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90_HB0428
215 ILCS 5/370c from Ch. 73, par. 982c
215 ILCS 5/370c-1 new
Amends the Illinois Insurance Code. Requires individual
and group policies of accident and health insurance and other
health care plans to provide coverage for serious mental
illness under the same terms and conditions as coverage is
provided for other illnesses. Provides that inpatient
treatment may be limited to 90 consecutive days. Defines
terms. Effective immediately.
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1 AN ACT to amend the Illinois Insurance Code by changing
2 Section 370c and adding Section 370c-1.
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 serious mental illnesses subject to
18 Section 370c-1, up to the limits provided in the policy for
19 other disorders or conditions, except (i) the insured may be
20 required to pay up to 50% of expenses incurred as a result of
21 the treatment or services, and (ii) the annual benefit limit
22 may be limited to the lesser of $10,000 or 25% of the
23 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
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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 serious mental illness.
22 (a) An insurer that provides coverage for hospital or
23 medical expenses under a group or individual policy of
24 accident and health insurance or health care plan amended,
25 delivered, issued, or renewed after the effective date of
26 this amendatory Act of 1997 shall provide coverage under the
27 policy for treatment of serious mental illness under the same
28 terms and conditions as coverage for hospital or medical
29 expenses related to other illnesses and diseases. The
30 coverage required under this Section must provide the same
31 durational limits, amount limits, deductibles, and
32 co-insurance requirements for serious mental illness as are
33 provided for other illnesses and diseases.
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1 (b) "Serious mental illness" means any mental disorders
2 that are caused by factors including a biological or
3 physiological disorder of the brain or psychosocial factors
4 that substantially limit the life activities of the person
5 with the illness. Examples include, but are not limited to,
6 the following as described in the most current edition of the
7 Diagnostic and Statistical Manual (DSM) published by the
8 American Psychiatric Association:
9 (1) Schizophrenia.
10 (2) Pervasive developmental disorder.
11 (3) Autistic disorders.
12 (4) Schizoaffective disorder.
13 (5) Delusional disorder.
14 (6) Bipolar disorder.
15 (7) Major depression.
16 (8) Obsessive compulsive disorder.
17 (9) Panic disorder.
18 (c) Upon request of the reimbursing insurer, a provider
19 of treatment of serious mental illness shall furnish medical
20 records or other necessary data that substantiate that
21 initial or continued treatment is at all times medically
22 necessary. An insurer shall provide a mechanism for the
23 timely review by a provider holding the same license and
24 practicing in the same specialty as the patient's provider,
25 who is unaffiliated with the insurer, jointly selected by the
26 patient (or the patient's next of kin or legal representative
27 if the patient is unable to act for himself or herself), the
28 patient's provider, and the insurer in the event of a dispute
29 between the insurer and patient's provider regarding the
30 medical necessity of a treatment proposed by a patient's
31 provider. If the reviewing provider determines the treatment
32 to be medically necessary, the insurer shall provide
33 reimbursement for the treatment. Future contractual or
34 employment actions by the insurer regarding the patient's
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1 provider shall not be based on the provider's participation
2 in this procedure. Nothing prevents the insured from
3 agreeing in writing to continue treatment at his or her
4 expense.
5 When making a determination of the medical necessity for
6 a treatment modality for serious mental illness, an insurer
7 must make the determination in a manner that is consistent
8 with the manner used to make that determination with respect
9 to other diseases or illnesses covered under the policy,
10 including an appeals process.
11 (d) Inpatient coverage under this Section when
12 continuous hospitalization is medically necessary may be
13 limited to 90 consecutive days.
14 Section 99. Effective date. This Act takes effect upon
15 becoming law.