[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
90_HB0081
215 ILCS 5/370c from Ch. 73, par. 982c
215 ILCS 5/370c-1 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/4003 from Ch. 73, par. 1504-3
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code. Requires individual
and group policies of accident and health insurance to
provide coverage for certain biologically-based mental
illnesses under the same terms and conditions as coverage is
provided for other illnesses. Amends the Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act to require identical
coverage under those Acts.
LRB9000060JScw
LRB9000060JScw
1 AN ACT concerning certain biologically-based mental
2 illnesses, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 changing Section 370c and adding Section 370c-1 as follows:
7 (215 ILCS 5/370c) (from Ch. 73, par. 982c)
8 Sec. 370c. Mental and emotional disorders.
9 (1) On and after the effective date of this Section,
10 every insurer which delivers, issues for delivery or renews
11 or modifies group A&H policies providing coverage for
12 hospital or medical treatment or services for illness on an
13 expense-incurred basis shall offer to the applicant or group
14 policyholder subject to the insurers standards of
15 insurability, coverage for reasonable and necessary treatment
16 and services for mental, emotional, or nervous disorders or
17 conditions, other than biologically-based mental illnesses
18 subject to Section 370c-1, up to the limits provided in the
19 policy for other disorders or conditions, except (i) the
20 insured may be required to pay up to 50% of expenses incurred
21 as a result of the treatment or services, and (ii) the annual
22 benefit limit may be limited to the lesser of $10,000 or 25%
23 of the lifetime policy limit.
24 (2) Each insured that is covered for mental, emotional
25 or nervous disorders or conditions shall be free to select
26 the physician licensed to practice medicine in all its
27 branches, licensed clinical psychologist, or licensed
28 clinical social worker of his choice to treat such disorders,
29 and the insurer shall pay the covered charges of such
30 physician licensed to practice medicine in all its branches,
31 licensed clinical psychologist, or licensed clinical social
-2- LRB9000060JScw
1 worker up to the limits of coverage, provided (i) the
2 disorder or condition treated is covered by the policy, and
3 (ii) the physician, licensed psychologist, or licensed
4 clinical social worker is authorized to provide said services
5 under the statutes of this State and in accordance with
6 accepted principles of his profession.
7 Insofar as this Section applies solely to licensed
8 clinical social workers, those persons who may provide
9 services to individuals shall do so after the licensed
10 clinical social worker has informed the patient of the
11 desirability of the patient conferring with the patient's
12 primary care physician and the licensed clinical social
13 worker has provided written notification to the patient's
14 primary care physician, if any, that services are being
15 provided to the patient. That notification may, however, be
16 waived by the patient on a written form. Those forms shall
17 be retained by the licensed clinical social worker for a
18 period of not less than 5 years.
19 (Source: P.A. 86-1434.)
20 (215 ILCS 5/370c-1 new)
21 Sec. 370c-1. Coverage for certain biologically-based
22 mental illnesses.
23 (a) For the purposes of this Section "mental illness"
24 means a clinically significant or psychological syndrome or
25 pattern that occurs in a person and that is associated with
26 present distress, a painful symptom or disability, impairment
27 in one or more important areas of functioning, or with a
28 significantly increased risk of suffering death, pain,
29 disability, or an important loss of freedom.
30 (b) An insurer that provides coverage for hospital or
31 medical expenses under a group or individual policy of
32 accident and health insurance amended, delivered, issued, or
33 renewed after the effective date of this amendatory Act of
-3- LRB9000060JScw
1 1997 shall provide coverage under the policy for treatment
2 and diagnosis of certain biologically-based mental illnesses
3 under the same terms and conditions as coverage for hospital
4 or medical expenses related to other illnesses and diseases.
5 (c) The following mental illnesses, as defined in the
6 most current edition of the Diagnostic and Statistical Manual
7 (DSM) of Mental Disorders published by the American
8 Psychiatric Association, shall be covered under this Section:
9 (1) Schizophrenia.
10 (2) Schizoaffective disorder.
11 (3) Major depressive disorder.
12 (4) Bioplar disorder.
13 (5) Paranoia and other psychotic disorders.
14 (6) Obsessive-compulsive disorders.
15 (7) Panic disorder.
16 (8) Pervasive developmental disorder or autism.
17 Section 10. The Health Maintenance Organization Act is
18 amended by changing Section 5-3 as follows:
19 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
20 Sec. 5-3. Insurance Code provisions.
21 (a) Health Maintenance Organizations shall be subject to
22 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
23 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
24 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 370c-1, 367i, 401,
25 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
26 subsection (2) of Section 367, and Articles VIII 1/2, XII,
27 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
28 Code.
29 (b) For purposes of the Illinois Insurance Code, except
30 for Articles XIII and XIII 1/2, Health Maintenance
31 Organizations in the following categories are deemed to be
32 "domestic companies":
-4- LRB9000060JScw
1 (1) a corporation authorized under the Medical
2 Service Plan Act, the Dental Service Plan Act, the Vision
3 Service Plan Act, the Pharmaceutical Service Plan Act,
4 the Voluntary Health Services Plan Act, or the Nonprofit
5 Health Care Service Plan Act;
6 (2) a corporation organized under the laws of this
7 State; or
8 (3) a corporation organized under the laws of
9 another state, 30% or more of the enrollees of which are
10 residents of this State, except a corporation subject to
11 substantially the same requirements in its state of
12 organization as is a "domestic company" under Article
13 VIII 1/2 of the Illinois Insurance Code.
14 (c) In considering the merger, consolidation, or other
15 acquisition of control of a Health Maintenance Organization
16 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17 (1) the Director shall give primary consideration
18 to the continuation of benefits to enrollees and the
19 financial conditions of the acquired Health Maintenance
20 Organization after the merger, consolidation, or other
21 acquisition of control takes effect;
22 (2)(i) the criteria specified in subsection (1)(b)
23 of Section 131.8 of the Illinois Insurance Code shall not
24 apply and (ii) the Director, in making his determination
25 with respect to the merger, consolidation, or other
26 acquisition of control, need not take into account the
27 effect on competition of the merger, consolidation, or
28 other acquisition of control;
29 (3) the Director shall have the power to require
30 the following information:
31 (A) certification by an independent actuary of
32 the adequacy of the reserves of the Health
33 Maintenance Organization sought to be acquired;
34 (B) pro forma financial statements reflecting
-5- LRB9000060JScw
1 the combined balance sheets of the acquiring company
2 and the Health Maintenance Organization sought to be
3 acquired as of the end of the preceding year and as
4 of a date 90 days prior to the acquisition, as well
5 as pro forma financial statements reflecting
6 projected combined operation for a period of 2
7 years;
8 (C) a pro forma business plan detailing an
9 acquiring party's plans with respect to the
10 operation of the Health Maintenance Organization
11 sought to be acquired for a period of not less than
12 3 years; and
13 (D) such other information as the Director
14 shall require.
15 (d) The provisions of Article VIII 1/2 of the Illinois
16 Insurance Code and this Section 5-3 shall apply to the sale
17 by any health maintenance organization of greater than 10% of
18 its enrollee population (including without limitation the
19 health maintenance organization's right, title, and interest
20 in and to its health care certificates).
21 (e) In considering any management contract or service
22 agreement subject to Section 141.1 of the Illinois Insurance
23 Code, the Director (i) shall, in addition to the criteria
24 specified in Section 141.2 of the Illinois Insurance Code,
25 take into account the effect of the management contract or
26 service agreement on the continuation of benefits to
27 enrollees and the financial condition of the health
28 maintenance organization to be managed or serviced, and (ii)
29 need not take into account the effect of the management
30 contract or service agreement on competition.
31 (f) Except for small employer groups as defined in the
32 Small Employer Rating, Renewability and Portability Health
33 Insurance Act and except for medicare supplement policies as
34 defined in Section 363 of the Illinois Insurance Code, a
-6- LRB9000060JScw
1 Health Maintenance Organization may by contract agree with a
2 group or other enrollment unit to effect refunds or charge
3 additional premiums under the following terms and conditions:
4 (i) the amount of, and other terms and conditions
5 with respect to, the refund or additional premium are set
6 forth in the group or enrollment unit contract agreed in
7 advance of the period for which a refund is to be paid or
8 additional premium is to be charged (which period shall
9 not be less than one year); and
10 (ii) the amount of the refund or additional premium
11 shall not exceed 20% of the Health Maintenance
12 Organization's profitable or unprofitable experience with
13 respect to the group or other enrollment unit for the
14 period (and, for purposes of a refund or additional
15 premium, the profitable or unprofitable experience shall
16 be calculated taking into account a pro rata share of the
17 Health Maintenance Organization's administrative and
18 marketing expenses, but shall not include any refund to
19 be made or additional premium to be paid pursuant to this
20 subsection (f)). The Health Maintenance Organization and
21 the group or enrollment unit may agree that the
22 profitable or unprofitable experience may be calculated
23 taking into account the refund period and the immediately
24 preceding 2 plan years.
25 The Health Maintenance Organization shall include a
26 statement in the evidence of coverage issued to each enrollee
27 describing the possibility of a refund or additional premium,
28 and upon request of any group or enrollment unit, provide to
29 the group or enrollment unit a description of the method used
30 to calculate (1) the Health Maintenance Organization's
31 profitable experience with respect to the group or enrollment
32 unit and the resulting refund to the group or enrollment unit
33 or (2) the Health Maintenance Organization's unprofitable
34 experience with respect to the group or enrollment unit and
-7- LRB9000060JScw
1 the resulting additional premium to be paid by the group or
2 enrollment unit.
3 In no event shall the Illinois Health Maintenance
4 Organization Guaranty Association be liable to pay any
5 contractual obligation of an insolvent organization to pay
6 any refund authorized under this Section.
7 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
8 Section 15. The Limited Health Service Organization Act
9 is amended by changing Section 4003 as follows:
10 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
11 Sec. 4003. Illinois Insurance Code provisions. Limited
12 health service organizations shall be subject to the
13 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
14 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
15 154.6, 154.7, 154.8, 155.04, 355.2, 370c-1, 401, 401.1, 402,
16 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
17 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
18 Code. For purposes of the Illinois Insurance Code, except
19 for Articles XIII and XIII 1/2, limited health service
20 organizations in the following categories are deemed to be
21 domestic companies:
22 (1) a corporation under the laws of this State; or
23 (2) a corporation organized under the laws of
24 another state, 30% of more of the enrollees of which are
25 residents of this State, except a corporation subject to
26 substantially the same requirements in its state of
27 organization as is a domestic company under Article VIII
28 1/2 of the Illinois Insurance Code.
29 (Source: P.A. 86-600; 87-587; 87-1090.)
30 Section 20. The Voluntary Health Services Plans Act is
31 amended by changing Section 10 as follows:
-8- LRB9000060JScw
1 (215 ILCS 165/10) (from Ch. 32, par. 604)
2 Sec. 10. Application of Insurance Code provisions.
3 Health services plan corporations and all persons interested
4 therein or dealing therewith shall be subject to the
5 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
6 143, 143c, 149, 354, 355.2, 356r, 367.2, 370c-1, 401, 401.1,
7 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
8 (15) of Section 367 of the Illinois Insurance Code.
9 (Source: P.A. 89-514, eff. 7-17-96.)