State of Illinois
92nd General Assembly

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SB1341 Enrolled                                LRB9208220JSpc

 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 Department of Insurance Law of the Civil
 5    Administrative Code of Illinois is amended by adding  Section
 6    1405-30 as follows:

 7        (20 ILCS 1405/1405-30)
 8        Sec. 1405-30. Mental health insurance study.
 9        (a)  The   Department   of  Insurance  shall  conduct  an
10    analysis and study of costs and  benefits  derived  from  the
11    implementation  of the coverage requirements for treatment of
12    mental  disorders  established  under  Section  370c  of  the
13    Illinois Insurance Code.  The study  shall  cover  the  years
14    2002, 2003, and 2004.  The study shall include an analysis of
15    the  effect  of  the  coverage  requirements  on  the cost of
16    insurance and health care, the results of the  treatments  to
17    patients,  any  improvements  in  care  of  patients, and any
18    improvements in the quality of life of patients.
19        (b)  The Department shall report the results of its study
20    to the General Assembly and the Governor on or  before  March
21    1, 2005.

22        Section  10.  The  Illinois  Insurance Code is amended by
23    changing Section 370c as follows:

24        (215 ILCS 5/370c) (from Ch. 73, par. 982c)
25        Sec. 370c.  Mental and emotional disorders.
26        (a) (1)  On and after the effective date of this Section,
27    every insurer which delivers, issues for delivery  or  renews
28    or   modifies  group  A&H  policies  providing  coverage  for
29    hospital or medical treatment or services for illness  on  an
SB1341 Enrolled             -2-                LRB9208220JSpc
 1    expense-incurred  basis shall offer to the applicant or group
 2    policyholder   subject   to   the   insurers   standards   of
 3    insurability, coverage for reasonable and necessary treatment
 4    and services for mental, emotional or  nervous  disorders  or
 5    conditions, other than serious mental illnesses as defined in
 6    item  (2) of subsection (b), up to the limits provided in the
 7    policy for other disorders  or  conditions,  except  (i)  the
 8    insured may be required to pay up to 50% of expenses incurred
 9    as a result of the treatment or services, and (ii) the annual
10    benefit  limit may be limited to the lesser of $10,000 or 25%
11    of the lifetime policy limit.
12        (2)  Each insured that is covered for  mental,  emotional
13    or  nervous  disorders  or conditions shall be free to select
14    the physician  licensed  to  practice  medicine  in  all  its
15    branches,   licensed   clinical   psychologist,  or  licensed
16    clinical social worker of his choice to treat such disorders,
17    and the  insurer  shall  pay  the  covered  charges  of  such
18    physician  licensed to practice medicine in all its branches,
19    licensed clinical psychologist, or licensed  clinical  social
20    worker  up  to  the  limits  of  coverage,  provided  (i) the
21    disorder or condition treated is covered by the  policy,  and
22    (ii)   the  physician,  licensed  psychologist,  or  licensed
23    clinical social worker is authorized to provide said services
24    under the statutes of  this  State  and  in  accordance  with
25    accepted principles of his profession.
26        (3)  Insofar  as  this Section applies solely to licensed
27    clinical  social  workers,  those  persons  who  may  provide
28    services to  individuals  shall  do  so  after  the  licensed
29    clinical  social  worker  has  informed  the  patient  of the
30    desirability of the patient  conferring  with  the  patient's
31    primary  care  physician  and  the  licensed  clinical social
32    worker has provided written  notification  to  the  patient's
33    primary  care  physician,  if  any,  that  services are being
34    provided to the patient.  That notification may, however,  be
SB1341 Enrolled             -3-                LRB9208220JSpc
 1    waived  by  the patient on a written form.  Those forms shall
 2    be retained by the licensed  clinical  social  worker  for  a
 3    period of not less than 5 years.
 4        (b) (1)  An  insurer  that provides coverage for hospital
 5    or medical expenses under a  group  policy  of  accident  and
 6    health  insurance  or  health  care  plan amended, delivered,
 7    issued,  or  renewed  after  the  effective  date   of   this
 8    amendatory  Act  of  the  92nd General Assembly shall provide
 9    coverage under the policy for  treatment  of  serious  mental
10    illness  under  the same terms and conditions as coverage for
11    hospital or medical expenses related to other  illnesses  and
12    diseases.   The  coverage  required  under  this Section must
13    provide  for   same   durational   limits,   amount   limits,
14    deductibles, and co-insurance requirements for serious mental
15    illness  as  are  provided  for other illnesses and diseases.
16    This subsection  does  not  apply  to  coverage  provided  to
17    employees by employers who have 50 or fewer employees.
18        (2)  "Serious   mental   illness"   means  the  following
19    psychiatric illnesses as defined in the most current  edition
20    of  the  Diagnostic and Statistical Manual (DSM) published by
21    the American Psychiatric Association:
22             (A)  schizophrenia;
23             (B)  paranoid and other psychotic disorders;
24             (C)  bipolar    disorders     (hypomanic,     manic,
25        depressive, and mixed);
26             (D)  major  depressive  disorders (single episode or
27        recurrent);
28             (E)  schizoaffective    disorders    (bipolar     or
29        depressive);
30             (F)  pervasive developmental disorders;
31             (G)  obsessive-compulsive disorders;
32             (H)  depression in childhood and adolescence; and
33             (I)  panic disorder.
34        (3)  Upon  request of the reimbursing insurer, a provider
SB1341 Enrolled             -4-                LRB9208220JSpc
 1    of treatment of serious mental illness shall furnish  medical
 2    records  or  other  necessary  data  that  substantiate  that
 3    initial  or  continued  treatment  is  at all times medically
 4    necessary.  An insurer shall  provide  a  mechanism  for  the
 5    timely  review  by  a  provider  holding the same license and
 6    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
14    to  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
19    in writing to continue treatment at his or her expense.  When
20    making  a  determination  of  the  medical  necessity  for  a
21    treatment modality for serous mental illness, an insurer must
22    make the determination in a manner that  is  consistent  with
23    the  manner  used  to make that determination with respect to
24    other  diseases  or  illnesses  covered  under  the   policy,
25    including an appeals process.
26        (4)  A group health benefit plan:
27             (A)  shall   provide  coverage  based  upon  medical
28        necessity for the following treatment of  mental  illness
29        in each calendar year;
30                  (i)  45 days of inpatient treatment; and
31                  (ii)  35   visits   for   outpatient  treatment
32             including group and individual outpatient treatment;
33             (B)  may not include a lifetime limit on the  number
34        of   days   of  inpatient  treatment  or  the  number  of
SB1341 Enrolled             -5-                LRB9208220JSpc
 1        outpatient visits covered under the plan; and
 2             (C)  shall   include   the   same   amount   limits,
 3        deductibles,  copayments,  and  coinsurance  factors  for
 4        serious mental illness as for physical illness.
 5        (5)  An issuer of a group health  benefit  plan  may  not
 6    count  toward  the number of outpatient visits required to be
 7    covered under  this  Section  an  outpatient  visit  for  the
 8    purpose   of   medication  management  and  shall  cover  the
 9    outpatient visits under the same terms and conditions  as  it
10    covers  outpatient  visits  for  the  treatment  of  physical
11    illness.
12        (6)  An issuer of a group health benefit plan may provide
13    or  offer  coverage  required  under  this  Section through a
14    managed care plan.
15        (7)  This Section shall not be interpreted to  require  a
16    group  health  benefit plan to provide coverage for treatment
17    of:
18             (A)  an  addiction  to  a  controlled  substance  or
19        cannabis that is used in violation of law; or
20             (B)  mental illness resulting  from  the  use  of  a
21        controlled substance or cannabis in violation of law.
22        (8)  This  subsection  (b)  is inoperative after December
23    31, 2005.
24    (Source: P.A. 86-1434.)

25        Section 99.   Effective  date.   This  Act  takes  effect
26    January 1, 2002.

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