102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB1592

 

Introduced 2/26/2021, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.14
215 ILCS 5/356z.15

    Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or managed care plan that provides individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders may not deny or refuse to provide otherwise covered services solely because of the location where services are provided. Provides that a group or individual policy of accident and health insurance or managed care plan that provides coverage for habilitative services for children under 19 years of age with a congenital, genetic, or early acquired disorder under specified conditions may not deny or refuse to provide otherwise covered services solely because of the location where services are provided.


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FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

SB1592LRB102 13156 BMS 18499 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing 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
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
16and health insurance or managed care plan.
17    (b) Coverage provided under this Section shall be subject
18to a maximum benefit of $36,000 per year, but shall not be
19subject to any limits on the number of visits to a service
20provider. After December 30, 2009, the Director of the
21Division of Insurance shall, on an annual basis, adjust the
22maximum benefit for inflation using the Medical Care Component
23of the United States Department of Labor Consumer Price Index

 

 

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

 

 

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1in this Section.
2    (e-5) An insurer may not deny or refuse to provide
3otherwise covered services under a group or individual policy
4of accident and health insurance or a managed care plan solely
5because of the location wherein the services are provided.
6    (f) Upon request of the reimbursing insurer, a provider of
7treatment for autism spectrum disorders shall furnish medical
8records, clinical notes, or other necessary data that
9substantiate that initial or continued medical treatment is
10medically necessary and is resulting in improved clinical
11status. When treatment is anticipated to require continued
12services to achieve demonstrable progress, the insurer may
13request a treatment plan consisting of diagnosis, proposed
14treatment by type, frequency, anticipated duration of
15treatment, the anticipated outcomes stated as goals, and the
16frequency by which the treatment plan will be updated.
17    (g) When making a determination of medical necessity for a
18treatment modality for autism spectrum disorders, an insurer
19must make the determination in a manner that is consistent
20with the manner used to make that determination with respect
21to other diseases or illnesses covered under the policy,
22including an appeals process. During the appeals process, any
23challenge to medical necessity must be viewed as reasonable
24only if the review includes a physician with expertise in the
25most current and effective treatment modalities for autism
26spectrum disorders.

 

 

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1    (h) Coverage for medically necessary early intervention
2services must be delivered by certified early intervention
3specialists, as defined in 89 Ill. Admin. Code 500 and any
4subsequent amendments thereto.
5    (h-5) If an individual has been diagnosed as having an
6autism spectrum disorder, meeting the diagnostic criteria in
7place at the time of diagnosis, and treatment is determined
8medically necessary, then that individual shall remain
9eligible for coverage under this Section even if subsequent
10changes to the diagnostic criteria are adopted by the American
11Psychiatric Association. If no changes to the diagnostic
12criteria are adopted after April 1, 2012, and before December
1331, 2014, then this subsection (h-5) shall be of no further
14force and effect.
15    (h-10) An insurer may not deny or refuse to provide
16covered services, or refuse to renew, refuse to reissue, or
17otherwise terminate or restrict coverage under an individual
18contract, for a person diagnosed with an autism spectrum
19disorder on the basis that the individual declined an
20alternative medication or covered service when the
21individual's health care provider has determined that such
22medication or covered service may exacerbate clinical
23symptomatology and is medically contraindicated for the
24individual and the individual has requested and received a
25medical exception as provided for under Section 45.1 of the
26Managed Care Reform and Patient Rights Act. For the purposes

 

 

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1of this subsection (h-10), "clinical symptomatology" means any
2indication of disorder or disease when experienced by an
3individual as a change from normal function, sensation, or
4appearance.
5    (h-15) If, at any time, the Secretary of the United States
6Department of Health and Human Services, or its successor
7agency, promulgates rules or regulations to be published in
8the Federal Register or publishes a comment in the Federal
9Register or issues an opinion, guidance, or other action that
10would require the State, pursuant to any provision of the
11Patient Protection and Affordable Care Act (Public Law
12111-148), including, but not limited to, 42 U.S.C.
1318031(d)(3)(B) or any successor provision, to defray the cost
14of any coverage outlined in subsection (h-10), then subsection
15(h-10) is inoperative with respect to all coverage outlined in
16subsection (h-10) other than that authorized under Section
171902 of the Social Security Act, 42 U.S.C. 1396a, and the State
18shall not assume any obligation for the cost of the coverage
19set forth in subsection (h-10).
20    (i) As used in this Section:
21    "Autism spectrum disorders" means pervasive developmental
22disorders as defined in the most recent edition of the
23Diagnostic and Statistical Manual of Mental Disorders,
24including autism, Asperger's disorder, and pervasive
25developmental disorder not otherwise specified.
26    "Diagnosis of autism spectrum disorders" means one or more

 

 

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

 

 

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1    services provided by a licensed psychologist.
2        (3) Habilitative or rehabilitative care, meaning
3    professional, counseling, and guidance services and
4    treatment programs, including applied behavior analysis,
5    that are intended to develop, maintain, and restore the
6    functioning of an individual. As used in this subsection
7    (i), "applied behavior analysis" means the design,
8    implementation, and evaluation of environmental
9    modifications using behavioral stimuli and consequences to
10    produce socially significant improvement in human
11    behavior, including the use of direct observation,
12    measurement, and functional analysis of the relations
13    between environment and behavior.
14        (4) Therapeutic care, including behavioral, speech,
15    occupational, and physical therapies that provide
16    treatment in the following areas: (i) self care and
17    feeding, (ii) pragmatic, receptive, and expressive
18    language, (iii) cognitive functioning, (iv) applied
19    behavior analysis, intervention, and modification, (v)
20    motor planning, and (vi) sensory processing.
21    (j) Rulemaking authority to implement this amendatory Act
22of the 95th General Assembly, if any, is conditioned on the
23rules being adopted in accordance with all provisions of the
24Illinois Administrative Procedure Act and all rules and
25procedures of the Joint Committee on Administrative Rules; any
26purported rule not so adopted, for whatever reason, is

 

 

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1unauthorized.
2(Source: P.A. 99-788, eff. 8-12-16.)
 
3    (215 ILCS 5/356z.15)
4    Sec. 356z.15. Habilitative services for children.
5    (a) As used in this Section, "habilitative services" means
6occupational therapy, physical therapy, speech therapy, and
7other services prescribed by the insured's treating physician
8pursuant to a treatment plan to enhance the ability of a child
9to function with a congenital, genetic, or early acquired
10disorder. A congenital or genetic disorder includes, but is
11not limited to, hereditary disorders. An early acquired
12disorder refers to a disorder resulting from illness, trauma,
13injury, or some other event or condition suffered by a child
14prior to that child developing functional life skills such as,
15but not limited to, walking, talking, or self-help skills.
16Congenital, genetic, and early acquired disorders may include,
17but are not limited to, autism or an autism spectrum disorder,
18cerebral palsy, and other disorders resulting from early
19childhood illness, trauma, or injury.
20    (b) A group or individual policy of accident and health
21insurance or managed care plan amended, delivered, issued, or
22renewed after the effective date of this amendatory Act of the
2395th General Assembly must provide coverage for habilitative
24services for children under 19 years of age with a congenital,
25genetic, or early acquired disorder so long as all of the

 

 

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1following conditions are met:
2        (1) A physician licensed to practice medicine in all
3    its branches has diagnosed the child's congenital,
4    genetic, or early acquired disorder.
5        (2) The treatment is administered by a licensed
6    speech-language pathologist, licensed audiologist,
7    licensed occupational therapist, licensed physical
8    therapist, licensed physician, licensed nurse, licensed
9    optometrist, licensed nutritionist, licensed social
10    worker, or licensed psychologist upon the referral of a
11    physician licensed to practice medicine in all its
12    branches.
13        (3) The initial or continued treatment must be
14    medically necessary and therapeutic and not experimental
15    or investigational.
16    (c) The coverage required by this Section shall be subject
17to other general exclusions and limitations of the policy,
18including coordination of benefits, participating provider
19requirements, restrictions on services provided by family or
20household members, utilization review of health care services,
21including review of medical necessity, case management,
22experimental, and investigational treatments, and other
23managed care provisions.
24    (d) Coverage under this Section does not apply to those
25services that are solely educational in nature or otherwise
26paid under State or federal law for purely educational

 

 

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1services. Nothing in this subsection (d) relieves an insurer
2or similar third party from an otherwise valid obligation to
3provide or to pay for services provided to a child with a
4disability.
5    (e) Coverage under this Section for children under age 19
6shall not apply to treatment of mental or emotional disorders
7or illnesses as covered under Section 370 of this Code as well
8as any other benefit based upon a specific diagnosis that may
9be otherwise required by law.
10    (f) The provisions of this Section do not apply to
11short-term travel, accident-only, limited, or specific disease
12policies.
13    (g) Any denial of care for habilitative services shall be
14subject to appeal and external independent review procedures
15as provided by Section 45 of the Managed Care Reform and
16Patient Rights Act.
17    (h) Upon request of the reimbursing insurer, the provider
18under whose supervision the habilitative services are being
19provided shall furnish medical records, clinical notes, or
20other necessary data to allow the insurer to substantiate that
21initial or continued medical treatment is medically necessary
22and that the patient's condition is clinically improving. When
23the treating provider anticipates that continued treatment is
24or will be required to permit the patient to achieve
25demonstrable progress, the insurer may request that the
26provider furnish a treatment plan consisting of diagnosis,

 

 

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1proposed treatment by type, frequency, anticipated duration of
2treatment, the anticipated goals of treatment, and how
3frequently the treatment plan will be updated.
4    (i) Rulemaking authority to implement this amendatory Act
5of the 95th General Assembly, if any, is conditioned on the
6rules being adopted in accordance with all provisions of the
7Illinois Administrative Procedure Act and all rules and
8procedures of the Joint Committee on Administrative Rules; any
9purported rule not so adopted, for whatever reason, is
10unauthorized.
11    (j) An insurer may not deny or refuse to provide otherwise
12covered services under a group or individual policy of
13accident and health insurance or a managed care plan solely
14because of the location wherein the services are provided.
15(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10;
1696-1000, eff. 7-2-10.)