Bill Text: IL HB1332 | 2017-2018 | 100th General Assembly | Engrossed


Bill Title: Amends the Illinois Insurance Code. Makes a technical change in a Section concerning the short title.

Spectrum: Partisan Bill (Democrat 9-0)

Status: (Engrossed) 2017-05-26 - Rule 2-10 Third Reading Deadline Established As May 31, 2017 [HB1332 Detail]

Download: Illinois-2017-HB1332-Engrossed.html



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1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5changing Section 370c as follows:
6 (215 ILCS 5/370c) (from Ch. 73, par. 982c)
7 Sec. 370c. Mental and emotional disorders.
8 (a) (1) On and after the effective date of this amendatory
9Act of the 97th General Assembly, every insurer which amends,
10delivers, issues, or renews group accident and health policies
11providing coverage for hospital or medical treatment or
12services for illness on an expense-incurred basis shall offer
13to the applicant or group policyholder subject to the insurer's
14standards of insurability, coverage for reasonable and
15necessary treatment and services for mental, emotional or
16nervous disorders or conditions, other than serious mental
17illnesses as defined in item (2) of subsection (b), consistent
18with the parity requirements of Section 370c.1 of this Code.
19 (2) Each insured that is covered for mental, emotional,
20nervous, or substance use disorders or conditions shall be free
21to select the physician licensed to practice medicine in all
22its branches, licensed clinical psychologist, licensed
23clinical social worker, licensed clinical professional

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1counselor, licensed marriage and family therapist, licensed
2speech-language pathologist, or other licensed or certified
3professional at a program licensed pursuant to the Illinois
4Alcoholism and Other Drug Abuse and Dependency Act of his
5choice to treat such disorders, and the insurer shall pay the
6covered charges of such physician licensed to practice medicine
7in all its branches, licensed clinical psychologist, licensed
8clinical social worker, licensed clinical professional
9counselor, licensed marriage and family therapist, licensed
10speech-language pathologist, or other licensed or certified
11professional at a program licensed pursuant to the Illinois
12Alcoholism and Other Drug Abuse and Dependency Act up to the
13limits of coverage, provided (i) the disorder or condition
14treated is covered by the policy, and (ii) the physician,
15licensed psychologist, licensed clinical social worker,
16licensed clinical professional counselor, licensed marriage
17and family therapist, licensed speech-language pathologist, or
18other licensed or certified professional at a program licensed
19pursuant to the Illinois Alcoholism and Other Drug Abuse and
20Dependency Act is authorized to provide said services under the
21statutes of this State and in accordance with accepted
22principles of his profession.
23 (3) Insofar as this Section applies solely to licensed
24clinical social workers, licensed clinical professional
25counselors, licensed marriage and family therapists, licensed
26speech-language pathologists, and other licensed or certified

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1professionals at programs licensed pursuant to the Illinois
2Alcoholism and Other Drug Abuse and Dependency Act, those
3persons who may provide services to individuals shall do so
4after the licensed clinical social worker, licensed clinical
5professional counselor, licensed marriage and family
6therapist, licensed speech-language pathologist, or other
7licensed or certified professional at a program licensed
8pursuant to the Illinois Alcoholism and Other Drug Abuse and
9Dependency Act has informed the patient of the desirability of
10the patient conferring with the patient's primary care
11physician and the licensed clinical social worker, licensed
12clinical professional counselor, licensed marriage and family
13therapist, licensed speech-language pathologist, or other
14licensed or certified professional at a program licensed
15pursuant to the Illinois Alcoholism and Other Drug Abuse and
16Dependency Act has provided written notification to the
17patient's primary care physician, if any, that services are
18being provided to the patient. That notification may, however,
19be waived by the patient on a written form. Those forms shall
20be retained by the licensed clinical social worker, licensed
21clinical professional counselor, licensed marriage and family
22therapist, licensed speech-language pathologist, or other
23licensed or certified professional at a program licensed
24pursuant to the Illinois Alcoholism and Other Drug Abuse and
25Dependency Act for a period of not less than 5 years.
26 (b) (1) An insurer that provides coverage for hospital or

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1medical expenses under a group or individual policy of accident
2and health insurance or health care plan amended, delivered,
3issued, or renewed on or after the effective date of this
4amendatory Act of the 100th General Assembly this amendatory
5Act of the 97th General Assembly shall provide coverage under
6the policy for treatment of serious mental illness and
7substance use disorders consistent with the parity
8requirements of Section 370c.1 of this Code. This subsection
9does not apply to any group policy of accident and health
10insurance or health care plan for any plan year of a small
11employer as defined in Section 5 of the Illinois Health
12Insurance Portability and Accountability Act.
13 (2) "Serious mental illness" means the following
14psychiatric illnesses as defined in the most current edition of
15the Diagnostic and Statistical Manual (DSM) published by the
16American Psychiatric Association:
17 (A) schizophrenia;
18 (B) paranoid and other psychotic disorders;
19 (C) bipolar disorders (hypomanic, manic, depressive,
20 and mixed);
21 (D) major depressive disorders (single episode or
22 recurrent);
23 (E) schizoaffective disorders (bipolar or depressive);
24 (F) pervasive developmental disorders;
25 (G) obsessive-compulsive disorders;
26 (H) depression in childhood and adolescence;

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1 (I) panic disorder;
2 (J) post-traumatic stress disorders (acute, chronic,
3 or with delayed onset); and
4 (K) eating disorders, including, but not limited to,
5 anorexia nervosa, and bulimia nervosa, pica, rumination
6 disorder, avoidant/restrictive food intake disorder, other
7 specified feeding or eating disorder (OSFED), and any other
8 eating disorder contained in the most recent version of the
9 Diagnostic and Statistical Manual of Mental Disorders
10 published by the American Psychiatric Association.
11 (2.5) "Substance use disorder" means the following mental
12disorders as defined in the most current edition of the
13Diagnostic and Statistical Manual (DSM) published by the
14American Psychiatric Association:
15 (A) substance abuse disorders;
16 (B) substance dependence disorders; and
17 (C) substance induced disorders.
18 (3) Unless otherwise prohibited by federal law and
19consistent with the parity requirements of Section 370c.1 of
20this Code, the reimbursing insurer, a provider of treatment of
21serious mental illness or substance use disorder shall furnish
22medical records or other necessary data that substantiate that
23initial or continued treatment is at all times medically
24necessary. An insurer shall provide a mechanism for the timely
25review by a provider holding the same license and practicing in
26the same specialty as the patient's provider, who is

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1unaffiliated with the insurer, jointly selected by the patient
2(or the patient's next of kin or legal representative if the
3patient is unable to act for himself or herself), the patient's
4provider, and the insurer in the event of a dispute between the
5insurer and patient's provider regarding the medical necessity
6of a treatment proposed by a patient's provider. If the
7reviewing provider determines the treatment to be medically
8necessary, the insurer shall provide reimbursement for the
9treatment. Future contractual or employment actions by the
10insurer regarding the patient's provider may not be based on
11the provider's participation in this procedure. Nothing
12prevents the insured from agreeing in writing to continue
13treatment at his or her expense. When making a determination of
14the medical necessity for a treatment modality for serious
15mental illness or substance use disorder, an insurer must make
16the determination in a manner that is consistent with the
17manner used to make that determination with respect to other
18diseases or illnesses covered under the policy, including an
19appeals process. Medical necessity determinations for
20substance use disorders shall be made in accordance with
21appropriate patient placement criteria established by the
22American Society of Addiction Medicine. No additional criteria
23may be used to make medical necessity determinations for
24substance use disorders.
25 (4) A group health benefit plan amended, delivered, issued,
26or renewed on or after the effective date of this amendatory

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1Act of the 97th General Assembly:
2 (A) shall provide coverage based upon medical
3 necessity for the treatment of mental illness and substance
4 use disorders consistent with the parity requirements of
5 Section 370c.1 of this Code; provided, however, that in
6 each calendar year coverage shall not be less than the
7 following:
8 (i) 45 days of inpatient treatment; and
9 (ii) beginning on June 26, 2006 (the effective date
10 of Public Act 94-921), 60 visits for outpatient
11 treatment including group and individual outpatient
12 treatment; and
13 (iii) for plans or policies delivered, issued for
14 delivery, renewed, or modified after January 1, 2007
15 (the effective date of Public Act 94-906), 20
16 additional outpatient visits for speech therapy for
17 treatment of pervasive developmental disorders that
18 will be in addition to speech therapy provided pursuant
19 to item (ii) of this subparagraph (A); and
20 (B) may not include a lifetime limit on the number of
21 days of inpatient treatment or the number of outpatient
22 visits covered under the plan.
23 (C) (Blank).
24 (5) An issuer of a group health benefit plan may not count
25toward the number of outpatient visits required to be covered
26under this Section an outpatient visit for the purpose of

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1medication management and shall cover the outpatient visits
2under the same terms and conditions as it covers outpatient
3visits for the treatment of physical illness.
4 (5.5) An individual or group health benefit plan amended,
5delivered, issued, or renewed on or after the effective date of
6this amendatory Act of the 99th General Assembly shall offer
7coverage for medically necessary acute treatment services and
8medically necessary clinical stabilization services. The
9treating provider shall base all treatment recommendations and
10the health benefit plan shall base all medical necessity
11determinations for substance use disorders in accordance with
12the most current edition of the American Society of Addiction
13Medicine Patient Placement Criteria.
14 As used in this subsection:
15 "Acute treatment services" means 24-hour medically
16supervised addiction treatment that provides evaluation and
17withdrawal management and may include biopsychosocial
18assessment, individual and group counseling, psychoeducational
19groups, and discharge planning.
20 "Clinical stabilization services" means 24-hour treatment,
21usually following acute treatment services for substance
22abuse, which may include intensive education and counseling
23regarding the nature of addiction and its consequences, relapse
24prevention, outreach to families and significant others, and
25aftercare planning for individuals beginning to engage in
26recovery from addiction.

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1 (6) An issuer of a group health benefit plan may provide or
2offer coverage required under this Section through a managed
3care plan.
4 (7) (Blank).
5 (8) (Blank).
6 (9) With respect to substance use disorders, coverage for
7inpatient treatment shall include coverage for treatment in a
8residential treatment center licensed by the Department of
9Public Health or the Department of Human Services.
10 (c) This Section shall not be interpreted to require
11coverage for speech therapy or other habilitative services for
12those individuals covered under Section 356z.15 of this Code.
13 (d) The Department shall enforce the requirements of State
14and federal parity law, which includes ensuring compliance by
15individual and group policies; detecting violations of the law
16by individual and group policies proactively monitoring
17discriminatory practices; accepting, evaluating, and
18responding to complaints regarding such violations; and
19ensuring violations are appropriately remedied and deterred.
20 (e) Availability of plan information.
21 (1) The criteria for medical necessity determinations
22 made under a group health plan with respect to mental
23 health or substance use disorder benefits (or health
24 insurance coverage offered in connection with the plan with
25 respect to such benefits) must be made available by the
26 plan administrator (or the health insurance issuer

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1 offering such coverage) to any current or potential
2 participant, beneficiary, or contracting provider upon
3 request.
4 (2) The reason for any denial under a group health plan
5 (or health insurance coverage offered in connection with
6 such plan) of reimbursement or payment for services with
7 respect to mental health or substance use disorder benefits
8 in the case of any participant or beneficiary must be made
9 available within a reasonable time and in a reasonable
10 manner by the plan administrator (or the health insurance
11 issuer offering such coverage) to the participant or
12 beneficiary upon request.
13 (f) As used in this Section, "group policy of accident and
14health insurance" and "group health benefit plan" includes (1)
15State-regulated employer-sponsored group health insurance
16plans written in Illinois and (2) State employee health plans.
17(Source: P.A. 99-480, eff. 9-9-15.)
18 Section 99. Effective date. This Act takes effect upon
19becoming law.
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