Sen. Don Harmon

Filed: 2/29/2012





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2    AMENDMENT NO. ______. Amend Senate Bill 679 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.14 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.



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1    (b) Coverage provided under this Section shall be subject
2to a maximum benefit of $36,000 per year, but shall not be
3subject to any limits on the number of visits to a service
4provider. After December 30, 2009, the Director of the Division
5of Insurance shall, on an annual basis, adjust the maximum
6benefit for inflation using the Medical Care Component of the
7United States Department of Labor Consumer Price Index for All
8Urban Consumers. Payments made by an insurer on behalf of a
9covered individual for any care, treatment, intervention,
10service, or item, the provision of which was for the treatment
11of a health condition not diagnosed as an autism spectrum
12disorder, shall not be applied toward any maximum benefit
13established under this subsection.
14    (c) Coverage under this Section shall be subject to
15copayment, deductible, and coinsurance provisions of a policy
16of accident and health insurance or managed care plan to the
17extent that other medical services covered by the policy of
18accident and health insurance or managed care plan are subject
19to these provisions.
20    (d) This Section shall not be construed as limiting
21benefits that are otherwise available to an individual under a
22policy of accident and health insurance or managed care plan
23and benefits provided under this Section may not be subject to
24dollar limits, deductibles, copayments, or coinsurance
25provisions that are less favorable to the insured than the
26dollar limits, deductibles, or coinsurance provisions that



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1apply to physical illness generally.
2    (e) An insurer may not deny or refuse to provide otherwise
3covered services, or refuse to renew, refuse to reissue, or
4otherwise terminate or restrict coverage under an individual
5contract to provide services to an individual because the
6individual or their dependent is diagnosed with an autism
7spectrum disorder or due to the individual utilizing benefits
8in this Section.
9    (f) Upon request of the reimbursing insurer, a provider of
10treatment for autism spectrum disorders shall furnish medical
11records, clinical notes, or other necessary data that
12substantiate that initial or continued medical treatment is
13medically necessary and is resulting in improved clinical
14status. When treatment is anticipated to require continued
15services to achieve demonstrable progress, the insurer may
16request a treatment plan consisting of diagnosis, proposed
17treatment by type, frequency, anticipated duration of
18treatment, the anticipated outcomes stated as goals, and the
19frequency by which the treatment plan will be updated.
20    (g) When making a determination of medical necessity for a
21treatment modality for autism spectrum disorders, an insurer
22must make the determination in a manner that is consistent with
23the manner used to make that determination with respect to
24other diseases or illnesses covered under the policy, including
25an appeals process. During the appeals process, any challenge
26to medical necessity must be viewed as reasonable only if the



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1review includes a physician with expertise in the most current
2and effective treatment modalities for autism spectrum
4    (h) Coverage for medically necessary early intervention
5services must be delivered by certified early intervention
6specialists, as defined in 89 Ill. Admin. Code 500 and any
7subsequent amendments thereto.
8    (h-5) If an individual has been diagnosed as having an
9autism spectrum disorder, meeting the diagnostic criteria in
10place at the time of diagnosis, and treatment is determined
11medically necessary, then that individual shall remain
12eligible for coverage under this Section even if subsequent
13changes to diagnostic criteria are adopted.
14    (h-10) Scientific investigations have determined that
15co-existing pathophysiological conditions can occur with
16autism, including seizure disorders, immune dysregulation,
17allergies, gastrointestinal disturbances, neuroinflammation,
18mitochondrial dysfunction, and metabolic disturbances.
19Accurate assessment, testing, diagnosis, and treatment of
20underlying and co-existing medical conditions should be
21considered for persons with autism spectrum disorders and may
22incorporate findings developed from emerging biological
23science and clinical research.
24    (i) As used in this Section:
25    "Autism spectrum disorders" means a hetergenous group of
26neurobiological disorders, including autism, regressive



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1autism, Asperger syndrome, and pervasive developmental
2disorders not otherwise specified pervasive developmental
3disorders as defined in the most recent edition of the
4Diagnostic and Statistical Manual of Mental Disorders,
5including autism, Asperger's disorder, and pervasive
6developmental disorder not otherwise specified.
7    "Diagnosis of autism spectrum disorders" means one or more
8tests, evaluations, or assessments to diagnose whether an
9individual has autism spectrum disorder that is prescribed,
10performed, or ordered by (A) a physician licensed to practice
11medicine in all its branches or (B) a licensed clinical
12psychologist with expertise in diagnosing autism spectrum
14    "Medically necessary" means any care, treatment,
15intervention, service or item which will or is reasonably
16expected to do any of the following: (i) prevent the onset of
17an illness, condition, injury, disease or disability; (ii)
18reduce or ameliorate the physical, mental or developmental
19effects of an illness, condition, injury, disease or
20disability; or (iii) assist to achieve or maintain maximum
21functional activity in performing daily activities.
22    "Treatment for autism spectrum disorders" shall include
23the following care prescribed, provided, or ordered for an
24individual diagnosed with an autism spectrum disorder by (A) a
25physician licensed to practice medicine in all its branches or
26(B) a certified, registered, or licensed health care



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1professional with expertise in treating effects of autism
2spectrum disorders when the care is determined to be medically
3necessary and ordered by a physician licensed to practice
4medicine in all its branches:
5        (1) Psychiatric care, meaning direct, consultative, or
6    diagnostic services provided by a licensed psychiatrist.
7        (2) Psychological care, meaning direct or consultative
8    services provided by a licensed psychologist.
9        (3) Habilitative or rehabilitative care, meaning
10    professional, counseling, and guidance services and
11    treatment programs, including applied behavior analysis,
12    that are intended to develop, maintain, and restore the
13    functioning of an individual. As used in this subsection
14    (i), "applied behavior analysis" means the design,
15    implementation, and evaluation of environmental
16    modifications using behavioral stimuli and consequences to
17    produce socially significant improvement in human
18    behavior, including the use of direct observation,
19    measurement, and functional analysis of the relations
20    between environment and behavior.
21        (4) Therapeutic care, including behavioral, speech,
22    occupational, and physical therapies that provide
23    treatment in the following areas: (i) self care and
24    feeding, (ii) pragmatic, receptive, and expressive
25    language, (iii) cognitive functioning, (iv) applied
26    behavior analysis, intervention, and modification, (v)



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1    motor planning, and (vi) sensory processing.
2    (j) Rulemaking authority to implement this amendatory Act
3of the 95th General Assembly, if any, is conditioned on the
4rules being adopted in accordance with all provisions of the
5Illinois Administrative Procedure Act and all rules and
6procedures of the Joint Committee on Administrative Rules; any
7purported rule not so adopted, for whatever reason, is
9(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)".