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According to the National Alliance on Mental Illness,
mental disorders are the leading cause of disability in
North America. The most serious and disabling mental
conditions affect five to ten million adults (2.6 –
5.4%) and three to five million children ages five to
seventeen (5 - 9%)in the United States.
This Fact Sheet provides information regarding mental
health coverage in Illinois.
Serious Mental Illness
Who Must Provide the Coverage?
Illinois law
[215 ILCS 370c (b)]
requires insurance companies and HMOs (effective January
1, 2007) that provide coverage for hospital or medical
expenses to provide coverage for serious mental illness
to employee groups of more than 50 employees.
The law does not apply to self-insured employers or to
trusts or insurance policies written outside Illinois.
However, for HMOs, the law does apply in
certain situations to contracts written outside of
Illinois if the HMO member is a resident of Illinois and
the HMO has established a provider network in Illinois.
To determine if your HMO provides serious mental health
benefits as required by Illinois law, you should contact
the HMO directly or check your certificate of coverage.
NOTE: The law applies to HMOs effective January
1, 2007. The law previously applied to insurance
companies only and the serious mental health portion was
originally effective January 1, 2002.
What is Covered?
Illinois requires group insurance and HMO
plans that provide coverage for hospital or medical
expenses to cover the treatment of serious mental
illness under the same terms and conditions as coverage
for hospital and medical expenses related to other
illnesses or diseases. Serious mental illness includes:
-
Schizophrenia;
-
Paranoid and other psychotic disorders;
-
Bipolar disorders (hypomanic, manic, depressive, and
mixed);
-
Major depressive disorders (single episode or
recurrent)
-
Schizoaffective disorders (bipolar or depressive);
-
Pervasive developmental disorders;
-
Obsessive-compulsive disorders
-
Depression in childhood and adolescence;
-
Panic disorder; and
-
Post-traumatic stress disorders (acute, chronic, or
with delayed onset)
What are the Limits?
The group health benefit plans shall provide
coverage based upon medical necessity for the following
treatment of serious mental illness in each calendar
year:
-
45 days of inpatient treatment; and
-
60 visits for outpatient
treatment including group and individual treatment;
(effective June 26, 2006 was increased to 60 visits
from 35 visits by
Public Act 94-0921,
House Bill 4202); and
-
20 additional outpatient
visits for speech therapy for individual with
pervasive developmental disorders; (added effective
January 1, 2007 by
Public Act 94-0906,
House Bill 4125)
A group health benefit plan may not include a lifetime
limit on the number of days of inpatient treatment or
the number of outpatient visits covered under the plan.
The benefit plan shall include the same amount limits,
deductibles, copayments and coinsurance factors for
serious mental illness as for physical illness.
Outpatient visits for the purpose of medication
management shall not be counted toward the serious
mental illness limits, but shall be paid under the same
terms and conditions as a physical illness.
If you are covered by a managed care plan such as an HMO
or PPO, then you must follow the requirements of the
plan in order to receive optimum benefits for serious
mental illness. For example, you must use a preferred
provider under a PPO plan in order to receive the
preferred benefit level. In the HMO setting, you must
follow plan requirements regarding referrals from your
primary care physician in order to receive benefits.
What is Not Covered?
Your group insurance or HMO plan does not have to pay
for treatment of an addiction to a controlled substance
or cannabis that is used in violation of law, or for
mental illness resulting from the use of a controlled
substance or cannabis in violation of law.
Non-Serious Mental Illness
Who Must Offer the Coverage?
Illinois law
[215 ILCS 370c (a)]
requires insurance companies and HMOs (effective January
1, 2007) that provide group coverage for hospital or
medical expenses to offer coverage for
non-serious mental illness to the group policyholder,
regardless of the group size. The
group policyholder may accept, reject or modify the
offer. The law does not apply to self-insured employers
or to trusts or insurance policies written outside
Illinois. However, for HMOs, the law
does apply in certain situations to contracts written
outside of Illinois if the HMO member is a resident of
Illinois and the HMO has established a provider network
in Illinois. To determine if your HMO group plan
provides non-serious mental health benefits, you should
contact the HMO directly or check your certificate of
coverage.
NOTE: The law applies to HMOs effective January
1, 2007. The law previously applied to insurance
policies only and the non-serious mental illness portion
has been in effect for many years.
What is Covered?
For those group policies that accept the offer of
coverage, reasonable and necessary treatment and
services for mental, emotional or nervous disorders or
conditions, other than serious mental illnesses as
defined above, shall be covered.
If you are covered by a managed care plan such as an HMO
or PPO, you are not limited to preferred or contracted
providers to receive the non-serious mental illness
benefit. You may receive treatment for non-serious
mental illness from the licensed physician, licensed
clinical psychologist, licensed clinical social worker
or licensed clinical professional counselor of your
choice.
What are the Limits?
The insured may be required to pay up to 50% of expenses
incurred for non-serious mental illness and an annual
benefit maximum of the lesser of $10,000 or 25% of the
lifetime policy limit may be imposed by the policy.
Individual Coverage for Mental Illness
Individual insurance policies are not required by law to
provide coverage for mental illness.
In accordance with
50 Illinois Administrative Code
5421.130(h), individual
HMO certificates must provide the following coverage for
mental illness:
-
Ten days inpatient mental health care per year.
Care in a day hospital, residential non-hospital or
intensive outpatient mode may be substituted on a
two-to-one basis for inpatient hospital services as
deemed appropriate by the primary care physician.
-
Twenty individual outpatient mental health care
visits per enrollee per year, as appropriate for
evaluation, short-term treatment and crisis
intervention services. Group outpatient mental
health care visits may be substituted on a
two-to-one basis for individual mental health care
visits as deemed appropriate by the primary care
physician.
For More Information
-
Call our Consumer Services Section at (312) 814-2427
or
our Office of Consumer Health
Insurance toll free at (877) 527-9431
or visit us on our website at
http://www.idfpr.com/doi/default2.asp
The text of Public Act 094-0906 and Public Act 094-0921
can be viewed below.
Public Act 094-0906
HB4125 Enrolled LRB094 13838 LJB 48711 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) 35 visits for outpatient treatment including group
and individual outpatient treatment; and
(iii) for plans or policies delivered, issued for
delivery, renewed, or modified after the effective date
of this amendatory Act of the 94th General Assembly, 20
additional outpatient visits for speech therapy for
treatment of pervasive developmental disorders that will
be in addition to speech therapy provided pursuant to
item (ii) of this subparagraph (A);
(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 10. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
Sec. 5-3. Insurance Code provisions.
(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, 356z.4, 356z.5, 356z.6,
364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
368e, 370c, 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 Insurance
Code.
(b) For purposes of the Illinois Insurance Code, except
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":
(1) a corporation authorized under the Dental Service
Plan Act or the Voluntary Health Services Plans Act;
(2) a corporation organized under the laws of this
State; or
(3) a corporation organized under the laws of another
state, 30% or more of the enrollees of which are
residents of this State, except a corporation subject to
substantially the same requirements in its state of
organization as is a "domestic company" under Article
VIII 1/2 of the Illinois Insurance Code.
(c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance
Organization pursuant to Article VIII 1/2 of the
Illinois Insurance Code,
(1) the Director shall give primary consideration to the
continuation of benefits to enrollees and the financial
conditions of the acquired Health Maintenance
Organization after the merger, consolidation, or other
acquisition of control takes effect;
(2)(i) the criteria specified in subsection (1)(b) of
Section 131.8 of the Illinois Insurance Code shall not
apply and (ii) the Director, in making his determination
with respect to the merger, consolidation, or other
acquisition of control, need not take into account the
effect on competition of the merger, consolidation, or
other acquisition of control;
(3) the Director shall have the power to require the
following information:
(A) certification by an independent actuary of the
adequacy of the reserves of the Health Maintenance
Organization sought to be acquired;
(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;
(C) a pro forma business plan detailing an acquiring
party's plans with respect to the operation of the
Health Maintenance Organization sought to be acquired
for a period of not less than 3 years; and
(D) such other information as the Director shall
require.
(d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the
sale by any health maintenance organization of greater
than 10% of its enrollee population (including without
limitation the health maintenance organization's right,
title, and interest in and to its health care
certificates).
(e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois
Insurance Code, the Director (i) shall, in addition to
the criteria specified in Section 141.2 of the Illinois
Insurance Code, take into account the effect of the
management contract or service agreement on the
continuation of benefits to enrollees and the financial
condition of the health maintenance organization to be
managed or serviced, and (ii) need not take into account
the effect of the management contract or service
agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability
Health Insurance Act and except for medicare supplement
policies as 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:
(i) the amount of, and other terms and conditions with
respect to, the refund or additional premium are set
forth in the group or enrollment unit contract agreed in
advance of the period for which a refund is to be paid
or additional premium is to be charged (which period
shall not be less than one year); and
(ii) the amount of the refund or additional premium
shall not exceed 20% of the Health Maintenance
Organization's profitable or unprofitable experience
with respect to the group or other enrollment unit for
the period (and, for purposes of a refund or additional
premium, the profitable or unprofitable experience shall
be calculated taking into account a pro rata share of
the Health Maintenance Organization's administrative and
marketing expenses, but shall not include any refund to
be made or additional premium to be paid pursuant to
this subsection (f)). The Health Maintenance
Organization and the group or enrollment unit may agree
that the profitable or unprofitable experience may be
calculated taking into account the refund period and the
immediately preceding 2 plan years.
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 unit and the
resulting refund to the group or enrollment unit or (2)
the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit
and the resulting additional premium to be paid by the
group or enrollment unit.
In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to
pay any refund authorized under this Section.
(Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
93-261, eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff.
8-14-03; 93-853, eff. 1-1-05; 93-1000, eff. 1-1-05;
revised 10-14-04.)
Effective Date: 1/1/2007
Public Act 094-0921
HB4202
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
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