HB 1493 — INS EMOTIONAL DISORDERS

093_HB1493HB1493 Engrossed LRB093 07907 JLS 08098 b AN ACT concerning insurance.

(a) (1) On and after the effective date of this Section, every insurer which delivers, issues for delivery or renews or modifies group _______i________________________h______A&H --- policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis o___r________________________m___________ _____g_____________________n________________________d________________i_______________________i______________________t___________ _____o______________________M_____________________i____________e_____________________A___ 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 _r____________ choice to treat such disorders, and the insurer shall pay the covered charges of such physician licensed to HB1493 Engrossed -2- LRB093 07907 JLS 08098 b 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 o ______ profession.

(b) (1) An insurer that provides coverage for hospital or medical expenses under a group __________u___ policy of accident and health insurance,insurance__________a_____________________o_____________ _____________________m________________e_____________________1________________________M___________ _____i_______________________i______________________t________________i_____________ _____e______________________A____ or health care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 9________ ---- 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 HB1493 Engrossed -3- LRB093 07907 JLS 08098 b illnesses and diseases.

anda --- (I) panic disorder;_- _________________v_______________________b____________ _n_____________n________________ _________________v______________________r____________________________v______________________r_______ _________________i______________________u_____________ _r_____________________._ (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 -4- LRB093 07907 JLS 08098 b practicing in the same specialty as the patient's provider, who is unaffiliated with the insurer, jointly selected by the HB1493 Engrossed -4- LRB093 07907 JLS 08098 b 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.

and (ii) __35 -- visits for outpatient treatment including group and individual outpatient treatment;

(5) An issuer of a group health benefit plan may not -5- LRB093 07907 JLS 08098 b count toward the number of outpatient visits required to be covered under this Section an outpatient visit for the HB1493 Engrossed -5- LRB093 07907 JLS 08098 b 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.

-8----------------------(---------------------f-------------(8) -----0----This (Source:subsection (b) is inoperative after December 31, 2005.

(Source:

(a) Health Maintenance Organizations shall be subject to the provisions of Sections 133, 134, 137, 140, 141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, 356y, 356z.2, 367i, 368a, 3_____ 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois -6- LRB093 07907 JLS 08098 b Insurance Code.

(b) For purposes of the Illinois Insurance Code, except HB1493 Engrossed -6- LRB093 07907 JLS 08098 b for Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health Maintenance Organizations in the following categories are deemed to be "domestic companies":

(A) certification by an independent actuary of -7- LRB093 07907 JLS 08098 b the adequacy of the reserves of the Health Maintenance Organization sought to be acquired;

HB1493 Engrossed -7- LRB093 07907 JLS 08098 b (B) pro forma financial statements reflecting the combined balance sheets of the acquiring company and the Health Maintenance Organization sought to be acquired as of the end of the preceding year and as of a date 90 days prior to the acquisition, as well as pro forma financial statements reflecting projected combined operation for a period of 2 years;

(f) Except for small employer groups as defined in the -8- LRB093 07907 JLS 08098 b Small Employer Rating, Renewability and Portability Health Insurance Act and except for medicare supplement policies as HB1493 Engrossed -8- LRB093 07907 JLS 08098 b defined in Section 363 of the Illinois Insurance Code, a Health Maintenance Organization may by contract agree with a group or other enrollment unit to effect refunds or charge additional premiums under the following terms and conditions:

The Health Maintenance Organization shall include a statement in the evidence of coverage issued to each enrollee describing the possibility of a refund or additional premium, and upon request of any group or enrollment unit, provide to the group or enrollment unit a description of the method used to calculate (1) the Health Maintenance Organization's profitable experience with respect to the group or enrollment -9- LRB093 07907 JLS 08098 b unit and the resulting refund to the group or enrollment unit or (2) the Health Maintenance Organization's unprofitable HB1493 Engrossed -9- LRB093 07907 JLS 08098 b experience with respect to the group or enrollment unit and the resulting additional premium to be paid by the group or enrollment unit.