101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2845

 

Introduced , by Rep. Deb Conroy

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.11 new

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a Medicaid managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the Medicaid managed care plan. Provides that the coverage provided for the treatment of autism spectrum disorders shall not be subject to any limits on the number of visits to a service provider, but shall be subject to copayment, deductible, and coinsurance provisions of a Medicaid managed care plan to the extent that other medical services covered by the Medicaid managed care plan are subject to these provisions. Provides that the provisions of the amendatory Act shall not be construed as limiting benefits that are otherwise available to an individual under a Medicaid managed care plan and benefits provided under the amendatory Act may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally. Requires a provider of treatment for autism spectrum disorders to furnish, upon request to the reimbursing managed care organization, medical records, clinical notes, or other necessary data that substantiate that initial or continued medical treatment is medically necessary and is resulting in improved clinical status. Defines terms. Makes other changes.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5adding Section 5-30.11 as follows:
 
6    (305 ILCS 5/5-30.11 new)
7    Sec. 5-30.11. Autism spectrum disorders.
8    (a) As used in this Section:
9    "Autism spectrum disorders" means pervasive developmental
10disorders as defined in the most recent edition of the
11Diagnostic and Statistical Manual of Mental Disorders,
12including autism, Asperger's syndrome, and pervasive
13developmental disorder not otherwise specified.
14    "Diagnosis of autism spectrum disorders" means one or more
15tests, evaluations, or assessments to diagnose whether an
16individual has autism spectrum disorder that is prescribed,
17performed, or ordered by (A) a physician licensed to practice
18medicine in all its branches or (B) a licensed clinical
19psychologist with expertise in diagnosing autism spectrum
20disorders.
21    "Managed care organization" has the meaning ascribed to
22that term in Section 5-30.1.
23    "Medicaid managed care plan" means a health care plan

 

 

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1operated by a managed care organization under the Medical
2Assistance Program.
3    "Medically necessary" means any care, treatment,
4intervention, service, or item that will or is reasonably
5expected to do any of the following: (i) prevent the onset of
6an illness, condition, injury, disease, or disability; (ii)
7reduce or ameliorate the physical, mental or developmental
8effects of an illness, condition, injury, disease or
9disability; or (iii) assist to achieve or maintain maximum
10functional activity in performing daily activities.
11    "Treatment for autism spectrum disorders" includes the
12following care prescribed, provided, or ordered for an
13individual diagnosed with an autism spectrum disorder by (A) a
14physician licensed to practice medicine in all its branches or
15(B) a certified, registered, or licensed health care
16professional with expertise in treating effects of autism
17spectrum disorders when the care is determined to be medically
18necessary and ordered by a physician licensed to practice
19medicine in all its branches:
20        (1) Psychiatric care, meaning direct, consultative, or
21    diagnostic services provided by a licensed psychiatrist.
22        (2) Psychological care, meaning direct or consultative
23    services provided by a licensed psychologist.
24        (3) Habilitative or rehabilitative care, meaning
25    professional, counseling, and guidance services and
26    treatment programs, including applied behavior analysis,

 

 

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1    that are intended to develop, maintain, and restore the
2    functioning of an individual. As used in this subsection,
3    "applied behavior analysis" means the design,
4    implementation, and evaluation of environmental
5    modifications using behavioral stimuli and consequences to
6    produce socially significant improvement in human
7    behavior, including the use of direct observation,
8    measurement, and functional analysis of the relations
9    between environment and behavior.
10        (4) Therapeutic care, including behavioral, speech,
11    occupational, and physical therapies that provide
12    treatment in the following areas: (i) self care and
13    feeding, (ii) pragmatic, receptive, and expressive
14    language, (iii) cognitive functioning, (iv) applied
15    behavior analysis, intervention, and modification, (v)
16    motor planning, and (vi) sensory processing.
17    (b) A Medicaid managed care plan amended, delivered,
18issued, or renewed after the effective date of this amendatory
19Act of the 101st General Assembly must provide individuals
20under 21 years of age coverage for the diagnosis of autism
21spectrum disorders and for the treatment of autism spectrum
22disorders to the extent that the diagnosis and treatment of
23autism spectrum disorders are not already covered by the
24managed care plan.
25    (c) Coverage provided under this Section shall not be
26subject to any limits on the number of visits to a service

 

 

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

 

 

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1    (g) Upon request of the reimbursing managed care
2organization, a provider of treatment for autism spectrum
3disorders shall furnish medical records, clinical notes, or
4other necessary data that substantiate that initial or
5continued medical treatment is medically necessary and is
6resulting in improved clinical status. When treatment is
7anticipated to require continued services to achieve
8demonstrable progress, the managed care organization 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    (h) When making a determination of medical necessity for a
14treatment modality for autism spectrum disorders, a managed
15care organization must make the determination in a manner that
16is consistent with the manner used to make that determination
17with respect to other diseases or illnesses covered under the
18Medicaid managed care plan, including an appeals process.
19During the appeals process, any challenge to medical necessity
20must be viewed as reasonable only if the review includes a
21physician with expertise in the most current and effective
22treatment modalities for autism spectrum disorders.
23    (i) Coverage for medically necessary early intervention
24services must be delivered by certified early intervention
25specialists, as defined in 89 Ill. Adm. Code 500 and any
26subsequent amendments.