Illinois Legislature attempts to eliminate the "habilitation"

exclusion from health insurance for children

NewPage added January 15, 2009

The Bill has now been attached to Senate Bill 101, through amendment 4.  Senate Bill 101 concerns many other topics, but an amendment was added to get the mandate passed into law.
On January 13, 2009, this bill was passed by both houses of the Illinois General Assembly.
On February  11, 2009, the bill was sent to the new governor, awaiting signature.

Bill summary:
  1. definition of "habilitative services"
  2. conditions must be met for coverage: licensed providers
  3. other policy provisions still in force
  4. educational programs not covered
  5. Serious Mental Illness mandate not affected
  6. applies only to health and medical policies
  7. review and appeal rules still apply
  8. must produce records to show continued necessity
  9. State may issue implementing regulations
  10. Coordination with Autism mandates

Text of relevant sections of Senate Bill
    (215 ILCS 5/356z.14 new) (section number will change)
  Sec. 356z.14. 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.

(215 ILCS 5/370c)
       (c) This Section shall not be interpreted to require coverage for speech therapy or other habilitative services for
those individuals covered under Section 356z.14 of this Code. (Autism mandated coverage.)

Other sections of the bill apply the above mandate to insurance companies in Illinois, Illinois governmental health plans, and HMOs.  Self funded plans under ERISA are not affected.