101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB3611

 

Introduced 2/14/2020, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.14
215 ILCS 5/356z.15

    Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or managed care plan that provides individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders may not deny or refuse to provide otherwise covered services solely because of the location where services are provided. Provides that a group or individual policy of accident and health insurance or managed care plan that provides coverage for habilitative services for children under 19 years of age with a congenital, genetic, or early acquired disorder under specified conditions may not deny or refuse to provide otherwise covered services solely because of the location where services are provided.


LRB101 19743 BMS 69252 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

SB3611LRB101 19743 BMS 69252 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Sections 356z.14 and 356z.15 as 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
9insurance or managed care plan amended, delivered, issued, or
10renewed after the effective date of this amendatory Act of the
1195th General Assembly must provide individuals under 21 years
12of age coverage for the diagnosis of autism spectrum disorders
13and for the treatment of autism spectrum disorders to the
14extent that the diagnosis and treatment of autism spectrum
15disorders are not already covered by the policy of accident and
16health insurance or managed care plan.
17    (b) Coverage provided under this Section shall be subject
18to a maximum benefit of $36,000 per year, but shall not be
19subject to any limits on the number of visits to a service
20provider. After December 30, 2009, the Director of the Division
21of Insurance shall, on an annual basis, adjust the maximum
22benefit for inflation using the Medical Care Component of the
23United States Department of Labor Consumer Price Index for All

 

 

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1Urban Consumers. Payments made by an insurer on behalf of a
2covered individual for any care, treatment, intervention,
3service, or item, the provision of which was for the treatment
4of a health condition not diagnosed as an autism spectrum
5disorder, shall not be applied toward any maximum benefit
6established under this subsection.
7    (c) Coverage under this Section shall be subject to
8copayment, deductible, and coinsurance provisions of a policy
9of accident and health insurance or managed care plan to the
10extent that other medical services covered by the policy of
11accident and health insurance or managed care plan are subject
12to these provisions.
13    (d) This Section shall not be construed as limiting
14benefits that are otherwise available to an individual under a
15policy of accident and health insurance or managed care plan
16and benefits provided under this Section may not be subject to
17dollar limits, deductibles, copayments, or coinsurance
18provisions that are less favorable to the insured than the
19dollar limits, deductibles, or coinsurance provisions that
20apply to physical illness generally.
21    (e) An insurer may not deny or refuse to provide otherwise
22covered services, or refuse to renew, refuse to reissue, or
23otherwise terminate or restrict coverage under an individual
24contract to provide services to an individual because the
25individual or their dependent is diagnosed with an autism
26spectrum disorder or due to the individual utilizing benefits

 

 

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1in this Section.
2    (e-5) An insurer may not deny or refuse to provide
3otherwise covered services under a group or individual policy
4of accident and health insurance or a managed care plan solely
5because of the location wherein the services are provided.
6    (f) Upon request of the reimbursing insurer, a provider of
7treatment for autism spectrum disorders shall furnish medical
8records, clinical notes, or other necessary data that
9substantiate that initial or continued medical treatment is
10medically necessary and is resulting in improved clinical
11status. When treatment is anticipated to require continued
12services to achieve demonstrable progress, the insurer may
13request a treatment plan consisting of diagnosis, proposed
14treatment by type, frequency, anticipated duration of
15treatment, the anticipated outcomes stated as goals, and the
16frequency by which the treatment plan will be updated.
17    (g) When making a determination of medical necessity for a
18treatment modality for autism spectrum disorders, an insurer
19must make the determination in a manner that is consistent with
20the manner used to make that determination with respect to
21other diseases or illnesses covered under the policy, including
22an appeals process. During the appeals process, any challenge
23to medical necessity must be viewed as reasonable only if the
24review includes a physician with expertise in the most current
25and effective treatment modalities for autism spectrum
26disorders.

 

 

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1    (h) Coverage for medically necessary early intervention
2services must be delivered by certified early intervention
3specialists, as defined in 89 Ill. Admin. Code 500 and any
4subsequent amendments thereto.
5    (h-5) If an individual has been diagnosed as having an
6autism spectrum disorder, meeting the diagnostic criteria in
7place at the time of diagnosis, and treatment is determined
8medically necessary, then that individual shall remain
9eligible for coverage under this Section even if subsequent
10changes to the diagnostic criteria are adopted by the American
11Psychiatric Association. If no changes to the diagnostic
12criteria are adopted after April 1, 2012, and before December
1331, 2014, then this subsection (h-5) shall be of no further
14force and effect.
15    (h-10) An insurer may not deny or refuse to provide covered
16services, or refuse to renew, refuse to reissue, or otherwise
17terminate or restrict coverage under an individual contract,
18for a person diagnosed with an autism spectrum disorder on the
19basis that the individual declined an alternative medication or
20covered service when the individual's health care provider has
21determined that such medication or covered service may
22exacerbate clinical symptomatology and is medically
23contraindicated for the individual and the individual has
24requested and received a medical exception as provided for
25under Section 45.1 of the Managed Care Reform and Patient
26Rights Act. For the purposes of this subsection (h-10),

 

 

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1"clinical symptomatology" means any indication of disorder or
2disease when experienced by an individual as a change from
3normal function, sensation, or appearance.
4    (h-15) If, at any time, the Secretary of the United States
5Department of Health and Human Services, or its successor
6agency, promulgates rules or regulations to be published in the
7Federal Register or publishes a comment in the Federal Register
8or issues an opinion, guidance, or other action that would
9require the State, pursuant to any provision of the Patient
10Protection and Affordable Care Act (Public Law 111-148),
11including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
12successor provision, to defray the cost of any coverage
13outlined in subsection (h-10), then subsection (h-10) is
14inoperative with respect to all coverage outlined in subsection
15(h-10) other than that authorized under Section 1902 of the
16Social Security Act, 42 U.S.C. 1396a, and the State shall not
17assume any obligation for the cost of the coverage set forth in
18subsection (h-10).
19    (i) As used in this Section:
20    "Autism spectrum disorders" means pervasive developmental
21disorders as defined in the most recent edition of the
22Diagnostic and Statistical Manual of Mental Disorders,
23including autism, Asperger's disorder, and pervasive
24developmental disorder not otherwise specified.
25    "Diagnosis of autism spectrum disorders" means one or more
26tests, evaluations, or assessments to diagnose whether an

 

 

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1individual has autism spectrum disorder that is prescribed,
2performed, or ordered by (A) a physician licensed to practice
3medicine in all its branches or (B) a licensed clinical
4psychologist with expertise in diagnosing autism spectrum
5disorders.
6    "Medically necessary" means any care, treatment,
7intervention, service or item which will or is reasonably
8expected to do any of the following: (i) prevent the onset of
9an illness, condition, injury, disease or disability; (ii)
10reduce or ameliorate the physical, mental or developmental
11effects of an illness, condition, injury, disease or
12disability; or (iii) assist to achieve or maintain maximum
13functional activity in performing daily activities.
14    "Treatment for autism spectrum disorders" shall include
15the following care prescribed, provided, or ordered for an
16individual diagnosed with an autism spectrum disorder by (A) a
17physician licensed to practice medicine in all its branches or
18(B) a certified, registered, or licensed health care
19professional with expertise in treating effects of autism
20spectrum disorders when the care is determined to be medically
21necessary and ordered by a physician licensed to practice
22medicine in all its branches:
23        (1) Psychiatric care, meaning direct, consultative, or
24    diagnostic services provided by a licensed psychiatrist.
25        (2) Psychological care, meaning direct or consultative
26    services provided by a licensed psychologist.

 

 

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1        (3) Habilitative or rehabilitative care, meaning
2    professional, counseling, and guidance services and
3    treatment programs, including applied behavior analysis,
4    that are intended to develop, maintain, and restore the
5    functioning of an individual. As used in this subsection
6    (i), "applied behavior analysis" means the design,
7    implementation, and evaluation of environmental
8    modifications using behavioral stimuli and consequences to
9    produce socially significant improvement in human
10    behavior, including the use of direct observation,
11    measurement, and functional analysis of the relations
12    between environment and behavior.
13        (4) Therapeutic care, including behavioral, speech,
14    occupational, and physical therapies that provide
15    treatment in the following areas: (i) self care and
16    feeding, (ii) pragmatic, receptive, and expressive
17    language, (iii) cognitive functioning, (iv) applied
18    behavior analysis, intervention, and modification, (v)
19    motor planning, and (vi) sensory processing.
20    (j) Rulemaking authority to implement this amendatory Act
21of the 95th General Assembly, if any, is conditioned on the
22rules being adopted in accordance with all provisions of the
23Illinois Administrative Procedure Act and all rules and
24procedures of the Joint Committee on Administrative Rules; any
25purported rule not so adopted, for whatever reason, is
26unauthorized.

 

 

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1(Source: P.A. 99-788, eff. 8-12-16.)
 
2    (215 ILCS 5/356z.15)
3    Sec. 356z.15. Habilitative services for children.
4    (a) As used in this Section, "habilitative services" means
5occupational therapy, physical therapy, speech therapy, and
6other services prescribed by the insured's treating physician
7pursuant to a treatment plan to enhance the ability of a child
8to function with a congenital, genetic, or early acquired
9disorder. A congenital or genetic disorder includes, but is not
10limited to, hereditary disorders. An early acquired disorder
11refers to a disorder resulting from illness, trauma, injury, or
12some other event or condition suffered by a child prior to that
13child developing functional life skills such as, but not
14limited to, walking, talking, or self-help skills. Congenital,
15genetic, and early acquired disorders may include, but are not
16limited to, autism or an autism spectrum disorder, cerebral
17palsy, and other disorders resulting from early childhood
18illness, trauma, or injury.
19    (b) A group or individual policy of accident and health
20insurance or managed care plan amended, delivered, issued, or
21renewed after the effective date of this amendatory Act of the
2295th General Assembly must provide coverage for habilitative
23services for children under 19 years of age with a congenital,
24genetic, or early acquired disorder so long as all of the
25following conditions are met:

 

 

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1        (1) A physician licensed to practice medicine in all
2    its branches has diagnosed the child's congenital,
3    genetic, or early acquired disorder.
4        (2) The treatment is administered by a licensed
5    speech-language pathologist, licensed audiologist,
6    licensed occupational therapist, licensed physical
7    therapist, licensed physician, licensed nurse, licensed
8    optometrist, licensed nutritionist, licensed social
9    worker, or licensed psychologist upon the referral of a
10    physician licensed to practice medicine in all its
11    branches.
12        (3) The initial or continued treatment must be
13    medically necessary and therapeutic and not experimental
14    or investigational.
15    (c) The coverage required by this Section shall be subject
16to other general exclusions and limitations of the policy,
17including coordination of benefits, participating provider
18requirements, restrictions on services provided by family or
19household members, utilization review of health care services,
20including review of medical necessity, case management,
21experimental, and investigational treatments, and other
22managed care provisions.
23    (d) Coverage under this Section does not apply to those
24services that are solely educational in nature or otherwise
25paid under State or federal law for purely educational
26services. Nothing in this subsection (d) relieves an insurer or

 

 

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1similar third party from an otherwise valid obligation to
2provide or to pay for services provided to a child with a
3disability.
4    (e) Coverage under this Section for children under age 19
5shall not apply to treatment of mental or emotional disorders
6or illnesses as covered under Section 370 of this Code as well
7as any other benefit based upon a specific diagnosis that may
8be otherwise required by law.
9    (f) The provisions of this Section do not apply to
10short-term travel, accident-only, limited, or specific disease
11policies.
12    (g) Any denial of care for habilitative services shall be
13subject to appeal and external independent review procedures as
14provided by Section 45 of the Managed Care Reform and Patient
15Rights Act.
16    (h) Upon request of the reimbursing insurer, the provider
17under whose supervision the habilitative services are being
18provided shall furnish medical records, clinical notes, or
19other necessary data to allow the insurer to substantiate that
20initial or continued medical treatment is medically necessary
21and that the patient's condition is clinically improving. When
22the treating provider anticipates that continued treatment is
23or will be required to permit the patient to achieve
24demonstrable progress, the insurer may request that the
25provider furnish a treatment plan consisting of diagnosis,
26proposed treatment by type, frequency, anticipated duration of

 

 

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1treatment, the anticipated goals of treatment, and how
2frequently the treatment plan will be updated.
3    (i) Rulemaking authority to implement this amendatory Act
4of the 95th General Assembly, if any, is conditioned on the
5rules being adopted in accordance with all provisions of the
6Illinois Administrative Procedure Act and all rules and
7procedures of the Joint Committee on Administrative Rules; any
8purported rule not so adopted, for whatever reason, is
9unauthorized.
10    (j) An insurer may not deny or refuse to provide otherwise
11covered services under a group or individual policy of accident
12and health insurance or a managed care plan solely because of
13the location wherein the services are provided.
14(Source: P.A. 95-1049, eff. 1-1-10; 96-833, eff. 6-1-10;
1596-1000, eff. 7-2-10.)