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Public Act 097-0972


 

Public Act 0972 97TH GENERAL ASSEMBLY



 


 
Public Act 097-0972
 
SB0679 EnrolledLRB097 04947 ASK 44987 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.14 and 356z.16 as follows:
 
    (215 ILCS 5/356z.14)
    Sec. 356z.14. Autism spectrum disorders.
    (a) A group or individual policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed after the effective date of this amendatory Act of the
95th General Assembly 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 policy of accident and
health insurance or managed care plan.
    (b) Coverage provided under this Section shall be subject
to a maximum benefit of $36,000 per year, but shall not be
subject to any limits on the number of visits to a service
provider. After December 30, 2009, the Director of the Division
of Insurance shall, on an annual basis, adjust the maximum
benefit for inflation using the Medical Care Component of the
United States Department of Labor Consumer Price Index for All
Urban Consumers. Payments made by an insurer on behalf of a
covered individual for any care, treatment, intervention,
service, or item, the provision of which was for the treatment
of a health condition not diagnosed as an autism spectrum
disorder, shall not be applied toward any maximum benefit
established under this subsection.
    (c) Coverage under this Section shall be subject to
copayment, deductible, and coinsurance provisions of a policy
of accident and health insurance or managed care plan to the
extent that other medical services covered by the policy of
accident and health insurance or managed care plan are subject
to these provisions.
    (d) This Section shall not be construed as limiting
benefits that are otherwise available to an individual under a
policy of accident and health insurance or managed care plan
and benefits provided under this Section 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.
    (e) An insurer may not deny or refuse to provide otherwise
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual
contract to provide services to an individual because the
individual or their dependent is diagnosed with an autism
spectrum disorder or due to the individual utilizing benefits
in this Section.
    (f) Upon request of the reimbursing insurer, a provider of
treatment for autism spectrum disorders shall furnish 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. When treatment is anticipated to require continued
services to achieve demonstrable progress, the insurer may
request a treatment plan consisting of diagnosis, proposed
treatment by type, frequency, anticipated duration of
treatment, the anticipated outcomes stated as goals, and the
frequency by which the treatment plan will be updated.
    (g) When making a determination of medical necessity for a
treatment modality for autism spectrum disorders, an insurer
must make the determination in a manner that is consistent with
the manner used to make that determination with respect to
other diseases or illnesses covered under the policy, including
an appeals process. During the appeals process, any challenge
to medical necessity must be viewed as reasonable only if the
review includes a physician with expertise in the most current
and effective treatment modalities for autism spectrum
disorders.
    (h) Coverage for medically necessary early intervention
services must be delivered by certified early intervention
specialists, as defined in 89 Ill. Admin. Code 500 and any
subsequent amendments thereto.
    (h-5) If an individual has been diagnosed as having an
autism spectrum disorder, meeting the diagnostic criteria in
place at the time of diagnosis, and treatment is determined
medically necessary, then that individual shall remain
eligible for coverage under this Section even if subsequent
changes to the diagnostic criteria are adopted by the American
Psychiatric Association. If no changes to the diagnostic
criteria are adopted after April 1, 2012, and before December
31, 2014, then this subsection (h-5) shall be of no further
force and effect.
    (i) As used in this Section:
    "Autism spectrum disorders" means pervasive developmental
disorders as defined in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders,
including autism, Asperger's disorder, and pervasive
developmental disorder not otherwise specified.
    "Diagnosis of autism spectrum disorders" means one or more
tests, evaluations, or assessments to diagnose whether an
individual has autism spectrum disorder that is prescribed,
performed, or ordered by (A) a physician licensed to practice
medicine in all its branches or (B) a licensed clinical
psychologist with expertise in diagnosing autism spectrum
disorders.
    "Medically necessary" means any care, treatment,
intervention, service or item which will or is reasonably
expected to do any of the following: (i) prevent the onset of
an illness, condition, injury, disease or disability; (ii)
reduce or ameliorate the physical, mental or developmental
effects of an illness, condition, injury, disease or
disability; or (iii) assist to achieve or maintain maximum
functional activity in performing daily activities.
    "Treatment for autism spectrum disorders" shall include
the following care prescribed, provided, or ordered for an
individual diagnosed with an autism spectrum disorder by (A) a
physician licensed to practice medicine in all its branches or
(B) a certified, registered, or licensed health care
professional with expertise in treating effects of autism
spectrum disorders when the care is determined to be medically
necessary and ordered by a physician licensed to practice
medicine in all its branches:
        (1) Psychiatric care, meaning direct, consultative, or
    diagnostic services provided by a licensed psychiatrist.
        (2) Psychological care, meaning direct or consultative
    services provided by a licensed psychologist.
        (3) Habilitative or rehabilitative care, meaning
    professional, counseling, and guidance services and
    treatment programs, including applied behavior analysis,
    that are intended to develop, maintain, and restore the
    functioning of an individual. As used in this subsection
    (i), "applied behavior analysis" means the design,
    implementation, and evaluation of environmental
    modifications using behavioral stimuli and consequences to
    produce socially significant improvement in human
    behavior, including the use of direct observation,
    measurement, and functional analysis of the relations
    between environment and behavior.
        (4) Therapeutic care, including behavioral, speech,
    occupational, and physical therapies that provide
    treatment in the following areas: (i) self care and
    feeding, (ii) pragmatic, receptive, and expressive
    language, (iii) cognitive functioning, (iv) applied
    behavior analysis, intervention, and modification, (v)
    motor planning, and (vi) sensory processing.
    (j) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, if any, is conditioned on the
rules being adopted in accordance with all provisions of the
Illinois Administrative Procedure Act and all rules and
procedures of the Joint Committee on Administrative Rules; any
purported rule not so adopted, for whatever reason, is
unauthorized.
(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)
 
    (215 ILCS 5/356z.16)
    Sec. 356z.16. Applicability of mandated benefits to
supplemental policies. Unless specified otherwise, the
following Sections of the Illinois Insurance Code do not apply
to short-term travel, disability income, long-term care,
accident only, or limited or specified disease policies: 356b,
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t,
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
356z.8, 356z.12, 356z.14, 356z.19, 356z.21 356z.19, 364.01,
367.2-5, and 367e.
(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10;
96-1034, eff. 1-1-11; 97-91, eff. 1-1-12; 97-282, eff. 8-9-11;
97-592, eff. 1-1-12; revised 10-13-11.)

Effective Date: 1/1/2013