Full Text of HB1332 100th General Assembly
HB1332ham001 100TH GENERAL ASSEMBLY | Rep. Laura Fine Filed: 3/16/2017
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| 1 | | AMENDMENT TO HOUSE BILL 1332
| 2 | | AMENDMENT NO. ______. Amend House Bill 1332 by replacing | 3 | | everything after the enacting clause with the following:
| 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 |
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| 1 | | illnesses as defined in item (2) of subsection (b), consistent | 2 | | with the parity requirements of Section 370c.1 of this Code.
| 3 | | (2) Each insured that is covered for mental, emotional, | 4 | | nervous, or substance use
disorders or conditions shall be free | 5 | | to select the physician licensed to
practice medicine in all | 6 | | its branches, licensed clinical psychologist,
licensed | 7 | | clinical social worker, licensed clinical professional | 8 | | counselor, licensed marriage and family therapist, licensed | 9 | | speech-language pathologist, or other licensed or certified | 10 | | professional at a program licensed pursuant to the Illinois | 11 | | Alcoholism and Other Drug Abuse and Dependency Act of
his | 12 | | choice to treat such disorders, and
the insurer shall pay the | 13 | | covered charges of such physician licensed to
practice medicine | 14 | | in all its branches, licensed clinical psychologist,
licensed | 15 | | clinical social worker, licensed clinical professional | 16 | | counselor, licensed marriage and family therapist, licensed | 17 | | speech-language pathologist, or other licensed or certified | 18 | | professional at a program licensed pursuant to the Illinois | 19 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the | 20 | | limits of coverage, provided (i)
the disorder or condition | 21 | | treated is covered by the policy, and (ii) the
physician, | 22 | | licensed psychologist, licensed clinical social worker, | 23 | | licensed
clinical professional counselor, licensed marriage | 24 | | and family therapist, licensed speech-language pathologist, or | 25 | | other licensed or certified professional at a program licensed | 26 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and |
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| 1 | | Dependency Act is
authorized to provide said services under the | 2 | | statutes of this State and in
accordance with accepted | 3 | | principles of his profession.
| 4 | | (3) Insofar as this Section applies solely to licensed | 5 | | clinical social
workers, licensed clinical professional | 6 | | counselors, licensed marriage and family therapists, licensed | 7 | | speech-language pathologists, and other licensed or certified | 8 | | professionals at programs licensed pursuant to the Illinois | 9 | | Alcoholism and Other Drug Abuse and Dependency Act, those | 10 | | persons who may
provide services to individuals shall do so
| 11 | | after the licensed clinical social worker, licensed clinical | 12 | | 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 informed the patient of the
desirability of | 17 | | the patient conferring with the patient's primary care
| 18 | | physician and the licensed clinical social worker, licensed | 19 | | clinical
professional counselor, licensed marriage and family | 20 | | therapist, licensed speech-language pathologist, or other | 21 | | licensed or certified professional at a program licensed | 22 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 23 | | Dependency Act has
provided written
notification to the | 24 | | patient's primary care physician, if any, that services
are | 25 | | being provided to the patient. That notification may, however, | 26 | | be
waived by the patient on a written form. Those forms shall |
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| 1 | | be retained by
the licensed clinical social worker, licensed | 2 | | clinical professional counselor, licensed marriage and family | 3 | | therapist, licensed speech-language pathologist, or other | 4 | | licensed or certified professional at a program licensed | 5 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 6 | | Dependency Act
for a period of not less than 5 years.
| 7 | | (b) (1) An insurer that provides coverage for hospital or | 8 | | medical
expenses under a group policy of accident and health | 9 | | insurance or
health care plan amended, delivered, issued, or | 10 | | renewed on or after the effective
date of this amendatory Act | 11 | | of the 97th General Assembly shall provide coverage
under the | 12 | | policy for treatment of serious mental illness and substance | 13 | | use disorders consistent with the parity requirements of | 14 | | Section 370c.1 of this Code. This subsection does not apply to | 15 | | any group policy of accident and health insurance or health | 16 | | care plan for any plan year of a small employer as defined in | 17 | | Section 5 of the Illinois Health Insurance Portability and | 18 | | Accountability Act.
| 19 | | (1.5) On and after the effective date of this amendatory | 20 | | Act of the 100th General Assembly, every insurer that amends, | 21 | | delivers, issues, or renews a group or individual policy of | 22 | | accident and health insurance, a managed care plan, or a | 23 | | qualified health plan offered for sale through the health | 24 | | insurance marketplace in this State providing coverage for | 25 | | hospital or medical treatment shall provide coverage based upon | 26 | | medical necessity for the treatment of eating disorders |
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| 1 | | consistent with the parity requirements of Section 370c.1 of | 2 | | this Code. | 3 | | For the purposes of this item (1.5), "eating disorder" | 4 | | includes, but is not limited to, anorexia nervosa, bulimia | 5 | | nervosa, pica, rumination disorder, avoidant/restrictive food | 6 | | intake disorder, other specified feeding or eating disorder | 7 | | (OSFED), and any other eating disorder contained in the most | 8 | | recent version of the Diagnostic and Statistical Manual of | 9 | | Mental Disorders published by the American Psychiatric | 10 | | Association. | 11 | | (2) "Serious mental illness" means the following | 12 | | psychiatric illnesses as
defined in the most current edition of | 13 | | the Diagnostic and Statistical Manual
(DSM) published by the | 14 | | American Psychiatric Association:
| 15 | | (A) schizophrenia;
| 16 | | (B) paranoid and other psychotic disorders;
| 17 | | (C) bipolar disorders (hypomanic, manic, depressive, | 18 | | and mixed);
| 19 | | (D) major depressive disorders (single episode or | 20 | | recurrent);
| 21 | | (E) schizoaffective disorders (bipolar or depressive);
| 22 | | (F) pervasive developmental disorders;
| 23 | | (G) obsessive-compulsive disorders;
| 24 | | (H) depression in childhood and adolescence;
| 25 | | (I) panic disorder; | 26 | | (J) post-traumatic stress disorders (acute, chronic, |
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| 1 | | or with delayed onset); and
| 2 | | (K) anorexia nervosa and bulimia nervosa. | 3 | | (2.5) "Substance use disorder" means the following mental | 4 | | disorders as defined in the most current edition of the | 5 | | Diagnostic and Statistical Manual (DSM) published by the | 6 | | American Psychiatric Association: | 7 | | (A) substance abuse disorders; | 8 | | (B) substance dependence disorders; and | 9 | | (C) substance induced disorders. | 10 | | (3) Unless otherwise prohibited by federal law and | 11 | | consistent with the parity requirements of Section 370c.1 of | 12 | | this Code, the reimbursing insurer, a provider of treatment of
| 13 | | serious mental illness or substance use disorder shall furnish | 14 | | medical records or other necessary data
that substantiate that | 15 | | initial or continued treatment is at all times medically
| 16 | | necessary. An insurer shall provide a mechanism for the timely | 17 | | review by a
provider holding the same license and practicing in | 18 | | the same specialty as the
patient's provider, who is | 19 | | unaffiliated with the insurer, jointly selected by
the patient | 20 | | (or the patient's next of kin or legal representative if the
| 21 | | patient is unable to act for himself or herself), the patient's | 22 | | provider, and
the insurer in the event of a dispute between the | 23 | | insurer and patient's
provider regarding the medical necessity | 24 | | of a treatment proposed by a patient's
provider. If the | 25 | | reviewing provider determines the treatment to be medically
| 26 | | necessary, the insurer shall provide reimbursement for the |
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| 1 | | treatment. Future
contractual or employment actions by the | 2 | | insurer regarding the patient's
provider may not be based on | 3 | | the provider's participation in this procedure.
Nothing | 4 | | prevents
the insured from agreeing in writing to continue | 5 | | treatment at his or her
expense. When making a determination of | 6 | | the medical necessity for a treatment
modality for serious | 7 | | mental illness or substance use disorder, an insurer must make | 8 | | the determination in a
manner that is consistent with the | 9 | | manner used to make that determination with
respect to other | 10 | | diseases or illnesses covered under the policy, including an
| 11 | | appeals process. Medical necessity determinations for | 12 | | substance use disorders shall be made in accordance with | 13 | | appropriate patient placement criteria established by the | 14 | | American Society of Addiction Medicine. No additional criteria | 15 | | may be used to make medical necessity determinations for | 16 | | substance use disorders.
| 17 | | (4) A group health benefit plan amended, delivered, issued, | 18 | | or renewed on or after the effective date of this amendatory | 19 | | Act of the 97th General Assembly:
| 20 | | (A) shall provide coverage based upon medical | 21 | | necessity for the
treatment of mental illness and substance | 22 | | use disorders consistent with the parity requirements of | 23 | | Section 370c.1 of this Code; provided, however, that in | 24 | | each calendar year coverage shall not be less than the | 25 | | following:
| 26 | | (i) 45 days of inpatient treatment; and
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| 1 | | (ii) beginning on June 26, 2006 (the effective date | 2 | | of Public Act 94-921), 60 visits for outpatient | 3 | | treatment including group and individual
outpatient | 4 | | treatment; and | 5 | | (iii) for plans or policies delivered, issued for | 6 | | delivery, renewed, or modified after January 1, 2007 | 7 | | (the effective date of Public Act 94-906),
20 | 8 | | additional outpatient visits for speech therapy for | 9 | | treatment of pervasive developmental disorders that | 10 | | will be in addition to speech therapy provided pursuant | 11 | | to item (ii) of this subparagraph (A); and
| 12 | | (B) may not include a lifetime limit on the number of | 13 | | days of inpatient
treatment or the number of outpatient | 14 | | visits covered under the plan.
| 15 | | (C) (Blank).
| 16 | | (5) An issuer of a group health benefit plan may not count | 17 | | toward the number
of outpatient visits required to be covered | 18 | | under this Section an outpatient
visit for the purpose of | 19 | | medication management and shall cover the outpatient
visits | 20 | | under the same terms and conditions as it covers outpatient | 21 | | visits for
the treatment of physical illness.
| 22 | | (5.5) An individual or group health benefit plan amended, | 23 | | delivered, issued, or renewed on or after the effective date of | 24 | | this amendatory Act of the 99th General Assembly shall offer | 25 | | coverage for medically necessary acute treatment services and | 26 | | medically necessary clinical stabilization services. The |
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| 1 | | treating provider shall base all treatment recommendations and | 2 | | the health benefit plan shall base all medical necessity | 3 | | determinations for substance use disorders in accordance with | 4 | | the most current edition of the American Society of Addiction | 5 | | Medicine Patient Placement Criteria. | 6 | | As used in this subsection: | 7 | | "Acute treatment services" means 24-hour medically | 8 | | supervised addiction treatment that provides evaluation and | 9 | | withdrawal management and may include biopsychosocial | 10 | | assessment, individual and group counseling, psychoeducational | 11 | | groups, and discharge planning. | 12 | | "Clinical stabilization services" means 24-hour treatment, | 13 | | usually following acute treatment services for substance | 14 | | abuse, which may include intensive education and counseling | 15 | | regarding the nature of addiction and its consequences, relapse | 16 | | prevention, outreach to families and significant others, and | 17 | | aftercare planning for individuals beginning to engage in | 18 | | recovery from addiction. | 19 | | (6) An issuer of a group health benefit
plan may provide or | 20 | | offer coverage required under this Section through a
managed | 21 | | care plan.
| 22 | | (7) (Blank).
| 23 | | (8)
(Blank).
| 24 | | (9) With respect to substance use disorders, coverage for | 25 | | inpatient treatment shall include coverage for treatment in a | 26 | | residential treatment center licensed by the Department of |
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| 1 | | Public Health or the Department of Human Services. | 2 | | (c) This Section shall not be interpreted to require | 3 | | coverage for speech therapy or other habilitative services for | 4 | | those individuals covered under Section 356z.15
of this Code. | 5 | | (d) The Department shall enforce the requirements of State | 6 | | and federal parity law, which includes ensuring compliance by | 7 | | individual and group policies; detecting violations of the law | 8 | | by individual and group policies proactively monitoring | 9 | | discriminatory practices; accepting, evaluating, and | 10 | | responding to complaints regarding such violations; and | 11 | | ensuring violations are appropriately remedied and deterred. | 12 | | (e) Availability of plan information. | 13 | | (1) The criteria for medical necessity determinations | 14 | | made under a group health plan with respect to mental | 15 | | health or substance use disorder benefits (or health | 16 | | insurance coverage offered in connection with the plan with | 17 | | respect to such benefits) must be made available by the | 18 | | plan administrator (or the health insurance issuer | 19 | | offering such coverage) to any current or potential | 20 | | participant, beneficiary, or contracting provider upon | 21 | | request. | 22 | | (2) The reason for any denial under a group health plan | 23 | | (or health insurance coverage offered in connection with | 24 | | such plan) of reimbursement or payment for services with | 25 | | respect to mental health or substance use disorder benefits | 26 | | in the case of any participant or beneficiary must be made |
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| 1 | | available within a reasonable time and in a reasonable | 2 | | manner by the plan administrator (or the health insurance | 3 | | issuer offering such coverage) to the participant or | 4 | | beneficiary upon request. | 5 | | (f) As used in this Section, "group policy of accident and | 6 | | health insurance" and "group health benefit plan" includes (1) | 7 | | State-regulated employer-sponsored group health insurance | 8 | | plans written in Illinois and (2) State employee health plans. | 9 | | (Source: P.A. 99-480, eff. 9-9-15.)
| 10 | | Section 99. Effective date. This Act takes effect upon | 11 | | becoming law.".
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