Illinois General Assembly - Full Text of SB0679
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Full Text of SB0679  97th General Assembly



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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.16 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 and
16health 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 Division
21of Insurance shall, on an annual basis, adjust the maximum
22benefit for inflation using the Medical Care Component of the
23United States Department of Labor Consumer Price Index for All



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1Urban Consumers. Payments made by an insurer on behalf of a
2covered 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



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1in this Section.
2    (f) Upon request of the reimbursing insurer, a provider of
3treatment for autism spectrum disorders shall furnish medical
4records, clinical notes, or other necessary data that
5substantiate that initial or continued medical treatment is
6medically necessary and is resulting in improved clinical
7status. When treatment is anticipated to require continued
8services to achieve demonstrable progress, the insurer may
9request a treatment plan consisting of diagnosis, proposed
10treatment by type, frequency, anticipated duration of
11treatment, the anticipated outcomes stated as goals, and the
12frequency by which the treatment plan will be updated.
13    (g) When making a determination of medical necessity for a
14treatment modality for autism spectrum disorders, an insurer
15must make the determination in a manner that is consistent with
16the manner used to make that determination with respect to
17other diseases or illnesses covered under the policy, including
18an appeals process. During the appeals process, any challenge
19to medical necessity must be viewed as reasonable only if the
20review includes a physician with expertise in the most current
21and effective treatment modalities for autism spectrum
23    (h) Coverage for medically necessary early intervention
24services must be delivered by certified early intervention
25specialists, as defined in 89 Ill. Admin. Code 500 and any
26subsequent amendments thereto.



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1    (h-5) If an individual has been diagnosed as having an
2autism spectrum disorder, meeting the diagnostic criteria in
3place at the time of diagnosis, and treatment is determined
4medically necessary, then that individual shall remain
5eligible for coverage under this Section even if subsequent
6changes to the diagnostic criteria are adopted by the American
7Psychiatric Association. If no changes to the diagnostic
8criteria are adopted after April 1, 2012, and before December
931, 2014, then this subsection (h-5) shall be of no further
10force and effect.
11    (i) As used in this Section:
12    "Autism spectrum disorders" means pervasive developmental
13disorders as defined in the most recent edition of the
14Diagnostic and Statistical Manual of Mental Disorders,
15including autism, Asperger's disorder, and pervasive
16developmental disorder not otherwise specified.
17    "Diagnosis of autism spectrum disorders" means one or more
18tests, evaluations, or assessments to diagnose whether an
19individual has autism spectrum disorder that is prescribed,
20performed, or ordered by (A) a physician licensed to practice
21medicine in all its branches or (B) a licensed clinical
22psychologist with expertise in diagnosing autism spectrum
24    "Medically necessary" means any care, treatment,
25intervention, service or item which will or is reasonably
26expected to do any of the following: (i) prevent the onset of



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1an illness, condition, injury, disease or disability; (ii)
2reduce or ameliorate the physical, mental or developmental
3effects of an illness, condition, injury, disease or
4disability; or (iii) assist to achieve or maintain maximum
5functional activity in performing daily activities.
6    "Treatment for autism spectrum disorders" shall include
7the following care prescribed, provided, or ordered for an
8individual diagnosed with an autism spectrum disorder by (A) a
9physician licensed to practice medicine in all its branches or
10(B) a certified, registered, or licensed health care
11professional with expertise in treating effects of autism
12spectrum disorders when the care is determined to be medically
13necessary and ordered by a physician licensed to practice
14medicine in all its branches:
15        (1) Psychiatric care, meaning direct, consultative, or
16    diagnostic services provided by a licensed psychiatrist.
17        (2) Psychological care, meaning direct or consultative
18    services provided by a licensed psychologist.
19        (3) Habilitative or rehabilitative care, meaning
20    professional, counseling, and guidance services and
21    treatment programs, including applied behavior analysis,
22    that are intended to develop, maintain, and restore the
23    functioning of an individual. As used in this subsection
24    (i), "applied behavior analysis" means the design,
25    implementation, and evaluation of environmental
26    modifications using behavioral stimuli and consequences to



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1    produce socially significant improvement in human
2    behavior, including the use of direct observation,
3    measurement, and functional analysis of the relations
4    between environment and behavior.
5        (4) Therapeutic care, including behavioral, speech,
6    occupational, and physical therapies that provide
7    treatment in the following areas: (i) self care and
8    feeding, (ii) pragmatic, receptive, and expressive
9    language, (iii) cognitive functioning, (iv) applied
10    behavior analysis, intervention, and modification, (v)
11    motor planning, and (vi) sensory processing.
12    (j) Rulemaking authority to implement this amendatory Act
13of the 95th General Assembly, if any, is conditioned on the
14rules being adopted in accordance with all provisions of the
15Illinois Administrative Procedure Act and all rules and
16procedures of the Joint Committee on Administrative Rules; any
17purported rule not so adopted, for whatever reason, is
19(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)
20    (215 ILCS 5/356z.16)
21    Sec. 356z.16. Applicability of mandated benefits to
22supplemental policies. Unless specified otherwise, the
23following Sections of the Illinois Insurance Code do not apply
24to short-term travel, disability income, long-term care,
25accident only, or limited or specified disease policies: 356b,



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1356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t,
2356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
3356z.8, 356z.12, 356z.14, 356z.19, 356z.21 356z.19, 364.01,
4367.2-5, and 367e.
5(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10;
696-1034, eff. 1-1-11; 97-91, eff. 1-1-12; 97-282, eff. 8-9-11;
797-592, eff. 1-1-12; revised 10-13-11.)