HB1432 Enrolled LRB095 10175 KBJ 30389 b

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 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
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% of
22 the lifetime policy limit.
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 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, or licensed clinical professional
9 counselor up to the limits of coverage, provided (i) the
10 disorder or condition treated is covered by the policy, and
11 (ii) the physician, licensed psychologist, licensed clinical
12 social worker, or licensed clinical professional counselor is
13 authorized to provide said services under the statutes of this
14 State and in accordance with accepted principles of his
15 profession.
16     (3) Insofar as this Section applies solely to licensed
17 clinical social workers and licensed clinical professional
18 counselors, those persons who may provide services to
19 individuals shall do so after the licensed clinical social
20 worker or licensed clinical professional counselor has
21 informed the patient of the desirability of the patient
22 conferring with the patient's primary care physician and the
23 licensed clinical social worker or licensed clinical
24 professional counselor has provided written notification to
25 the patient's primary care physician, if any, that services are
26 being provided to the patient. That notification may, however,



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1 be waived by the patient on a written form. Those forms shall
2 be retained by the licensed clinical social worker or licensed
3 clinical professional counselor for a period of not less than 5
4 years.
5     (b) (1) An insurer that provides coverage for hospital or
6 medical expenses under a group policy of accident and health
7 insurance or health care plan amended, delivered, issued, or
8 renewed after the effective date of this amendatory Act of the
9 92nd General Assembly shall provide coverage under the policy
10 for treatment of serious mental illness under the same terms
11 and conditions as coverage for hospital or medical expenses
12 related to other illnesses and diseases. The coverage required
13 under this Section must provide for same durational limits,
14 amount limits, deductibles, and co-insurance requirements for
15 serious mental illness as are provided for other illnesses and
16 diseases. This subsection does not apply to coverage provided
17 to employees by employers who have 50 or fewer employees.
18     (2) "Serious mental illness" means the following
19 psychiatric illnesses as defined in the most current edition of
20 the Diagnostic and Statistical Manual (DSM) published by the
21 American Psychiatric Association:
22         (A) schizophrenia;
23         (B) paranoid and other psychotic disorders;
24         (C) bipolar disorders (hypomanic, manic, depressive,
25     and mixed);
26         (D) major depressive disorders (single episode or



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1     recurrent);
2         (E) schizoaffective disorders (bipolar or depressive);
3         (F) pervasive developmental disorders;
4         (G) obsessive-compulsive disorders;
5         (H) depression in childhood and adolescence;
6         (I) panic disorder; and
7         (J) post-traumatic stress disorders (acute, chronic,
8     or with delayed onset); and .
9         (K) anorexia nervosa and bulimia nervosa.
10     (3) Upon request of the reimbursing insurer, a provider of
11 treatment of serious mental illness shall furnish medical
12 records or other necessary data that substantiate that initial
13 or continued treatment is at all times medically necessary. An
14 insurer shall provide a mechanism for the timely review by a
15 provider holding the same license and practicing in the same
16 specialty as the patient's provider, who is unaffiliated with
17 the insurer, jointly selected by the patient (or the patient's
18 next of kin or legal representative if the patient is unable to
19 act for himself or herself), the patient's provider, and the
20 insurer in the event of a dispute between the insurer and
21 patient's provider regarding the medical necessity of a
22 treatment proposed by a patient's provider. If the reviewing
23 provider determines the treatment to be medically necessary,
24 the insurer shall provide reimbursement for the treatment.
25 Future contractual or employment actions by the insurer
26 regarding the patient's provider may not be based on the



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1 provider's participation in this procedure. Nothing prevents
2 the insured from agreeing in writing to continue treatment at
3 his or her expense. When making a determination of the medical
4 necessity for a treatment modality for serous mental illness,
5 an insurer must make the determination in a manner that is
6 consistent with the manner used to make that determination with
7 respect to other diseases or illnesses covered under the
8 policy, including an appeals process.
9     (4) A group health benefit plan:
10         (A) shall provide coverage based upon medical
11     necessity for the following treatment of mental illness in
12     each calendar year:
13             (i) 45 days of inpatient treatment; and
14             (ii) beginning on June 26, 2006 (the effective date
15         of Public Act 94-921) this amendatory Act of the 94th
16         General Assembly, 60 visits for outpatient treatment
17         including group and individual outpatient treatment;
18         and
19             (iii) for plans or policies delivered, issued for
20         delivery, renewed, or modified after January 1, 2007
21         (the effective date of Public Act 94-906) this
22         amendatory Act of the 94th General Assembly, 20
23         additional outpatient visits for speech therapy for
24         treatment of pervasive developmental disorders that
25         will be in addition to speech therapy provided pursuant
26         to item (ii) of this subparagraph (A);



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1         (B) may not include a lifetime limit on the number of
2     days of inpatient treatment or the number of outpatient
3     visits covered under the plan; and
4         (C) shall include the same amount limits, deductibles,
5     copayments, and coinsurance factors for serious mental
6     illness as for physical illness.
7     (5) An issuer of a group health benefit plan may not count
8 toward the number of outpatient visits required to be covered
9 under this Section an outpatient visit for the purpose of
10 medication management and shall cover the outpatient visits
11 under the same terms and conditions as it covers outpatient
12 visits for the treatment of physical illness.
13     (6) An issuer of a group health benefit plan may provide or
14 offer coverage required under this Section through a managed
15 care plan.
16     (7) This Section shall not be interpreted to require a
17 group health benefit plan to provide coverage for treatment of:
18         (A) an addiction to a controlled substance or cannabis
19     that is used in violation of law; or
20         (B) mental illness resulting from the use of a
21     controlled substance or cannabis in violation of law.
22     (8) (Blank).
23 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
24 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; revised 8-3-06.)