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1 | AN ACT concerning insurance coverage.
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2 | Be it enacted by the People of the State of Illinois, | |||||||||||||||||||
3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | |||||||||||||||||||
5 | changing
Section 370c as follows:
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6 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
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7 | Sec. 370c. Mental and emotional disorders.
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8 | (a) (1) On and after the effective date of this Section,
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9 | every insurer which delivers, issues for delivery or renews or | |||||||||||||||||||
10 | modifies
group A&H policies providing coverage for hospital or | |||||||||||||||||||
11 | 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
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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
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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% of | |||||||||||||||||||
22 | the lifetime policy limit.
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23 | (2) Each insured that is covered for mental, emotional or |
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1 | nervous
disorders or conditions shall be free to select the | ||||||
2 | physician licensed to
practice medicine in all its branches, | ||||||
3 | licensed clinical psychologist,
licensed clinical social | ||||||
4 | worker, or licensed clinical professional counselor , or | ||||||
5 | licensed marriage and family therapist of
his choice to treat | ||||||
6 | such disorders, and
the insurer shall pay the covered charges | ||||||
7 | of such physician licensed to
practice medicine in all its | ||||||
8 | branches, licensed clinical psychologist,
licensed clinical | ||||||
9 | social worker, or licensed clinical professional counselor , or | ||||||
10 | licensed marriage and family therapist up
to the limits of | ||||||
11 | coverage, provided (i)
the disorder or condition treated is | ||||||
12 | covered by the policy, and (ii) the
physician, licensed | ||||||
13 | psychologist, licensed clinical social worker, or licensed
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14 | clinical professional counselor , or licensed marriage and | ||||||
15 | family therapist is
authorized to provide said services under | ||||||
16 | the statutes of this State and in
accordance with accepted | ||||||
17 | principles of his profession.
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18 | (3) Insofar as this Section applies solely to licensed | ||||||
19 | clinical social
workers ,
and licensed clinical professional | ||||||
20 | counselors, and licensed marriage and family therapists, those | ||||||
21 | persons who may
provide services to individuals shall do so
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22 | after the licensed clinical social worker ,
or licensed clinical | ||||||
23 | professional
counselor , or licensed marriage and family | ||||||
24 | therapist has informed the patient of the
desirability of the | ||||||
25 | patient conferring with the patient's primary care
physician | ||||||
26 | and the licensed clinical social worker ,
or licensed clinical
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1 | professional counselor , or licensed marriage and family | ||||||
2 | therapist has
provided written
notification to the patient's | ||||||
3 | primary care physician, if any, that services
are being | ||||||
4 | provided to the patient. That notification may, however, be
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5 | waived by the patient on a written form. Those forms shall be | ||||||
6 | retained by
the licensed clinical social worker ,
or licensed | ||||||
7 | clinical professional counselor , or licensed marriage and | ||||||
8 | family therapist
for a period of not less than 5 years.
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9 | (b) (1) An insurer that provides coverage for hospital or | ||||||
10 | medical
expenses under a group policy of accident and health | ||||||
11 | insurance or
health care plan amended, delivered, issued, or | ||||||
12 | renewed after the effective
date of this amendatory Act of the | ||||||
13 | 92nd General Assembly shall provide coverage
under the policy | ||||||
14 | for treatment of serious mental illness under the same terms
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15 | and conditions as coverage for hospital or medical expenses | ||||||
16 | related to other
illnesses and diseases. The coverage required | ||||||
17 | under this Section must provide
for same durational limits, | ||||||
18 | amount limits, deductibles, and co-insurance
requirements for | ||||||
19 | serious mental illness as are provided for other illnesses
and | ||||||
20 | diseases. This subsection does not apply to coverage provided | ||||||
21 | to
employees by employers who have 50 or fewer employees.
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22 | (2) "Serious mental illness" means the following | ||||||
23 | psychiatric illnesses as
defined in the most current edition of | ||||||
24 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
25 | American Psychiatric Association:
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26 | (A) schizophrenia;
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1 | (B) paranoid and other psychotic disorders;
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2 | (C) bipolar disorders (hypomanic, manic, depressive, | ||||||
3 | and mixed);
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4 | (D) major depressive disorders (single episode or | ||||||
5 | recurrent);
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6 | (E) schizoaffective disorders (bipolar or depressive);
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7 | (F) pervasive developmental disorders;
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8 | (G) obsessive-compulsive disorders;
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9 | (H) depression in childhood and adolescence;
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10 | (I) panic disorder; and | ||||||
11 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
12 | or with delayed onset).
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13 | (3) Upon request of the reimbursing insurer, a provider of | ||||||
14 | treatment of
serious mental illness shall furnish medical | ||||||
15 | records or other necessary data
that substantiate that initial | ||||||
16 | or continued treatment is at all times medically
necessary. An | ||||||
17 | insurer shall provide a mechanism for the timely review by a
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18 | provider holding the same license and practicing in the same | ||||||
19 | specialty as the
patient's provider, who is unaffiliated with | ||||||
20 | the insurer, jointly selected by
the patient (or the patient's | ||||||
21 | next of kin or legal representative if the
patient is unable to | ||||||
22 | act for himself or herself), the patient's provider, and
the | ||||||
23 | insurer in the event of a dispute between the insurer and | ||||||
24 | patient's
provider regarding the medical necessity of a | ||||||
25 | treatment proposed by a patient's
provider. If the reviewing | ||||||
26 | provider determines the treatment to be medically
necessary, |
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1 | the insurer shall provide reimbursement for the treatment. | ||||||
2 | Future
contractual or employment actions by the insurer | ||||||
3 | regarding the patient's
provider may not be based on the | ||||||
4 | provider's participation in this procedure.
Nothing prevents
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5 | the insured from agreeing in writing to continue treatment at | ||||||
6 | his or her
expense. When making a determination of the medical | ||||||
7 | necessity for a treatment
modality for serous mental illness, | ||||||
8 | an insurer must make the determination in a
manner that is | ||||||
9 | consistent with the manner used to make that determination with
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10 | respect to other diseases or illnesses covered under the | ||||||
11 | policy, including an
appeals process.
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12 | (4) A group health benefit plan:
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13 | (A) shall provide coverage based upon medical | ||||||
14 | necessity for the following
treatment of mental illness in | ||||||
15 | each calendar year:
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16 | (i) 45 days of inpatient treatment; and
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17 | (ii) beginning on June 26, 2006 ( the effective date | ||||||
18 | of Public Act 94-921)
this amendatory Act of the 94th | ||||||
19 | General Assembly , 60 visits for outpatient treatment | ||||||
20 | including group and individual
outpatient treatment; | ||||||
21 | and | ||||||
22 | (iii) for plans or policies delivered, issued for | ||||||
23 | delivery, renewed, or modified after January 1, 2007 | ||||||
24 | ( the effective date of Public Act 94-906)
this | ||||||
25 | amendatory Act of the 94th General Assembly ,
20 | ||||||
26 | additional outpatient visits for speech therapy for |
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1 | treatment of pervasive developmental disorders that | ||||||
2 | will be in addition to speech therapy provided pursuant | ||||||
3 | to item (ii) of this subparagraph (A);
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4 | (B) may not include a lifetime limit on the number of | ||||||
5 | days of inpatient
treatment or the number of outpatient | ||||||
6 | visits covered under the plan; and
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7 | (C) shall include the same amount limits, deductibles, | ||||||
8 | copayments, and
coinsurance factors for serious mental | ||||||
9 | illness as for physical illness.
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10 | (5) An issuer of a group health benefit plan may not count | ||||||
11 | toward the number
of outpatient visits required to be covered | ||||||
12 | under this Section an outpatient
visit for the purpose of | ||||||
13 | medication management and shall cover the outpatient
visits | ||||||
14 | under the same terms and conditions as it covers outpatient | ||||||
15 | visits for
the treatment of physical illness.
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16 | (6) An issuer of a group health benefit
plan may provide or | ||||||
17 | offer coverage required under this Section through a
managed | ||||||
18 | care plan.
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19 | (7) This Section shall not be interpreted to require a | ||||||
20 | group health benefit
plan to provide coverage for treatment of:
| ||||||
21 | (A) an addiction to a controlled substance or cannabis | ||||||
22 | that is used in
violation of law; or
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23 | (B) mental illness resulting from the use of a | ||||||
24 | controlled substance or
cannabis in violation of law.
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25 | (8)
(Blank).
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26 | (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05; |
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1 | 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; revised 8-3-06.)
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2 | Section 99. Effective date. This Act takes effect upon | ||||||
3 | becoming law. |