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92_SB1341enr 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.