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Public Act 102-0322


 

Public Act 0322 102ND GENERAL ASSEMBLY

  
  
  

 


 
Public Act 102-0322
 
SB1592 EnrolledLRB102 13156 BMS 18499 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.15 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.
    (e-5) An insurer may not deny or refuse to provide
otherwise covered services under a group or individual policy
of accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
    (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.
    (h-10) An insurer may not deny or refuse to provide
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual
contract, for a person diagnosed with an autism spectrum
disorder on the basis that the individual declined an
alternative medication or covered service when the
individual's health care provider has determined that such
medication or covered service may exacerbate clinical
symptomatology and is medically contraindicated for the
individual and the individual has requested and received a
medical exception as provided for under Section 45.1 of the
Managed Care Reform and Patient Rights Act. For the purposes
of this subsection (h-10), "clinical symptomatology" means any
indication of disorder or disease when experienced by an
individual as a change from normal function, sensation, or
appearance.
    (h-15) If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage outlined in subsection (h-10), then subsection
(h-10) is inoperative with respect to all coverage outlined in
subsection (h-10) other than that authorized under Section
1902 of the Social Security Act, 42 U.S.C. 1396a, and the State
shall not assume any obligation for the cost of the coverage
set forth in subsection (h-10).
    (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. 99-788, eff. 8-12-16.)
 
    (215 ILCS 5/356z.15)
    Sec. 356z.15. Habilitative services for children.
    (a) As used in this Section, "habilitative services" means
occupational therapy, physical therapy, speech therapy, and
other services prescribed by the insured's treating physician
pursuant to a treatment plan to enhance the ability of a child
to function with a congenital, genetic, or early acquired
disorder. A congenital or genetic disorder includes, but is
not limited to, hereditary disorders. An early acquired
disorder refers to a disorder resulting from illness, trauma,
injury, or some other event or condition suffered by a child
prior to that child developing functional life skills such as,
but not limited to, walking, talking, or self-help skills.
Congenital, genetic, and early acquired disorders may include,
but are not limited to, autism or an autism spectrum disorder,
cerebral palsy, and other disorders resulting from early
childhood illness, trauma, or injury.
    (b) 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 coverage for habilitative
services for children under 19 years of age with a congenital,
genetic, or early acquired disorder so long as all of the
following conditions are met:
        (1) A physician licensed to practice medicine in all
    its branches has diagnosed the child's congenital,
    genetic, or early acquired disorder.
        (2) The treatment is administered by a licensed
    speech-language pathologist, licensed audiologist,
    licensed occupational therapist, licensed physical
    therapist, licensed physician, licensed nurse, licensed
    optometrist, licensed nutritionist, licensed social
    worker, or licensed psychologist upon the referral of a
    physician licensed to practice medicine in all its
    branches.
        (3) The initial or continued treatment must be
    medically necessary and therapeutic and not experimental
    or investigational.
    (c) The coverage required by this Section shall be subject
to other general exclusions and limitations of the policy,
including coordination of benefits, participating provider
requirements, restrictions on services provided by family or
household members, utilization review of health care services,
including review of medical necessity, case management,
experimental, and investigational treatments, and other
managed care provisions.
    (d) Coverage under this Section does not apply to those
services that are solely educational in nature or otherwise
paid under State or federal law for purely educational
services. Nothing in this subsection (d) relieves an insurer
or similar third party from an otherwise valid obligation to
provide or to pay for services provided to a child with a
disability.
    (e) Coverage under this Section for children under age 19
shall not apply to treatment of mental or emotional disorders
or illnesses as covered under Section 370 of this Code as well
as any other benefit based upon a specific diagnosis that may
be otherwise required by law.
    (f) The provisions of this Section do not apply to
short-term travel, accident-only, limited, or specific disease
policies.
    (g) Any denial of care for habilitative services shall be
subject to appeal and external independent review procedures
as provided by Section 45 of the Managed Care Reform and
Patient Rights Act.
    (h) Upon request of the reimbursing insurer, the provider
under whose supervision the habilitative services are being
provided shall furnish medical records, clinical notes, or
other necessary data to allow the insurer to substantiate that
initial or continued medical treatment is medically necessary
and that the patient's condition is clinically improving. When
the treating provider anticipates that continued treatment is
or will be required to permit the patient to achieve
demonstrable progress, the insurer may request that the
provider furnish a treatment plan consisting of diagnosis,
proposed treatment by type, frequency, anticipated duration of
treatment, the anticipated goals of treatment, and how
frequently the treatment plan will be updated.
    (i) 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.
    (j) An insurer may not deny or refuse to provide otherwise
covered services under a group or individual policy of
accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10;
96-1000, eff. 7-2-10.)

Effective Date: 1/1/2022