State of Illinois
92nd General Assembly
Legislation

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92_SB1673

 
                                               LRB9211353JSpc

 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
10    or   modifies  group  A&H  policies  providing  coverage  for
11    hospital or 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%
22    of the lifetime policy limit.
23        (2)  Each insured that is covered for  mental,  emotional
24    or  nervous  disorders  or conditions shall be free to select
25    the physician  licensed  to  practice  medicine  in  all  its
26    branches,  licensed  clinical psychologist, licensed clinical
27    social worker, or licensed clinical  professional  counselor,
28    or  licensed  marriage  and family therapist of his choice to
29    treat such disorders, and the insurer shall pay  the  covered
30    charges  of  such  physician licensed to practice medicine in
31    all its branches, licensed  clinical  psychologist,  licensed
 
                            -2-                LRB9211353JSpc
 1    clinical  social  worker,  or  licensed clinical professional
 2    counselor, or licensed marriage and family  therapist  up  to
 3    the   limits  of  coverage,  provided  (i)  the  disorder  or
 4    condition treated is covered by  the  policy,  and  (ii)  the
 5    physician,  licensed  psychologist,  licensed clinical social
 6    worker,  or  licensed  clinical  professional  counselor,  or
 7    licensed marriage  and  family  therapist  is  authorized  to
 8    provide said services under the statutes of this State and in
 9    accordance with accepted principles of his profession.
10        (3)  Insofar  as  this Section applies solely to licensed
11    clinical social workers, and licensed  clinical  professional
12    counselors,  and  licensed  marriage  and  family therapists,
13    those persons who may provide services to  individuals  shall
14    do  so after the licensed clinical social worker, or licensed
15    clinical professional counselor,  or  licensed  marriage  and
16    family therapist has informed the patient of the desirability
17    of  the  patient  conferring  with the patient's primary care
18    physician  and  the  licensed  clinical  social  worker,   or
19    licensed   clinical   professional   counselor,  or  licensed
20    marriage  and   family   therapist   has   provided   written
21    notification to the patient's primary care physician, if any,
22    that  services  are  being  provided  to  the  patient.  That
23    notification may, however, be waived  by  the  patient  on  a
24    written  form.  Those forms shall be retained by the licensed
25    clinical social worker,  or  licensed  clinical  professional
26    counselor,  or  licensed  marriage and family therapist for a
27    period of not less than 5 years.
28        (b) (1)  An insurer that provides coverage  for  hospital
29    or  medical  expenses  under  a  group policy of accident and
30    health insurance or  health  care  plan  amended,  delivered,
31    issued,   or   renewed  after  the  effective  date  of  this
32    amendatory Act of the 92nd  General  Assembly  shall  provide
33    coverage  under  the  policy  for treatment of serious mental
34    illness under the same terms and conditions as  coverage  for
 
                            -3-                LRB9211353JSpc
 1    hospital  or  medical expenses related to other illnesses and
 2    diseases.  The coverage  required  under  this  Section  must
 3    provide   for   same   durational   limits,   amount  limits,
 4    deductibles, and co-insurance requirements for serious mental
 5    illness as are provided for  other  illnesses  and  diseases.
 6    This  subsection  does  not  apply  to  coverage  provided to
 7    employees by employers who have 50 or fewer 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        (3)  Upon request of the reimbursing insurer, a  provider
25    of  treatment of serious mental illness shall furnish medical
26    records  or  other  necessary  data  that  substantiate  that
27    initial or continued treatment  is  at  all  times  medically
28    necessary.   An  insurer  shall  provide  a mechanism for the
29    timely review by a provider  holding  the  same  license  and
30    practicing  in  the same specialty as the patient's provider,
31    who is unaffiliated with the insurer, jointly selected by the
32    patient (or the patient's next of kin or legal representative
33    if the patient is unable to act for himself or herself),  the
34    patient's provider, and the insurer in the event of a dispute
 
                            -4-                LRB9211353JSpc
 1    between  the  insurer  and  patient's  provider regarding the
 2    medical necessity of a  treatment  proposed  by  a  patient's
 3    provider.  If the reviewing provider determines the treatment
 4    to   be   medically  necessary,  the  insurer  shall  provide
 5    reimbursement  for  the  treatment.   Future  contractual  or
 6    employment actions by the  insurer  regarding  the  patient's
 7    provider  may not be based on the provider's participation in
 8    this procedure. Nothing prevents the insured from agreeing in
 9    writing to continue treatment at his or  her  expense.   When
10    making  a  determination  of  the  medical  necessity  for  a
11    treatment modality for serous mental illness, an insurer must
12    make  the  determination  in a manner that is consistent with
13    the manner used to make that determination  with  respect  to
14    other   diseases  or  illnesses  covered  under  the  policy,
15    including an appeals process.
16        (4)  A group health benefit plan:
17             (A)  shall  provide  coverage  based  upon   medical
18        necessity  for  the following treatment of mental illness
19        in each calendar year;
20                  (i)  45 days of inpatient treatment; and
21                  (ii)  35  visits   for   outpatient   treatment
22             including group and individual outpatient treatment;
23             (B)  may  not include a lifetime limit on the number
24        of  days  of  inpatient  treatment  or  the   number   of
25        outpatient visits covered under the plan; and
26             (C)  shall   include   the   same   amount   limits,
27        deductibles,  copayments,  and  coinsurance  factors  for
28        serious mental illness as for physical illness.
29        (5)  An  issuer  of  a  group health benefit plan may not
30    count toward the number of outpatient visits required  to  be
31    covered  under  this  Section  an  outpatient  visit  for the
32    purpose  of  medication  management  and  shall   cover   the
33    outpatient  visits  under the same terms and conditions as it
34    covers  outpatient  visits  for  the  treatment  of  physical
 
                            -5-                LRB9211353JSpc
 1    illness.
 2        (6)  An issuer of a group health benefit plan may provide
 3    or offer coverage  required  under  this  Section  through  a
 4    managed care plan.
 5        (7)  This  Section  shall not be interpreted to require a
 6    group health benefit plan to provide coverage  for  treatment
 7    of:
 8             (A)  an  addiction  to  a  controlled  substance  or
 9        cannabis that is used in violation of law; or
10             (B)  mental  illness  resulting  from  the  use of a
11        controlled substance or cannabis in violation of law.
12        (8)  This subsection (b) is  inoperative  after  December
13    31, 2005.
14    (Source:  P.A.  92-182,  eff.  7-27-01;  92-185, eff. 1-1-02;
15    revised 9-18-01.)

16        Section 99.  Effective date.  This Act takes effect  upon
17    becoming law.

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