Full Text of HB1530 97th General Assembly
HB1530eng 97TH GENERAL ASSEMBLY |
| | HB1530 Engrossed | | LRB097 09356 RPM 49491 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 Sections 356z.14, 356z.15, and 370c and by adding | 6 | | Section 370c.1 as follows: | 7 | | (215 ILCS 5/356z.14) | 8 | | Sec. 356z.14. Autism spectrum disorders. | 9 | | (a) A group or individual policy of accident and health | 10 | | insurance or managed care plan amended, delivered, issued, or | 11 | | renewed after the effective date of this amendatory Act of the | 12 | | 95th General Assembly must provide individuals under 21 years | 13 | | of age coverage for the diagnosis of autism spectrum disorders | 14 | | and for the treatment of autism spectrum disorders to the | 15 | | extent that the diagnosis and treatment of autism spectrum | 16 | | disorders are not already covered by the policy of accident and | 17 | | health insurance or managed care plan. | 18 | | (b) Coverage provided under this Section through a group or | 19 | | individual policy of accident and health insurance or managed | 20 | | care plan shall be subject to the parity requirements of | 21 | | Section 370c.1 of this Code; provided, however, that a group or | 22 | | individual policy of accident and health insurance or managed | 23 | | care plan amended, delivered, issued, or renewed on or after |
| | | HB1530 Engrossed | - 2 - | LRB097 09356 RPM 49491 b |
|
| 1 | | the effective date of this amendatory Act of the 97th General | 2 | | Assembly must provide a minimum maximum benefit of $36,000 per | 3 | | year, and but shall not be subject to any limits on the number | 4 | | of visits to a service provider. After December 30, 2009, the | 5 | | Director of the Division of Insurance shall, on an annual | 6 | | basis, adjust the minimum maximum benefit for inflation using | 7 | | the Medical Care Component of the United States Department of | 8 | | Labor Consumer Price Index for All Urban Consumers. Payments | 9 | | made by an insurer on behalf of a covered individual for any | 10 | | care, treatment, intervention, service, or item, the provision | 11 | | of which was for the treatment of a health condition not | 12 | | diagnosed as an autism spectrum disorder, shall not be applied | 13 | | toward any minimum maximum benefit established under this | 14 | | subsection. | 15 | | (c) (Blank). Coverage under this Section shall be subject | 16 | | to copayment, deductible, and coinsurance provisions of a | 17 | | policy of accident and health insurance or managed care plan to | 18 | | the extent that other medical services covered by the policy of | 19 | | accident and health insurance or managed care plan are subject | 20 | | to these provisions. | 21 | | (d) This Section shall not be construed as limiting | 22 | | benefits that are otherwise available to an individual under a | 23 | | policy of accident and health insurance or managed care plan | 24 | | and benefits provided under this Section may not be subject to | 25 | | dollar limits, deductibles, copayments, or coinsurance | 26 | | provisions that are less favorable to the insured than the |
| | | HB1530 Engrossed | - 3 - | LRB097 09356 RPM 49491 b |
|
| 1 | | dollar limits, deductibles, or coinsurance provisions that | 2 | | apply to physical illness generally . | 3 | | (e) An insurer may not deny or refuse to provide otherwise | 4 | | covered services, or refuse to renew, refuse to reissue, or | 5 | | otherwise terminate or restrict coverage under an individual | 6 | | contract to provide services to an individual because the | 7 | | individual or their dependent is diagnosed with an autism | 8 | | spectrum disorder or due to the individual utilizing benefits | 9 | | in this Section. | 10 | | (f) Upon request of the reimbursing insurer, a provider of | 11 | | treatment for autism spectrum disorders shall furnish medical | 12 | | records, clinical notes, or other necessary data that | 13 | | substantiate that initial or continued medical treatment is | 14 | | medically necessary and is resulting in improved clinical | 15 | | status. When treatment is anticipated to require continued | 16 | | services to achieve demonstrable progress, the insurer may | 17 | | request a treatment plan consisting of diagnosis, proposed | 18 | | treatment by type, frequency, anticipated duration of | 19 | | treatment, the anticipated outcomes stated as goals, and the | 20 | | frequency by which the treatment plan will be updated. | 21 | | (g) When making a determination of medical necessity for a | 22 | | treatment modality for autism spectrum disorders, an insurer | 23 | | must make the determination in a manner that is consistent with | 24 | | the manner used to make that determination with respect to | 25 | | other diseases or illnesses covered under the policy, including | 26 | | an appeals process. During the appeals process, any challenge |
| | | HB1530 Engrossed | - 4 - | LRB097 09356 RPM 49491 b |
|
| 1 | | to medical necessity must be viewed as reasonable only if the | 2 | | review includes a physician with expertise in the most current | 3 | | and effective treatment modalities for autism spectrum | 4 | | disorders. | 5 | | (h) Coverage for medically necessary early intervention | 6 | | services must be delivered by certified early intervention | 7 | | specialists, as defined in 89 Ill. Admin. Code 500 and any | 8 | | subsequent amendments thereto. | 9 | | (i) As used in this Section: | 10 | | "Autism spectrum disorders" means pervasive developmental | 11 | | disorders as defined in the most recent edition of the | 12 | | Diagnostic and Statistical Manual of Mental Disorders, | 13 | | including autism, Asperger's disorder, and pervasive | 14 | | developmental disorder not otherwise specified. | 15 | | "Diagnosis of autism spectrum disorders" means one or more | 16 | | tests, evaluations, or assessments to diagnose whether an | 17 | | individual has autism spectrum disorder that is prescribed, | 18 | | performed, or ordered by (A) a physician licensed to practice | 19 | | medicine in all its branches or (B) a licensed clinical | 20 | | psychologist with expertise in diagnosing autism spectrum | 21 | | disorders. | 22 | | "Medically necessary" means any care, treatment, | 23 | | intervention, service or item which will or is reasonably | 24 | | expected to do any of the following: (i) prevent the onset of | 25 | | an illness, condition, injury, disease or disability; (ii) | 26 | | reduce or ameliorate the physical, mental or developmental |
| | | HB1530 Engrossed | - 5 - | LRB097 09356 RPM 49491 b |
|
| 1 | | effects of an illness, condition, injury, disease or | 2 | | disability; or (iii) assist to achieve or maintain maximum | 3 | | functional activity in performing daily activities. | 4 | | "Treatment for autism spectrum disorders" shall include | 5 | | the following care prescribed, provided, or ordered for an | 6 | | individual diagnosed with an autism spectrum disorder by (A) a | 7 | | physician licensed to practice medicine in all its branches or | 8 | | (B) a certified, registered, or licensed health care | 9 | | professional with expertise in treating effects of autism | 10 | | spectrum disorders when the care is determined to be medically | 11 | | necessary and ordered by a physician licensed to practice | 12 | | medicine in all its branches: | 13 | | (1) Psychiatric care, meaning direct, consultative, or | 14 | | diagnostic services provided by a licensed psychiatrist. | 15 | | (2) Psychological care, meaning direct or consultative | 16 | | services provided by a licensed psychologist. | 17 | | (3) Habilitative or rehabilitative care, meaning | 18 | | professional, counseling, and guidance services and | 19 | | treatment programs, including applied behavior analysis, | 20 | | that are intended to develop, maintain, and restore the | 21 | | functioning of an individual. As used in this subsection | 22 | | (i), "applied behavior analysis" means the design, | 23 | | implementation, and evaluation of environmental | 24 | | modifications using behavioral stimuli and consequences to | 25 | | produce socially significant improvement in human | 26 | | behavior, including the use of direct observation, |
| | | HB1530 Engrossed | - 6 - | LRB097 09356 RPM 49491 b |
|
| 1 | | measurement, and functional analysis of the relations | 2 | | between environment and behavior. | 3 | | (4) Therapeutic care, including behavioral, speech, | 4 | | occupational, and physical therapies that provide | 5 | | treatment in the following areas: (i) self care and | 6 | | feeding, (ii) pragmatic, receptive, and expressive | 7 | | language, (iii) cognitive functioning, (iv) applied | 8 | | behavior analysis, intervention, and modification, (v) | 9 | | motor planning, and (vi) sensory processing. | 10 | | (j) Rulemaking authority to implement this amendatory Act | 11 | | of the 95th General Assembly, if any, is conditioned on the | 12 | | rules being adopted in accordance with all provisions of the | 13 | | Illinois Administrative Procedure Act and all rules and | 14 | | procedures of the Joint Committee on Administrative Rules; any | 15 | | purported rule not so adopted, for whatever reason, is | 16 | | unauthorized.
| 17 | | (Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.) | 18 | | (215 ILCS 5/356z.15) | 19 | | Sec. 356z.15. Habilitative services for children. | 20 | | (a) As used in this Section, "habilitative services" means | 21 | | occupational therapy, physical therapy, speech therapy, and | 22 | | other services prescribed by the insured's treating physician | 23 | | pursuant to a treatment plan to enhance the ability of a child | 24 | | to function with a congenital, genetic, or early acquired | 25 | | disorder. A congenital or genetic disorder includes, but is not |
| | | HB1530 Engrossed | - 7 - | LRB097 09356 RPM 49491 b |
|
| 1 | | limited to, hereditary disorders. An early acquired disorder | 2 | | refers to a disorder resulting from illness, trauma, injury, or | 3 | | some other event or condition suffered by a child prior to that | 4 | | child developing functional life skills such as, but not | 5 | | limited to, walking, talking, or self-help skills. Congenital, | 6 | | genetic, and early acquired disorders may include, but are not | 7 | | limited to, autism or an autism spectrum disorder, cerebral | 8 | | palsy, and other disorders resulting from early childhood | 9 | | illness, trauma, or injury. | 10 | | (b) A group or individual policy of accident and health | 11 | | insurance or managed care plan amended, delivered, issued, or | 12 | | renewed after the effective date of this amendatory Act of the | 13 | | 95th General Assembly must provide coverage for habilitative | 14 | | services for children under 19 years of age with a congenital, | 15 | | genetic, or early acquired disorder so long as all of the | 16 | | following conditions are met: | 17 | | (1) A physician licensed to practice medicine in all | 18 | | its branches has diagnosed the child's congenital, | 19 | | genetic, or early acquired disorder. | 20 | | (2) The treatment is administered by a licensed | 21 | | speech-language pathologist, licensed audiologist, | 22 | | licensed occupational therapist, licensed physical | 23 | | therapist, licensed physician, licensed nurse, licensed | 24 | | optometrist, licensed nutritionist, licensed social | 25 | | worker, or licensed psychologist upon the referral of a | 26 | | physician licensed to practice medicine in all its |
| | | HB1530 Engrossed | - 8 - | LRB097 09356 RPM 49491 b |
|
| 1 | | branches. | 2 | | (3) The initial or continued treatment must be | 3 | | medically necessary and therapeutic and not experimental | 4 | | or investigational. | 5 | | (c) The coverage required by this Section shall be subject | 6 | | to other general exclusions and limitations of the policy, | 7 | | including coordination of benefits, participating provider | 8 | | requirements, restrictions on services provided by family or | 9 | | household members, utilization review of health care services, | 10 | | including review of medical necessity, case management, | 11 | | experimental, and investigational treatments, and other | 12 | | managed care provisions. | 13 | | (d) Coverage under this Section does not apply to those | 14 | | services that are solely educational in nature or otherwise | 15 | | paid under State or federal law for purely educational | 16 | | services. Nothing in this subsection (d) relieves an insurer or | 17 | | similar third party from an otherwise valid obligation to | 18 | | provide or to pay for services provided to a child with a | 19 | | disability. | 20 | | (e) Coverage under this Section for children under age 19 | 21 | | shall not apply to treatment of mental or emotional disorders | 22 | | or illnesses as covered under Section 370 of this Code as well | 23 | | as any other benefit based upon a specific diagnosis that may | 24 | | be otherwise required by law. | 25 | | (f) The provisions of this Section do not apply to | 26 | | short-term travel, accident-only, limited, or specific disease |
| | | HB1530 Engrossed | - 9 - | LRB097 09356 RPM 49491 b |
|
| 1 | | policies. | 2 | | (g) Any denial of care for habilitative services shall be | 3 | | subject to appeal and external independent review procedures as | 4 | | provided by Section 45 of the Managed Care Reform and Patient | 5 | | Rights Act. | 6 | | (h) Upon request of the reimbursing insurer, the provider | 7 | | under whose supervision the habilitative services are being | 8 | | provided shall furnish medical records, clinical notes, or | 9 | | other necessary data to allow the insurer to substantiate that | 10 | | initial or continued medical treatment is medically necessary | 11 | | and that the patient's condition is clinically improving. When | 12 | | the treating provider anticipates that continued treatment is | 13 | | or will be required to permit the patient to achieve | 14 | | demonstrable progress, the insurer may request that the | 15 | | provider furnish a treatment plan consisting of diagnosis, | 16 | | proposed treatment by type, frequency, anticipated duration of | 17 | | treatment, the anticipated goals of treatment, and how | 18 | | frequently the treatment plan will be updated. | 19 | | (i) Rulemaking authority to implement this amendatory Act | 20 | | of the 95th General Assembly, if any, is conditioned on the | 21 | | rules being adopted in accordance with all provisions of the | 22 | | Illinois Administrative Procedure Act and all rules and | 23 | | procedures of the Joint Committee on Administrative Rules; any | 24 | | purported rule not so adopted, for whatever reason, is | 25 | | unauthorized.
| 26 | | (j) Coverage provided under this Section through a group or |
| | | HB1530 Engrossed | - 10 - | LRB097 09356 RPM 49491 b |
|
| 1 | | individual policy of accident and health insurance or managed | 2 | | care plan for the treatment of mental, emotional, nervous, or | 3 | | substance use disorders or conditions shall be subject to the | 4 | | parity requirements of Section 370c.1 of this Code. | 5 | | (Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10; | 6 | | 96-1000, eff. 7-2-10.)
| 7 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| 8 | | Sec. 370c. Mental and emotional disorders.
| 9 | | (a) (1) On and after the effective date of this amendatory | 10 | | Act of the 97th General Assembly Section ,
every insurer which | 11 | | amends, delivers, issues, or renews delivers, issues for | 12 | | delivery or renews or modifies
group accident and health A&H | 13 | | policies providing coverage for hospital or medical treatment | 14 | | or
services for illness on an expense-incurred basis shall | 15 | | offer to the
applicant or group policyholder subject to the | 16 | | insurer's insurers standards of
insurability, coverage for | 17 | | reasonable and necessary treatment and services
for mental, | 18 | | emotional or nervous disorders or conditions, other than | 19 | | serious
mental illnesses as defined in item (2) of subsection | 20 | | (b), consistent with the parity requirements of Section 370c.1 | 21 | | of this Code up to the limits
provided in the policy for other | 22 | | disorders or conditions, except (i) the
insured may be required | 23 | | to pay up to 50% of expenses incurred as a result
of the | 24 | | treatment or services, and (ii) the annual benefit limit may be
| 25 | | limited to the lesser of $10,000 or 25% of the lifetime policy |
| | | HB1530 Engrossed | - 11 - | LRB097 09356 RPM 49491 b |
|
| 1 | | limit .
| 2 | | (2) Each insured that is covered for mental, emotional , or | 3 | | nervous , or substance use
disorders or conditions shall be free | 4 | | to select the physician licensed to
practice medicine in all | 5 | | its branches, licensed clinical psychologist,
licensed | 6 | | clinical social worker, licensed clinical professional | 7 | | counselor, or licensed marriage and family therapist , licensed | 8 | | speech-language pathologist, or other licensed or certified | 9 | | professional at a program licensed pursuant to the Illinois | 10 | | Alcoholism and Other Drug Abuse and Dependency Act of
his | 11 | | choice to treat such disorders, and
the insurer shall pay the | 12 | | covered charges of such physician licensed to
practice medicine | 13 | | in all its branches, licensed clinical psychologist,
licensed | 14 | | clinical social worker, licensed clinical professional | 15 | | counselor, or licensed marriage and family therapist , licensed | 16 | | speech-language pathologist, or other licensed or certified | 17 | | professional at a program licensed pursuant to the Illinois | 18 | | Alcoholism and Other Drug Abuse and Dependency Act up
to the | 19 | | limits of coverage, provided (i)
the disorder or condition | 20 | | treated is covered by the policy, and (ii) the
physician, | 21 | | licensed psychologist, licensed clinical social worker, | 22 | | licensed
clinical professional counselor, or licensed marriage | 23 | | and family therapist , licensed speech-language pathologist, or | 24 | | other licensed or certified professional at a program licensed | 25 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 26 | | Dependency Act is
authorized to provide said services under the |
| | | HB1530 Engrossed | - 12 - | LRB097 09356 RPM 49491 b |
|
| 1 | | statutes of this State and in
accordance with accepted | 2 | | principles of his profession.
| 3 | | (3) Insofar as this Section applies solely to licensed | 4 | | clinical social
workers, licensed clinical professional | 5 | | counselors, and licensed marriage and family therapists, | 6 | | licensed speech-language pathologist, and other licensed or | 7 | | certified professionals at programs licensed pursuant to the | 8 | | Illinois Alcoholism and Other Drug Abuse and Dependency Act, | 9 | | those persons who may
provide services to individuals shall do | 10 | | so
after the licensed clinical social worker, licensed clinical | 11 | | professional
counselor, or licensed marriage and family | 12 | | therapist , licensed speech-language pathologist, or other | 13 | | licensed or certified professional at a program licensed | 14 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 15 | | Dependency Act has informed the patient of the
desirability of | 16 | | the patient conferring with the patient's primary care
| 17 | | physician and the licensed clinical social worker, licensed | 18 | | clinical
professional counselor, or licensed marriage and | 19 | | family therapist , licensed speech-language pathologist, or | 20 | | other licensed or certified professional at a program licensed | 21 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 22 | | Dependency Act has
provided written
notification to the | 23 | | patient's primary care physician, if any, that services
are | 24 | | being provided to the patient. That notification may, however, | 25 | | be
waived by the patient on a written form. Those forms shall | 26 | | be retained by
the licensed clinical social worker, licensed |
| | | HB1530 Engrossed | - 13 - | LRB097 09356 RPM 49491 b |
|
| 1 | | clinical professional counselor, or licensed marriage and | 2 | | family therapist , licensed speech-language pathologist, or | 3 | | other licensed or certified professional at a program licensed | 4 | | pursuant to the Illinois Alcoholism and Other Drug Abuse and | 5 | | Dependency Act
for a period of not less than 5 years.
| 6 | | (b) (1) An insurer that provides coverage for hospital or | 7 | | medical
expenses under a group policy of accident and health | 8 | | insurance or
health care plan amended, delivered, issued, or | 9 | | renewed on or after the effective
date of this amendatory Act | 10 | | of the 97th 92nd General Assembly shall provide coverage
under | 11 | | the policy for treatment of serious mental illness and | 12 | | substance use disorders consistent with the parity | 13 | | requirements of Section 370c.1 of this Code under the same | 14 | | terms
and conditions as coverage for hospital or medical | 15 | | expenses related to other
illnesses and diseases. The coverage | 16 | | required under this Section must provide
for same durational | 17 | | limits, amount limits, deductibles, and co-insurance
| 18 | | requirements for serious mental illness as are provided for | 19 | | other illnesses
and diseases . This subsection does not apply to | 20 | | any group policy of accident and health insurance or health | 21 | | care plan for any plan year of a small employer as defined in | 22 | | Section 5 of the Illinois Health Insurance Portability and | 23 | | Accountability Act coverage provided to
employees by employers | 24 | | 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 |
| | | HB1530 Engrossed | - 14 - | LRB097 09356 RPM 49491 b |
|
| 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; | 14 | | (J) post-traumatic stress disorders (acute, chronic, | 15 | | or with delayed onset); and
| 16 | | (K) anorexia nervosa and bulimia nervosa. | 17 | | (2.5) "Substance use disorder" means the following mental | 18 | | disorders as defined in the most current edition of the | 19 | | Diagnostic and Statistical Manual (DSM) published by the | 20 | | American Psychiatric Association: | 21 | | (A) substance abuse disorders; | 22 | | (B) substance dependence disorders; and | 23 | | (C) substance induced disorders. | 24 | | (3) Unless otherwise prohibited by federal law and | 25 | | consistent with the parity requirements of Section 370c.1 of | 26 | | this Code, Upon request of the reimbursing insurer, a provider |
| | | HB1530 Engrossed | - 15 - | LRB097 09356 RPM 49491 b |
|
| 1 | | of treatment of
serious mental illness or substance use | 2 | | disorder shall furnish medical records or other necessary data
| 3 | | that substantiate that initial or continued treatment is at all | 4 | | times medically
necessary. An insurer shall provide a mechanism | 5 | | for the timely review by a
provider holding the same license | 6 | | and practicing in the same specialty as the
patient's provider, | 7 | | who is unaffiliated with the insurer, jointly selected by
the | 8 | | patient (or the patient's next of kin or legal representative | 9 | | if the
patient is unable to act for himself or herself), the | 10 | | patient's provider, and
the insurer in the event of a dispute | 11 | | between the insurer and patient's
provider regarding the | 12 | | medical necessity of a treatment proposed by a patient's
| 13 | | provider. If the reviewing provider determines the treatment to | 14 | | be medically
necessary, the insurer shall provide | 15 | | reimbursement for the treatment. Future
contractual or | 16 | | employment actions by the insurer regarding the patient's
| 17 | | provider may not be based on the provider's participation in | 18 | | this procedure.
Nothing prevents
the insured from agreeing in | 19 | | writing to continue treatment at his or her
expense. When | 20 | | making a determination of the medical necessity for a treatment
| 21 | | modality for serious serous mental illness or substance use | 22 | | disorder , an insurer must make the determination in a
manner | 23 | | that is consistent with the manner used to make that | 24 | | determination with
respect to other diseases or illnesses | 25 | | covered under the policy, including an
appeals process. Medical | 26 | | necessity determinations for substance use disorders shall be |
| | | HB1530 Engrossed | - 16 - | LRB097 09356 RPM 49491 b |
|
| 1 | | made in accordance with appropriate patient placement criteria | 2 | | established by the American Society of Addiction Medicine.
| 3 | | (4) A group health benefit plan amended, delivered, issued, | 4 | | or renewed on or after the effective date of this amendatory | 5 | | Act of the 97th General Assembly :
| 6 | | (A) shall provide coverage based upon medical | 7 | | necessity for the following
treatment of mental illness and | 8 | | substance use disorders consistent with the parity | 9 | | requirements of Section 370c.1 of this Code; provided, | 10 | | however, that in each calendar year coverage shall not be | 11 | | less than the following :
| 12 | | (i) 45 days of inpatient treatment; and
| 13 | | (ii) beginning on June 26, 2006 (the effective date | 14 | | of Public Act 94-921), 60 visits for outpatient | 15 | | treatment including group and individual
outpatient | 16 | | treatment; and | 17 | | (iii) for plans or policies delivered, issued for | 18 | | delivery, renewed, or modified after January 1, 2007 | 19 | | (the effective date of Public Act 94-906),
20 | 20 | | additional outpatient visits for speech therapy for | 21 | | treatment of pervasive developmental disorders that | 22 | | will be in addition to speech therapy provided pursuant | 23 | | to item (ii) of this subparagraph (A); and
| 24 | | (B) may not include a lifetime limit on the number of | 25 | | days of inpatient
treatment or the number of outpatient | 26 | | visits covered under the plan . ; and
|
| | | HB1530 Engrossed | - 17 - | LRB097 09356 RPM 49491 b |
|
| 1 | | (C) (Blank). shall include the same amount limits, | 2 | | deductibles, copayments, and
coinsurance factors for | 3 | | serious mental illness as for physical illness.
| 4 | | (5) An issuer of a group health benefit plan may not count | 5 | | toward the number
of outpatient visits required to be covered | 6 | | under this Section an outpatient
visit for the purpose of | 7 | | medication management and shall cover the outpatient
visits | 8 | | under the same terms and conditions as it covers outpatient | 9 | | visits for
the treatment of physical illness.
| 10 | | (6) An issuer of a group health benefit
plan may provide or | 11 | | offer coverage required under this Section through a
managed | 12 | | care plan.
| 13 | | (7) (Blank). This Section shall not be interpreted to | 14 | | require a group health benefit
plan to provide coverage for | 15 | | treatment of:
| 16 | | (A) an addiction to a controlled substance or cannabis | 17 | | that is used in
violation of law; or
| 18 | | (B) mental illness resulting from the use of a | 19 | | controlled substance or
cannabis in violation of law.
| 20 | | (8)
(Blank).
| 21 | | (9) With respect to substance use disorders, coverage for | 22 | | inpatient treatment shall include coverage for treatment in a | 23 | | residential treatment center licensed by the Department of | 24 | | Public Health or the Department of Human Services, Division of | 25 | | Alcoholism and Substance Abuse. | 26 | | (c) This Section shall not be interpreted to require |
| | | HB1530 Engrossed | - 18 - | LRB097 09356 RPM 49491 b |
|
| 1 | | coverage for speech therapy or other habilitative services for | 2 | | those individuals covered under Section 356z.15
of this Code. | 3 | | (Source: P.A. 95-331, eff. 8-21-07; 95-972, eff. 9-22-08; | 4 | | 95-973, eff. 1-1-09; 95-1049, eff. 1-1-10; 96-328, eff. | 5 | | 8-11-09; 96-1000, eff. 7-2-10.) | 6 | | (215 ILCS 5/370c.1 new) | 7 | | Sec. 370c.1. Mental health parity. | 8 | | (a) On and after the effective date of this amendatory Act | 9 | | of the 97th General Assembly, every insurer that amends, | 10 | | delivers, issues, or renews a group policy of accident and | 11 | | health insurance in this State providing coverage for hospital | 12 | | or medical treatment and for the treatment of mental, | 13 | | emotional, nervous, or substance use disorders or conditions | 14 | | shall ensure that: | 15 | | (1) the financial requirements applicable to such | 16 | | mental, emotional, nervous, or substance use disorder or | 17 | | condition benefits are no more restrictive than the | 18 | | predominant financial requirements applied to | 19 | | substantially all hospital and medical benefits covered by | 20 | | the policy and that there are no separate cost-sharing | 21 | | requirements that are applicable only with respect to | 22 | | mental, emotional, nervous, or substance use disorder or | 23 | | condition benefits; and | 24 | | (2) the treatment limitations applicable to such | 25 | | mental, emotional, nervous, or substance use disorder or |
| | | HB1530 Engrossed | - 19 - | LRB097 09356 RPM 49491 b |
|
| 1 | | condition benefits are no more restrictive than the | 2 | | predominant treatment limitations applied to substantially | 3 | | all hospital and medical benefits covered by the policy and | 4 | | that there are no separate treatment limitations that are | 5 | | applicable only with respect to mental, emotional, | 6 | | nervous, or substance use disorder or condition benefits. | 7 | | (b) The following provisions shall apply concerning | 8 | | aggregate lifetime limits: | 9 | | (1) In the case of a group policy of accident and | 10 | | health insurance amended, delivered, issued, or renewed in | 11 | | this State on or after the effective date of this | 12 | | amendatory Act of the 97th General Assembly that provides | 13 | | coverage for hospital or medical treatment and for the | 14 | | treatment of mental, emotional, nervous, or substance use | 15 | | disorders or conditions the following provisions shall | 16 | | apply: | 17 | | (A) if the policy does not include an aggregate | 18 | | lifetime limit on substantially all hospital and | 19 | | medical benefits, then the policy may not impose any | 20 | | aggregate lifetime limit on mental, emotional, | 21 | | nervous, or substance use disorder or condition | 22 | | benefits; or | 23 | | (B) if the policy includes an aggregate lifetime | 24 | | limit on substantially all hospital and medical | 25 | | benefits (in this subsection referred to as the | 26 | | "applicable lifetime limit"), then the policy shall |
| | | HB1530 Engrossed | - 20 - | LRB097 09356 RPM 49491 b |
|
| 1 | | either: | 2 | | (i) apply the applicable lifetime limit both | 3 | | to the hospital and medical benefits to which it | 4 | | otherwise would apply and to mental, emotional, | 5 | | nervous, or substance use disorder or condition | 6 | | benefits and not distinguish in the application of | 7 | | the limit between the hospital and medical | 8 | | benefits and mental, emotional, nervous, or | 9 | | substance use disorder or condition benefits; or | 10 | | (ii) not include any aggregate lifetime limit | 11 | | on mental, emotional, nervous, or substance use | 12 | | disorder or condition benefits that is less than | 13 | | the applicable lifetime limit. | 14 | | (2) In the case of a policy that is not described in | 15 | | paragraph (1) of subsection (b) of this Section and that | 16 | | includes no or different aggregate lifetime limits on | 17 | | different categories of hospital and medical benefits, the | 18 | | Director shall establish rules under which subparagraph | 19 | | (B) of paragraph (1) of subsection (b) of this Section is | 20 | | applied to such policy with respect to mental, emotional, | 21 | | nervous, or substance use disorder or condition benefits by | 22 | | substituting for the applicable lifetime limit an average | 23 | | aggregate lifetime limit that is computed taking into | 24 | | account the weighted average of the aggregate lifetime | 25 | | limits applicable to such categories. | 26 | | (c) The following provisions shall apply concerning annual |
| | | HB1530 Engrossed | - 21 - | LRB097 09356 RPM 49491 b |
|
| 1 | | limits: | 2 | | (1) In the case of a group policy of accident and | 3 | | health insurance amended, delivered, issued, or renewed in | 4 | | this State on or after the effective date of this | 5 | | amendatory Act of the 97th General Assembly that provides | 6 | | coverage for hospital or medical treatment and for the | 7 | | treatment of mental, emotional, nervous, or substance use | 8 | | disorders or conditions the following provisions shall | 9 | | apply: | 10 | | (A) if the policy does not include an annual limit | 11 | | on substantially all hospital and medical benefits, | 12 | | then the policy may not impose any annual limits on | 13 | | mental, emotional, nervous, or substance use disorder | 14 | | or condition benefits; or | 15 | | (B) if the policy includes an annual limit on | 16 | | substantially all hospital and medical benefits (in | 17 | | this subsection referred to as the "applicable annual | 18 | | limit"), then the policy shall either: | 19 | | (i) apply the applicable annual limit both to | 20 | | the hospital and medical benefits to which it | 21 | | otherwise would apply and to mental, emotional, | 22 | | nervous, or substance use disorder or condition | 23 | | benefits and not distinguish in the application of | 24 | | the limit between the hospital and medical | 25 | | benefits and mental, emotional, nervous, or | 26 | | substance use disorder or condition benefits; or |
| | | HB1530 Engrossed | - 22 - | LRB097 09356 RPM 49491 b |
|
| 1 | | (ii) not include any annual limit on mental, | 2 | | emotional, nervous, or substance use disorder or | 3 | | condition benefits that is less than the | 4 | | applicable annual limit. | 5 | | (2) In the case of a policy that is not described in | 6 | | paragraph (1) of subsection (c) of this Section and that | 7 | | includes no or different annual limits on different | 8 | | categories of hospital and medical benefits, the Director | 9 | | shall establish rules under which subparagraph (B) of | 10 | | paragraph (1) of subsection (c) of this Section is applied | 11 | | to such policy with respect to mental, emotional, nervous, | 12 | | or substance use disorder or condition benefits by | 13 | | substituting for the applicable annual limit an average | 14 | | annual limit that is computed taking into account the | 15 | | weighted average of the annual limits applicable to such | 16 | | categories. | 17 | | (d) This Section shall be interpreted in a manner | 18 | | consistent with the interim final regulations promulgated by | 19 | | the U.S. Department of Health and Human Services at 75 FR 5410, | 20 | | including the prohibition against applying a cumulative | 21 | | financial requirement or cumulative quantitative treatment | 22 | | limitation for mental, emotional, nervous, or substance use | 23 | | disorder benefits that accumulates separately from any | 24 | | cumulative financial requirement or cumulative quantitative | 25 | | treatment limitation established for hospital and medical | 26 | | benefits in the same classification. |
| | | HB1530 Engrossed | - 23 - | LRB097 09356 RPM 49491 b |
|
| 1 | | (e) The provisions of subsections (b) and (c) of this | 2 | | Section shall not be interpreted to allow the use of lifetime | 3 | | or annual limits otherwise prohibited by State or federal law. | 4 | | (f) As used in this Section: | 5 | | "Financial requirement" includes deductibles, copayments, | 6 | | coinsurance, and out-of-pocket maximums, but does not include | 7 | | an aggregate lifetime limit or an annual limit subject to | 8 | | subsections (b) and (c). | 9 | | "Treatment limitation" includes limits on benefits based | 10 | | on the frequency of treatment, number of visits, days of | 11 | | coverage, days in a waiting period, or other similar limits on | 12 | | the scope or duration of treatment. "Treatment limitation" | 13 | | includes both quantitative treatment limitations, which are | 14 | | expressed numerically (such as 50 outpatient visits per year), | 15 | | and nonquantitative treatment limitations, which otherwise | 16 | | limit the scope or duration of treatment. A permanent exclusion | 17 | | of all benefits for a particular condition or disorder shall | 18 | | not be considered a treatment limitation. | 19 | | Section 10. The Health Maintenance Organization Act is | 20 | | amended by changing Section 5-3 as follows:
| 21 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 22 | | Sec. 5-3. Insurance Code provisions.
| 23 | | (a) Health Maintenance Organizations
shall be subject to | 24 | | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, |
| | | HB1530 Engrossed | - 24 - | LRB097 09356 RPM 49491 b |
|
| 1 | | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | 2 | | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | 3 | | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | 4 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | 5 | | 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | 6 | | 368e, 370c, 370c.1,
401, 401.1, 402, 403, 403A,
408, 408.2, | 7 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | 8 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | 9 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 10 | | (b) For purposes of the Illinois Insurance Code, except for | 11 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 12 | | Maintenance Organizations in
the following categories are | 13 | | deemed to be "domestic companies":
| 14 | | (1) a corporation authorized under the
Dental Service | 15 | | Plan Act or the Voluntary Health Services Plans Act;
| 16 | | (2) a corporation organized under the laws of this | 17 | | State; or
| 18 | | (3) a corporation organized under the laws of another | 19 | | state, 30% or more
of the enrollees of which are residents | 20 | | of this State, except a
corporation subject to | 21 | | substantially the same requirements in its state of
| 22 | | organization as is a "domestic company" under Article VIII | 23 | | 1/2 of the
Illinois Insurance Code.
| 24 | | (c) In considering the merger, consolidation, or other | 25 | | acquisition of
control of a Health Maintenance Organization | 26 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
|
| | | HB1530 Engrossed | - 25 - | LRB097 09356 RPM 49491 b |
|
| 1 | | (1) the Director shall give primary consideration to | 2 | | the continuation of
benefits to enrollees and the financial | 3 | | conditions of the acquired Health
Maintenance Organization | 4 | | after the merger, consolidation, or other
acquisition of | 5 | | control takes effect;
| 6 | | (2)(i) the criteria specified in subsection (1)(b) of | 7 | | Section 131.8 of
the Illinois Insurance Code shall not | 8 | | apply and (ii) the Director, in making
his determination | 9 | | with respect to the merger, consolidation, or other
| 10 | | acquisition of control, need not take into account the | 11 | | effect on
competition of the merger, consolidation, or | 12 | | other acquisition of control;
| 13 | | (3) the Director shall have the power to require the | 14 | | following
information:
| 15 | | (A) certification by an independent actuary of the | 16 | | adequacy
of the reserves of the Health Maintenance | 17 | | Organization sought to be acquired;
| 18 | | (B) pro forma financial statements reflecting the | 19 | | combined balance
sheets of the acquiring company and | 20 | | the Health Maintenance Organization sought
to be | 21 | | acquired as of the end of the preceding year and as of | 22 | | a date 90 days
prior to the acquisition, as well as pro | 23 | | forma financial statements
reflecting projected | 24 | | combined operation for a period of 2 years;
| 25 | | (C) a pro forma business plan detailing an | 26 | | acquiring party's plans with
respect to the operation |
| | | HB1530 Engrossed | - 26 - | LRB097 09356 RPM 49491 b |
|
| 1 | | of the Health Maintenance Organization sought to
be | 2 | | acquired for a period of not less than 3 years; and
| 3 | | (D) such other information as the Director shall | 4 | | require.
| 5 | | (d) The provisions of Article VIII 1/2 of the Illinois | 6 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 7 | | any health maintenance
organization of greater than 10% of its
| 8 | | enrollee population (including without limitation the health | 9 | | maintenance
organization's right, title, and interest in and to | 10 | | its health care
certificates).
| 11 | | (e) In considering any management contract or service | 12 | | agreement subject
to Section 141.1 of the Illinois Insurance | 13 | | Code, the Director (i) shall, in
addition to the criteria | 14 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 15 | | into account the effect of the management contract or
service | 16 | | agreement on the continuation of benefits to enrollees and the
| 17 | | financial condition of the health maintenance organization to | 18 | | be managed or
serviced, and (ii) need not take into account the | 19 | | effect of the management
contract or service agreement on | 20 | | competition.
| 21 | | (f) Except for small employer groups as defined in the | 22 | | Small Employer
Rating, Renewability and Portability Health | 23 | | Insurance Act and except for
medicare supplement policies as | 24 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 25 | | Maintenance Organization may by contract agree with a
group or | 26 | | other enrollment unit to effect refunds or charge additional |
| | | HB1530 Engrossed | - 27 - | LRB097 09356 RPM 49491 b |
|
| 1 | | premiums
under the following terms and conditions:
| 2 | | (i) the amount of, and other terms and conditions with | 3 | | respect to, the
refund or additional premium are set forth | 4 | | in the group or enrollment unit
contract agreed in advance | 5 | | of the period for which a refund is to be paid or
| 6 | | additional premium is to be charged (which period shall not | 7 | | be less than one
year); and
| 8 | | (ii) the amount of the refund or additional premium | 9 | | shall not exceed 20%
of the Health Maintenance | 10 | | Organization's profitable or unprofitable experience
with | 11 | | respect to the group or other enrollment unit for the | 12 | | period (and, for
purposes of a refund or additional | 13 | | premium, the profitable or unprofitable
experience shall | 14 | | be calculated taking into account a pro rata share of the
| 15 | | Health Maintenance Organization's administrative and | 16 | | marketing expenses, but
shall not include any refund to be | 17 | | made or additional premium to be paid
pursuant to this | 18 | | subsection (f)). The Health Maintenance Organization and | 19 | | the
group or enrollment unit may agree that the profitable | 20 | | or unprofitable
experience may be calculated taking into | 21 | | account the refund period and the
immediately preceding 2 | 22 | | plan years.
| 23 | | The Health Maintenance Organization shall include a | 24 | | statement in the
evidence of coverage issued to each enrollee | 25 | | describing the possibility of a
refund or additional premium, | 26 | | and upon request of any group or enrollment unit,
provide to |
| | | HB1530 Engrossed | - 28 - | LRB097 09356 RPM 49491 b |
|
| 1 | | the group or enrollment unit a description of the method used | 2 | | to
calculate (1) the Health Maintenance Organization's | 3 | | profitable experience with
respect to the group or enrollment | 4 | | unit and the resulting refund to the group
or enrollment unit | 5 | | or (2) the Health Maintenance Organization's unprofitable
| 6 | | experience with respect to the group or enrollment unit and the | 7 | | resulting
additional premium to be paid by the group or | 8 | | enrollment unit.
| 9 | | In no event shall the Illinois Health Maintenance | 10 | | Organization
Guaranty Association be liable to pay any | 11 | | contractual obligation of an
insolvent organization to pay any | 12 | | refund authorized under this Section.
| 13 | | (g) Rulemaking authority to implement Public Act 95-1045, | 14 | | if any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | 20 | | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | 21 | | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | 22 | | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | 23 | | 6-1-10; 96-1000, eff. 7-2-10.)
| 24 | | Section 99. Effective date. This Act takes effect upon | 25 | | becoming law.
|
|