and conditions:
 7             (i)  the  amount  of, and other terms and conditions
 8        with respect to, the refund or additional premium are set
 9        forth in the group or enrollment unit contract agreed  in
10        advance of the period for which a refund is to be paid or
11        additional  premium  is to be charged (which period shall
12        not be less than one year); and
13             (ii)  the amount of the refund or additional premium
14        shall  not  exceed  20%   of   the   Health   Maintenance
15        Organization's profitable or unprofitable experience with
16        respect  to  the  group  or other enrollment unit for the
17        period (and, for  purposes  of  a  refund  or  additional
18        premium,  the profitable or unprofitable experience shall
19        be calculated taking into account a pro rata share of the
20        Health  Maintenance  Organization's  administrative   and
21        marketing  expenses,  but shall not include any refund to
22        be made or additional premium to be paid pursuant to this
23        subsection (f)).  The Health Maintenance Organization and
24        the  group  or  enrollment  unit  may  agree   that   the
25        profitable  or  unprofitable experience may be calculated
26        taking into account the refund period and the immediately
27        preceding 2 plan years.
28        The  Health  Maintenance  Organization  shall  include  a
29    statement in the evidence of coverage issued to each enrollee
30    describing the possibility of a refund or additional premium,
31    and upon request of any group or enrollment unit, provide  to
32    the group or enrollment unit a description of the method used
33    to   calculate  (1)  the  Health  Maintenance  Organization's
34    profitable experience with respect to the group or enrollment
 
                            -9-      LRB093 07907 JLS 08098 b
 1    unit and the resulting refund to the group or enrollment unit
 2    or (2) the  Health  Maintenance  Organization's  unprofitable
 3    experience  with  respect to the group or enrollment unit and
 4    the resulting additional premium to be paid by the  group  or
 5    enrollment unit.
 6        In   no  event  shall  the  Illinois  Health  Maintenance
 7    Organization  Guaranty  Association  be  liable  to  pay  any
 8    contractual obligation of an insolvent  organization  to  pay
 9    any refund authorized under this Section.
10    (Source: P.A.  91-357,  eff.  7-29-99;  91-406,  eff. 1-1-00;
11    91-549, eff. 8-14-99; 91-605,  eff.  12-14-99;  91-788,  eff.
12    6-9-00; 92-764, eff. 1-1-03.)

13        Section  99.  Effective date.  This Act takes effect upon
14    becoming law.