093_SB0601eng
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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 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 of
28 his or her choice to treat such disorders, and the insurer
29 shall pay the covered charges of such physician licensed to
30 practice medicine in all its branches, licensed clinical
31 psychologist, licensed clinical social worker, or licensed
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1 clinical professional counselor up to the limits of coverage,
2 provided (i) the disorder or condition treated is covered by
3 the policy, and (ii) the physician, licensed psychologist,
4 licensed clinical social worker, or licensed clinical
5 professional counselor is authorized to provide said services
6 under the statutes of this State and in accordance with
7 accepted principles of his or her profession.
8 (3) Insofar as this Section applies solely to licensed
9 clinical social workers and licensed clinical professional
10 counselors, those persons who may provide services to
11 individuals shall do so after the licensed clinical social
12 worker or licensed clinical professional counselor has
13 informed the patient of the desirability of the patient
14 conferring with the patient's primary care physician and the
15 licensed clinical social worker or licensed clinical
16 professional counselor has provided written notification to
17 the patient's primary care physician, if any, that services
18 are being provided to the patient. That notification may,
19 however, be waived by the patient on a written form. Those
20 forms shall be retained by the licensed clinical social
21 worker or licensed clinical professional counselor for a
22 period of not less than 5 years.
23 (b) (1) An insurer that provides coverage for hospital
24 or medical expenses under a group policy of accident and
25 health insurance or health care plan amended, delivered,
26 issued, or renewed after the effective date of this
27 amendatory Act of the 93rd 92nd General Assembly shall
28 provide coverage under the policy for treatment of serious
29 mental illness under the same terms and conditions as
30 coverage for hospital or medical expenses related to other
31 illnesses and diseases. The coverage required under this
32 Section must provide for same durational limits, amount
33 limits, deductibles, and co-insurance requirements for
34 serious mental illness as are provided for other illnesses
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1 and diseases. This subsection does not apply to coverage
2 provided to employees by employers who have 50 or fewer
3 employees.
4 (2) "Serious mental illness" means the following
5 psychiatric illnesses as defined in the most current edition
6 of the Diagnostic and Statistical Manual (DSM) published by
7 the American Psychiatric Association:
8 (A) schizophrenia;
9 (B) paranoid and other psychotic disorders;
10 (C) bipolar disorders (hypomanic, manic,
11 depressive, and mixed);
12 (D) major depressive disorders (single episode or
13 recurrent);
14 (E) schizoaffective disorders (bipolar or
15 depressive);
16 (F) pervasive developmental disorders;
17 (G) obsessive-compulsive disorders;
18 (H) depression in childhood and adolescence; and
19 (I) panic disorder;.
20 (J) anorexia nervosa (restricting or binge-eating
21 and purging); and
22 (K) bulimia nervosa (purging or nonpurging).
23 (3) Upon request of the reimbursing insurer, a provider
24 of treatment of serious mental illness shall furnish medical
25 records or other necessary data that substantiate that
26 initial or continued treatment is at all times medically
27 necessary. An insurer shall provide a mechanism for the
28 timely review by a provider holding the same license and
29 practicing in the same specialty as the patient's provider,
30 who is unaffiliated with the insurer, jointly selected by the
31 patient (or the patient's next of kin or legal representative
32 if the patient is unable to act for himself or herself), the
33 patient's provider, and the insurer in the event of a dispute
34 between the insurer and patient's provider regarding the
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1 medical necessity of a treatment proposed by a patient's
2 provider. If the reviewing provider determines the treatment
3 to be medically necessary, the insurer shall provide
4 reimbursement for the treatment. Future contractual or
5 employment actions by the insurer regarding the patient's
6 provider may not be based on the provider's participation in
7 this procedure. Nothing prevents the insured from agreeing in
8 writing to continue treatment at his or her expense. When
9 making a determination of the medical necessity for a
10 treatment modality for serous mental illness, an insurer must
11 make the determination in a manner that is consistent with
12 the manner used to make that determination with respect to
13 other diseases or illnesses covered under the policy,
14 including an appeals process.
15 (4) A group health benefit plan:
16 (A) shall provide coverage based upon medical
17 necessity for the following treatment of mental illness
18 in each calendar year;
19 (i) 45 days of inpatient treatment; and
20 (ii) 35 visits for outpatient treatment
21 including group and individual outpatient treatment;
22 (B) may not include a lifetime limit on the number
23 of days of inpatient treatment or the number of
24 outpatient visits covered under the plan; and
25 (C) shall include the same amount limits,
26 deductibles, copayments, and coinsurance factors for
27 serious mental illness as for physical illness.
28 (5) An issuer of a group health benefit plan may not
29 count toward the number of outpatient visits required to be
30 covered under this Section an outpatient visit for the
31 purpose of medication management and shall cover the
32 outpatient visits under the same terms and conditions as it
33 covers outpatient visits for the treatment of physical
34 illness.
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1 (6) An issuer of a group health benefit plan may provide
2 or offer coverage required under this Section through a
3 managed care plan.
4 (7) This Section shall not be interpreted to require a
5 group health benefit plan to provide coverage for treatment
6 of:
7 (A) an addiction to a controlled substance or
8 cannabis that is used in violation of law; or
9 (B) mental illness resulting from the use of a
10 controlled substance or cannabis in violation of law.
11 (8) This subsection (b) is inoperative after December
12 31, 2005.
13 (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02;
14 92-651, eff. 7-11-02.)
15 Section 99. Effective date. This Act takes effect upon
16 becoming law.