Full Text of SB0679 97th General Assembly
SB0679enr 97TH GENERAL ASSEMBLY |
| | SB0679 Enrolled | | LRB097 04947 ASK 44987 b |
|
| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Sections 356z.14 and 356z.16 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 | 9 | | insurance or managed care plan amended, delivered, issued, or | 10 | | renewed after the effective date of this amendatory Act of the | 11 | | 95th General Assembly must provide individuals under 21 years | 12 | | of age coverage for the diagnosis of autism spectrum disorders | 13 | | and for the treatment of autism spectrum disorders to the | 14 | | extent that the diagnosis and treatment of autism spectrum | 15 | | disorders are not already covered by the policy of accident and | 16 | | health insurance or managed care plan. | 17 | | (b) Coverage provided under this Section shall be subject | 18 | | to a maximum benefit of $36,000 per year, but shall not be | 19 | | subject to any limits on the number of visits to a service | 20 | | provider. After December 30, 2009, the Director of the Division | 21 | | of Insurance shall, on an annual basis, adjust the maximum | 22 | | benefit for inflation using the Medical Care Component of the | 23 | | United States Department of Labor Consumer Price Index for All |
| | | SB0679 Enrolled | - 2 - | LRB097 04947 ASK 44987 b |
|
| 1 | | Urban Consumers. Payments made by an insurer on behalf of a | 2 | | covered individual for any care, treatment, intervention, | 3 | | service, or item, the provision of which was for the treatment | 4 | | of a health condition not diagnosed as an autism spectrum | 5 | | disorder, shall not be applied toward any maximum benefit | 6 | | established under this subsection. | 7 | | (c) Coverage under this Section shall be subject to | 8 | | copayment, deductible, and coinsurance provisions of a policy | 9 | | of accident and health insurance or managed care plan to the | 10 | | extent that other medical services covered by the policy of | 11 | | accident and health insurance or managed care plan are subject | 12 | | to these provisions. | 13 | | (d) This Section shall not be construed as limiting | 14 | | benefits that are otherwise available to an individual under a | 15 | | policy of accident and health insurance or managed care plan | 16 | | and benefits provided under this Section may not be subject to | 17 | | dollar limits, deductibles, copayments, or coinsurance | 18 | | provisions that are less favorable to the insured than the | 19 | | dollar limits, deductibles, or coinsurance provisions that | 20 | | apply to physical illness generally. | 21 | | (e) An insurer may not deny or refuse to provide otherwise | 22 | | covered services, or refuse to renew, refuse to reissue, or | 23 | | otherwise terminate or restrict coverage under an individual | 24 | | contract to provide services to an individual because the | 25 | | individual or their dependent is diagnosed with an autism | 26 | | spectrum disorder or due to the individual utilizing benefits |
| | | SB0679 Enrolled | - 3 - | LRB097 04947 ASK 44987 b |
|
| 1 | | in this Section. | 2 | | (f) Upon request of the reimbursing insurer, a provider of | 3 | | treatment for autism spectrum disorders shall furnish medical | 4 | | records, clinical notes, or other necessary data that | 5 | | substantiate that initial or continued medical treatment is | 6 | | medically necessary and is resulting in improved clinical | 7 | | status. When treatment is anticipated to require continued | 8 | | services to achieve demonstrable progress, the insurer may | 9 | | request a treatment plan consisting of diagnosis, proposed | 10 | | treatment by type, frequency, anticipated duration of | 11 | | treatment, the anticipated outcomes stated as goals, and the | 12 | | frequency by which the treatment plan will be updated. | 13 | | (g) When making a determination of medical necessity for a | 14 | | treatment modality for autism spectrum disorders, an insurer | 15 | | must make the determination in a manner that is consistent with | 16 | | the manner used to make that determination with respect to | 17 | | other diseases or illnesses covered under the policy, including | 18 | | an appeals process. During the appeals process, any challenge | 19 | | to medical necessity must be viewed as reasonable only if the | 20 | | review includes a physician with expertise in the most current | 21 | | and effective treatment modalities for autism spectrum | 22 | | disorders. | 23 | | (h) Coverage for medically necessary early intervention | 24 | | services must be delivered by certified early intervention | 25 | | specialists, as defined in 89 Ill. Admin. Code 500 and any | 26 | | subsequent amendments thereto. |
| | | SB0679 Enrolled | - 4 - | LRB097 04947 ASK 44987 b |
|
| 1 | | (h-5) If an individual has been diagnosed as having an | 2 | | autism spectrum disorder, meeting the diagnostic criteria in | 3 | | place at the time of diagnosis, and treatment is determined | 4 | | medically necessary, then that individual shall remain | 5 | | eligible for coverage under this Section even if subsequent | 6 | | changes to the diagnostic criteria are adopted by the American | 7 | | Psychiatric Association. If no changes to the diagnostic | 8 | | criteria are adopted after April 1, 2012, and before December | 9 | | 31, 2014, then this subsection (h-5) shall be of no further | 10 | | force and effect. | 11 | | (i) As used in this Section: | 12 | | "Autism spectrum disorders" means pervasive developmental | 13 | | disorders as defined in the most recent edition of the | 14 | | Diagnostic and Statistical Manual of Mental Disorders, | 15 | | including autism, Asperger's disorder, and pervasive | 16 | | developmental disorder not otherwise specified. | 17 | | "Diagnosis of autism spectrum disorders" means one or more | 18 | | tests, evaluations, or assessments to diagnose whether an | 19 | | individual has autism spectrum disorder that is prescribed, | 20 | | performed, or ordered by (A) a physician licensed to practice | 21 | | medicine in all its branches or (B) a licensed clinical | 22 | | psychologist with expertise in diagnosing autism spectrum | 23 | | disorders. | 24 | | "Medically necessary" means any care, treatment, | 25 | | intervention, service or item which will or is reasonably | 26 | | expected to do any of the following: (i) prevent the onset of |
| | | SB0679 Enrolled | - 5 - | LRB097 04947 ASK 44987 b |
|
| 1 | | an illness, condition, injury, disease or disability; (ii) | 2 | | reduce or ameliorate the physical, mental or developmental | 3 | | effects of an illness, condition, injury, disease or | 4 | | disability; or (iii) assist to achieve or maintain maximum | 5 | | functional activity in performing daily activities. | 6 | | "Treatment for autism spectrum disorders" shall include | 7 | | the following care prescribed, provided, or ordered for an | 8 | | individual diagnosed with an autism spectrum disorder by (A) a | 9 | | physician licensed to practice medicine in all its branches or | 10 | | (B) a certified, registered, or licensed health care | 11 | | professional with expertise in treating effects of autism | 12 | | spectrum disorders when the care is determined to be medically | 13 | | necessary and ordered by a physician licensed to practice | 14 | | medicine in all its branches: | 15 | | (1) Psychiatric care, meaning direct, consultative, or | 16 | | diagnostic services provided by a licensed psychiatrist. | 17 | | (2) Psychological care, meaning direct or consultative | 18 | | services provided by a licensed psychologist. | 19 | | (3) Habilitative or rehabilitative care, meaning | 20 | | professional, counseling, and guidance services and | 21 | | treatment programs, including applied behavior analysis, | 22 | | that are intended to develop, maintain, and restore the | 23 | | functioning of an individual. As used in this subsection | 24 | | (i), "applied behavior analysis" means the design, | 25 | | implementation, and evaluation of environmental | 26 | | modifications using behavioral stimuli and consequences to |
| | | SB0679 Enrolled | - 6 - | LRB097 04947 ASK 44987 b |
|
| 1 | | produce socially significant improvement in human | 2 | | behavior, including the use of direct observation, | 3 | | measurement, and functional analysis of the relations | 4 | | between environment and behavior. | 5 | | (4) Therapeutic care, including behavioral, speech, | 6 | | occupational, and physical therapies that provide | 7 | | treatment in the following areas: (i) self care and | 8 | | feeding, (ii) pragmatic, receptive, and expressive | 9 | | language, (iii) cognitive functioning, (iv) applied | 10 | | behavior analysis, intervention, and modification, (v) | 11 | | motor planning, and (vi) sensory processing. | 12 | | (j) Rulemaking authority to implement this amendatory Act | 13 | | of the 95th General Assembly, if any, is conditioned on the | 14 | | rules being adopted in accordance with all provisions of the | 15 | | Illinois Administrative Procedure Act and all rules and | 16 | | procedures of the Joint Committee on Administrative Rules; any | 17 | | purported rule not so adopted, for whatever reason, is | 18 | | unauthorized.
| 19 | | (Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.) | 20 | | (215 ILCS 5/356z.16) | 21 | | Sec. 356z.16. Applicability of mandated benefits to | 22 | | supplemental policies. Unless specified otherwise, the | 23 | | following Sections of the Illinois Insurance Code do not apply | 24 | | to short-term travel, disability income, long-term care, | 25 | | accident only, or limited or specified disease policies: 356b, |
| | | SB0679 Enrolled | - 7 - | LRB097 04947 ASK 44987 b |
|
| 1 | | 356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, | 2 | | 356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | 3 | | 356z.8, 356z.12, 356z.14, 356z.19, 356z.21 356z.19 , 364.01, | 4 | | 367.2-5, and 367e.
| 5 | | (Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; | 6 | | 96-1034, eff. 1-1-11; 97-91, eff. 1-1-12; 97-282, eff. 8-9-11; | 7 | | 97-592, eff. 1-1-12; revised 10-13-11.)
|
|