Illinois General Assembly - Full Text of SB1592
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Full Text of SB1592  102nd General Assembly

SB1592enr 102ND GENERAL ASSEMBLY

  
  
  

 


 
SB1592 EnrolledLRB102 13156 BMS 18499 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 356z.14 and 356z.15 as follows:
 
6    (215 ILCS 5/356z.14)
7    Sec. 356z.14. Autism spectrum disorders.
8    (a) A group or individual policy of accident and health
9insurance or managed care plan amended, delivered, issued, or
10renewed after the effective date of this amendatory Act of the
1195th General Assembly must provide individuals under 21 years
12of age coverage for the diagnosis of autism spectrum disorders
13and for the treatment of autism spectrum disorders to the
14extent that the diagnosis and treatment of autism spectrum
15disorders are not already covered by the policy of accident
16and health insurance or managed care plan.
17    (b) Coverage provided under this Section shall be subject
18to a maximum benefit of $36,000 per year, but shall not be
19subject to any limits on the number of visits to a service
20provider. After December 30, 2009, the Director of the
21Division of Insurance shall, on an annual basis, adjust the
22maximum benefit for inflation using the Medical Care Component
23of the United States Department of Labor Consumer Price Index

 

 

SB1592 Enrolled- 2 -LRB102 13156 BMS 18499 b

1for All Urban Consumers. Payments made by an insurer on behalf
2of a covered individual for any care, treatment, intervention,
3service, or item, the provision of which was for the treatment
4of a health condition not diagnosed as an autism spectrum
5disorder, shall not be applied toward any maximum benefit
6established under this subsection.
7    (c) Coverage under this Section shall be subject to
8copayment, deductible, and coinsurance provisions of a policy
9of accident and health insurance or managed care plan to the
10extent that other medical services covered by the policy of
11accident and health insurance or managed care plan are subject
12to these provisions.
13    (d) This Section shall not be construed as limiting
14benefits that are otherwise available to an individual under a
15policy of accident and health insurance or managed care plan
16and benefits provided under this Section may not be subject to
17dollar limits, deductibles, copayments, or coinsurance
18provisions that are less favorable to the insured than the
19dollar limits, deductibles, or coinsurance provisions that
20apply to physical illness generally.
21    (e) An insurer may not deny or refuse to provide otherwise
22covered services, or refuse to renew, refuse to reissue, or
23otherwise terminate or restrict coverage under an individual
24contract to provide services to an individual because the
25individual or their dependent is diagnosed with an autism
26spectrum disorder or due to the individual utilizing benefits

 

 

SB1592 Enrolled- 3 -LRB102 13156 BMS 18499 b

1in this Section.
2    (e-5) An insurer may not deny or refuse to provide
3otherwise covered services under a group or individual policy
4of accident and health insurance or a managed care plan solely
5because of the location wherein the clinically appropriate
6services are provided.
7    (f) Upon request of the reimbursing insurer, a provider of
8treatment for autism spectrum disorders shall furnish medical
9records, clinical notes, or other necessary data that
10substantiate that initial or continued medical treatment is
11medically necessary and is resulting in improved clinical
12status. When treatment is anticipated to require continued
13services to achieve demonstrable progress, the insurer may
14request a treatment plan consisting of diagnosis, proposed
15treatment by type, frequency, anticipated duration of
16treatment, the anticipated outcomes stated as goals, and the
17frequency by which the treatment plan will be updated.
18    (g) When making a determination of medical necessity for a
19treatment modality for autism spectrum disorders, an insurer
20must make the determination in a manner that is consistent
21with the manner used to make that determination with respect
22to other diseases or illnesses covered under the policy,
23including an appeals process. During the appeals process, any
24challenge to medical necessity must be viewed as reasonable
25only if the review includes a physician with expertise in the
26most current and effective treatment modalities for autism

 

 

SB1592 Enrolled- 4 -LRB102 13156 BMS 18499 b

1spectrum disorders.
2    (h) Coverage for medically necessary early intervention
3services must be delivered by certified early intervention
4specialists, as defined in 89 Ill. Admin. Code 500 and any
5subsequent amendments thereto.
6    (h-5) If an individual has been diagnosed as having an
7autism spectrum disorder, meeting the diagnostic criteria in
8place at the time of diagnosis, and treatment is determined
9medically necessary, then that individual shall remain
10eligible for coverage under this Section even if subsequent
11changes to the diagnostic criteria are adopted by the American
12Psychiatric Association. If no changes to the diagnostic
13criteria are adopted after April 1, 2012, and before December
1431, 2014, then this subsection (h-5) shall be of no further
15force and effect.
16    (h-10) An insurer may not deny or refuse to provide
17covered services, or refuse to renew, refuse to reissue, or
18otherwise terminate or restrict coverage under an individual
19contract, for a person diagnosed with an autism spectrum
20disorder on the basis that the individual declined an
21alternative medication or covered service when the
22individual's health care provider has determined that such
23medication or covered service may exacerbate clinical
24symptomatology and is medically contraindicated for the
25individual and the individual has requested and received a
26medical exception as provided for under Section 45.1 of the

 

 

SB1592 Enrolled- 5 -LRB102 13156 BMS 18499 b

1Managed Care Reform and Patient Rights Act. For the purposes
2of this subsection (h-10), "clinical symptomatology" means any
3indication of disorder or disease when experienced by an
4individual as a change from normal function, sensation, or
5appearance.
6    (h-15) If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage outlined in subsection (h-10), then subsection
16(h-10) is inoperative with respect to all coverage outlined in
17subsection (h-10) other than that authorized under Section
181902 of the Social Security Act, 42 U.S.C. 1396a, and the State
19shall not assume any obligation for the cost of the coverage
20set forth in subsection (h-10).
21    (i) As used in this Section:
22    "Autism spectrum disorders" means pervasive developmental
23disorders as defined in the most recent edition of the
24Diagnostic and Statistical Manual of Mental Disorders,
25including autism, Asperger's disorder, and pervasive
26developmental disorder not otherwise specified.

 

 

SB1592 Enrolled- 6 -LRB102 13156 BMS 18499 b

1    "Diagnosis of autism spectrum disorders" means one or more
2tests, evaluations, or assessments to diagnose whether an
3individual has autism spectrum disorder that is prescribed,
4performed, or ordered by (A) a physician licensed to practice
5medicine in all its branches or (B) a licensed clinical
6psychologist with expertise in diagnosing autism spectrum
7disorders.
8    "Medically necessary" means any care, treatment,
9intervention, service or item which will or is reasonably
10expected to do any of the following: (i) prevent the onset of
11an illness, condition, injury, disease or disability; (ii)
12reduce or ameliorate the physical, mental or developmental
13effects of an illness, condition, injury, disease or
14disability; or (iii) assist to achieve or maintain maximum
15functional activity in performing daily activities.
16    "Treatment for autism spectrum disorders" shall include
17the following care prescribed, provided, or ordered for an
18individual diagnosed with an autism spectrum disorder by (A) a
19physician licensed to practice medicine in all its branches or
20(B) a certified, registered, or licensed health care
21professional with expertise in treating effects of autism
22spectrum disorders when the care is determined to be medically
23necessary and ordered by a physician licensed to practice
24medicine in all its branches:
25        (1) Psychiatric care, meaning direct, consultative, or
26    diagnostic services provided by a licensed psychiatrist.

 

 

SB1592 Enrolled- 7 -LRB102 13156 BMS 18499 b

1        (2) Psychological care, meaning direct or consultative
2    services provided by a licensed psychologist.
3        (3) Habilitative or rehabilitative care, meaning
4    professional, counseling, and guidance services and
5    treatment programs, including applied behavior analysis,
6    that are intended to develop, maintain, and restore the
7    functioning of an individual. As used in this subsection
8    (i), "applied behavior analysis" means the design,
9    implementation, and evaluation of environmental
10    modifications using behavioral stimuli and consequences to
11    produce socially significant improvement in human
12    behavior, including the use of direct observation,
13    measurement, and functional analysis of the relations
14    between environment and behavior.
15        (4) Therapeutic care, including behavioral, speech,
16    occupational, and physical therapies that provide
17    treatment in the following areas: (i) self care and
18    feeding, (ii) pragmatic, receptive, and expressive
19    language, (iii) cognitive functioning, (iv) applied
20    behavior analysis, intervention, and modification, (v)
21    motor planning, and (vi) sensory processing.
22    (j) Rulemaking authority to implement this amendatory Act
23of the 95th General Assembly, if any, is conditioned on the
24rules being adopted in accordance with all provisions of the
25Illinois Administrative Procedure Act and all rules and
26procedures of the Joint Committee on Administrative Rules; any

 

 

SB1592 Enrolled- 8 -LRB102 13156 BMS 18499 b

1purported rule not so adopted, for whatever reason, is
2unauthorized.
3(Source: P.A. 99-788, eff. 8-12-16.)
 
4    (215 ILCS 5/356z.15)
5    Sec. 356z.15. Habilitative services for children.
6    (a) As used in this Section, "habilitative services" means
7occupational therapy, physical therapy, speech therapy, and
8other services prescribed by the insured's treating physician
9pursuant to a treatment plan to enhance the ability of a child
10to function with a congenital, genetic, or early acquired
11disorder. A congenital or genetic disorder includes, but is
12not limited to, hereditary disorders. An early acquired
13disorder refers to a disorder resulting from illness, trauma,
14injury, or some other event or condition suffered by a child
15prior to that child developing functional life skills such as,
16but not limited to, walking, talking, or self-help skills.
17Congenital, genetic, and early acquired disorders may include,
18but are not limited to, autism or an autism spectrum disorder,
19cerebral palsy, and other disorders resulting from early
20childhood illness, trauma, or injury.
21    (b) A group or individual policy of accident and health
22insurance or managed care plan amended, delivered, issued, or
23renewed after the effective date of this amendatory Act of the
2495th General Assembly must provide coverage for habilitative
25services for children under 19 years of age with a congenital,

 

 

SB1592 Enrolled- 9 -LRB102 13156 BMS 18499 b

1genetic, or early acquired disorder so long as all of the
2following conditions are met:
3        (1) A physician licensed to practice medicine in all
4    its branches has diagnosed the child's congenital,
5    genetic, or early acquired disorder.
6        (2) The treatment is administered by a licensed
7    speech-language pathologist, licensed audiologist,
8    licensed occupational therapist, licensed physical
9    therapist, licensed physician, licensed nurse, licensed
10    optometrist, licensed nutritionist, licensed social
11    worker, or licensed psychologist upon the referral of a
12    physician licensed to practice medicine in all its
13    branches.
14        (3) The initial or continued treatment must be
15    medically necessary and therapeutic and not experimental
16    or investigational.
17    (c) The coverage required by this Section shall be subject
18to other general exclusions and limitations of the policy,
19including coordination of benefits, participating provider
20requirements, restrictions on services provided by family or
21household members, utilization review of health care services,
22including review of medical necessity, case management,
23experimental, and investigational treatments, and other
24managed care provisions.
25    (d) Coverage under this Section does not apply to those
26services that are solely educational in nature or otherwise

 

 

SB1592 Enrolled- 10 -LRB102 13156 BMS 18499 b

1paid under State or federal law for purely educational
2services. Nothing in this subsection (d) relieves an insurer
3or similar third party from an otherwise valid obligation to
4provide or to pay for services provided to a child with a
5disability.
6    (e) Coverage under this Section for children under age 19
7shall not apply to treatment of mental or emotional disorders
8or illnesses as covered under Section 370 of this Code as well
9as any other benefit based upon a specific diagnosis that may
10be otherwise required by law.
11    (f) The provisions of this Section do not apply to
12short-term travel, accident-only, limited, or specific disease
13policies.
14    (g) Any denial of care for habilitative services shall be
15subject to appeal and external independent review procedures
16as provided by Section 45 of the Managed Care Reform and
17Patient Rights Act.
18    (h) Upon request of the reimbursing insurer, the provider
19under whose supervision the habilitative services are being
20provided shall furnish medical records, clinical notes, or
21other necessary data to allow the insurer to substantiate that
22initial or continued medical treatment is medically necessary
23and that the patient's condition is clinically improving. When
24the treating provider anticipates that continued treatment is
25or will be required to permit the patient to achieve
26demonstrable progress, the insurer may request that the

 

 

SB1592 Enrolled- 11 -LRB102 13156 BMS 18499 b

1provider furnish a treatment plan consisting of diagnosis,
2proposed treatment by type, frequency, anticipated duration of
3treatment, the anticipated goals of treatment, and how
4frequently the treatment plan will be updated.
5    (i) Rulemaking authority to implement this amendatory Act
6of the 95th General Assembly, if any, is conditioned on the
7rules being adopted in accordance with all provisions of the
8Illinois Administrative Procedure Act and all rules and
9procedures of the Joint Committee on Administrative Rules; any
10purported rule not so adopted, for whatever reason, is
11unauthorized.
12    (j) An insurer may not deny or refuse to provide otherwise
13covered services under a group or individual policy of
14accident and health insurance or a managed care plan solely
15because of the location wherein the clinically appropriate
16services are provided.
17(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10;
1896-1000, eff. 7-2-10.)