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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.
(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.
(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. 96-1000, eff. 7-2-10; 97-972, eff. 1-1-13.)
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(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.
(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10; 96-1000, eff.
7-2-10.)
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Illinois Budget
Implementation Act requires Medicaid to pay for ABA