Illinois-2017-HB3375-Introduced

100TH GENERAL ASSEMBLY State of Illinois 2017 and 2018 HB3375

Introduced , by Rep. Lou Lang

SYNOPSIS AS INTRODUCED:

215 ILCS 5/370c from Ch. 73, par. 982c

Amends the Illinois Insurance Code. Provides that each insured residing in an area designated as a mental health professional shortage area may obtain services from professionals licensed under the Illinois Alcoholism and Other Drug Abuse and Dependency Act through the use of telehealth services.

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A BILL FOR

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1 AN ACT concerning regulation.

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 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

9 Act of the 97th General Assembly, every insurer which amends,

10 delivers, issues, or renews group accident and health policies

11 providing coverage for hospital or medical treatment or

12 services for illness on an expense-incurred basis shall offer

13 to the applicant or group policyholder subject to the insurer's

14 standards of insurability, coverage for reasonable and

15 necessary treatment and services for mental, emotional or

16 nervous disorders or conditions, other than serious mental

17 illnesses as defined in item (2) of subsection (b), consistent

18 with the parity requirements of Section 370c.1 of this Code.

19 (2) Each insured that is covered for mental, emotional,

20 nervous, or substance use disorders or conditions shall be free

21 to select the physician licensed to practice medicine in all

22 its branches, licensed clinical psychologist, licensed

23 clinical social worker, licensed clinical professional

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1 counselor, licensed marriage and family therapist, licensed

2 speech-language pathologist, or other licensed or certified

3 professional at a program licensed pursuant to the Illinois

4 Alcoholism and Other Drug Abuse and Dependency Act of his

5 choice to treat such disorders, and the insurer shall pay the

6 covered charges of such physician licensed to practice medicine

7 in all its branches, licensed clinical psychologist, licensed

8 clinical social worker, licensed clinical professional

9 counselor, licensed marriage and family therapist, licensed

10 speech-language pathologist, or other licensed or certified

11 professional at a program licensed pursuant to the Illinois

12 Alcoholism and Other Drug Abuse and Dependency Act up to the

13 limits of coverage, provided (i) the disorder or condition

14 treated is covered by the policy, and (ii) the physician,

15 licensed psychologist, licensed clinical social worker,

16 licensed clinical professional counselor, licensed marriage

17 and family therapist, licensed speech-language pathologist, or

18 other licensed or certified professional at a program licensed

19 pursuant to the Illinois Alcoholism and Other Drug Abuse and

20 Dependency Act is authorized to provide said services under the

21 statutes of this State and in accordance with accepted

22 principles of his profession.

23 Each insured residing in an area designated as a mental

24 health professional shortage area by the U.S. Department of

25 Health and Human Services may obtain services from the licensed

26 professionals described in this item (2) through the use of

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1 telehealth services as defined in Section 356z.22 of this Code.

2 (3) Insofar as this Section applies solely to licensed

3 clinical social workers, licensed clinical professional

4 counselors, licensed marriage and family therapists, licensed

5 speech-language pathologists, and other licensed or certified

6 professionals at programs licensed pursuant to the Illinois

7 Alcoholism and Other Drug Abuse and Dependency Act, those

8 persons who may provide services to individuals shall do so

9 after the licensed clinical social worker, licensed clinical

10 professional counselor, licensed marriage and family

11 therapist, licensed speech-language pathologist, or other

12 licensed or certified professional at a program licensed

13 pursuant to the Illinois Alcoholism and Other Drug Abuse and

14 Dependency Act has informed the patient of the desirability of

15 the patient conferring with the patient's primary care

16 physician and the licensed clinical social worker, licensed

17 clinical professional counselor, licensed marriage and family

18 therapist, licensed speech-language pathologist, or other

19 licensed or certified professional at a program licensed

20 pursuant to the Illinois Alcoholism and Other Drug Abuse and

21 Dependency Act has provided written notification to the

22 patient's primary care physician, if any, that services are

23 being provided to the patient. That notification may, however,

24 be waived by the patient on a written form. Those forms shall

25 be retained by the licensed clinical social worker, licensed

26 clinical professional counselor, licensed marriage and family

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1 therapist, licensed speech-language pathologist, or other

2 licensed or certified professional at a program licensed

3 pursuant to the Illinois Alcoholism and Other Drug Abuse and

4 Dependency Act for a period of not less than 5 years.

5 (b) (1) An insurer that provides coverage for hospital or

6 medical expenses under a group policy of accident and health

7 insurance or health care plan amended, delivered, issued, or

8 renewed on or after the effective date of this amendatory Act

9 of the 97th General Assembly shall provide coverage under the

10 policy for treatment of serious mental illness and substance

11 use disorders consistent with the parity requirements of

12 Section 370c.1 of this Code. This subsection does not apply to

13 any group policy of accident and health insurance or health

14 care plan for any plan year of a small employer as defined in

15 Section 5 of the Illinois Health Insurance Portability and

16 Accountability Act.

17 (2) "Serious mental illness" means the following

18 psychiatric illnesses as defined in the most current edition of

19 the Diagnostic and Statistical Manual (DSM) published by the

20 American Psychiatric Association:

21 (A) schizophrenia;

22 (B) paranoid and other psychotic disorders;

23 (C) bipolar disorders (hypomanic, manic, depressive,

24 and mixed);

25 (D) major depressive disorders (single episode or

26 recurrent);

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1 (E) schizoaffective disorders (bipolar or depressive);

2 (F) pervasive developmental disorders;

3 (G) obsessive-compulsive disorders;

4 (H) depression in childhood and adolescence;

5 (I) panic disorder;

6 (J) post-traumatic stress disorders (acute, chronic,

7 or with delayed onset); and

8 (K) anorexia nervosa and bulimia nervosa.

9 (2.5) "Substance use disorder" means the following mental

10 disorders as defined in the most current edition of the

11 Diagnostic and Statistical Manual (DSM) published by the

12 American Psychiatric Association:

13 (A) substance abuse disorders;

14 (B) substance dependence disorders; and

15 (C) substance induced disorders.

16 (3) Unless otherwise prohibited by federal law and

17 consistent with the parity requirements of Section 370c.1 of

18 this Code, the reimbursing insurer, a provider of treatment of

19 serious mental illness or substance use disorder shall furnish

20 medical 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 timely

23 review by a provider holding the same license and practicing in

24 the same specialty as the patient's provider, who is

25 unaffiliated with the insurer, jointly selected by the patient

26 (or the patient's next of kin or legal representative if the

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1 patient is unable to act for himself or herself), the patient's

2 provider, and the insurer in the event of a dispute between the

3 insurer and patient's provider regarding the medical necessity

4 of a treatment proposed by a patient's provider. If the

5 reviewing provider determines the treatment to be medically

6 necessary, the insurer shall provide reimbursement for the

7 treatment. Future contractual or employment actions by the

8 insurer regarding the patient's provider may not be based on

9 the provider's participation in this procedure. Nothing

10 prevents the insured from agreeing in writing to continue

11 treatment at his or her expense. When making a determination of

12 the medical necessity for a treatment modality for serious

13 mental illness or substance use disorder, an insurer must make

14 the determination in a manner that is consistent with the

15 manner used to make that determination with respect to other

16 diseases or illnesses covered under the policy, including an

17 appeals process. Medical necessity determinations for

18 substance use disorders shall be made in accordance with

19 appropriate patient placement criteria established by the

20 American Society of Addiction Medicine. No additional criteria

21 may be used to make medical necessity determinations for

22 substance use disorders.

23 (4) A group health benefit plan amended, delivered, issued,

24 or renewed on or after the effective date of this amendatory

25 Act of the 97th General Assembly:

26 (A) shall provide coverage based upon medical

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1 necessity for the treatment of mental illness and substance

2 use disorders consistent with the parity requirements of

3 Section 370c.1 of this Code; provided, however, that in

4 each calendar year coverage shall not be less than the

5 following:

6 (i) 45 days of inpatient treatment; and

7 (ii) beginning on June 26, 2006 (the effective date

8 of Public Act 94-921), 60 visits for outpatient

9 treatment including group and individual outpatient

10 treatment; and

11 (iii) for plans or policies delivered, issued for

12 delivery, renewed, or modified after January 1, 2007

13 (the effective date of Public Act 94-906), 20

14 additional outpatient visits for speech therapy for

15 treatment of pervasive developmental disorders that

16 will be in addition to speech therapy provided pursuant

17 to item (ii) of this subparagraph (A); and

18 (B) may not include a lifetime limit on the number of

19 days of inpatient treatment or the number of outpatient

20 visits covered under the plan.

21 (C) (Blank).

22 (5) An issuer of a group health benefit plan may not count

23 toward the number of outpatient visits required to be covered

24 under this Section an outpatient visit for the purpose of

25 medication management and shall cover the outpatient visits

26 under the same terms and conditions as it covers outpatient

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1 visits for the treatment of physical illness.

2 (5.5) An individual or group health benefit plan amended,

3 delivered, issued, or renewed on or after the effective date of

4 this amendatory Act of the 99th General Assembly shall offer

5 coverage for medically necessary acute treatment services and

6 medically necessary clinical stabilization services. The

7 treating provider shall base all treatment recommendations and

8 the health benefit plan shall base all medical necessity

9 determinations for substance use disorders in accordance with

10 the most current edition of the American Society of Addiction

11 Medicine Patient Placement Criteria.

12 As used in this subsection:

13 "Acute treatment services" means 24-hour medically

14 supervised addiction treatment that provides evaluation and

15 withdrawal management and may include biopsychosocial

16 assessment, individual and group counseling, psychoeducational

17 groups, and discharge planning.

18 "Clinical stabilization services" means 24-hour treatment,

19 usually following acute treatment services for substance

20 abuse, which may include intensive education and counseling

21 regarding the nature of addiction and its consequences, relapse

22 prevention, outreach to families and significant others, and

23 aftercare planning for individuals beginning to engage in

24 recovery from addiction.

25 (6) An issuer of a group health benefit plan may provide or

26 offer coverage required under this Section through a managed

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1 care plan.

2 (7) (Blank).

3 (8) (Blank).

4 (9) With respect to substance use disorders, coverage for

5 inpatient treatment shall include coverage for treatment in a

6 residential treatment center licensed by the Department of

7 Public Health or the Department of Human Services.

8 (c) This Section shall not be interpreted to require

9 coverage for speech therapy or other habilitative services for

10 those individuals covered under Section 356z.15 of this Code.

11 (d) The Department shall enforce the requirements of State

12 and federal parity law, which includes ensuring compliance by

13 individual and group policies; detecting violations of the law

14 by individual and group policies proactively monitoring

15 discriminatory practices; accepting, evaluating, and

16 responding to complaints regarding such violations; and

17 ensuring violations are appropriately remedied and deterred.

18 (e) Availability of plan information.

19 (1) The criteria for medical necessity determinations

20 made under a group health plan with respect to mental

21 health or substance use disorder benefits (or health

22 insurance coverage offered in connection with the plan with

23 respect to such benefits) must be made available by the

24 plan administrator (or the health insurance issuer

25 offering such coverage) to any current or potential

26 participant, beneficiary, or contracting provider upon

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1 request.

2 (2) The reason for any denial under a group health plan

3 (or health insurance coverage offered in connection with

4 such plan) of reimbursement or payment for services with

5 respect to mental health or substance use disorder benefits

6 in the case of any participant or beneficiary must be made

7 available within a reasonable time and in a reasonable

8 manner by the plan administrator (or the health insurance

9 issuer offering such coverage) to the participant or

10 beneficiary upon request.

11 (f) As used in this Section, "group policy of accident and

12 health insurance" and "group health benefit plan" includes (1)

13 State-regulated employer-sponsored group health insurance

14 plans written in Illinois and (2) State employee health plans.

15 (Source: P.A. 99-480, eff. 9-9-15.)