Autism News Network

Illinois Insurance Law update.

News

The importance of "Essential Health Services" under the Affordable Care Act.

Health Care reform could cause the repeal of autism-treatment mandates.

September 26, 2011.
In general, the Federal PPACA requires new plans to include Essential Health Services.

The Act defines certain categories of benefits as "Essential Health Benefits." (Sec. 1302.)
The categories of essential health benefits are:

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care

Congress delegated to the Department of Health and Human Services the task of determining what specific medical benefits qualify under these categories. Right now, the Department is going through thousands of services which medical providers and patients believe to be essential. The Department is weighing the costs and benefits of each service. If the Department issues regulations that allow too many services as required, then the cost of the plans rises, and more employers will drop private plans and direct employees to the exchanges to get insurance.

Here is the catch. Where a State mandate adds an entirely new benefit class to qualified health plans sold in exchanges, a state must pay the cost differential for coverage of these benefits. (Sec. 1311.) In other words, if a service does not qualify as "essential" under the upcoming Federal regulations, but the State mandates the coverage, the State must pay. Most States today have some autism treatment coverage mandates, including Illinois with the mandate described lower on this page. If the Federal government fails to find autism treatment such as ABA to be essential, the State will be forced to pay the cost of the program. You can be sure that revenue-strapped States, especially Illinois which cannot fund its Medicaid program, will quickly drop its autism treatment mandate rather than have to fund it. The Department must issue its regulations in time for plans to be ready for the 2014 effective date. In making its decision of which benefits are essential, the Department must:

(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

(C) take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

Let us hope that the Federal government looks at the evidence and the cost of an individual with autism will bear if he does not get early treatment, and rules that behavioural treatment for autism is essential.

Here is the way out. On December 16, 2011, the Department of Health and Human Services announced that it would not be issuing a list of essential health benefits. Instead, it would let the individual States flexibility to select a benchmark plan reflecting the scope of a typical employer plan. The benchmark would contain the same basket of benefits available from, for example, the largest of small group plans in the State, or the largest State employee plan. The basket of benefits and services included in the benchmark health insurance plan selected by the State would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage. Since these benchmarks are generally regulated by the State and would be subject to State mandates applicable to the small group market, those mandates would be included in the State essential health benefits package if the State elected one of the three largest small group plans in that state as its benchmark. Thus, the State can choose as a benchmark a plan which is subject to the mandates, and the mandates would be included as essential, and then possibly Federally subsidized. If the State choose a benchmark plan not subject to the mandates, then the mandates would be outside the essential list and the State would have to finance the mandated benefits.

Does the HHS solution comply with the law as written by Congress? We will have to see the final regulations when the HHS issues them.

New: Affordable Care Act requires coverage to screen infants for autism

The Department of Health and Human Services has implemented regulations under the Federal law of 2010, the Affordable Care Act. This act requires health plans to cover prevention services. The services must be covered without your having to pay a copayment or co-insurance or meet your deductible, when delivered by a network provider. Included are many vaccinations, heaing testing, screening for many diseases and

Autism screening for children at 18 and 24 months
Behavioral assessments for children of all ages

The complete list for preventive services, adults and children, is http://www.healthcare.gov/law/about/provisions/services/lists.html
The new regulations start, in general, for plan years commencing after September 2010. The regulations apply to both insured and self-funded plans, but do not apply to plans which opt out of the new Act if they are "grandfathered" and meet the standards for a grandfathered plan.

Blue Cross Blue Shield of Michigan settles class-action ABA autism lawsuit

In denying claims, Blue Cross claimed that behavioral therapy for children with autism spectrum disorder was “experimental” treatment" But the patients' attorney Mantese said Blue Cross’ own documents showed that the company believes the autism therapy to be a valid treatment. A draft of a 2005 Blue Cross medical policy stated: “Applied behavioral analysis is currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment. …”
http://www.crainsdetroit.com/article/20090619/FREE/906199973#

October 2008: Congress has passed a bill requiring parity in insurance coverage for mental-health treatment--
--Autism Not Included? Mental Health Parity

Illinois law now mandates insurance coverage for Illinois children with autism

Senate Bill 1900 enacted. November 22, 2008, as part of Senate Bill 934

Proposed Illinois law would restrict the "habilitation" exclusion. (February 11, 2009)

Illinois should eliminate the "habilitation" exclusion from health insurance
Senate Bill 101 as amended

California Department of Managed Health Care reverses denial of coverage for ABA therapy based on Medical Necessity

April 24, 2008. The California Department of Managed Health Care provides independent medical review of HMO decisions. In the Arce decision, the Department reversed the Kaiser Health Plan's denial of coverage for ABA and other therapy for a boy with autism and found the therapy was medically necessary. The Department relied upon :

Management of Children With Autism Spectrum Disorders, by Scott M. Myers, MD, Chris Plauché Johnson, MD, MEd the Council on Children With Disabilities. PDF (219 kb) or Pediatrics link (html)

The Department determined that that Arce's request for 10 hours of OT, twice weekly speech therapy, and 20 hours of ABA was medically necessary, and thus Kaiser was bound to cover it.

The Illinois Department of Insurance does not provide such review, nor would review apply to self funded plans. However, the Pediatrics article and the studies it cites may help your appeal or lawsuit for coverage.

The Pediatrics article (above links) was a survey of different medical interventions and needs of children with autism. The article included:

Applied behavior analysis (ABA) is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior. ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community. The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology [fn], and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. [fn] Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. [fn]

(emphasis added.)

California Insurers Balk At Autism Therapy: Switch reason for denying claims

March 6, 2009: The California department had been sending disputes over the treatment to panels of independent physicians. Increasingly over the last year, those panels had been deciding that the treatments were medically necessary, and the insurers were made to pay. Then, late last year, Kaiser Permanente, the state's largest nonprofit health insurer, changed its rationale for denying the coverage. Instead of saying the treatment is not medically necessary, Kaiser now says the therapy is not covered because it is educational and not medical
http://www.consumerwatchdog.org/patients/articles/?storyId=25146

California insurer may be barred from denying ABA claims when therapist is not licensed.

October 27, 2009
In a preliminary ruling, Los Angeles County Superior Court Judge James C. Chalfant found that Kaiser Permanente's refusal to pay for a child's autism treatment because the provider was not licensed by the state runs counter to California's Mental Health Parity Act. That act requires insurers to cover care for mental and behavioral problems at the same levels they do for physical illnesses.
http://www.latimes.com/business/la-fi-autism27-2009oct27,0,7328448.story

New Jersey Court rejects "restorative and non-restorative" exclusion of insurance. 2007

"In addition, while the Handbook excludes treatment for development of a function or skill beyond that previously demonstrated, there is no definition of "development" or "developmental." Children are constantly developing. "Developmental" defines childhood. The words "restorative" and "non-restorative" when used in this context are also ambiguous and largely inapplicable to infants and young children. Every child is born with the potential to develop those skills necessary to life in society. Autistic children and other children afflicted with BBMIs are hindered from achieving that potential. The treatment for Jake can restore some of his potential. Even with the therapies described, Jake's prognosis is uncertain, but there is no claim that the treatment is futile. To the contrary, there is the expectation that, to some degree, he will share the skills and functions of more fortunate children, including his siblings."

Micheletti v. State Health Benefits Commission

New Link: A Blueprint for Parents: Covering ABA through Health Insurance in Indiana

In July 2001, House Enrollment Act 1122 went into effect as Indiana Code 27-8-14.2, mandating insurance coverage for individuals with Autism Spectrum Disorders for any accident or health insurance policy that is issued on a group basis (large or small). Also, insurers selling individual policies must offer the option to include coverage for Autism Spectrum Disorders (ASD). This page has good information n how to establish a claim.

: Illinois should eliminate the "habilitation" exclusion from health insurance

Tip: when submitting a bill for behavior modification/applied behavior analysis, you can try to use CPT Procedure Code 90808.
A Diagnosis code that often works for therapy is neuromotor coordination disorder. Some people report that static encepalopathy is an effective diagnosis.

Doctors should bill for the actual medical symptoms:

Doctors and therapists should be reminded that they are not treating "autism"...they are treating related disorders in which autistic symptoms manifest. They should evidence these diagnoses in the initial evaluation and subsequent visits. All insurers require medical-service providers to include a diagnosis code (usually called ICD-9). The codes should reflect accurate information. Using these codes is not only more accurate, but also can help avoid insurers that automatically exclude all coverage for autism, either blatantly or under the false exclusion that nothing can help.

**Possibly billable diagnoses involved in autistic symptoms**
Diagnosis	ICD-9 Code
Hypotonia/Dyspraxia	781.3
Atypical Communication	784.5
Myoneural disorder (impairment of the sensory organs)	358.8
hypotonia	784.5
oral motor verbal apraxia	784.69
encephalopathy	348.3
petit mal seizure status	345.2
Partial Epilepsy, With Impairment Of Consciousness	345.4
aphasia	784.3
Nonspecific Abnormal Electroencephalogram (EEG)	794.02
Abnormal Auditory Perception, Unspecified	388.40

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Articles:

Study Backs Equal Coverage for Mental Ills

A new study involving federal employees has found that providing better mental health coverage does not lead to an explosion in insurance costs, a potentially important development in an old national debate over what insurance plans should cover.

The study, published today in the New England Journal of Medicine, examined seven federal health plans in the years after 1999, when President Bill Clinton ordered companies in the Federal Employees Health Benefits Program to provide coverage for mental health and substance abuse that is comparable to that for other health conditions.

http://www.washingtonpost.com/wp-dyn/content/article/2006/03/29/AR2006032901861.html?nav=rss_business
http://www.nytimes.com/2006/03/30/health/30mental.html

----------------------------------------

Medical bills pave way to poorhouse. Chicago Tribune, February 2, 2005,

Medical bills may lurk behind about half of personal bankruptcy filings in the United States, according to Harvard University researchers who also found a majority of the debtors they surveyed were middle-class, owned homes and had health insurance at the onset of their illness....For many, health problems set in motion a downward spiral that led to unemployment and subsequently the loss of health insurance; Or, their coverage was filled with so many high co-payments, deductibles and uncovered services that they couldn't pay their bills. Out-of-pocket expenses averaged $11,854 for the medically bankrupt.

December 2004 New York Times article about trouble getting insurance coverage.
NYTimesInsurance.html

This article from the ASA Advocate in 1994, describes one Illinois parent's efforts to make an insurer cover ABA therapy. TravABA.tif
(image format, 1683 KB, if it does not open, download and open with Start>Programs>Accessories>Imaging)

Legal Discussion

Autism Patient wins court case against Aetna Insurance Co. for coverage for Speech, PT and OT.

added Aug. 11, 2003.
The Dr. Chez patient "B" prevailed when the U.S. District Court for the Northern District of Illinois found the insurance company failed to follow the language and terms of the policy.

The letters justifying the denial of coverage "utterly fail to consider the actual language of the plan at issue here. The letters also largely fail to connect Aetna's denial of benefits to the specific situation and B's diagnosis," the court added.

Addressing the denial of coverage for speech therapy, the court said there was support in the medical history from which to conclude that autism caused B to lose his previously existing speech skills. Under the plan, speech therapy was covered if a participant had speech function that was lost as the result of a disease, which was expected to be restored by the therapy. The court said Aetna never explained why B did not meet this test.

Next addressing the denial of coverage for sensory integration therapy, the court found that Aetna failed to make an individualized determination of the possible outcome of the treatment. Instead, Aetna said the effectiveness of the therapy was unproven and therefore, by implication, unnecessary, the court said. In doing this, Aetna "failed to consider the express terms of the plan--the definitions of 'necessary' and 'appropriate,' and it failed to make a rational connection between the particular medical evidence and its conclusion to terminate benefits for this therapy," the court said.

Also finding that the denial of coverage for occupational therapy was arbitrary, the court said Aetna's explanation that it did not cover long-term occupational therapy for patients with chronic diseases was not based on any language in the plan.

The court noted the plan was ambiguous regarding the issue of whether developmental delays were covered if they were caused by autism. The court found that the developmental delay exclusion was inapplicable to developmental delays caused by autism, because otherwise the provision for coverage of autism would be meaningless.

BW case in html (52 kb)
BWcase in pdf (832 kb, 31 pages)

Autism is not a mental illness

Similarly, in 1990, a court ruled that an insurance company could not treat autism as a mental illness for the purpose of its restrictions on mental illness coverages. See Kunin. Kunin is a Ninth Cirucit case directly involving autism. The Seventh Circuit Court of Appeals, which covers Illinois, adopted the Kunin (1992) analysis in Phillips, which was cited by Judge Grady in the 2003 case. Your situation may differ, but casting your claims as medical rather than mental is important. Since the Illinois staute on serious mental illnesses does not apply the ERISA plans, but only insurance polices, these cases will help. The Phillips court said:

The district court questioned Lincoln's definition of "mental illness", reasoning that "aberrant behavioral symptoms are a necessary but not sufficient component of any definition of mental illness" because "[t]here is no question that some conditions are marked primarily by symptoms of dementia and aberrant behavior yet would not be considered mental illnesses. Indeed, under Lincoln's proposed 'unambiguous' meaning of 'mental illness,' an accident victim who exhibits abnormal behavior as the result of a traumatic head injury, a person suffering from brain cancer who develops unusual behavior and an elderly person who has contracted Alzheimer's Disease would all be considered mentally ill. To this list we add a person suffering from a high fever caused by a staph infection who is rendered delirious by his condition. The facts that James behaves abnormally and that he has received medication, psychotherapy and training to modify his behavior do not necessarily mean that he suffers from a mental illness. Those facts do not preclude the possibility that he might be suffering from a physical illness whose symptoms are behavioral."

Unfortunately, not every case has been favorable.

A long term disability plan that limited benefits for mental impairments to 18 months did not violate the Americans with Disabilities Act (ADA). This was the ruling of the Second Circuit U.S. Court of Appeals in Fuller v. J.P. Morgan Chase & Co. (No. 03-7829).

"[W]here the written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, we will not disturb the administrator's ultimate conclusion unless it is 'arbitrary and capricious.'" Pagan v. NYNEX Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995). Under this highly deferential standard of review, this Court cannot substitute its judgment for that of the Plan Administrator and will not overturn a decision to deny or terminate benefits unless "it was 'without reason, unsupported by substantial evidence or erroneous as a matter of law.'"
On appeal, the patient had cited her physician's opinion stating that bipolar disorder is a manifestation of "biochemical abnormalities in the brain." Thus, Ms. Fuller argued that bipolar disorder arises from a physical cause within the meaning of the LTD plan, and that she therefore was entitled to benefits until age 65. In rejecting that argument, the Second Circuit stated, "The plan administrator exercised its authority in a plainly reasonable manner by consulting the DSM-IV, an objective authority on the subject of mental disorders, and by relying on that reference work (as it had in the past). It may well be that bipolarity is a manifestation of a chemical or electrical reaction in the brain and that it may be said to arise ultimately from a physical cause. But the issue under the plan wording is whether Fuller's disability 'arises from' a mental disorder, a question quite distinct from whether the disorder itself arises from a physical cause.... Fuller's argument conflates her disability with its underlying cause. Since Fuller's disability arises from a mental syndrome known as bipolar disorder, it is neither arbitrary nor capricious to limit Fuller's benefits, regardless of whether that disorder in turn has a physical cause."

Similarly, a Federal Court in Illinois ruled in Rucker v. Regit... Plan, N.D. Ill. 1994, ruled that bipolar disorder was not a mental illness, stating that the issue in its case was not what caused the disorder but whether it was mental. The different result may arise because of the type of coverage. In Kunin the issue is the medical condition itself. Fuller is one step removed, inasmuch as the issue is whether a disability arises from a medical or mental condition. In another case an insurer lost its argument that depression is a mental disorder, Luton v. Prudential Ins Co America, 88 F. Supp. 2d 1364 (S.D. Fla. 2000).

Recent cases help define the Burden of proof / Standard of review

In insurance litigation, the outcome often depends on which party has the burden of proof and which party has the right to interpret the written terms of the plan and the meaning of the medical evidence presented by the patient. However, recent cases have made the task more difficult.
[This topic was lengthened and moved to its own page, standard of review.]

In Mondry v. American Family Mutual Insurance Co., (W.D. Wisc., Nov. 21, 2006) the Plan and Cigna six times stonewalled the participant's efforts to obtain the written plan documents determining when the Plan would cover speech therapy. Only after lawyers were involved did the plan provide the documents and reverse its denial of the service, which it had initially denied under the habilitation guise. Similarly, the Sixth Circuit has ruled that the claims determination must be a deliberate, reasoned process. Elliott v. Metro Life Ins. Co. (6th Cir. 2006):

New: March 6, 2009: The 7th Circuit Court of Appeals reviewed Mondry, writing

In particular, nothing in the SPD suggests that therapy must be “restorative” in order to qualify as “medically necessary.” In short, CIGNA had been relying on [its internal criteria manuals] as the equivalent of plan language, treating the former documents as if they were dispositive and citing them to Mondry as such....

Because Cigna relied on the documents, ERISA required the Plan to produce them. The wrinkle was that while Cigna had these secret documents, American Family was the Plan, and it was the Plan's duty, and not Cigna's to deliver the documents. The court found the Plan liable for statutory penalties for not delivering the documents, suggesting that the Plan should have forced its claims administrator, Cigna, to deliver the documents which showed Cigna's position was wrong. While the documents eventually helped Mondry recover the cost of the speech therapy. the deliver came too late for her to elect COBRA coverage. Since Cigna misrepresented that speech therapy was not covered, Mondry did not continue the coverage. The court ruled that ERISA did not provide a remedy for this injury, and that topic is beyond the scope of this article.
Mondry-7thCir.pdf

Comment

Not every case will have the same outcome as BW v. Aetna (above). Each insurance policy or plan contains different language which controls:

what benefits can be provided;
when exclusions apply;
the limits of a particular benefit;
who has the poweir to interpret the contract.

Note also that coverage is easier to prove for regressive autism -- speech therapy is covered for rehabilitation as opposed to habilitation -- that is, to recover what was lost. (but see note above)

Most claims are disputed by insurance companies as:

the treatment is not medically necessary, or maximum improvement reached;
not arising out of an injury or illness;
the treatment is educational not medical;
the treatment is experimental; or
the treatment is not rendered by licensed physicians or nurses.

The enactment of a new Illinois statute (see below) has created a tension in strategies. Most patients are better off with the general coverages of their health plans. Autism is technically a syndrome, not an illness since it is defined through its sysmptoms, not its causes. Autism has physical and organic causes (encephalopathy, epilepsy, gut reaction, etc.) which may manifest themselves with mental symptoms. (See Kunin and Phillips.) Since general medical insurance coverage does not have the severe restrictions that restrict mental health coverage (e.g., number of visits or dollar maximums), patients were better off claiming that autism was not a mental illness. Now the Illinois legislature has done us a 'favor' by stating that PDD is a mental illness. (See statute following.) On the one hand, it is good to have some coverage mandated. On the other hand, will we see insurance companies trying to deny claims under general medical coverages because they can point to the legislature's statute that autism is a mental illness? You must be vigilant to assure that claims are submitted for a physical diagnosis to avoid the trap.

The National Conference of State Legislatures has a tracking paper on parity in different States:
http://www.hpts.org/info/info.nsf/0/8a9e7d91048f8e4985256d0f006f8e8d?OpenDocument

ERISA and Parity

For the latest news, click Mental Health Parity

Self-funded health plans - as opposed to insured plans - may be covered under the Federal ERISA laws. If the company's plan is self-funded, the State statute is preempted and does not apply to the plan. Daley v. Marriott Int'l, Inc., (8th Cir. 2005) (pdf) In Daley, an employee sued, arguing claimed that her employer's health plan's limitations of the number of mental health visits for which benefits would be paid (a plan-year maximum of 30 visits and a lifetime maximum of 200 visits) violated Nebraska's State statute mandating mental health parity benefits. This State statute required annual and lifetime limits on mental health benefits to be the same as or better than plan limits on physical health benefits. The Federal Eighth Circuit Court of Appeals held that ERISA preempted Nebraska's mental health parity law as it related to self-funded ERISA plans. The Federal government did have a limited mental health parity section in the 1996 HIPAA amendments. Although that part of HIPAA has sunsetted, the Department of Labor has extended its effect through 2005. 29 CFR 2590.712 http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/cfr_2002/julqtr/29cfr2590.712.htm

The House and Senate passed the Tax Relief and Health Care Bill of 2006 (H.R. 6111, Public Law 109-432), extending the Mental Health Parity Act from December 31, 2006 to the end of 2007 under the Internal Revenue Code, ERISA, and the Public Health Service Act (PHSA). President Bush signed it into Public Law 109-432. The previous extension, H.R. 4579, extended through Dec. 31, 2006, a 1996 law that bans health care plans from offering lower annual and lifetime dollar limits on coverage for mental health conditions than for other medical conditions.

December 31, 2007  Mental Health Parity Law Extended One Year

Congress has given final approval to legislation that extends through 2008 the federal law that bans group health care plans from imposing lower annual and lifetime dollar limits for coverage of mental disorders than for other medical conditions.
The one-year extension of the law, which was set to expire on December 31, 2007, buys time so federal lawmakers can decide whether to expand the parity law to make other plan designs discriminatory. Congress gave final approval to the one-year extension earlier this week.

This part of HIPAA/ERISA applies to self-funded as well as insured health plans. The old Mental Health Parity part still allows a plan to limit the amount, duration, or scope of mental health benefits under group health plans, except to lifetime and annual dollar limits. Thus, a plan can still limit the number of visits which it will cover.

The Department of Labor has since instituted disability nondiscrimination regulations which may apply in some cases. The regulations are complex; for example, they would prohibit a plan from refusing to enroll participants with autism into the general medical benefits plan, but the regulations would not prohibit the exclusion of benefits for the treatment of autism itself, so long as the exclusion applied to all members of the plan equally. Similarly, limits on speech therapy which apply to all illnesses would be acceptable. However, a plan cannot modify its rules in response to a particular person's claims. See Discrimination in Health Plan Benefit Plans and 29 CFR sec. 2590.702.

General Anesthesia for Dentistry for child with disabilities. see IllDentalIns.html

New Statute in Illinois requires insurers to cover "serious mental illnesses," including PDD, ASD

(Note: these definitions were deleted in 2019 as part of the Parity act.)

The Statute includes pervasive developmental disorders (includes autism).
The Statute requires policies shall include the same amount limits, deductibles, copayments, and coinsurance factors for serious mental illness as for physical illness.
Review of disputes by knowledgable specialist.
Policies for "nonserious" mental, emotional or nervous disorders or conditions may be limited to $10,000 for the benefit, and other restirctions may apply.
The Statute's sunset was extended past December 31, 2005, as of August 2, 2005, by Public Act 94-402.
The Statute may not apply to self-funded (ERISA) benefit plans, which has its own parity provisions.
does this statute cause more harm by stating autism is a mental illness rather than a mental manifestation of a physical illness? See above.

**Section 370c Summary**:
a. Nonserious mental conditions Mandated coverage, but can be limited. Patient choice of therapists Referral forms b. Serious Mental Illness 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. List of Seious Mental Illnesses, includes PDDs Records, timely review, and medical necessity Mandated coverage - 35 visits

Actual text:
(215 ILCS 5/370c)

Sec. 370c. Mental and emotional disorders.
(a) "Nonserious" mental conditions (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) "Serious mental illness" (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; and (I) panic disorder. (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; (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) This subsection (b) is inoperative after December 31, 2005. (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02; 92-651, eff. 7-11-02.)

New! Effective June 23, 2006:

Public Act 94-0906 adds the following language:

(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);

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