State of Illinois
92nd General Assembly

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 1        AN ACT in relation to 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 and adding Section 370c-1 as follows:

 6        (215 ILCS 5/370c) (from Ch. 73, par. 982c)
 7        Sec. 370c.  Mental and emotional disorders.
 8        (1)  On  and  after  the  effective date of this Section,
 9    every insurer which delivers, issues for delivery  or  renews
10    or   modifies  group  A&H  policies  providing  coverage  for
11    hospital or 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 subject to
17    Section 370c-1, up to the limits provided in the  policy  for
18    other  disorders or conditions, except (i) the insured may be
19    required to pay up to 50% of expenses incurred as a result of
20    the treatment or services, and (ii) the annual benefit  limit
21    may  be  limited  to  the  lesser  of  $10,000  or 25% of the
22    lifetime policy limit.
23        (2)  Each insured that is covered for  mental,  emotional
24    or  nervous  disorders  or conditions shall be free to select
25    the physician  licensed  to  practice  medicine  in  all  its
26    branches,   licensed   clinical   psychologist,  or  licensed
27    clinical social worker of his choice to treat such disorders,
28    and the  insurer  shall  pay  the  covered  charges  of  such
29    physician  licensed to practice medicine in all its branches,
30    licensed clinical psychologist, or licensed  clinical  social
31    worker  up  to  the  limits  of  coverage,  provided  (i) the
                            -2-                LRB9201977JSpc
 1    disorder or condition treated is covered by the  policy,  and
 2    (ii)   the  physician,  licensed  psychologist,  or  licensed
 3    clinical social worker is authorized to provide said services
 4    under the statutes of  this  State  and  in  accordance  with
 5    accepted principles of his profession.
 6        Insofar  as  this  Section  applies  solely  to  licensed
 7    clinical  social  workers,  those  persons  who  may  provide
 8    services  to  individuals  shall  do  so  after  the licensed
 9    clinical social  worker  has  informed  the  patient  of  the
10    desirability  of  the  patient  conferring with the patient's
11    primary care  physician  and  the  licensed  clinical  social
12    worker  has  provided  written  notification to the patient's
13    primary care physician,  if  any,  that  services  are  being
14    provided  to the patient.  That notification may, however, be
15    waived by the patient on a written form.  Those  forms  shall
16    be  retained  by  the  licensed  clinical social worker for a
17    period of not less than 5 years.
18    (Source: P.A. 86-1434.)

19        (215 ILCS 5/370c-1 new)
20        Sec. 370c-1.  Coverage for serious mental illness.
21        (a)  An insurer that provides coverage  for  hospital  or
22    medical  expenses  under  a  group  or  individual  policy of
23    accident and health insurance or health  care  plan  amended,
24    delivered,  issued,  or  renewed  after the effective date of
25    this amendatory  Act  of  the  92nd  General  Assembly  shall
26    provide  coverage  under  the policy for treatment of serious
27    mental  illness  under  the  same  terms  and  conditions  as
28    coverage for hospital or medical expenses  related  to  other
29    illnesses  and  diseases.   The  coverage required under this
30    Section must  provide  the  same  durational  limits,  amount
31    limits,   deductibles,   and  co-insurance  requirements  for
32    serious mental illness as are provided  for  other  illnesses
33    and diseases.
                            -3-                LRB9201977JSpc
 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
                            -4-                LRB9201977JSpc
 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.

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