Sen. Don Harmon

Filed: 4/24/2012





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2    AMENDMENT NO. ______. Amend Senate Bill 679, AS AMENDED, by
3replacing everything after the enacting clause with the
5    "Section 5. The Illinois Insurance Code is amended by
6changing Section 356z.14 as follows:
7    (215 ILCS 5/356z.14)
8    Sec. 356z.14. Autism spectrum disorders.
9    (a) A group or individual policy of accident and health
10insurance or managed care plan amended, delivered, issued, or
11renewed after the effective date of this amendatory Act of the
1295th General Assembly must provide individuals under 21 years
13of age coverage for the diagnosis of autism spectrum disorders
14and for the treatment of autism spectrum disorders to the
15extent that the diagnosis and treatment of autism spectrum
16disorders are not already covered by the policy of accident and



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



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



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1to medical necessity must be viewed as reasonable only if the
2review includes a physician with expertise in the most current
3and effective treatment modalities for autism spectrum
5    (h) Coverage for medically necessary early intervention
6services must be delivered by certified early intervention
7specialists, as defined in 89 Ill. Admin. Code 500 and any
8subsequent amendments thereto.
9    (h-5) If an individual has been diagnosed as having an
10autism spectrum disorder, meeting the diagnostic criteria in
11place at the time of diagnosis, and treatment is determined
12medically necessary, then that individual shall remain
13eligible for coverage under this Section even if subsequent
14changes to the diagnostic criteria are adopted. If no changes
15to the diagnostic criteria are adopted after April 1, 2012, and
16before December 31, 2014, then this subsection (h-5) shall be
17of no further force and effect.
18    (i) As used in this Section:
19    "Autism spectrum disorders" means pervasive developmental
20disorders as defined in the most recent edition of the
21Diagnostic and Statistical Manual of Mental Disorders,
22including autism, Asperger's disorder, and pervasive
23developmental disorder not otherwise specified.
24    "Diagnosis of autism spectrum disorders" means one or more
25tests, evaluations, or assessments to diagnose whether an
26individual has autism spectrum disorder that is prescribed,



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



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1    professional, counseling, and guidance services and
2    treatment programs, including applied behavior analysis,
3    that are intended to develop, maintain, and restore the
4    functioning of an individual. As used in this subsection
5    (i), "applied behavior analysis" means the design,
6    implementation, and evaluation of environmental
7    modifications using behavioral stimuli and consequences to
8    produce socially significant improvement in human
9    behavior, including the use of direct observation,
10    measurement, and functional analysis of the relations
11    between environment and behavior.
12        (4) Therapeutic care, including behavioral, speech,
13    occupational, and physical therapies that provide
14    treatment in the following areas: (i) self care and
15    feeding, (ii) pragmatic, receptive, and expressive
16    language, (iii) cognitive functioning, (iv) applied
17    behavior analysis, intervention, and modification, (v)
18    motor planning, and (vi) sensory processing.
19    (j) Rulemaking authority to implement this amendatory Act
20of the 95th General Assembly, if any, is conditioned on the
21rules being adopted in accordance with all provisions of the
22Illinois Administrative Procedure Act and all rules and
23procedures of the Joint Committee on Administrative Rules; any
24purported rule not so adopted, for whatever reason, is
26(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)".