Public Act 094-0921
 
HB4202 Enrolled LRB094 14922 LJB 49994 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Section 370c as follows:
 
    (215 ILCS 5/370c)  (from Ch. 73, par. 982c)
    Sec. 370c. Mental and emotional disorders.
    (a) (1) On and after the effective date of this Section,
every insurer which delivers, issues for delivery or renews or
modifies group A&H policies providing coverage for hospital or
medical treatment or services for illness on an
expense-incurred basis shall offer to the applicant or group
policyholder subject to the insurers standards of
insurability, coverage for reasonable and necessary treatment
and services for mental, emotional or nervous disorders or
conditions, other than serious mental illnesses as defined in
item (2) of subsection (b), up to the limits provided in the
policy for other disorders or conditions, except (i) the
insured may be required to pay up to 50% of expenses incurred
as a result of the treatment or services, and (ii) the annual
benefit limit may be limited to the lesser of $10,000 or 25% of
the lifetime policy limit.
    (2) Each insured that is covered for mental, emotional or
nervous disorders or conditions shall be free to select the
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, licensed clinical social
worker, or licensed clinical professional counselor of his
choice to treat such disorders, and the insurer shall pay the
covered charges of such physician licensed to practice medicine
in all its branches, licensed clinical psychologist, licensed
clinical social worker, or licensed clinical professional
counselor up to the limits of coverage, provided (i) the
disorder or condition treated is covered by the policy, and
(ii) the physician, licensed psychologist, licensed clinical
social worker, or licensed clinical professional counselor is
authorized to provide said services under the statutes of this
State and in accordance with accepted principles of his
profession.
    (3) Insofar as this Section applies solely to licensed
clinical social workers and licensed clinical professional
counselors, those persons who may provide services to
individuals shall do so after the licensed clinical social
worker or licensed clinical professional counselor has
informed the patient of the desirability of the patient
conferring with the patient's primary care physician and the
licensed clinical social worker or licensed clinical
professional counselor has provided written notification to
the patient's primary care physician, if any, that services are
being provided to the patient. That notification may, however,
be waived by the patient on a written form. Those forms shall
be retained by the licensed clinical social worker or licensed
clinical professional counselor for a period of not less than 5
years.
    (b) (1) An insurer that provides coverage for hospital or
medical expenses under a group policy of accident and health
insurance or health care plan amended, delivered, issued, or
renewed after the effective date of this amendatory Act of the
92nd General Assembly shall provide coverage under the policy
for treatment of serious mental illness under the same terms
and conditions as coverage for hospital or medical expenses
related to other illnesses and diseases. The coverage required
under this Section must provide for same durational limits,
amount limits, deductibles, and co-insurance requirements for
serious mental illness as are provided for other illnesses and
diseases. This subsection does not apply to coverage provided
to employees by employers who have 50 or fewer employees.
    (2) "Serious mental illness" means the following
psychiatric illnesses as defined in the most current edition of
the Diagnostic and Statistical Manual (DSM) published by the
American Psychiatric Association:
        (A) schizophrenia;
        (B) paranoid and other psychotic disorders;
        (C) bipolar disorders (hypomanic, manic, depressive,
    and mixed);
        (D) major depressive disorders (single episode or
    recurrent);
        (E) schizoaffective disorders (bipolar or depressive);
        (F) pervasive developmental disorders;
        (G) obsessive-compulsive disorders;
        (H) depression in childhood and adolescence;
        (I) panic disorder; and
        (J) post-traumatic stress disorders (acute, chronic,
    or with delayed onset).
    (3) Upon request of the reimbursing insurer, a provider of
treatment of serious mental illness shall furnish medical
records or other necessary data that substantiate that initial
or continued treatment is at all times medically necessary. An
insurer shall provide a mechanism for the timely review by a
provider holding the same license and practicing in the same
specialty as the patient's provider, who is unaffiliated with
the insurer, jointly selected by the patient (or the patient's
next of kin or legal representative if the patient is unable to
act for himself or herself), the patient's provider, and the
insurer in the event of a dispute between the insurer and
patient's provider regarding the medical necessity of a
treatment proposed by a patient's provider. If the reviewing
provider determines the treatment to be medically necessary,
the insurer shall provide reimbursement for the treatment.
Future contractual or employment actions by the insurer
regarding the patient's provider may not be based on the
provider's participation in this procedure. Nothing prevents
the insured from agreeing in writing to continue treatment at
his or her expense. When making a determination of the medical
necessity for a treatment modality for serous mental illness,
an insurer must make the determination in a manner that is
consistent with the manner used to make that determination with
respect to other diseases or illnesses covered under the
policy, including an appeals process.
    (4) A group health benefit plan:
        (A) shall provide coverage based upon medical
    necessity for the following treatment of mental illness in
    each calendar year;
            (i) 45 days of inpatient treatment; and
            (ii) beginning on the effective date of this
        amendatory Act of the 94th General Assembly, 60 35
        visits for outpatient treatment including group and
        individual outpatient treatment;
        (B) may not include a lifetime limit on the number of
    days of inpatient treatment or the number of outpatient
    visits covered under the plan; and
        (C) shall include the same amount limits, deductibles,
    copayments, and coinsurance factors for serious mental
    illness as for physical illness.
    (5) An issuer of a group health benefit plan may not count
toward the number of outpatient visits required to be covered
under this Section an outpatient visit for the purpose of
medication management and shall cover the outpatient visits
under the same terms and conditions as it covers outpatient
visits for the treatment of physical illness.
    (6) An issuer of a group health benefit plan may provide or
offer coverage required under this Section through a managed
care plan.
    (7) This Section shall not be interpreted to require a
group health benefit plan to provide coverage for treatment of:
        (A) an addiction to a controlled substance or cannabis
    that is used in violation of law; or
        (B) mental illness resulting from the use of a
    controlled substance or cannabis in violation of law.
    (8) (Blank).
(Source: P.A. 94-402, eff. 8-2-05; P.A. 94-584, eff. 8-15-05;
revised 8-19-05.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 6/26/2006