Full Text of HB1332 100th General Assembly
HB1332enr 100TH GENERAL ASSEMBLY |
| | HB1332 Enrolled | | LRB100 03040 RPS 13045 b |
|
| 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 |
| | | HB1332 Enrolled | - 2 - | LRB100 03040 RPS 13045 b |
|
| 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 |
| | | HB1332 Enrolled | - 3 - | LRB100 03040 RPS 13045 b |
|
| 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 |
| | | HB1332 Enrolled | - 4 - | LRB100 03040 RPS 13045 b |
|
| 1 | | medical
expenses under a group or individual policy of accident | 2 | | and health insurance or
health care plan amended, delivered, | 3 | | issued, or renewed on or after the effective
date of this | 4 | | amendatory Act of the 100th General Assembly this amendatory | 5 | | Act of the 97th General Assembly shall provide coverage
under | 6 | | the policy for treatment of serious mental illness and | 7 | | substance use disorders consistent with the parity | 8 | | requirements of Section 370c.1 of this Code. This subsection | 9 | | does not apply to any group policy of accident and health | 10 | | insurance or health care plan for any plan year of a small | 11 | | employer as defined in Section 5 of the Illinois Health | 12 | | Insurance Portability and Accountability Act.
| 13 | | (2) "Serious mental illness" means the following | 14 | | psychiatric illnesses as
defined in the most current edition of | 15 | | the Diagnostic and Statistical Manual
(DSM) published by the | 16 | | American Psychiatric Association:
| 17 | | (A) schizophrenia;
| 18 | | (B) paranoid and other psychotic disorders;
| 19 | | (C) bipolar disorders (hypomanic, manic, depressive, | 20 | | and mixed);
| 21 | | (D) major depressive disorders (single episode or | 22 | | recurrent);
| 23 | | (E) schizoaffective disorders (bipolar or depressive);
| 24 | | (F) pervasive developmental disorders;
| 25 | | (G) obsessive-compulsive disorders;
| 26 | | (H) depression in childhood and adolescence;
|
| | | HB1332 Enrolled | - 5 - | LRB100 03040 RPS 13045 b |
|
| 1 | | (I) panic disorder; | 2 | | (J) post-traumatic stress disorders (acute, chronic, | 3 | | or with delayed onset); and
| 4 | | (K) eating disorders, including, but not limited to, | 5 | | anorexia nervosa , and bulimia nervosa , pica, rumination | 6 | | disorder, avoidant/restrictive food intake disorder, other | 7 | | specified feeding or eating disorder (OSFED), and any other | 8 | | eating disorder contained in the most recent version of the | 9 | | Diagnostic and Statistical Manual of Mental Disorders | 10 | | published by the American Psychiatric Association . | 11 | | (2.5) "Substance use disorder" means the following mental | 12 | | disorders as defined in the most current edition of the | 13 | | Diagnostic and Statistical Manual (DSM) published by the | 14 | | American Psychiatric Association: | 15 | | (A) substance abuse disorders; | 16 | | (B) substance dependence disorders; and | 17 | | (C) substance induced disorders. | 18 | | (3) Unless otherwise prohibited by federal law and | 19 | | consistent with the parity requirements of Section 370c.1 of | 20 | | this Code, the reimbursing insurer, a provider of treatment of
| 21 | | serious mental illness or substance use disorder shall furnish | 22 | | medical records or other necessary data
that substantiate that | 23 | | initial or continued treatment is at all times medically
| 24 | | necessary. An insurer shall provide a mechanism for the timely | 25 | | review by a
provider holding the same license and practicing in | 26 | | the same specialty as the
patient's provider, who is |
| | | HB1332 Enrolled | - 6 - | LRB100 03040 RPS 13045 b |
|
| 1 | | unaffiliated with the insurer, jointly selected by
the patient | 2 | | (or the patient's next of kin or legal representative if the
| 3 | | patient is unable to act for himself or herself), the patient's | 4 | | provider, and
the insurer in the event of a dispute between the | 5 | | insurer and patient's
provider regarding the medical necessity | 6 | | of a treatment proposed by a patient's
provider. If the | 7 | | reviewing provider determines the treatment to be medically
| 8 | | necessary, the insurer shall provide reimbursement for the | 9 | | treatment. Future
contractual or employment actions by the | 10 | | insurer regarding the patient's
provider may not be based on | 11 | | the provider's participation in this procedure.
Nothing | 12 | | prevents
the insured from agreeing in writing to continue | 13 | | treatment at his or her
expense. When making a determination of | 14 | | the medical necessity for a treatment
modality for serious | 15 | | mental illness or substance use disorder, an insurer must make | 16 | | the determination in a
manner that is consistent with the | 17 | | manner used to make that determination with
respect to other | 18 | | diseases or illnesses covered under the policy, including an
| 19 | | appeals process. Medical necessity determinations for | 20 | | substance use disorders shall be made in accordance with | 21 | | appropriate patient placement criteria established by the | 22 | | American Society of Addiction Medicine. No additional criteria | 23 | | may be used to make medical necessity determinations for | 24 | | substance use disorders.
| 25 | | (4) A group health benefit plan amended, delivered, issued, | 26 | | or renewed on or after the effective date of this amendatory |
| | | HB1332 Enrolled | - 7 - | LRB100 03040 RPS 13045 b |
|
| 1 | | Act of the 97th General Assembly:
| 2 | | (A) shall provide coverage based upon medical | 3 | | necessity for the
treatment of mental illness and substance | 4 | | use disorders consistent with the parity requirements of | 5 | | Section 370c.1 of this Code; provided, however, that in | 6 | | each calendar year coverage shall not be less than the | 7 | | following:
| 8 | | (i) 45 days of inpatient treatment; and
| 9 | | (ii) beginning on June 26, 2006 (the effective date | 10 | | of Public Act 94-921), 60 visits for outpatient | 11 | | treatment including group and individual
outpatient | 12 | | treatment; and | 13 | | (iii) for plans or policies delivered, issued for | 14 | | delivery, renewed, or modified after January 1, 2007 | 15 | | (the effective date of Public Act 94-906),
20 | 16 | | additional outpatient visits for speech therapy for | 17 | | treatment of pervasive developmental disorders that | 18 | | will be in addition to speech therapy provided pursuant | 19 | | to item (ii) of this subparagraph (A); and
| 20 | | (B) may not include a lifetime limit on the number of | 21 | | days of inpatient
treatment or the number of outpatient | 22 | | visits covered under the plan.
| 23 | | (C) (Blank).
| 24 | | (5) An issuer of a group health benefit plan may not count | 25 | | toward the number
of outpatient visits required to be covered | 26 | | under this Section an outpatient
visit for the purpose of |
| | | HB1332 Enrolled | - 8 - | LRB100 03040 RPS 13045 b |
|
| 1 | | medication management and shall cover the outpatient
visits | 2 | | under the same terms and conditions as it covers outpatient | 3 | | visits for
the treatment of physical illness.
| 4 | | (5.5) An individual or group health benefit plan amended, | 5 | | delivered, issued, or renewed on or after the effective date of | 6 | | this amendatory Act of the 99th General Assembly shall offer | 7 | | coverage for medically necessary acute treatment services and | 8 | | medically necessary clinical stabilization services. The | 9 | | treating provider shall base all treatment recommendations and | 10 | | the health benefit plan shall base all medical necessity | 11 | | determinations for substance use disorders in accordance with | 12 | | the most current edition of the American Society of Addiction | 13 | | Medicine Patient Placement Criteria. | 14 | | As used in this subsection: | 15 | | "Acute treatment services" means 24-hour medically | 16 | | supervised addiction treatment that provides evaluation and | 17 | | withdrawal management and may include biopsychosocial | 18 | | assessment, individual and group counseling, psychoeducational | 19 | | groups, and discharge planning. | 20 | | "Clinical stabilization services" means 24-hour treatment, | 21 | | usually following acute treatment services for substance | 22 | | abuse, which may include intensive education and counseling | 23 | | regarding the nature of addiction and its consequences, relapse | 24 | | prevention, outreach to families and significant others, and | 25 | | aftercare planning for individuals beginning to engage in | 26 | | recovery from addiction. |
| | | HB1332 Enrolled | - 9 - | LRB100 03040 RPS 13045 b |
|
| 1 | | (6) An issuer of a group health benefit
plan may provide or | 2 | | offer coverage required under this Section through a
managed | 3 | | care plan.
| 4 | | (7) (Blank).
| 5 | | (8)
(Blank).
| 6 | | (9) With respect to substance use disorders, coverage for | 7 | | inpatient treatment shall include coverage for treatment in a | 8 | | residential treatment center licensed by the Department of | 9 | | Public Health or the Department of Human Services. | 10 | | (c) This Section shall not be interpreted to require | 11 | | coverage for speech therapy or other habilitative services for | 12 | | those individuals covered under Section 356z.15
of this Code. | 13 | | (d) The Department shall enforce the requirements of State | 14 | | and federal parity law, which includes ensuring compliance by | 15 | | individual and group policies; detecting violations of the law | 16 | | by individual and group policies proactively monitoring | 17 | | discriminatory practices; accepting, evaluating, and | 18 | | responding to complaints regarding such violations; and | 19 | | ensuring violations are appropriately remedied and deterred. | 20 | | (e) Availability of plan information. | 21 | | (1) The criteria for medical necessity determinations | 22 | | made under a group health plan with respect to mental | 23 | | health or substance use disorder benefits (or health | 24 | | insurance coverage offered in connection with the plan with | 25 | | respect to such benefits) must be made available by the | 26 | | plan administrator (or the health insurance issuer |
| | | HB1332 Enrolled | - 10 - | LRB100 03040 RPS 13045 b |
|
| 1 | | offering such coverage) to any current or potential | 2 | | participant, beneficiary, or contracting provider upon | 3 | | request. | 4 | | (2) The reason for any denial under a group health plan | 5 | | (or health insurance coverage offered in connection with | 6 | | such plan) of reimbursement or payment for services with | 7 | | respect to mental health or substance use disorder benefits | 8 | | in the case of any participant or beneficiary must be made | 9 | | available within a reasonable time and in a reasonable | 10 | | manner by the plan administrator (or the health insurance | 11 | | issuer offering such coverage) to the participant or | 12 | | beneficiary upon request. | 13 | | (f) As used in this Section, "group policy of accident and | 14 | | health insurance" and "group health benefit plan" includes (1) | 15 | | State-regulated employer-sponsored group health insurance | 16 | | plans written in Illinois and (2) State employee health plans. | 17 | | (Source: P.A. 99-480, eff. 9-9-15.)
| 18 | | Section 99. Effective date. This Act takes effect upon | 19 | | becoming law.
|
|