Full Text of SB0345 99th General Assembly
SB0345sam003 99TH GENERAL ASSEMBLY | Sen. Don Harmon Filed: 5/18/2016
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| 1 | | AMENDMENT TO SENATE BILL 345
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 345 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be cited as the | 5 | | Autism and Co-Occurring Medical Conditions Awareness Act. | 6 | | Section 5. Findings. The General Assembly finds the | 7 | | following: | 8 | | (1) The medical consensus is that autism is an | 9 | | idiopathic disorder that has complex and multiple | 10 | | etiologies. The development of autism appears to be a | 11 | | complex interaction of multiple genetic and environmental | 12 | | factors. Both the prevalence and incidence of autism has | 13 | | risen in recent decades. | 14 | | (2) The Centers for Disease Control estimates that one | 15 | | in 68 children born in 2002 and one in 42 boys have been | 16 | | identified as living with autism. |
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| 1 | | (3) A 2012 survey conducted by the Centers for Disease | 2 | | Control of U.S. households estimated one in 50 children | 3 | | ages 6 to 17 has an autism spectrum disorder. | 4 | | (4) Autism spectrum disorders occur among all racial, | 5 | | ethnic, and socioeconomic groups. | 6 | | (5) Autism spectrum disorders are almost 5 times more | 7 | | common among boys than among girls. | 8 | | (6) According to the Centers for Disease Control, | 9 | | autism rates increased 78% between 2002 and 2008. The most | 10 | | recent estimate is roughly 30% higher than the estimate for | 11 | | 2008 (one in 88), 60% higher than the estimate for 2006 | 12 | | (one in 110), and 120% higher than the estimates for 2000 | 13 | | and 2002 (one in 150). | 14 | | (7) While autism spectrum disorders have primarily | 15 | | been diagnosed in measuring deficits in the areas of | 16 | | communication, socialization, and behavior, recent | 17 | | clinical and scientific investigations have determined | 18 | | that co-occurring pathophysiological conditions may occur | 19 | | more commonly in persons also diagnosed with autism.
These | 20 | | pathologies include, but are not limited to, allergies, | 21 | | autoimmune conditions, gastrointestinal diseases, immune | 22 | | dysregulation, metabolic disturbances, mitochondrial | 23 | | abnormalities, oxidative stress, neuroinflammation, and | 24 | | seizure disorders. | 25 | | (8) Scientific inquiry is providing evidence of | 26 | | biological markers, including, but not limited to, single |
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| 1 | | nucleotide polymorphisms, indications of cellular | 2 | | inflammation, increased cellular oxidation and damage, and | 3 | | abnormal DNA methylation, that may be clinically | 4 | | significant in the provision of appropriate medical care | 5 | | for persons also diagnosed with an autism spectrum | 6 | | disorder. | 7 | | Therefore, it is the intention of the General Assembly to | 8 | | promote a greater awareness and the detection, diagnosis, and | 9 | | treatment of underlying and co-occurring medical conditions | 10 | | that occur more commonly in persons with autism to further | 11 | | awareness, scientific understanding, and health outcomes for | 12 | | persons living with autism. | 13 | | Section 10. Definitions. In this Act: | 14 | | "Autism spectrum disorder" means a neurobiological | 15 | | disorder, including autism, regressive autism, Asperger | 16 | | Syndrome, and pervasive developmental disorders not otherwise | 17 | | specified. | 18 | | "Clinical symptomatology" means any indication of disorder | 19 | | or disease when experienced by an individual as a change from | 20 | | normal function, sensation, or appearance. | 21 | | "Co-occurring or otherwise diagnosed medical condition" | 22 | | means a simultaneous illness, condition, injury, disease, | 23 | | pathology, or disability that is not primarily diagnosed as an | 24 | | autism spectrum disorder. | 25 | | "Department" means the Department of Financial and |
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| 1 | | Professional Regulation. | 2 | | "Pathophysiological" means the functional alterations in | 3 | | the body related to a disease or syndrome. | 4 | | "Provider" means any provider of healthcare services in | 5 | | this State. | 6 | | Section 15. Study and education. Public partnerships and | 7 | | private partnerships supporting the discovery of biomarkers | 8 | | and their implications in pathophysiological conditions shall | 9 | | be encouraged and information derived from such discoveries | 10 | | shall be disseminated to providers and made available to the | 11 | | general public through research initiatives that may be | 12 | | promoted by universities, medical clinics, health care | 13 | | providers, consortiums, State agencies, private organizations, | 14 | | public organizations, and any party that may contribute to the | 15 | | scientific understanding of medical conditions associated or | 16 | | occurring more often in persons also diagnosed with an autism | 17 | | spectrum disorder than in the general population. | 18 | | Universities, private organizations, public organizations, | 19 | | and associations are encouraged to develop for providers who | 20 | | treat persons with autism spectrum disorders continuing | 21 | | education courses which address training in evaluation, | 22 | | diagnosis, and treatments for co-occurring and otherwise | 23 | | diagnosed pathophysiological conditions in autism spectrum | 24 | | disorders to promote and align standard of care practices to | 25 | | reflect emerging clinical findings and promising practices |
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| 1 | | derived from improved patient outcomes. | 2 | | Section 20. Treatment or service of persons with an autism | 3 | | spectrum disorder. Providers are strongly encouraged to | 4 | | evaluate persons diagnosed with an autism spectrum disorder for | 5 | | co-occurring or otherwise diagnosed medical conditions when | 6 | | clinical symptomatology is present or suspected and prescribe | 7 | | appropriate treatments or services in alignment with care | 8 | | practices for the condition, illness, injury, disease, or | 9 | | disability. Providers may consider, without limitation, | 10 | | whether or not a medication or any ingredient, allergen, | 11 | | potential toxicant, or artificial agent may exacerbate | 12 | | clinical symptomatology of autism spectrum disorder or a | 13 | | related or co-occurring or otherwise diagnosed medical | 14 | | condition and, if so, may consider adopting measures that would | 15 | | result in the reduction or elimination of risk to the patient. | 16 | | Section 25. Complaints. Any person with an autism spectrum | 17 | | disorder, or the person's parent or legal guardian on his or | 18 | | her behalf, who believes they have not received an appropriate | 19 | | medical assessment, evaluation, diagnosis, service or | 20 | | treatment from a provider because he or she is also diagnosed | 21 | | with an autism spectrum disorder may report the incident to the | 22 | | Department. | 23 | | Section 30. Right to seek new care. A person with an autism |
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| 1 | | spectrum disorder, or the person's parent or legal guardian on | 2 | | his or her behalf, retains the right to seek further medical | 3 | | opinions or care from other providers. | 4 | | A parent or legal guardian shall not be threatened with | 5 | | loss of parental or legal guardianship rights for a person with | 6 | | autism spectrum disorder for pursuing additional medical | 7 | | expertise, especially in the case of trying to ascertain | 8 | | appropriate identification and diagnosis of underlying or | 9 | | co-occurring medical conditions that may or may not be | 10 | | exacerbating symptoms primarily associated with an autism | 11 | | spectrum disorder. This Section does not abrogate or restrict | 12 | | any responsibilities set forth under the Abused and Neglected | 13 | | Child Reporting Act. | 14 | | Any person diagnosed as having an autism spectrum disorder | 15 | | or his or her parent or legal guardian shall not be denied the | 16 | | right to pursue appropriate and available medical | 17 | | interventions or treatments that may help to ameliorate or | 18 | | improve the symptoms primarily associated with an autism | 19 | | spectrum disorder or co-occurring or otherwise diagnosed | 20 | | medical condition. | 21 | | Any person diagnosed as having an autism spectrum disorder | 22 | | or his or her parent or legal guardian shall not be denied the | 23 | | right to decline a medical treatment or intervention. | 24 | | Section 35. Repeal. In order to consider the most | 25 | | innovative medical study and research involving autism and |
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| 1 | | co-occurring medical conditions, this Act is repealed 5 year | 2 | | after the effective date of this Act. | 3 | | Section 90. The Illinois Insurance Code is amended by | 4 | | changing Section 356z.14 and by adding Section 356z.24 as | 5 | | 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 and | 16 | | 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 Division | 21 | | of Insurance shall, on an annual basis, adjust the maximum | 22 | | benefit for inflation using the Medical Care Component of the | 23 | | United States Department of Labor Consumer Price Index for All | 24 | | Urban Consumers. Payments made by an insurer on behalf of a |
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| 1 | | covered individual for any care, treatment, intervention, | 2 | | service, or item, the provision of which was for the treatment | 3 | | of a health condition not diagnosed as an autism spectrum | 4 | | disorder, shall not be applied toward any maximum benefit | 5 | | established under this subsection. | 6 | | (c) Coverage under this Section shall be subject to | 7 | | copayment, deductible, and coinsurance provisions of a policy | 8 | | of accident and health insurance or managed care plan to the | 9 | | extent that other medical services covered by the policy of | 10 | | accident and health insurance or managed care plan are subject | 11 | | to these provisions. | 12 | | (d) This Section shall not be construed as limiting | 13 | | benefits that are otherwise available to an individual under a | 14 | | policy of accident and health insurance or managed care plan | 15 | | and benefits provided under this Section may not be subject to | 16 | | dollar limits, deductibles, copayments, or coinsurance | 17 | | provisions that are less favorable to the insured than the | 18 | | dollar limits, deductibles, or coinsurance provisions that | 19 | | apply to physical illness generally. | 20 | | (e) An insurer may not deny or refuse to provide otherwise | 21 | | covered services, or refuse to renew, refuse to reissue, or | 22 | | otherwise terminate or restrict coverage under an individual | 23 | | contract to provide services to an individual because the | 24 | | individual or their dependent is diagnosed with an autism | 25 | | spectrum disorder or due to the individual utilizing benefits | 26 | | in this Section. |
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| 1 | | (f) Upon request of the reimbursing insurer, a provider of | 2 | | treatment for autism spectrum disorders shall furnish medical | 3 | | records, clinical notes, or other necessary data that | 4 | | substantiate that initial or continued medical treatment is | 5 | | medically necessary and is resulting in improved clinical | 6 | | status. When treatment is anticipated to require continued | 7 | | services to achieve demonstrable progress, the insurer may | 8 | | request a treatment plan consisting of diagnosis, proposed | 9 | | treatment by type, frequency, anticipated duration of | 10 | | treatment, the anticipated outcomes stated as goals, and the | 11 | | frequency by which the treatment plan will be updated. | 12 | | (g) When making a determination of medical necessity for a | 13 | | treatment modality for autism spectrum disorders, an insurer | 14 | | must make the determination in a manner that is consistent with | 15 | | the manner used to make that determination with respect to | 16 | | other diseases or illnesses covered under the policy, including | 17 | | an appeals process. During the appeals process, any challenge | 18 | | to medical necessity must be viewed as reasonable only if the | 19 | | review includes a physician with expertise in the most current | 20 | | and effective treatment modalities for autism spectrum | 21 | | disorders. | 22 | | (h) Coverage for medically necessary early intervention | 23 | | services must be delivered by certified early intervention | 24 | | specialists, as defined in 89 Ill. Admin. Code 500 and any | 25 | | subsequent amendments thereto. | 26 | | (h-5) If an individual has been diagnosed as having an |
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| 1 | | autism spectrum disorder, meeting the diagnostic criteria in | 2 | | place at the time of diagnosis, and treatment is determined | 3 | | medically necessary, then that individual shall remain | 4 | | eligible for coverage under this Section even if subsequent | 5 | | changes to the diagnostic criteria are adopted by the American | 6 | | Psychiatric Association. If no changes to the diagnostic | 7 | | criteria are adopted after April 1, 2012, and before December | 8 | | 31, 2014, then this subsection (h-5) shall be of no further | 9 | | force and effect. | 10 | | (h-10) An insurer may not deny or refuse to provide covered | 11 | | services, or refuse to renew, refuse to reissue, or otherwise | 12 | | terminate or restrict coverage under an individual contract, | 13 | | for a person diagnosed with an autism spectrum disorder on the | 14 | | basis that the individual declined an alternative medication or | 15 | | covered service when the individual's health care provider has | 16 | | determined that such medication or covered service may | 17 | | exacerbate clinical symptomatology and is medically | 18 | | contraindicated for the individual and the individual has | 19 | | requested and received a medical exception as provided for | 20 | | under Section 45.1 of the Managed Care Reform and Patient | 21 | | Rights Act. For the purposes of this subsection (h-10), | 22 | | "clinical symptomatology" means any indication of disorder or | 23 | | disease when experienced by an individual as a change from | 24 | | normal function, sensation, or appearance. | 25 | | (h-15) If, at any time, the Secretary of the United States | 26 | | Department of Health and Human Services, or its successor |
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| 1 | | agency, promulgates rules or regulations to be published in the | 2 | | Federal Register or publishes a comment in the Federal Register | 3 | | or issues an opinion, guidance, or other action that would | 4 | | require the State, pursuant to any provision of the Patient | 5 | | Protection and Affordable Care Act (Public Law 111–148), | 6 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 7 | | successor provision, to defray the cost of any coverage | 8 | | outlined in subsection (h-10), then subsection (h-10) is | 9 | | inoperative with respect to all coverage outlined in subsection | 10 | | (h-10) other than that authorized under Section 1902 of the | 11 | | Social Security Act, 42 U.S.C. 1396a, and the State shall not | 12 | | assume any obligation for the cost of the coverage set forth in | 13 | | subsection (h-10). | 14 | | (i) As used in this Section: | 15 | | "Autism spectrum disorders" means pervasive developmental | 16 | | disorders as defined in the most recent edition of the | 17 | | Diagnostic and Statistical Manual of Mental Disorders, | 18 | | including autism, Asperger's disorder, and pervasive | 19 | | developmental disorder not otherwise specified. | 20 | | "Diagnosis of autism spectrum disorders" means one or more | 21 | | tests, evaluations, or assessments to diagnose whether an | 22 | | individual has autism spectrum disorder that is prescribed, | 23 | | performed, or ordered by (A) a physician licensed to practice | 24 | | medicine in all its branches or (B) a licensed clinical | 25 | | psychologist with expertise in diagnosing autism spectrum | 26 | | disorders. |
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| 1 | | "Medically necessary" means any care, treatment, | 2 | | intervention, service or item which will or is reasonably | 3 | | expected to do any of the following: (i) prevent the onset of | 4 | | an illness, condition, injury, disease or disability; (ii) | 5 | | reduce or ameliorate the physical, mental or developmental | 6 | | effects of an illness, condition, injury, disease or | 7 | | disability; or (iii) assist to achieve or maintain maximum | 8 | | functional activity in performing daily activities. | 9 | | "Treatment for autism spectrum disorders" shall include | 10 | | the following care prescribed, provided, or ordered for an | 11 | | individual diagnosed with an autism spectrum disorder by (A) a | 12 | | physician licensed to practice medicine in all its branches or | 13 | | (B) a certified, registered, or licensed health care | 14 | | professional with expertise in treating effects of autism | 15 | | spectrum disorders when the care is determined to be medically | 16 | | necessary and ordered by a physician licensed to practice | 17 | | medicine in all its branches: | 18 | | (1) Psychiatric care, meaning direct, consultative, or | 19 | | diagnostic services provided by a licensed psychiatrist. | 20 | | (2) Psychological care, meaning direct or consultative | 21 | | services provided by a licensed psychologist. | 22 | | (3) Habilitative or rehabilitative care, meaning | 23 | | professional, counseling, and guidance services and | 24 | | treatment programs, including applied behavior analysis, | 25 | | that are intended to develop, maintain, and restore the | 26 | | functioning of an individual. As used in this subsection |
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| 1 | | (i), "applied behavior analysis" means the design, | 2 | | implementation, and evaluation of environmental | 3 | | modifications using behavioral stimuli and consequences to | 4 | | produce socially significant improvement in human | 5 | | behavior, including the use of direct observation, | 6 | | measurement, and functional analysis of the relations | 7 | | between environment and behavior. | 8 | | (4) Therapeutic care, including behavioral, speech, | 9 | | occupational, and physical therapies that provide | 10 | | treatment in the following areas: (i) self care and | 11 | | feeding, (ii) pragmatic, receptive, and expressive | 12 | | language, (iii) cognitive functioning, (iv) applied | 13 | | behavior analysis, intervention, and modification, (v) | 14 | | motor planning, and (vi) sensory processing. | 15 | | (j) Rulemaking authority to implement this amendatory Act | 16 | | of the 95th General Assembly, if any, is conditioned on the | 17 | | rules being adopted in accordance with all provisions of the | 18 | | Illinois Administrative Procedure Act and all rules and | 19 | | procedures of the Joint Committee on Administrative Rules; any | 20 | | purported rule not so adopted, for whatever reason, is | 21 | | unauthorized.
| 22 | | (Source: P.A. 96-1000, eff. 7-2-10; 97-972, eff. 1-1-13.) | 23 | | (215 ILCS 5/356z.24 new) | 24 | | Sec. 356z.24. Immune gamma globulin therapy. | 25 | | (a) A group or individual policy of accident and health |
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| 1 | | insurance or managed care plan amended, delivered, issued, or | 2 | | renewed after the effective date of this amendatory Act of the | 3 | | 99th General Assembly may not allow for the delay, | 4 | | discontinuation, or interruption of immune gamma globulin | 5 | | therapy for persons who are diagnosed with a primary | 6 | | immunodeficiency when prescribed as medically necessary by a | 7 | | physician licensed to practice medicine in all of its branches, | 8 | | based on documented immunopathological findings and a | 9 | | provider's clinical judgment, and if provided as a covered | 10 | | benefit under the plan. Nothing in this Section shall prevent | 11 | | an insurer from applying appropriate utilization review | 12 | | standards to the ongoing coverage of immune gamma globulin | 13 | | therapy for persons diagnosed with a primary immunodeficiency | 14 | | by a physician licensed to practice medicine in all of its | 15 | | branches. For the purposes of this subsection (a), | 16 | | "immunopathological findings" means clinical findings related | 17 | | to the structural and functional manifestations associated | 18 | | with immune responses to disease or function of antibodies. | 19 | | (b) Upon diagnosis of primary immunodeficiency by the | 20 | | prescribing physician, determination of an initial | 21 | | authorization for immune gamma globulin therapy shall be no | 22 | | less than 3 months. Reauthorization for immune gamma globulin | 23 | | therapy for patients with a primary immunodeficiency diagnosis | 24 | | may occur every 6 months thereafter. For patients with a | 25 | | diagnosis of primary immunodeficiency who have been receiving | 26 | | immune gamma globulin therapy for at least 2 years with |
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| 1 | | sustained beneficial response based on the treatment notes or | 2 | | clinical narrative detailing progress to date, reauthorization | 3 | | shall be no less than 12 months unless a more frequent duration | 4 | | has been indicated by the prescribing physician. | 5 | | (c) If, at any time, the Secretary of the United States | 6 | | Department of Health and Human Services, or its successor | 7 | | agency, promulgates rules or regulations to be published in the | 8 | | Federal Register or publishes a comment in the Federal Register | 9 | | or issues an opinion, guidance, or other action that would | 10 | | require the State, pursuant to any provision of the Patient | 11 | | Protection and Affordable Care Act (Public Law 111–148), | 12 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 13 | | successor provision, to defray the cost of any coverage | 14 | | outlined in subsections (a) and (b), then subsections (a) and | 15 | | (b) are inoperative with respect to all coverage outlined in | 16 | | subsections (a) and (b) other than that authorized under | 17 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 18 | | the State shall not assume any obligation for the cost of the | 19 | | coverage set forth in subsections (a) and (b). | 20 | | Section 99. Effective date. This Act takes effect upon | 21 | | becoming law.".
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