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(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 co-payment, 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 the early
intervention operational standards by the Department of Human
Services and in accordance with applicable certification
requirements.
(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 a diagnosis of an individual with an autism spectrum
disorder 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, including diagnostic
services.
- (2) Psychological assessments and
treatments.
- (3) Rehabilitative
treatments.
- (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.
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