Full Text of SB1592 102nd General Assembly
SB1592enr 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing 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 | 9 | | insurance or managed care plan amended, delivered, issued, or | 10 | | renewed after the effective date of this amendatory Act of the | 11 | | 95th General Assembly must provide individuals under 21 years | 12 | | of age coverage for the diagnosis of autism spectrum disorders | 13 | | and for the treatment of autism spectrum disorders to the | 14 | | extent that the diagnosis and treatment of autism spectrum | 15 | | disorders are not already covered by the policy of accident | 16 | | and health insurance or managed care plan. | 17 | | (b) Coverage provided under this Section shall be subject | 18 | | to a maximum benefit of $36,000 per year, but shall not be | 19 | | subject to any limits on the number of visits to a service | 20 | | provider. After December 30, 2009, the Director of the | 21 | | Division of Insurance shall, on an annual basis, adjust the | 22 | | maximum benefit for inflation using the Medical Care Component | 23 | | of the United States Department of Labor Consumer Price Index |
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| 1 | | for All Urban Consumers. Payments made by an insurer on behalf | 2 | | of a covered individual for any care, treatment, intervention, | 3 | | service, or item, the provision of which was for the treatment | 4 | | of a health condition not diagnosed as an autism spectrum | 5 | | disorder, shall not be applied toward any maximum benefit | 6 | | established under this subsection. | 7 | | (c) Coverage under this Section shall be subject to | 8 | | copayment, deductible, and coinsurance provisions of a policy | 9 | | of accident and health insurance or managed care plan to the | 10 | | extent that other medical services covered by the policy of | 11 | | accident and health insurance or managed care plan are subject | 12 | | to these provisions. | 13 | | (d) This Section shall not be construed as limiting | 14 | | benefits that are otherwise available to an individual under a | 15 | | policy of accident and health insurance or managed care plan | 16 | | and benefits provided under this Section may not be subject to | 17 | | dollar limits, deductibles, copayments, or coinsurance | 18 | | provisions that are less favorable to the insured than the | 19 | | dollar limits, deductibles, or coinsurance provisions that | 20 | | apply to physical illness generally. | 21 | | (e) An insurer may not deny or refuse to provide otherwise | 22 | | covered services, or refuse to renew, refuse to reissue, or | 23 | | otherwise terminate or restrict coverage under an individual | 24 | | contract to provide services to an individual because the | 25 | | individual or their dependent is diagnosed with an autism | 26 | | spectrum disorder or due to the individual utilizing benefits |
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| 1 | | in this Section. | 2 | | (e-5) An insurer may not deny or refuse to provide | 3 | | otherwise covered services under a group or individual policy | 4 | | of accident and health insurance or a managed care plan solely | 5 | | because of the location wherein the clinically appropriate | 6 | | services are provided. | 7 | | (f) Upon request of the reimbursing insurer, a provider of | 8 | | treatment for autism spectrum disorders shall furnish medical | 9 | | records, clinical notes, or other necessary data that | 10 | | substantiate that initial or continued medical treatment is | 11 | | medically necessary and is resulting in improved clinical | 12 | | status. When treatment is anticipated to require continued | 13 | | services to achieve demonstrable progress, the insurer may | 14 | | request a treatment plan consisting of diagnosis, proposed | 15 | | treatment by type, frequency, anticipated duration of | 16 | | treatment, the anticipated outcomes stated as goals, and the | 17 | | frequency by which the treatment plan will be updated. | 18 | | (g) When making a determination of medical necessity for a | 19 | | treatment modality for autism spectrum disorders, an insurer | 20 | | must make the determination in a manner that is consistent | 21 | | with the manner used to make that determination with respect | 22 | | to other diseases or illnesses covered under the policy, | 23 | | including an appeals process. During the appeals process, any | 24 | | challenge to medical necessity must be viewed as reasonable | 25 | | only if the review includes a physician with expertise in the | 26 | | most current and effective treatment modalities for autism |
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| 1 | | spectrum disorders. | 2 | | (h) Coverage for medically necessary early intervention | 3 | | services must be delivered by certified early intervention | 4 | | specialists, as defined in 89 Ill. Admin. Code 500 and any | 5 | | subsequent amendments thereto. | 6 | | (h-5) If an individual has been diagnosed as having an | 7 | | autism spectrum disorder, meeting the diagnostic criteria in | 8 | | place at the time of diagnosis, and treatment is determined | 9 | | medically necessary, then that individual shall remain | 10 | | eligible for coverage under this Section even if subsequent | 11 | | changes to the diagnostic criteria are adopted by the American | 12 | | Psychiatric Association. If no changes to the diagnostic | 13 | | criteria are adopted after April 1, 2012, and before December | 14 | | 31, 2014, then this subsection (h-5) shall be of no further | 15 | | force and effect. | 16 | | (h-10) An insurer may not deny or refuse to provide | 17 | | covered services, or refuse to renew, refuse to reissue, or | 18 | | otherwise terminate or restrict coverage under an individual | 19 | | contract, for a person diagnosed with an autism spectrum | 20 | | disorder on the basis that the individual declined an | 21 | | alternative medication or covered service when the | 22 | | individual's health care provider has determined that such | 23 | | medication or covered service may exacerbate clinical | 24 | | symptomatology and is medically contraindicated for the | 25 | | individual and the individual has requested and received a | 26 | | medical exception as provided for under Section 45.1 of the |
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| 1 | | Managed Care Reform and Patient Rights Act. For the purposes | 2 | | of this subsection (h-10), "clinical symptomatology" means any | 3 | | indication of disorder or disease when experienced by an | 4 | | individual as a change from normal function, sensation, or | 5 | | appearance. | 6 | | (h-15) If, at any time, the Secretary of the United States | 7 | | Department of Health and Human Services, or its successor | 8 | | agency, promulgates rules or regulations to be published in | 9 | | the Federal Register or publishes a comment in the Federal | 10 | | Register or issues an opinion, guidance, or other action that | 11 | | would require the State, pursuant to any provision of the | 12 | | Patient Protection and Affordable Care Act (Public Law | 13 | | 111-148), including, but not limited to, 42 U.S.C. | 14 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 15 | | of any coverage outlined in subsection (h-10), then subsection | 16 | | (h-10) is inoperative with respect to all coverage outlined in | 17 | | subsection (h-10) other than that authorized under Section | 18 | | 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State | 19 | | shall not assume any obligation for the cost of the coverage | 20 | | set forth in subsection (h-10). | 21 | | (i) As used in this Section: | 22 | | "Autism spectrum disorders" means pervasive developmental | 23 | | disorders as defined in the most recent edition of the | 24 | | Diagnostic and Statistical Manual of Mental Disorders, | 25 | | including autism, Asperger's disorder, and pervasive | 26 | | developmental disorder not otherwise specified. |
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| 1 | | "Diagnosis of autism spectrum disorders" means one or more | 2 | | tests, evaluations, or assessments to diagnose whether an | 3 | | individual has autism spectrum disorder that is prescribed, | 4 | | performed, or ordered by (A) a physician licensed to practice | 5 | | medicine in all its branches or (B) a licensed clinical | 6 | | psychologist with expertise in diagnosing autism spectrum | 7 | | disorders. | 8 | | "Medically necessary" means any care, treatment, | 9 | | intervention, service or item which will or is reasonably | 10 | | expected to do any of the following: (i) prevent the onset of | 11 | | an illness, condition, injury, disease or disability; (ii) | 12 | | reduce or ameliorate the physical, mental or developmental | 13 | | effects of an illness, condition, injury, disease or | 14 | | disability; or (iii) assist to achieve or maintain maximum | 15 | | functional activity in performing daily activities. | 16 | | "Treatment for autism spectrum disorders" shall include | 17 | | the following care prescribed, provided, or ordered for an | 18 | | individual diagnosed with an autism spectrum disorder by (A) a | 19 | | physician licensed to practice medicine in all its branches or | 20 | | (B) a certified, registered, or licensed health care | 21 | | professional with expertise in treating effects of autism | 22 | | spectrum disorders when the care is determined to be medically | 23 | | necessary and ordered by a physician licensed to practice | 24 | | medicine in all its branches: | 25 | | (1) Psychiatric care, meaning direct, consultative, or | 26 | | diagnostic services provided by a licensed psychiatrist. |
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| 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 | 23 | | of the 95th General Assembly, if any, is conditioned on the | 24 | | rules being adopted in accordance with all provisions of the | 25 | | Illinois Administrative Procedure Act and all rules and | 26 | | procedures of the Joint Committee on Administrative Rules; any |
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| 1 | | purported rule not so adopted, for whatever reason, is | 2 | | unauthorized.
| 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 | 7 | | occupational therapy, physical therapy, speech therapy, and | 8 | | other services prescribed by the insured's treating physician | 9 | | pursuant to a treatment plan to enhance the ability of a child | 10 | | to function with a congenital, genetic, or early acquired | 11 | | disorder. A congenital or genetic disorder includes, but is | 12 | | not limited to, hereditary disorders. An early acquired | 13 | | disorder refers to a disorder resulting from illness, trauma, | 14 | | injury, or some other event or condition suffered by a child | 15 | | prior to that child developing functional life skills such as, | 16 | | but not limited to, walking, talking, or self-help skills. | 17 | | Congenital, genetic, and early acquired disorders may include, | 18 | | but are not limited to, autism or an autism spectrum disorder, | 19 | | cerebral palsy, and other disorders resulting from early | 20 | | childhood illness, trauma, or injury. | 21 | | (b) A group or individual policy of accident and health | 22 | | insurance or managed care plan amended, delivered, issued, or | 23 | | renewed after the effective date of this amendatory Act of the | 24 | | 95th General Assembly must provide coverage for habilitative | 25 | | services for children under 19 years of age with a congenital, |
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| 1 | | genetic, or early acquired disorder so long as all of the | 2 | | following 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 | 18 | | to other general exclusions and limitations of the policy, | 19 | | including coordination of benefits, participating provider | 20 | | requirements, restrictions on services provided by family or | 21 | | household members, utilization review of health care services, | 22 | | including review of medical necessity, case management, | 23 | | experimental, and investigational treatments, and other | 24 | | managed care provisions. | 25 | | (d) Coverage under this Section does not apply to those | 26 | | services that are solely educational in nature or otherwise |
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| 1 | | paid under State or federal law for purely educational | 2 | | services. Nothing in this subsection (d) relieves an insurer | 3 | | or similar third party from an otherwise valid obligation to | 4 | | provide or to pay for services provided to a child with a | 5 | | disability. | 6 | | (e) Coverage under this Section for children under age 19 | 7 | | shall not apply to treatment of mental or emotional disorders | 8 | | or illnesses as covered under Section 370 of this Code as well | 9 | | as any other benefit based upon a specific diagnosis that may | 10 | | be otherwise required by law. | 11 | | (f) The provisions of this Section do not apply to | 12 | | short-term travel, accident-only, limited, or specific disease | 13 | | policies. | 14 | | (g) Any denial of care for habilitative services shall be | 15 | | subject to appeal and external independent review procedures | 16 | | as provided by Section 45 of the Managed Care Reform and | 17 | | Patient Rights Act. | 18 | | (h) Upon request of the reimbursing insurer, the provider | 19 | | under whose supervision the habilitative services are being | 20 | | provided shall furnish medical records, clinical notes, or | 21 | | other necessary data to allow the insurer to substantiate that | 22 | | initial or continued medical treatment is medically necessary | 23 | | and that the patient's condition is clinically improving. When | 24 | | the treating provider anticipates that continued treatment is | 25 | | or will be required to permit the patient to achieve | 26 | | demonstrable progress, the insurer may request that the |
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| 1 | | provider furnish a treatment plan consisting of diagnosis, | 2 | | proposed treatment by type, frequency, anticipated duration of | 3 | | treatment, the anticipated goals of treatment, and how | 4 | | frequently the treatment plan will be updated. | 5 | | (i) Rulemaking authority to implement this amendatory Act | 6 | | of the 95th General Assembly, if any, is conditioned on the | 7 | | rules being adopted in accordance with all provisions of the | 8 | | Illinois Administrative Procedure Act and all rules and | 9 | | procedures of the Joint Committee on Administrative Rules; any | 10 | | purported rule not so adopted, for whatever reason, is | 11 | | unauthorized.
| 12 | | (j) An insurer may not deny or refuse to provide
otherwise | 13 | | covered services under a group or individual policy
of | 14 | | accident and health insurance or a managed care plan solely
| 15 | | because of the location wherein the clinically appropriate
| 16 | | services are provided. | 17 | | (Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10; | 18 | | 96-1000, eff. 7-2-10.)
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