HB5225eng 104TH GENERAL ASSEMBLY

HB5225 Engrossed LRB104 20453 AAS 33918 b

AN ACT concerning regulation.

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 356z.14 as follows:

(215 ILCS 5/356z.14)

Sec. 356z.14. Autism spectrum disorders.

(a) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after December 12, 2008 (the effective date of Public Act 95-1005) must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy of accident and health insurance or managed care plan.

(b) Coverage provided under this Section shall be subject to a maximum benefit of $36,000 per year but shall not be subject to any limits on the number of visits to a service provider. The Director of Insurance shall, on an annual basis, adjust the maximum benefit for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.

(c) Coverage under this Section shall be subject to copayment, deductible, and coinsurance provisions of a policy of accident and health insurance or managed care plan to the extent that other medical services covered by the policy of accident and health insurance or managed care plan are subject to these provisions.

(d) This Section shall not be construed as limiting benefits that are otherwise available to an individual under a policy of accident and health insurance or managed care plan and benefits provided under this Section may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally.

(e) An insurer may not deny or refuse to provide otherwise covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract to provide services to an individual because the individual or the individual's dependent is diagnosed with an autism spectrum disorder or due to the individual utilizing benefits in this Section.

(e-5) An insurer may not deny or refuse to provide otherwise covered services under a group or individual policy of accident and health insurance or a managed care plan solely because of the location wherein the clinically appropriate services are provided.

(f) Upon request of the insurer, a provider of treatment for autism spectrum disorders shall furnish medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated. Nothing in this subsection supersedes the prohibition on prior authorization for mental health treatment under subsection (w) of Section 370c.

(g) When making a determination of medical necessity for a treatment modality for autism spectrum disorders, 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. During the appeals process, any challenge to medical necessity must be viewed as reasonable only if the review includes a physician with expertise in the most current and effective treatment modalities for autism spectrum disorders.

(h) Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined in 89 Ill. Adm. Code 500 and any subsequent amendments thereto.

(h-5) If an individual has been diagnosed as having an autism spectrum disorder, meeting the diagnostic criteria in place at the time of diagnosis, and treatment is determined medically necessary, then that individual shall remain eligible for coverage under this Section even if subsequent changes to the diagnostic criteria are adopted by the American Psychiatric Association. If no changes to the diagnostic criteria are adopted after April 1, 2012, and before December 31, 2014, then this subsection (h-5) shall be of no further force and effect.

(h-10) An insurer may not deny or refuse to provide covered services, or refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage under an individual contract, for a person diagnosed with an autism spectrum disorder on the basis that the individual declined an alternative medication or covered service when the individual's health care provider has determined that such medication or covered service may exacerbate clinical symptomatology and is medically contraindicated for the individual and the individual has requested and received a medical exception as provided for under Section 45.1 of the Managed Care Reform and Patient Rights Act. For the purposes of this subsection (h-10), "clinical symptomatology" means any indication of disorder or disease when experienced by an individual as a change from normal function, sensation, or appearance.

(h-15) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage outlined in subsection (h-10), then subsection (h-10) is inoperative with respect to all coverage outlined in subsection (h-10) other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage set forth in subsection (h-10).

(i) As used in this Section:

"Autism spectrum disorders" means pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autism, Asperger's disorder, and pervasive developmental disorder not otherwise specified.

"Diagnosis of autism spectrum disorders" means one or more tests, evaluations, or assessments to diagnose whether an individual has autism spectrum disorder that are is prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches, or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders, or (C) a licensed speech-language pathologist with expertise in diagnosing autism spectrum disorders in children under age 3.

"Medically necessary" means any care, treatment, intervention, service, or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease, or disability; (ii) reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, disease, or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities.

"Treatment for autism spectrum disorders" shall include the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by (A) a physician licensed to practice medicine in all its branches or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches:

(1) Psychiatric care, meaning direct, consultative, or diagnostic services provided by a licensed psychiatrist.

(2) Psychological care, meaning direct or consultative services provided by a licensed psychologist.

(3) Habilitative or rehabilitative care, meaning professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are intended to develop, maintain, and restore the functioning of an individual. As used in this subsection (i), "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

(4) Therapeutic care, including behavioral, speech, occupational, and physical therapies that provide treatment in the following areas: (i) self care and feeding, (ii) pragmatic, receptive, and expressive language, (iii) cognitive functioning, (iv) applied behavior analysis, intervention, and modification, (v) motor planning, and (vi) sensory processing.

(j) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 103-154, eff. 6-30-23; 104-28, eff. 1-1-26; 104-417, eff. 8-15-25.)

Section 10. The Illinois Speech-Language Pathology and Audiology Practice Act is amended by changing Section 3 and by adding Section 8.4 as follows:

(225 ILCS 110/3) (from Ch. 111, par. 7903)

(Section scheduled to be repealed on January 1, 2028)

Sec. 3. Definitions. The following words and phrases shall have the meaning ascribed to them in this Section unless the context clearly indicates otherwise:

(a) "Department" means the Department of Financial and Professional Regulation.

(b) "Secretary" means the Secretary of Financial and Professional Regulation.

(c) "Board" means the Board of Speech-Language Pathology and Audiology established under Section 5 of this Act.

(d) "Speech-Language Pathologist" means a person who has received a license pursuant to this Act and who engages in the practice of speech-language pathology.

(e) "Audiologist" means a person who has received a license pursuant to this Act and who engages in the practice of audiology.

(f) "Public member" means a person who is not a health professional. For purposes of board membership, any person with a significant financial interest in a health service or profession is not a public member.

(g) "The practice of audiology" is the application of nonsurgical methods and procedures for the screening, identification, measurement, monitoring, testing, appraisal, prediction, interpretation, habilitation, rehabilitation, or instruction related to audiologic or vestibular disorders, including hearing and disorders of hearing. These procedures are for the purpose of counseling, consulting and rendering or offering to render services or for participating in the planning, directing or conducting of programs that are designed to modify communicative disorders involving speech, language, auditory, or vestibular function related to hearing loss. The practice of audiology may include, but shall not be limited to, the following:

(1) any task, procedure, act, or practice that is necessary for the evaluation and management of audiologic, hearing, or vestibular function, including, but not limited to, neurophysiologic intraoperative monitoring of the seventh or eighth cranial nerve function;

(2) training in the use of amplification devices;

(3) the evaluation, fitting, dispensing, or servicing of hearing instruments and auditory prosthetic devices, such as cochlear implants, auditory osseointegrated devices, and brainstem implants;

(4) cerumen removal;

(5) performing basic speech and language screening tests and procedures consistent with audiology training; and

(6) performing basic health screenings in accordance with Section 8.3 of this Act.

(h) "The practice of speech-language pathology" is the application of nonmedical methods and procedures for the identification, measurement, testing, appraisal, prediction, habilitation, rehabilitation, and modification related to communication development, and disorders or disabilities of speech, language, voice, swallowing, and other speech, language and voice related disorders. These procedures are for the purpose of counseling, consulting and rendering or offering to render services, or for participating in the planning, directing or conducting of programs that are designed to modify communicative disorders and conditions in individuals or groups of individuals involving speech, language, voice and swallowing function.

"The practice of speech-language pathology" shall include, but shall not be limited to, the following:

(1) hearing screening tests and aural rehabilitation procedures consistent with speech-language pathology training;

(2) tasks, procedures, acts or practices that are necessary for the evaluation of, and training in the use of, augmentative communication systems, communication variation, cognitive rehabilitation, non-spoken language production and comprehension;

(3) the use of rigid or flexible laryngoscopes for the sole purpose of observing and obtaining images of the pharynx and larynx in accordance with Section 9.3 of this Act; and

(4) performing basic health screenings in accordance with Section 8.3 of this Act; and .

(5) diagnosing autism spectrum disorders in accordance with Section 8.4 of this Act.

(i) "Speech-language pathology assistant" means a person who has received a license pursuant to this Act to assist a speech-language pathologist in the manner provided in this Act.

(j) "Physician" means a physician licensed to practice medicine in all its branches under the Medical Practice Act of 1987.

(k) "Email address of record" means the designated email address recorded by the Department in the applicant's application file or the licensee's license file, as maintained by the Department's licensure maintenance unit.

(l) "Address of record" means the designated address recorded by the Department in the applicant's or licensee's application file or license file as maintained by the Department's licensure maintenance unit.

(m) "Neurophysiologic intraoperative monitoring" means the process of continual testing and interpretation of test results using electrodiagnostic modalities to monitor the seventh and eighth cranial nerve function during a surgical procedure. Neurophysiologic intraoperative monitoring does not include testing and interpretation of test results using electrodiagnostic modalities to monitor the spinal cord, peripheral nerves (other than the seventh and eighth cranial nerve), cerebral hemispheres, or brainstem. Neurophysiologic intraoperative monitoring may be performed by an audiologist only if authorized by the physician performing the surgical procedure.

(Source: P.A. 100-530, eff. 1-1-18.)

(225 ILCS 110/8.4 new)

Sec. 8.4. Diagnosing autism spectrum disorders. A speech-language pathologist may diagnose autism spectrum disorders if:

(1) the child is under 3 years of age and has no known co-occurring medical conditions, such as seizures, gastrointestinal problems, or sleep disorders;

(2) the speech-language pathologist has an active autism evaluation credential issued by the Illinois Early Intervention Program;

(3) the speech-language pathologist has, upon renewal of the speech-language pathologist's license, certified to the Department that at least 5 of the speech-language pathologist's required continuing education hours were in age-appropriate autism diagnostic evaluation methods provided by an approved continuing education sponsor; and

(4) the diagnosis occurs as part of the Illinois Early Intervention Program.

The speech-language pathologist must refer the child to the appropriate medical personnel for further evaluation or management for services outside the scope of practice of a speech-language pathologist.

Section 15. The Illinois Public Aid Code is amended by changing Section 5-30.11 as follows:

(305 ILCS 5/5-30.11)

Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches, or a psychologist licensed by the Department of Financial and Professional Regulation, or a speech-language pathologist licensed by the Department of Financial and Professional Regulation, so long as the diagnosis by the speech-language pathologist occurs as part of the Illinois Early Intervention Program, and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.

(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)

Section 99. Effective date. This Act takes effect January 1, 2028.