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(215 ILCS 5/370c) (from Ch.
73, par. 982c)
(Text of Section from P.A.
95‑972)
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,
licensed clinical professional counselor, or licensed marriage and family
therapist 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, licensed clinical professional counselor, or licensed marriage and
family therapist 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, licensed
clinical professional counselor, or licensed marriage and family therapist 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, licensed clinical
professional counselors, and licensed marriage and family therapists, those
persons who may provide services to individuals shall do so after the
licensed clinical social worker, licensed clinical professional counselor, or
licensed marriage and family therapist has informed the patient of the desirability
of the patient conferring with the patient's primary care physician and the
licensed clinical social worker, licensed clinical professional counselor, or
licensed marriage and family therapist 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, licensed clinical professional counselor, or licensed
marriage and family therapist 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,
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(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
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