HB2845 101ST GENERAL ASSEMBLY

LRB101 10016 KTG 55118 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2845

Introduced , by Rep. Deb Conroy

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-30.11 new

Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a Medicaid managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act 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 Medicaid managed care plan. Provides that the coverage provided for the treatment of autism spectrum disorders shall not be subject to any limits on the number of visits to a service provider, but shall be subject to copayment, deductible, and coinsurance provisions of a Medicaid managed care plan to the extent that other medical services covered by the Medicaid managed care plan are subject to these provisions. Provides that the provisions of the amendatory Act shall not be construed as limiting benefits that are otherwise available to an individual under a Medicaid managed care plan and benefits provided under the amendatory Act 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. Requires a provider of treatment for autism spectrum disorders to furnish, upon request to the reimbursing managed care organization, 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. Defines terms. Makes other changes.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by adding Section 5-30.11 as follows:

(305 ILCS 5/5-30.11 new)

Sec. 5-30.11. Autism spectrum disorders.

(a) 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 syndrome, 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.

"Managed care organization" has the meaning ascribed to that term in Section 5-30.1.

"Medicaid managed care plan" means a health care plan operated by a managed care organization under the Medical Assistance Program.

"Medically necessary" means any care, treatment, intervention, service, or item that 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" includes 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, "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.

(b) A Medicaid managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 101st 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 managed care plan.

(c) Coverage provided under this Section shall not be subject to any limits on the number of visits to a service provider. Payments made by a managed care organization 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.

(d) Coverage under this Section shall be subject to copayment, deductible, and coinsurance provisions of a Medicaid managed care plan to the extent that other medical services covered by the Medicaid managed care plan are subject to these provisions.

(e) This Section shall not be construed as limiting benefits that are otherwise available to an individual under a Medicaid 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.

(f) A managed care organization 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.

(g) Upon request of the reimbursing managed care organization, 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 managed care organization 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.

(h) When making a determination of medical necessity for a treatment modality for autism spectrum disorders, a managed care organization 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 Medicaid managed care plan, 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.

(i) Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined in 89 Ill. Adm. Code 500 and any subsequent amendments.