Illinois General Assembly - Full Text of HB1432
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Full Text of HB1432  95th General Assembly


Rep. Fred Crespo

Filed: 4/20/2007





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2     AMENDMENT NO. ______. Amend House Bill 1432 by replacing
3 everything after the enacting clause with the following:
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



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1 item (2) of subsection (b), up to the limits provided in the
2 policy for other disorders or conditions, except (i) the
3 insured may be required to pay up to 50% of expenses incurred
4 as a result of the treatment or services, and (ii) the annual
5 benefit limit may be limited to the lesser of $10,000 or 25% of
6 the lifetime policy limit.
7     (2) Each insured that is covered for mental, emotional or
8 nervous disorders or conditions shall be free to select the
9 physician licensed to practice medicine in all its branches,
10 licensed clinical psychologist, licensed clinical social
11 worker, or licensed clinical professional counselor of his
12 choice to treat such disorders, and the insurer shall pay the
13 covered charges of such physician licensed to practice medicine
14 in all its branches, licensed clinical psychologist, licensed
15 clinical social worker, or licensed clinical professional
16 counselor up to the limits of coverage, provided (i) the
17 disorder or condition treated is covered by the policy, and
18 (ii) the physician, licensed psychologist, licensed clinical
19 social worker, or licensed clinical professional counselor is
20 authorized to provide said services under the statutes of this
21 State and in accordance with accepted principles of his
22 profession.
23     (3) Insofar as this Section applies solely to licensed
24 clinical social workers and licensed clinical professional
25 counselors, those persons who may provide services to
26 individuals shall do so after the licensed clinical social



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1 worker or licensed clinical professional counselor has
2 informed the patient of the desirability of the patient
3 conferring with the patient's primary care physician and the
4 licensed clinical social worker or licensed clinical
5 professional counselor has provided written notification to
6 the patient's primary care physician, if any, that services are
7 being provided to the patient. That notification may, however,
8 be waived by the patient on a written form. Those forms shall
9 be retained by the licensed clinical social worker or licensed
10 clinical professional counselor for a period of not less than 5
11 years.
12     (b) (1) An insurer that provides coverage for hospital or
13 medical expenses under a group policy of accident and health
14 insurance or health care plan amended, delivered, issued, or
15 renewed after the effective date of this amendatory Act of the
16 92nd General Assembly shall provide coverage under the policy
17 for treatment of serious mental illness under the same terms
18 and conditions as coverage for hospital or medical expenses
19 related to other illnesses and diseases. The coverage required
20 under this Section must provide for same durational limits,
21 amount limits, deductibles, and co-insurance requirements for
22 serious mental illness as are provided for other illnesses and
23 diseases. This subsection does not apply to coverage provided
24 to employees by employers who have 50 or fewer employees.
25     (2) "Serious mental illness" means the following
26 psychiatric illnesses as defined in the most current edition of



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1 the Diagnostic and Statistical Manual (DSM) published by the
2 American Psychiatric Association:
3         (A) schizophrenia;
4         (B) paranoid and other psychotic disorders;
5         (C) bipolar disorders (hypomanic, manic, depressive,
6     and mixed);
7         (D) major depressive disorders (single episode or
8     recurrent);
9         (E) schizoaffective disorders (bipolar or depressive);
10         (F) pervasive developmental disorders;
11         (G) obsessive-compulsive disorders;
12         (H) depression in childhood and adolescence;
13         (I) panic disorder; and
14         (J) post-traumatic stress disorders (acute, chronic,
15     or with delayed onset); and .
16         (K) eating disorders, including anorexia nervosa,
17     bulimia nervosa, and Eating Disorders Not Otherwise
18     Specified (EDNOS), as recognized by the most current
19     edition of the DSM.
20     (3) Upon request of the reimbursing insurer, a provider of
21 treatment of serious mental illness shall furnish medical
22 records or other necessary data that substantiate that initial
23 or continued treatment is at all times medically necessary. An
24 insurer shall provide a mechanism for the timely review by a
25 provider holding the same license and practicing in the same
26 specialty as the patient's provider, who is unaffiliated with



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1 the insurer, jointly selected by the patient (or the patient's
2 next of kin or legal representative if the patient is unable to
3 act for himself or herself), the patient's provider, and the
4 insurer in the event of a dispute between the insurer and
5 patient's provider regarding the medical necessity of a
6 treatment proposed by a patient's provider. If the reviewing
7 provider determines the treatment to be medically necessary,
8 the insurer shall provide reimbursement for the treatment.
9 Future contractual or employment actions by the insurer
10 regarding the patient's provider may not be based on the
11 provider's participation in this procedure. Nothing prevents
12 the insured from agreeing in writing to continue treatment at
13 his or her expense. When making a determination of the medical
14 necessity for a treatment modality for serous mental illness,
15 an insurer must make the determination in a manner that is
16 consistent with the manner used to make that determination with
17 respect to other diseases or illnesses covered under the
18 policy, including an appeals process.
19     (4) A group health benefit plan:
20         (A) shall provide coverage based upon medical
21     necessity for the following treatment of mental illness in
22     each calendar year:
23             (i) 45 days of inpatient treatment; and
24             (ii) beginning on June 26, 2006 (the effective date
25         of Public Act 94-921) this amendatory Act of the 94th
26         General Assembly, 60 visits for outpatient treatment



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1         including group and individual outpatient treatment;
2         and
3             (iii) for plans or policies delivered, issued for
4         delivery, renewed, or modified after January 1, 2007
5         (the effective date of Public Act 94-906) this
6         amendatory Act of the 94th General Assembly, 20
7         additional outpatient visits for speech therapy for
8         treatment of pervasive developmental disorders that
9         will be in addition to speech therapy provided pursuant
10         to item (ii) of this subparagraph (A);
11         (B) may not include a lifetime limit on the number of
12     days of inpatient treatment or the number of outpatient
13     visits covered under the plan; and
14         (C) shall include the same amount limits, deductibles,
15     copayments, and coinsurance factors for serious mental
16     illness as for physical illness.
17     (5) An issuer of a group health benefit plan may not count
18 toward the number of outpatient visits required to be covered
19 under this Section an outpatient visit for the purpose of
20 medication management and shall cover the outpatient visits
21 under the same terms and conditions as it covers outpatient
22 visits for the treatment of physical illness.
23     (6) An issuer of a group health benefit plan may provide or
24 offer coverage required under this Section through a managed
25 care plan.
26     (7) This Section shall not be interpreted to require a



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1 group health benefit plan to provide coverage for treatment of:
2         (A) an addiction to a controlled substance or cannabis
3     that is used in violation of law; or
4         (B) mental illness resulting from the use of a
5     controlled substance or cannabis in violation of law.
6     (8) (Blank).
7 (Source: P.A. 94-402, eff. 8-2-05; 94-584, eff. 8-15-05;
8 94-906, eff. 1-1-07; 94-921, eff. 6-26-06; revised 8-3-06.)".